Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Backgrounds/Aims: Appropriate management for multifocal branch duct type intraductal papillary mucinous neoplasms (BD-IPMNs) of the pancreas is still controversial. This study was intended to reveal surgicaloutcomesofsurgical re- section for multifocal BD-IPMNs, with BD-IPMNs in the remnant pancreas. Methods: Between January 1995 and December 2013, 699 patients underwent the pancreatic resection due to IPMN ofpancreas in our institution. Among them, 37 patients showed multifocal BD-IPMNs. After excluding patients who had BD-IPMNs completely resected, medi- cal records of 22 patients with remained BD-IPMNs in the remnant pancreas were retrospectively reviewed. Results:
Introduction: Cystic neoplasmof the pancreas is a diverse group of lesions varying from benign to invasive malignant tumours.
Though uncommon, they are diagnosed with increased frequency due to the widespread use of cross-sectional imaging for abdominal complaints.
Methods: We analysed this data from a prospectively maintained database from 1990 to 2020 at a tertiary care hospital in Southern India. Patients’ demographic profile, tumour distribution, surgical procedures, and perioperative outcomes including complications were studied.
Our results show that a high level of preoperative bilir- ubin was the only significant risk factor for postoperative complications. Jaundice is associated with a higher risk of postoperative bleeding following PD and biliary drain- age can increases the risk of septic complications. 27 Although odds ratio of accompanying illness and intra- operative transfusion were also high, 2.67 and 3.04 re- spectively, these factors were not statistically significant, and no factors were associated with operative morbidity by multivariate analysis. These factors affect postoperative outcomes in other studies, but statistical insignificance in this study may be due to small case numbers. In this study, although the older patients had significantly more comorbid disease preoperatively, we could not find any significant differences in postoperative mortality and mor- bidity rates in the older group, and the age of the patient was not an independent risk factor for postoperative complications. Moreover, survival rates of older patients were comparable with younger patients. Richter et al. in 2002, had found that resections of cancers of the head of the pancreas are justified in patients over the age of 70 years, which is similar to our results. 28 Their results showed that patients over 70 may have a more favorable long-term outcome than younger patients if the patient had ductal adenocarcinoma in the pancreatic head. They insisted that the resection is independent of age if there were no medical contraindications. These results and our data suggest that old age is not a reason for avoiding PD, and curative resection should be carried out in the elderly whenever oncologically feasible in the treatment of distal CBD cancer. Although in our study, combined disease was not an independent risk factor for postoperative mor- bidity, when patients had combined comorbid disease, the incidence of postoperative morbidity was higher, thus we should pay special attention to detecting and treating co- morbid diseases before performing operations in the elderly.
Jee Yeon Lee, Seoung Yoon Rho, Dai Hoon Han, Jin Sub Choi, Gi Hong Choi
Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
Since the introduction of laparoscopic liver resection in the early 1990s, current laparoscopic liver resection is considered as an oncologically safe and standard procedure owing to the development of technical advances and postoperative management [1,2]. Previous studies on surgicaloutcomes between laparoscopic and open liver resection showed that
In recent years, the incidence of proximal gastric cancer has increased, most likely due to Barrett’s esophagus and distal esophagus adenocarcinoma caused by increased BMI and modern eating habits. The current standard treatment of proximal gastric cancer in Korea is total gastrectomy with D2 lymph node dissection. Although Dutch and MRC trials reported poor outcomesof D2 dissection with combined resection of the spleen and/or tail of the pancreas compared to D1 dissection, 8, 9 splenectomy had been justified to completely remove the lymph nodes around the splenic artery and hilum for extended radical surgery. 10, 11
parameters are often used when comparing surgical procedures and their possible adverse effects on pa- tients. Needless to say, shorter hospital stay, de- creased blood loss, and lower need for transfusion are all positive aspects that advocate for the recommen- dation of MI surgery in selected patients with SPN of the proximal pancreas. These findings coincide with those of Torres et al. who reported a successful lap- aroscopic pancreaticoduodenectomy in a 19/F with SPN who was discharged after 6 days without compli- cation . Similarly, Senthilnathan et al. reported five successful laparoscopic pancreaticoduodenectomy operations in their 8-year experience .
Department of Surgical Gastroenterology, JIPMER, Pondicherry, India
Introduction: Large tumors in the head of the pancreas pose technical challenges during resection in minimally invasive pancre- atoduodenectomy (PD). The precise and systematic vascular control of the pancreaticoduodenal branches of the superior mesenteric artery and vein during robotic PD for a large solidpseudopapillary tumor of the pancreas is described in this video.
These studies however lack comparative analysis against SPPN managed via a conventional open approach.
In our comparative study, we found an overall and ma- jor postoperative morbidity rate of 35.0% and 10.0% respect- ively, which was similar to that reported previously. 9,11,37 Our findings demonstrate comparable short-term perioper- ative outcomes between open and MIP for SPPN, includ- ing intraoperative blood loss and transfusion requirements, postoperative morbidity and mortality rates, as well as re- operation and readmission rates. In addition, oncological safety in terms of resection margins and lymph node yield was also comparable. The benefit of a shorter postoper- ative length of stay associated with MIP came with the tradeoff of a longer median operating time in our study.
International consensus guidelines for the management of IPMN were established in 2006, and revised in 2012. 12,13 In the 2012 guidelines, surgical resection for MD-IPMN was strongly recommended for all surgically fit patients, with the exception of cases having a main pancreatic duct (MPD) dilation of 5-9 mm; in this in- stance, the treatment strategies for BD-IPMN are more complicated, and it is these cases for which the concepts of ‘high-risk stigmata of malignancy’ and ‘worrisome fea- tures’ were adopted. ‘High-risk stigmata of malignancy’, in BD-IPMN, includes obstructive jaundice in a patient with a cystic lesion of the head of the pancreas, an en- hancing solid component within the cyst, and an MPD size of ≥10 mm. ‘Worrisome features’ include a cyst size of ≥3 cm, thickened/enhancing cyst walls, an MPD size of 5-9 mm, a non-enhancing mural nodule, and an abrupt change in the caliber of the pancreatic duct with distal pancreatic atrophy. 13
Indah JAMTANI, Adianto NUGROHO*, Rofi SAUNAR, Aditomo WIDARSO, Taslim PONIMAN Department of Surgery, Fatmawati General Hospital, Jakarta, Indonesia
Introduction: Solid pseudopapillary neoplasia of the pancreas is an extremely rare epithelial tumor of low malignant potential that primarily affects young female.
Only one patient (patient 6) underwent preoperative USG-
guided fine needle aspiration cytology (FNAC), which confirmed the diagnosis of SPT of the pancreas.
Surgical procedures included distal pancreatectomy with splenectomy in four patients, pylorus preserving pancreatico- duodenectomy in four, distal pancreatectomy in two, and subtotal pancreatectomy with splenectomy in one. One patient (patient 4) who presented with hemoperitoneum due to tumor rupture underwent an initial exploratory laparotomy and bleeding control because the mass was unresectable, followed by postoperative 3 cycles of chemotherapy (ifosfamide, etoposide, cisplatinum). Following tumor shrinkage, as shown by a repeat abdominal CT scan, this patient underwent a second exploratory operation 3 months later, during which subtotal pancreatectomy with splenectomy was performed. During follow-up, portal vein thrombosis and liver metastasis were observed, for which this patient underwent radiofrequency ablation and chemotherapy. At present, 97 months later, this patient is disease free, although she
tion (＜8 versus ≥8 mm), symptoms (absent versus pres- ent), and mural nodules (absent versus present) were put into the binary logistic regression model. It showed that
Recent advances in diagnostic imaging have resulted in an increased frequency of diagnosis for cystic mucin-pro- ducing pancreatic neoplasms. According to previous re- ports, IPMN represent about 1% of the pancreas exocrine tumors and about 12% of the pancreas cystic tumors. 4 Two-thirds of IPMN patients are men. The peak age is the sixth decade. Despite the more frequent reporting of IPMN, the natural history of this disease is not well understood. How to manage patients with IMPNs, espe- cially when it comes to timing of the surgical inter- vention, remains controversial.
Diagnosis and classification
IPMN was diagnosed by contrast-enhanced CT, MRI/magnetic resonance cholangiopancreatography. Lesions were classified into 3 types: MD, BD, and mixed type based on international consensus guidelines 2006 (ICG 2006 ). They were reclassified into 3 groups: ”high risk stigmata”, “worrisome features”, “no criteria” based on ICG 2012 . Then compare the results according to each guidelines. The number of high-risk stigmata was expressed as “HRS score”. Patients with any of the high risk stigmata were classified into the “high risk stigmata” group.
Recently, Liu et al.  published a case series of patients treated with single port RSC following a modified technique.
They attempted retroperitoneal tunneling techniques and asserted that they could more easily perform these tech- niques via a single port approach. A retroperitoneal tunnel was created by undermining the peritoneum with an ar- ticulated needle driver. The needle driver was placed in the peritoneal opening over the sacral promontory, and the tun- nel was created just medial to the right uterosacral ligament in the direction of the vaginal vault by using forward pres- sure and a sweeping motion to create a space within the ret- roperitoneum. This approach allowed for easier adjustment and maintenance of mesh tension during the placement of sutures in the sacral promontory compared with opening the entire retroperitoneal space, and may reduce operative time and adhesion formation.
gery for appendicitis between 1 January 2013 and 31 December 2013 were included in the study.
Patients treated by drainage procedure, not by resection, were excluded. In our center, conservative treatment for appendicitis with antibiotics alone was not adopted. Medical records were reviewed to identify the following factors: gender, age, time of symptom onset, when the patient presented at the hospital, when the operation started, surgical findings, postoperative complications, and length of hospital stay. The time when nausea, vomiting, dyspepsia, epigastric pain, or any other abdominal pain was reported by the patients was defined as the time of symptom onset. Surgical findings were divided into either uncomplicated appendicitis or complicated appendicitis.
Simple cholecystectomy vs. extended cholecystectomy
Jae Seung KANG, Yoo Jin CHOI, Hee Ju SOHN, Jung Min LEE, Youngmin HAN, Hongbeom KIM, Wooil KWON, Jin-Young JANG*
Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
There is an ongoing debate regarding the correlation be- tween the associated SMV, mesenteric vein gas or PI in HPVG patients and mortality rate. Heye et al. 12 reported a higher mortality rate in a group of 47 patients with HPVG when gas was present in the SMV. Morris et al. 13 advocated that the combination of HPVG and PI increases mortality. Another study reported that HPVG accompanied by PI increased the risk for fulminant bowel infarction. 14 In contrast, Faberman and Mayo-Smith 9 found no associa- tion between mesenteric vein gas and mortality. Another study reported that PI and HPVG do not reflect the se- verity of bowel ischemia. 15 In our study, presence of PI, main PVG, and SMV gas did not affect the mortality rate, leading us to conclude that the distribution of gas in the venous system was not associated with mortality.
Despite the strengths of this study, it does have its limitations. It was a single-center retrospective study. All patients had pathologic diagnosis after surgical resection. Many small cysts without worrisome features were excluded due to the lack of a pathologic diagnosis. Only patients who had both postoperative radiologic surveillance data and pathologic results were included in the analysis of cystic growth rate. Therefore, the number of patients available for evaluating cyst growth rate was limited; and therefore, the LR could not include this feature. A future study based on long-term regular surveillance would be needed to more fully address the role of cystic growth rate. Despite of these shortcomings, all the patients in the present study underwent diagnostic examination with standardized protocols, and the radiologic parameters were reviewed again by both a surgeon and a radiologist to improve diagnostic concordance.