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1.  YouTube as a source of patient information on gallstone disease 
AIM: To investigate the quality of YouTube videos on gallstone disease and to assess viewer response according to quality.
METHODS: A YouTube search was performed on September 18, 2013, using the keywords ‘‘gallbladder disease’’, ‘‘gallstone disease’’, and ‘‘gallstone treatment’’. Three researchers assessed the source, length, number of views, number of likes, and days since upload. The upload source was categorised as physician or hospital (PH), medical website or TV channel, commercial website (CW), or civilian. A usefulness score was devised to assess video quality and to categorise the videos into ‘‘very useful’’, ‘‘useful’’, ‘‘slightly useful’’, or ‘‘not useful’’. Videos with misleading content were categorised as ‘‘misleading’’.
RESULTS: One hundred and thirty-one videos were analysed. Seventy-four videos (56.5%) were misleading, 36 (27.5%) were slightly useful, 15 (11.5%) were useful, three (2.3%) were very useful, and three (2.3%) were not useful. The number of mean likes (1.3 ± 1.5 vs 17.2 ± 38.0, P = 0.007) and number of views (756.3 ± 701.0 vs 8910.7 ± 17094.7, P = 0.001) were both significantly lower in the very useful group compared with the misleading group. All three very useful videos were PH videos. Among the 74 misleading videos, 64 (86.5%) were uploaded by a CW. There was no correlation between usefulness and the number of views, the number of likes, or the length. The “gallstone flush” was the method advocated most frequently by misleading videos (25.7%).
CONCLUSION: More than half of the YouTube videos on gallstone disease are misleading. Credible videos uploaded by medical professionals and filtering by the staff of YouTube appear to be necessary.
PMCID: PMC3983464  PMID: 24744597
YouTube; Gallstone disease; Gallstone; Gallbladder; Cholecystitis
2.  Evaluation of prognostic factors on recurrence after curative resections for hepatocellular carcinoma 
World Journal of Gastroenterology : WJG  2014;20(45):17132-17140.
AIM: To select appropriate patients before surgical resection for hepatocellular carcinoma (HCC), especially those with advanced tumors.
METHODS: From January 2000 to December 2012, we retrospectively analyzed the medical records of 298 patients who had undergone surgical resections for HCC with curative intent at our hospital. We evaluated preoperative prognostic factors associated with histologic grade of tumor, recurrence and survival, especially the findings of pre-operative imaging studies such as positron emission tomography-computed tomography (PET-CT) and magnetic resonance imaging (MRI). And then, we established a scoring system to predict recurrence and survival after surgery dividing the patients into two groups based on a tumor size of 5 cm.
RESULTS: Of the 298 patients, 129 (43.3%) developed recurrence during the follow-up period. The 5 year disease free survival and overall survival were 47.0% and 58.7% respectively. In multivariate analysis, a serum alpha-fetoprotein (AFP) level of > 100 ng/mL and a standardized uptake value (SUV) of PET-CT of > 3.5 were predictive factors for histologic grade of tumor, recurrence, and survival. Tumor size of > 5 cm and a relative enhancement ratio (RER) calculated from preoperative MRI were also significantly associated with prognosis in univariate analysis. We established a scoring system to predict prognosis using AFP, SUV, and RER. In those with tumors of > 5 cm, it showed predicted both recurrence (P = 0.005) and survival (P = 0.001).
CONCLUSION: The AFP, tumor size, SUV and RER are useful for prognosis preoperatively. An accurate prediction of prognosis is possible using our scoring system in large size tumors.
PMCID: PMC4258583  PMID: 25493027
Carcinoma; Hepatocellular; Hepatectomy; Prognostic factor; Survival; Recurrence
3.  Inflammatory markers as selection criteria of hepatocellular carcinoma in living-donor liver transplantation 
AIM: To investigate that inflammatory markers can predict accurately the prognosis of hepatocelluar carcinoma (HCC) patients in living-donor liver transplantation (LDLT).
METHODS: From October 2000 to November 2011, 224 patients who underwent living donor liver transplantation for HCC at our institution were enrolled in this study. We analyzed disease-free survival (DFS) and overall survival (OS) after LT in patients with HCC and designed a new score model using pretransplant neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP).
RESULTS: The DFS and OS in patients with an NLR level ≥ 6.0 or CRP level ≥ 1.0 were significantly worse than those of patients with an NLR level < 6.0 or CRP level < 1.0 (P = 0.049, P = 0.003 for NLR and P = 0.010, P < 0.001 for CRP, respectively). Using a new score model using the pretransplant NLR and CRP, we can differentiate HCC patients beyond the Milan criteria with a good prognosis from those with a poor prognosis.
CONCLUSION: Combined with the Milan criteria, new score model using NLR and CRP represent new selection criteria for LDLT candidates with HCC, especially beyond the Milan criteria.
PMCID: PMC4047346  PMID: 24914382
C-reactive protein; Hepatocellular carcinoma; Liver transplantation; Neutrophil-lymphocyte ratio; Selection criteria
4.  Clinical outcome in patients with hepatocellular carcinoma after living-donor liver transplantation 
AIM: To investigate risk factors for hepatocellular carcinoma (HCC) recurrence after living donor liver transplantation (LDLT) and efficacy of various criteria.
METHODS: From October 2000 to November 2011, 233 adult patients underwent LDLT for HCC at our institution. After excluding nine postoperative mortality cases, we analyzed retrospectively 224 patients. To identify risk factors for recurrence, we evaluated recurrence, disease-free survival (DFS) rate, survival rate, and various other factors which are based on the characteristics of both the patient and tumor. Additionally, we developed our own criteria based on our data. Next, we compared our selection criteria with various tumor-grading scales, such as the Milan criteria, University of California, San Francisco (UCSF) criteria, TNM stage, Barcelona Clinic Liver Cancer (BCLC) stage and Cancer of the Liver Italian Program (CLIP) scoring system. The median follow up was 68 (6-139) mo.
RESULTS: In 224 patients who received LDLT for HCC, 37 (16.5%) experienced tumor recurrence during the follow-up period. The 5-year DFS and overall survival rates after LDLT in all patients with HCC were 80.9% and 76.4%, respectively. On multivariate analysis, the tumor diameter {5 cm; P < 0.001; exponentiation of the B coefficient [Exp(B)], 11.89; 95%CI: 3.784-37.368} and alpha fetoprotein level [AFP, 100 ng/mL; P = 0.021; Exp(B), 2.892; 95%CI: 1.172-7.132] had significant influences on HCC recurrence after LDLT. Therefore, these two factors were included in our criteria. Based on these data, we set our selection criteria as a tumor diameter ≤ 5 cm and AFP ≤ 100 ng/mL. Within our new criteria (140/214, 65.4%), the 5-year DFS and overall survival rates were 88.6% and 81.8%, respectively. Our criteria (P = 0.001), Milan criteria (P = 0.009), and UCSF criteria (P = 0.001) showed a significant difference in DFS rate. And our criteria (P = 0.006) and UCSF criteria (P = 0.009) showed a significant difference in overall survival rate. But Milan criteria did not show significant difference in overall survival rate (P = 0.137). Among stages 0, A, B and C of BCLC, stage C had a significantly higher recurrence rate (P = 0.001), lower DFS (P = 0.001), and overall survival rate (P = 0.005) compared with the other stages. Using the CLIP scoring system, the group with a score of 4 to 5 showed a high recurrence rate (P = 0.023) and lower DFS (P = 0.011); however, the overall survival rate did not differ from that of the lower scoring group. The TNM system showed a trend of increased recurrence rate, decreased DFS, or survival rate according to T stage, albeit without statistical significance.
CONCLUSION: LDLT is considered the preferred therapeutic option in patients with an AFP level less than 100 ng/mL and a tumor diameter of less than 5 cm.
PMCID: PMC3732846  PMID: 23922471
Hepatocellular carcinoma; Living donor liver transplantation; Selection criteria; Milan criteria; University of California, San Francisco criteria; Barcelona Clinic Liver Cancer; Cancer of the Liver Italian Program
5.  A comparison of the periumbilical incision and the intraumbilical incision in laparoscopic appendectomy 
The intraumbilical incision is being used more frequently, with increasing cases of single incision laparoscopic surgery. Since the umbilicus is deeper than the surrounding wall, it has abundant bacteria. No study has compared the adverse outcomes of periumbilical and intraumbilical incisions. We analyzed the wound complication rates of perforated appendicitis patients according to the types of umbilical incision.
A retrospective review was done of 280 patients with perforated appendicitis. One hundred fifty nine patients were treated with the intraumbilical incision, and 121 patients were treated with the periumbilical incision. We compared the perioperative outcomes according to each laparoscopic incision.
There was no difference in operation time, postoperative hospital stay and analgesic requirement between the two groups. One case in the intraumbilical group (0.6%) and three cases in the periumbilical group (2.5%) developed wound infections. The umbilical complication rate showed no difference.
The wound complication rate of intraumbilical and periumbilical incisions are not different. Although this retrospective study has inherent limitations, the intraumbilical incision seems to be a safe and feasible alternative for the periumbilical incision that can be easier to perform, with better cosmetic results.
PMCID: PMC3514478  PMID: 23230554
Intraumbilical; Laparoscopic technique; Appendectomy
6.  Transumbilical single port laparoscopic appendectomy using basic equipment: a comparison with the three ports method 
Single port laparoscopic surgery is a rapidly evolving laparoscopic surgical approach. We report a comparison of transumbilical single port laparoscopic appendectomy (TUSPLA) and conventional laparoscopic appendectomy (CLA) in a Korean military hospital.
This single-center retrospective study of 63 patients who received laparoscopic appendectomy was conducted between May 2011 and October 2011. Nineteen patients received TUSPLA and 44 patients received CLA. Clinical outcomes such as operation time, hospital stay, postoperative pain, diet, and postoperative complication were reviewed.
There were no statistically significant differences between TUSPLA and CLA patients, respectively, in operation time (58.9 minutes vs. 52.3 minutes, P = 0.262), duration of hospitalization (10.2 days vs. 10.6 days, P = 0.782), mean visual analogue scale score (2.6 vs. 2.5, P = 0.894), and return to diet (1.6 days vs. 1.7 days, P = 0.776). There were two cases (10.5%) of short-term complications in the TUSPLA group and four cases (9.1%) of short-term complications in the CLA group. All patients were fully recovered at discharge.
TUSPLA is a feasible alternative for CLA. When a glove port is used, no special instruments are needed. Thus, it can be performed in a hospital equipped with basic laparoscopic surgical instruments.
PMCID: PMC3467387  PMID: 23091793
Laparoscopy; Appendectomy; Single-port; Transumbilical; Scarless
7.  MicroRNA expression profiling of diagnostic needle aspirates from surgical pancreatic cancer specimens 
MicroRNAs (miRNAs) have been widely investigated as potential biomarkers for several malignancies. To establish the feasibility of miRNA expression profiling of small biopsy samples of pancreatic cancers, we assessed expression profiles in freshly collected aspirates obtained immediately after surgical resection of the pancreas.
We used separate fine needles (20-23 gauge) to aspirate the pancreatic cancer and adjacent normal pancreatic tissue. miRNAs that were differentially expressed in pancreatic cancers and matched paraneoplastic normal pancreatic tissues were identified using an miRNA microarray.
We identified 158 aberrantly expressed miRNAs in pancreatic cancers; 51 were overexpressed and 107 underexpressed compared with normal pancreatic tissue. To confirm the microarray findings, quantitative RT-PCR was performed on individual samples. We chose eight miRNAs for further analysis; of which five were overexpressed (miR-21, miR-27a, miR-146a, miR-200a, and miR-196a) and three underexpressed (miR-217, miR-20a, and miR-96) in pancreatic cancer samples compared to benign pancreatic tissue. Expression of miR-21, miR-27a, miR-146a, miR-200a, and miR-196a was significantly increased in cancer fine-needle aspirates relative to matched controls in all samples. Expression of miR-217, miR-20a, and miR-96 was significantly downregulated in almost all pancreatic cancer tissues.
We demonstrate the feasibility of performing miRNA profiling on very small specimens obtained using fine-needle aspiration of pancreatic cancers.
PMCID: PMC4255547  PMID: 25485236
MicroRNAs; Pancreatic neoplasms; Biopsy; Fine-needle
9.  Practical Guidelines for the Surgical Treatment of Gallbladder Cancer 
Journal of Korean Medical Science  2014;29(10):1333-1340.
At present, surgical treatment is the only curative option for gallbladder (GB) cancer. Many efforts therefore have been made to improve resectability and the survival rate. However, GB cancer has a low incidence, and no randomized, controlled trials have been conducted to establish the optimal treatment modalities. The present guidelines include recent recommendations based on current understanding and highlight controversial issues that require further research. For T1a GB cancer, the optimal treatment modality is simple cholecystectomy, which can be carried out as either a laparotomy or a laparoscopic surgery. For T1b GB cancer, either simple or an extended cholecystectomy is appropriate. An extended cholecystectomy is generally recommended for patients with GB cancer at stage T2 or above. In extended cholecystectomy, a wedge resection of the GB bed or a segmentectomy IVb/V can be performed and the optimal extent of lymph node dissection should include the cystic duct lymph node, the common bile duct lymph node, the lymph nodes around the hepatoduodenal ligament (the hepatic artery and portal vein lymph nodes), and the posterior superior pancreaticoduodenal lymph node. Depending on patient status and disease severity, surgeons may decide to perform palliative surgeries.
Graphical Abstract
PMCID: PMC4214932  PMID: 25368485
Gallbladder; Neoplasm; General Surgery; Guideline
10.  Definitive concurrent chemoradiotherapy in locally advanced pancreatic cancer 
Radiation Oncology Journal  2014;32(2):49-56.
Survival outcome of locally advanced pancreatic cancer has been poor and little is known about prognostic factors of the disease, especially in locally advanced cases treated with concurrent chemoradiation. This study was to analyze overall survival and prognostic factors of patients treated with concurrent chemoradiotherapy (CCRT) in locally advanced pancreatic cancer.
Materials and Methods
Medical records of 34 patients diagnosed with unresectable pancreatic cancer and treated with definitive CCRT, from December 2003 to December 2012, were reviewed. Median prescribed radiation dose was 50.4 Gy (range, 41.4 to 55.8 Gy), once daily, five times per week, 1.8 to 3 Gy per fraction.
With a mean follow-up of 10 months (range, 0 to 49 months), median overall survival was 9 months. The 1- and 2-year survival rates were 40% and 10%, respectively. Median and mean time to progression were 5 and 7 months, respectively. Prognostic parameters related to overall survival were post-CCRT CA19-9 (p = 0.02), the Eastern Cooperative Oncology Group (ECOG) status (p < 0.01), and radiation dose (p = 0.04) according to univariate analysis. In multivariate analysis, post-CCRT CA19-9 value below 180 U/mL and ECOG status 0 or 1 were statistically significant independent prognostic factors associated with improved overall survival (p < 0.01 and p = 0.02, respectively).
Overall treatment results in locally advanced pancreatic cancer are relatively poor and few improvements have been accomplished in the past decades. Post-treatment CA19-9 below 180 U/mL and ECOG performance status 0 and 1 were significantly associated with an improved overall survival.
PMCID: PMC4104219  PMID: 25061572
Pancreatic neoplasms; Chemoradiotherapy; CA19-9 antigen
11.  Outcomes of living donor liver transplantation using elderly donors 
Living donor liver transplantation (LDLT) using elderly donors is increasing in frequency in response to organ shortage. However, elderly donor graft has been reported to negatively affect graft patency and patient survival.
We retrospectively reviewed the medical records of 604 patients who underwent LDLT at Seoul St. Mary's Hospital, The Catholic University of Korea between May 1999 and September 2012. Elderly donors were defined as those ≥55 years of age. Here, we evaluate the survival differences and causes of death of recipients of elderly donor grafts.
The overall mortality rate of the recipients was significantly higher in the elderly donor group (group A) than in the younger donor group (group B: 46.2% vs. 18.1%, P = 0.004). The survival length of group A was significantly shorter than that of group B (31.2 ± 31.3 and 51.4 ± 40.8 months, P = 0.014). The significantly common causes of death in group A were biliary (41.7%) and arterial complication (16.7%), and it was higher than those in group B (P = 0.000 and P = 0.043, respectively).
LDLT using elderly donors could induce more serious complications and higher mortality rates than those at using younger donors. As such, careful donor selection is needed, especially with regard to assessing the condition of potential elderly donor livers. Furthermore, a large-volume and multicenter study of complications and outcomes of LDLT using elderly donor liver is required.
PMCID: PMC3996718  PMID: 24783177
Liver transplantation; Living donor; Survival; Prognosis
12.  ERCC1 Can Be a Prognostic Factor in Hilar Cholangiocarcinoma and Extrahepatic Bile Duct Cancer, But Not in Intrahepatic Cholangiocarcinoma 
There are three types of bile duct cancer, intrahepatic cholangiocarcinoma (ICC), hilar cholangiocarcinoma (HC), and extrahepatic cholangiocarcinoma (EHC). Despite different clinical presentation, the same protocol has been used in treatment of patients with these cancers. We analyzed clinicopathologic findings and protein expression in order to investigate the difference and the specific prognostic factors among these three types of cancers.
Materials and Methods
We conducted a retrospective review of 104 patients diagnosed with bile duct cancer at Seoul St. Mary's Hospital between January 1994 and May 2004. We performed immunohistochemical staining for p53, cyclin D1, thymidine phosphorylase, survivin, and excision repair cross-complementing group 1 (ERCC1).
Of the 104 patients, EHC was most common (44.2%). In pathologic findings, perineural invasion was significantly less common in ICC. Overall survival was similar among the three types of cancer. Lymph node invasion, lymphatic, and venous invasion showed a significant association with survival outcome in ICC, however, the differentiation of histologic grade had prognostic significance in HC and EHC. No difference in protein expression was observed among these types of cancer, however, ERCC1 showed a significant association with survival outcome in HC and EHC, not in ICC.
Based on our data, ICC showed different characteristics and prognostic factors, separate from the other two types of bile duct cancer. Conduct of further studies with a large sample size is required in order to confirm these data.
PMCID: PMC3629365  PMID: 23613672
Bile duct neoplasms; ERCC1; Prognosis
13.  An easy and secure pancreaticogastrostomy after pancreaticoduodenectomy: transpancreatic suture with a buttress method through an anterior gastrotomy 
The aim of this report was to describe a new reconstructive technique of pancreaticogastrostomy and to also discuss this procedure's effectiveness for reducing the incidence of postoperative complications.
We retrospectively analyzed early surgical outcomes in 21 consecutive patients who underwent this novel pancreaticogastrostomy after pancreaticoduodenectomy. Pancreaticogastrostomy was completed with 2 transpancreatic sutures with buttresses on both the upper and lower edges of the implanted pancreas through the retracted anterior gastrotomy.
Operative mortality was zero and morbidity was 23.8%. A significant pancreatic fistula occurred in 1 patient (4.7%; grade B).
This technique is very easy to perform, less traumatic to the pancreatic stump, can be performed through a mini-laparotomy due to good vision and straight sutures, and it is secure owing to anchoring of the invaginated pancreatic stump to the stomach's posterior wall with buttresses. The results of this pilot study indicate that the technique may provide a favorable outcome and could be an alternative method of pancreatoenteric anastomosis. However, to determine its superiority over the conventional procedures, this operative technique should be evaluated more comprehensively in a larger series.
PMCID: PMC3229002  PMID: 22148126
Pancreatic fistula; Pancreatoenteric anastomosis; Anterior gastrotomy
14.  Comparison of thymidine phosphorylase expression and prognostic factors in gallbladder and bile duct cancer 
BMC Cancer  2010;10:564.
Biliary tract cancers have limitations in information about different location-related pathogenesis and clinico-pathological characteristics. The goal of this study was to investigate anatomical site-related similarities and differences in biliary tract cancers and to assess the expression and clinical significance of functional proteins such as p53, cyclin D1, survivin, thymidine phosphorylase, and ERCC1.
One hundred and sixty-one patients with biliary tract adenocarcinomas, who underwent curative or palliative surgery in a single institution between October 1994 and December 2003 were evaluated, retrospectively. The level of protein expression of p53, cyclin D1, survivin, thymidine phosphorylase, and ERCC1 was assessed by immunohistochemistry.
With respect to clinico-pathological characteristics, gallbladder cancer was more frequent in women, and bile duct cancer was more common in men. Perineural invasion was more common in bile duct cancer. Recurrence as a distant metastasis was more common in gallbladder cancer. Immunohistochemical analysis revealed that thymidine phosphorylase expression was significantly higher in gallbladder cancer than in bile duct cancer. Positive thymidine phosphorylase and p53 staining were associated with an advanced stage. Differentiation, vascular invasion, perineural invasion, lymphatic invasion, lymph node metastasis, and TNM stage independently predicted poor prognosis in biliary tract cancer. These correlations were seen more clearly in gallbladder cancer. The immunohistochemical staining patterns of p53, cyclin D1, survivin, thymidine phosphorylase, and ERCC1 showed no prognostic significance in biliary tract cancers.
We concluded that gallbladder and bile duct cancers are considered to be separate diseases with different clinico-pathological characteristics and prognostic factors. In addition, we hypothesize that high expression of thymidine phosphorylase by gallbladder cancer results in a higher response rate to capecitabine by gallbladder cancer than bile duct cancer.
PMCID: PMC2974735  PMID: 20955617
15.  Elective Laparoscopic Repair after Colonoscopic Decompression for Incarcerated Morgagni Hernia 
Gut and Liver  2009;3(4):318-320.
Plain radiographs of an 88-year-old woman who had experienced vomiting and abdominal distention for 3 days revealed a severely obstructed ileus, and abdominopelvic computed tomography revealed an incarcerated Morgagni hernia. The endoscope was passed through the constrictions from the diaphragmatic indentations and a thin catheter was placed for decompression. The obstructive ileus regressed markedly after the procedure; the patient underwent elective laparoscopic repair of the hernia 1 week later. This is believed to be the first case of endoscopic preoperative decompression for an incarcerated Morgagni hernia.
PMCID: PMC2852740  PMID: 20431768
Hernia, Diaphragmatic; Decompression; Colonoscopy
16.  Giant Cell Malignant Fibrous Histiocytoma of the Breast: A Case Report 
Journal of Korean Medical Science  2004;19(3):477-480.
A case of primary malignant fibrous histiocytoma of the breast is reported. The patient was a 48-yr-old woman with a huge tumor involving almost the entire left breast. The central portion of her left breast was already rotted by extensive necrosis and inflammation. She was treated by radical mastectomy and axillary lymphadenectomy to level I. Pathologic examination supported by an immunohistochemical staining confirmed the tumor as malignant fibrous histiocytoma of giant cell type. Axillary lymph nodes were free from tumor metastasis. She had not taken any postoperative adjuvant therapy. The metastasis to lungs was found 2 months after the operation, and she died within 6 months.
PMCID: PMC2816856  PMID: 15201521
Breast Neoplasms; Sarcoma; Malignant Fibrous Histiocytoma; Myxosarcoma; Histiocytic Disorders, Malignant

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