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1.  Systematic review on the surgical treatment for T1 gallbladder cancer 
AIM: To evaluate the efficacy of simple and extended cholecystectomy for mucosa (T1a) or muscularis (T1b) gallbladder (GB) cancer.
METHODS: Original studies on simple and extended cholecystectomy for T1a or T1b GB cancer were searched from MEDLINE (PubMed), Cochrane Library, EMBase, and CancerLit using the search terms of GB, cancer/carcinoma/tumor/neoplasm.
RESULTS: Twenty-nine out of the 2312 potentially relevant publications met the eligibility criteria. Of the 1266 patients with GB cancer included in the publications, 706 (55.8%) and 560 (44.2%) had T1a and T1b GB cancer, respectively. Simple cholecystectomy for T1a and T1b GB cancer was performed in 590 (83.6%) and 375 (67.0%) patients, respectively (P < 0.01). In most series, the treatment of choice was simple cholecystectomy for T1a GB cancer patients with a 5-year survival rate of 100%. Lymph node metastasis was detected in 10.9% of the T1b GB cancer patients and in 1.8% of the T1a GB cancer patients, respectively (P < 0.01). Eight patients (1.1%) with T1a GB cancer and 52 patients (9.3%) with T1b GB cancer died of recurrent GB cancer (P < 0.01).
CONCLUSION: Simple cholecystectomy represents the adequate treatment of T1a GB cancer. There is no definite evidence that extended cholecystectomy is advantageous over simple cholecystectomy for T1b GB cancer.
doi:10.3748/wjg.v17.i2.174
PMCID: PMC3020370  PMID: 21245989
Gallbladder; Cancer; Cholecystectomy; Simple; Extended
2.  Identifying molecular subtypes related to clinicopathologic factors in pancreatic cancer 
BioMedical Engineering OnLine  2014;13(Suppl 2):S5.
Background
Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal tumors and usually presented with locally advanced and distant metastasis disease, which prevent curative resection or treatments. In this regard, we considered identifying molecular subtypes associated with clinicopathological factor as prognosis factors to stratify PDAC for appropriate treatment of patients.
Results
In this study, we identified three molecular subtypes which were significant on survival time and metastasis. We also identified significant genes and enriched pathways represented for each molecular subtype. Considering R0 resection patients included in each subtype, metastasis and survival times are significantly associated with subtype 1 and subtype 2.
Conclusions
We observed three PDAC molecular subtypes and demonstrated that those subtypes were significantly related with metastasis and survival time. The study may have utility in stratifying patients for cancer treatment.
doi:10.1186/1475-925X-13-S2-S5
PMCID: PMC4304250  PMID: 25560450
3.  Role of resection for Bismuth type IV hilar cholangiocarcinoma and analysis of determining factors for curative resection 
Purpose
Extended liver resection may provide long-term survival in selected patients with Bismuth type IV hilar cholangiocarcinoma (HCCA). The purpose of this study was to identify anatomical factors that predict curative-intended resection.
Methods
Thirty-three of 159 patients with Bismuth type IV HCCA underwent major hepato-biliary resection with curative intent (CIR) between 2000 and 2010. Disease extent and anatomical variations were analyzed as factors enabling CIR.
Results
CIR ratio with hilar trifurcation bile duct variation (13/16) was significantly higher than that with other bile duct variation types (18/25). Hilum to left second bile duct confluence and tumor infiltration over left second bile duct confluence lengths in right-sided CIR were significantly shorter than those lengths in left-sided CIR (10.8 ± 4.9 and 2.7 ± 0.8 mm vs. 16.5 ± 8.4 and 7.0 ± 5.3 mm, respectively). Left-sided CIR patients had a marginally higher proportion of tumors invading ≤5 mm over the right second confluence than that in right-sided CIR patients (13/17 vs. 6/16; P = 0.061). The 3-year survival rate after CIR (28%) was significantly higher than after non-CIR (6.1%).
Conclusion
We recommend the criteria of CIR as bile duct variation type, length of hilum to contralateral second bile duct confluence, and extent of tumor infiltration over the second confluence for Bismuth type IV HCCA.
doi:10.4174/astr.2014.87.2.87
PMCID: PMC4127903  PMID: 25114888
Klatskin's tumor; Bismuth type IV; Surgery; Anatomy
4.  Which method of pancreatic surgery do medical consumers prefer among open, laparoscopic, or robotic surgery? A survey 
Purpose
The consumers' preferences are not considered in developing or implementing new medical technologies. Furthermore, little efforts are made to investigate their demands. Therefore, their preferred surgical method and the factors affecting that preference were investigated in pancreatic surgery.
Methods
Six-hundred subjects including 100 medical personnel (MP) and 500 lay persons (LP) were surveyed. Questionnaire included basic information on different methods of distal pancreatectomy; open surgery (OS), laparoscopic surgery (LS), and robotic surgery (RS). Assuming they required the operation, participants were told to indicate their preferred method along with a reason and an acceptable cost for both benign and malignant conditions.
Results
For benign disease, the most preferred method was LS. Limiting the choice to LS and RS, LS was preferred for cost and well-established safety and efficacy. OS was favored in malignant disease for the concern for radicality. Limiting the choice to LS and RS, LS was favored for its better-established safety and efficacy. The majority thought that LS and RS were both overpriced. Comparing MP and LP responses, both groups preferred LS in benign and OS in malignant conditions. However, LP more than MP tended to prefer RS under both benign and malignant conditions. LP thought that LS was expensive whereas MP thought the cost reasonable. Both groups felt that RS was too expensive.
Conclusion
Though efforts for development of novel techniques and broadening indication should be encouraged, still more investments and research should focus on LS and OS to provide optimal management and satisfaction to the patients.
doi:10.4174/astr.2014.86.1.7
PMCID: PMC3994613  PMID: 24761401
Pancreas; Surgery; Consumer satisfaction; Survey
5.  Changes in Demographic Features of Gallstone Disease: 30 Years of Surgically Treated Patients 
Gut and Liver  2013;7(6):719-724.
Background/Aims
The aim of this study was to investigate changes in the clinical and demographical characteristics of gallstone disease in Korea, based on 30 years of surgically treated patients at a single institute.
Methods
In total, 7,949 gallstone patients who underwent surgery between 1981 and 2010 were analyzed. Patients were divided into six time periods: period I (1981 to 1985, n=831), period II (1986 to 1990, n=888), period III (1991 to 1995, n=1,040), period IV (1996 to 2000, n=1,261), period V (2001 to 2005, n=1,651) and period VI (2006 to 2010, n=2,278).
Results
The total number and mean age of the patients gradually increased, and the male/female ratio decreased. The proportion of gallbladder (GB)-stone cases increased, whereas the proportions of common bile duct (CBD)- and intrahepatic duct (IHD)-stone cases decreased. Differences in patient geographical origins also decreased. Based on the relationship between changes in the prevalence of gallstone disease and socioeconomic status, the prevalence of CBD stones showed a strong correlation with Engel's coefficient (p<0.001).
Conclusions
Our study indicates that although the total number of cases and the mean age of gallstone patients have continuously increased, there are trends of increasing GB-stone cases and decreasing CBD- and IHD-stone cases.
doi:10.5009/gnl.2013.7.6.719
PMCID: PMC3848536  PMID: 24312714
Cholelithiasis; Epidemiology; Surgery
6.  Cancer cells with p53 deletion detected by fluorescent in situ hybridization in peritoneal drainage fluid is correlated with early peritoneal seeding in resectable pancreatic cancer 
Purpose
Free tumor cells in peritoneal fluid in patients with pancreatic cancer may have prognostic significance but there are few reports on methods for the effective detection of free tumor cells. The aims of this study were to identify free cancer cells in peritoneal fluid with fluorescent in situ hybridization (FISH) technique and to investigate its prognostic significance.
Methods
Twenty-eight patients with resectable pancreatic cancer who underwent surgical resection were included. Peritoneal washing and peritoneal drainage fluid were examined by FISH for p53 deletion.
Results
Among the study subjects, the R0 resection rate was 75%. None of the patients had positive cytology with Papanicolaou's method. p53 deletion was detected in 9 peritoneal washings (32.1%) and in 5 peritoneal drainage fluids (17.9%). After a median of 18 months of follow-up, 25 patients (89.3%) experienced recurrence and 14 patients (50.0%) had peritoneal seeding. Patients with p53 deletion detected in the peritoneal drainage fluid had positive radial margin (60.0% vs. 17.4%, P = 0.046) more frequently and a lower peritoneal metastasis free survival (median, 11.1 months vs. 30.3 months; P = 0.030). Curative resection (P < 0.001) and p53 deletion in peritoneal drainage fluid (P = 0.030) were independent risk factors of peritoneal metastasis free survival after multivariate analysis.
Conclusion
FISH technique detects free cancer cells with higher sensitivity compared to Papanicolaou's method. p53 deletion detected in peritoneal drainage fluid is correlated with positive radial resection margin and results in early peritoneal seeding. Patients with p53 deletion in peritoneal drainage fluid need more aggressive adjuvant treatment.
doi:10.4174/jkss.2013.84.4.209
PMCID: PMC3616274  PMID: 23577315
Pancreatic neoplsms; Peritoneal fluid; Fluorescent in situ hybridization; p53 gene
7.  Proposal of an endoscopic retrograde cholangiopancreatography-related perforation management guideline based on perforation type 
Purpose
Consensus for endoscopic retrograde cholangiopancreatography (ERCP) related perforation management is lacking. We aimed to identify candidate patients for conservative management by examining treatment results and to introduce a simple, algorithm-based management guideline.
Methods
A retrospective review of 53 patients with ERCP-related perforation between 2000 and 2010 was conducted. Data on perforation site (duodenum lateral wall or jejunum, type I; para-Vaterian, type II), management method, complication, mortality, hospital stay, and hospital cost were reviewed. Comparative analysis was done according to the injury types and management methods.
Results
The outcome was greater in the conservative group than the operative group with shorter hospital stay (20.6 days vs. 29.8 days, P = 0.092), less cost (10.6 thousand United States Dollars [USD] vs. 19.9 thousand USD, P = 0.095), and lower morbidity rate (22.9% vs. 55.6%, P = 0.017). Eighty-one percent (17/21) of type I injuries were operatively managed and 96.9% (31/32) of type II injuries were conservatively managed. Between the types, type II showed better results over type I with shorter hospital stay (19.3 days vs. 30.6 days, P = 0.010), less cost (9.5 thousand USD vs. 20.1 thousand USD, P = 0.028), and lower complication rate (18.8% vs. 57.1%, P = 0.004). There was no difference in mortality.
Conclusion
Type II injuries were conservatively manageable and demonstrated better outcomes than type I injuries. The management algorithm suggests conservative management in type II injuries without severe peritonitis or unsolved problem requires immediate surgical correction, including operative management in type I injuries unless endoscopic intervention is possible. Conservative management offers socio-medical benefits. Conservative management is recommended in well-selected patients.
doi:10.4174/jkss.2012.83.4.218
PMCID: PMC3467388  PMID: 23091794
Endoscopic retrograde cholangiopancreatography; Intestinal perforation; Guideline; Algorithms
8.  Comparison of Clinical Outcome and Cost-Effectiveness after Various Preoperative Biliary Drainage Methods in Periampullary Cancer with Obstructive Jaundice 
Journal of Korean Medical Science  2012;27(4):356-362.
The aim of this study was to compare the clinical outcome and cost-effectiveness of preoperative biliary drainage (BD) methods in periampullary cancer, and to suggest guidelines for selecting the appropriate preoperative BD method. Between October 2004 and August 2010, 211 patients underwent pancreatoduodenectomy after preoperative BD. Clinical outcome and cost-effectiveness of the preoperative BD methods were compared based on the final drainage method used and on intention-to-treat analysis. There was no significant difference in drainage duration between percutaneous transhepatic biliary drainage (PTBD) and endoscopic BD groups (14.2 vs 16.6 days, respectively; P = 0.121) but daily diminution of serum bilirubin level was higher in the PTBD group (0.7 vs 0.6 mg/dL/day, respectively; P = 0.041). Based on intention-to-treat analysis, drainage duration was shorter (13.2 vs 16.5 days, respectively; P = 0.049), daily diminution of serum bilirubin level was higher (0.7 vs 0.6 mg/dL/day, respectively; P = 0.041). Medical care cost was lower (14.2 vs 15.7 × 103 USD, respectively; P = 0.040) in the PTBD group than in the endoscopic BD group. When selecting the preoperative BD method, practitioners should consider that PTBD is more cost-effective and safer than endoscopic BD.
doi:10.3346/jkms.2012.27.4.356
PMCID: PMC3314846  PMID: 22468097
Drainage; Biliary Cancer; Jaundice; Preoperative; Pancreatoduodenectomy
9.  A case of gangliocytic paraganglioma in the ampulla of Vater 
Background
Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have been reported to date.
Case presentation
The authors report a case of gangliocytic paraganglioma verified by post-op pathology after pancreaticoduodenectomy for a tumor in the ampulla of Vater. The 56-year-old male patient concerned visited our emergency room with melena that started one week prior to hospitalization. The patient was diagnosed to have a tumor in the ampulla of Vater with bleeding on its surface. However post-op, he was diagnosed as having gangliocytic paraganglioma by immunohistochemistry.
Conclusion
This tumor has precise clinical implications, and if continuous follow up is conducted after careful diagnosis and surgical treatment, invasive major operations, such as, radical pancreaticoduodenectomy can be avoided.
doi:10.1186/1477-7819-8-42
PMCID: PMC2887868  PMID: 20497533

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