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Background: Although advancements in desensitization protocols have led to increased ABO-incompatible (ABOi) living-donor liver transplantation (LDLT), a higher biliary complication rate remains a problem. This study evaluated the effect of baseline anti-ABO antibody titers before desensitization on biliary complications after ABOi LDLT. Methods: The study cohort comprised 116 patients in the ABO-compatible group (ABOc), 29 in the ABOi with the low titer (<1:128) group (ABOi-L), and 14 in the high titer (≥1:128) group (ABOi-H). Results: Biliary complications occurred more frequently in the ABOi-H group than in the ABOi-L and ABOc groups (7 [50.0%] vs. 8 [27.6%] and 24 [20.7%], respectively, p = 0.041). Biliary complication-free survival was significantly worse in the ABOi-H group than in the other groups (p = 0.043). Diffuse intrahepatic biliary strictures occurred more frequently in the ABOi-H group than in the other groups (p = 0.005). Multivariable analysis revealed that the high anti-ABO antibody titer (≥1:128) is an independent risk factor for biliary complications (hazard ratio 3.943 [1.635–9.506]; p = 0.002). Conclusions: A high baseline anti-ABO antibody titer (≥1:128), female sex, and hepatic artery complications are significant risk factors for biliary complications.

BackgroundMinimally invasive surgery appears to be developing in multiple directions, including single-port laparoscopic (SPL), single-port robotic, reduced port laparoscopic, or single-site plus one-port robotic approach. The aim of study was to compare the short-term perioperative variables and outcomes of patients undergoing reduced port minimally invasive distal pancreatectomy (DP) via the SPL, or robotic single-site plus one-port (RSS + 1) approach.MethodsThe medical records of 35 patients were retrospectively reviewed, who underwent SPL-DP (n = 22) or RSS + 1 DP (n = 13) at Korea University Ansan Hospital and Yonsei University Severance Hospital.ResultsThe mean operation time in SPL group was significantly higher than that of RSS + 1 group (281 vs 192, p = .001). The mean blood loss in SPL was significantly larger than that of RSS + 1 group (163 vs 12, p = .002). The mean length of free resection margin in SPL group was significantly longer than that of RSS + 1 group (2.1 vs 0.4 cm, p = .001). Spleen was significantly preserved in SPL group (54.5 vs 7.7%, p = .001). All RSS + 1 cases had tumors located near spleen hilum (p < .001). SPL approach had significantly grade IIIa complications (p = .014). Moreover, the mean hospital stay in SPL group was significantly longer than that of RSS + 1 group (14.4 vs 7.4 days, p = .004). Postoperative pancreatic fistula (POPF) was significantly observed in longer operation time (p = .043) and smaller tumor size (p = .037) in the univariate analysis. Higher BMI was significantly important factor for prolonged operation time (p = .034) in the multivariate analysis. Prolonged hospital stay was related to spleen preservation (p = .014) in the multivariate analysis.ConclusionsBoth SPL and RSS + 1 are technically feasible and safe. RSS + 1-DP is superior to SPL-DP in terms of operation time, blood loss, severe complications, and hospital stay. SPL-DP shows advantages in terms of single wound site, less trocar usage, higher rate of spleen preservation, and wider range of operative field.

Background Most adjuvant therapies for hepatocellular carcinoma (HCC) have failed except for autologous cytokine-induced killer (CIK) therapy, which prolonged recurrence-free survival (RFS) in a previously reported randomized controlled trial (RCT) and real-world data (RWD). Methods This study aimed to assess the long-term outcomes of adjuvant CIK therapy using both an extended follow-up of the original RCT and a retrospective cohort study. An extended follow-up analysis of the RCT included 226 patients (114 in the CIK group and 112 in the control group). The follow-up duration was extended from 2 to 9 years after the enrollment of the last patient. In parallel, a retrospective RWD study was performed involving 577 patients from two tertiary centers in Korea, including 251 who received adjuvant CIK therapy and 326 controls. Propensity score matching (PSM) was applied to adjust for baseline imbalances. The primary endpoint was RFS in both studies. Results In the RWD study (median follow-up = 57.2 months), the CIK group demonstrated significantly prolonged RFS than controls both before PSM (median = 101.2 versus 64.7 months; HR = 0.69, 95% CI 0.53–0.90, P  = 0.006) and after PSM (median = 101.2 vs. 65.7 months; HR = 0.64, 95% CI 0.45–0.91, P  = 0.01). In the extended follow-up of the RCT (median follow-up = 116.1 months), the CIK group exhibited significantly prolonged RFS (median = 44.0 vs. 30.0 months; hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.54–0.97, P  = 0.033) compared to the control group. Conclusions Adjuvant CIK cell therapy significantly improved RFS in both a RWD study and a 9-year extended RCT follow-up, supporting its reproducible benefit in reducing recurrence after curative treatment of HCC. These consistent findings provide strong evidence for the clinical utility of CIK therapy as a durable adjuvant immunotherapeutic strategy for HCC.

Purpose Ampulla of Vater (AoV) cancer often presents with bile flow obstruction requiring bile drainage. Endoscopic sphincterotomy (EST) for AoV cancer may result in inflammation and spread of the tumor due to the abundant lymphatic channels and microvascular structures around the AoV, which may impact the postoperative and oncologic outcomes. This study aimed to evaluate the postoperative and oncological effects of EST on AoV cancer. Methods Medical records of 131 patients with AoV cancer who underwent pancreaticoduodeenectomy between 2011 and 2020 were reviewed. We compared the perioperative outcomes, overall survival, and disease recurrence in the patients. Results Approximately 71 patients underwent EST for preoperative biliary drainage, whereas 60 did not receive any procedure or underwent percutaneous transhepatic biliary drainage. No significant differences were observed in the 5-year overall survival rate (EST 69.9% vs. no EST 75.1%, P  = 0.804) or the 5-year cumulative recurrence rate (EST 49.1% vs. no EST 56.8%, P  = 0.855). However, in subgroup analysis using the T stage, EST was associated with reduced 5-year overall survival in the T3 and T4 stages (EST 34.8% vs. no EST 78.0%: P  = 0.038). Conclusion and Discussion Preoperative endoscopic intervention for AoV cancer did not affect oncologic outcomes. However, in the advanced stage, direct manipulation of cancer may result in lower overall survival, requiring careful consideration for preoperative biliary drainage.

BackgroundAlthough single-incision laparoscopic cholecystectomy (SILC) is a common procedure, the change in its surgical indications and perioperative outcomes has not been analyzed.MethodsWe collected the clinical data of patients who underwent pure SILC in 9 centers between 2009 and 2018 and compared the perioperative outcomes.ResultsIn this period, 6497 patients underwent SILC. Of these, 2583 were for gallbladder (GB) stone (39.7%), 774 were for GB polyp (11.9%), 994 were for chronic cholecystitis (15.3%), and 1492 were for acute cholecystitis (AC) (23%). 162 patients (2.5%) experienced complication, including 20 patients (0.2%) suffering from biliary leakage. The number of patients who underwent SILC for AC increased over time (p = 0.028), leading to an accumulation of experience (27.4 vs 23.7%, p = 0.002). The patients in late period were more likely to have undergone a previous laparotomy (29.5 vs 20.2%, p = 0.006), and to have a shorter operation time (47.0 vs 58.8 min, p < 0.001). Male (odds ratio [OR]; 1.673, 95% confidence interval [CI] 1.090–2.569, p = 0.019) and moderate or severe acute cholecystitis (OR; 2.602, 95% CI 1.677–4.037, p < 0.001) were independent predictive factors for gallbladder perforation during surgery, and open conversion (OR; 5.793, 95% CI 3.130–10.721, p < 0.001) and pathologically proven acute cholecystitis or empyema (OR; 4.107, 95% CI 2.461–6.854, p < 0.001) were related with intraoperative gallbladder perforationConclusionSILC has expanded indication in late period. In this period, the patients had shorter operation times and a similar rate of severe complications, despite there being more numerous patients with AC.

Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholelithiasis in patients with situs inversus totalis (SIT). Nowadays, singleincision multiport laparoscopic surgery is safe and feasible for treating benign gallbladder disease. We report a case of successful single-incision multiport laparoscopic cholecystectomy for a patient with SIT, and describe its technical advantages.

The aim of this study was to investigate the clinicopathological and immunohistochemical (including VEGF, Akt, HSP70, and HSP20 expression) factors that affect the overall and disease-free survival of HCC patients following surgical resection. 234 patients with HCC following surgical resection were enrolled. Clinicopathological and survival data were analyzed, and immunohistochemical staining was performed on tissue microarray sections using the anti-VEGF, anti-Akt, anti-HSP70, and anti-HSP27 antibodies. The 3- and 5-year overall survival rates were 86.5 and 81.54%, respectively. Multivariate analysis revealed that VEGF expression (P = 0.017, HR = 2.573) and T stage (P < 0.001, HR = 4.953) were independent prognostic factors for overall survival. Immunohistochemical staining showed that the expression of Akt, HSP70, and HSP27 did not affect the overall survival rate. The 3- and 5-year disease-free survival rates were 58.2 and 49.4%, respectively. Compared to the VEGF(-)/(+) group, the VEGF(++)/(+++) group demonstrated significantly higher proportion of patients with AFP levels > 400 ng/mL, capsule invasion, and microvascular invasion. VEGF overexpression was associated with capsule invasion, microvascular invasion, and a poor overall survival rate.

Background Depth of tumor invasion is an important prognostic factor for gallbladder cancer. The aim of this study was to investigate the clinicopathological prognostic factors of T2 gallbladder cancer. Methods We retrospectively reviewed the clinicopathological data and survival for 83 patients with T2 gallbladder cancers who underwent surgical resection between January 1995 and December 2007. Results The overall survival rates were 48.9% at 3 years and 29.3% at 5 years. Univariate analysis revealed that R0 resection ( P  < 0.001), extended surgery ( P  = 0.028), lymph node dissection ( P  = 0.024), non-infiltrative tumors ( P  = 0.001), well differentiation ( P  = 0.001), absence of lymphatic ( P  = 0.025), perineural ( P  = 0.001), and vascular ( P  = 0.025) invasion, absence of lymph node metastasis ( P  = 0.001), negative resection margin ( P  = 0.016), and stage ( P  = 0.002) were significantly better predictors for survival. A significant difference in survival between Rx and R1 was not found. R0 resection, lymph node dissection, well differentiation, and absence of perineural and vascular invasion were significantly independent prognostic factors for overall survival. Recurrence occurred in 48 patients (57.8%). Age older than 65 years, R0 resection, non-infiltrative tumors, and good differentiation were significant independent predictors of disease-free survival by multivariate analysis. Conclusions For T2 tumors, radical surgery including lymph node dissection should be performed to achieve R0 resection. Tumors with infiltrative types and suspicious lymph node metastasis in the intraoperative findings were candidates for aggressive surgical management to improve patient survival.

Background Laparoscopic cholecystectomy (LC) is the treatment of choice for benign gallbladder disease. Gallbladder cancers have been found following LC. The aim of the present study was to evaluate the survival outcome and prognosis of incidental gallbladder cancer diagnosed after LC. Methods From January 2002 to December 2007, 3,145 patients underwent LC at the Department of Surgery, Korea University Medical Center. Of these, 33 patients (1.05%) were diagnosed with gallbladder cancer after LC. Clinicopathological characteristics were retrospectively reviewed in this study. Results Of the 33 patients studied, 9 were men and 24 were women. Laparoscopic cholecystectomy alone was performed in 26 patients, and additional radical surgery was performed in 7 others. Regarding tumor staging, there were 2 Tis, 6 T1a, 4 T1b, 17 T2, and 4 T3 tumors. Male patients had a significantly higher incidence of moderately and poorly differentiated tumors ( P  < 0.001), T2 and T3 tumors ( P  = 0.02), additional second operations ( P  = 0.046), and recurrence ( P  = 0.016). The cumulative 1-, 3-, and 5-year survival rates were 87.2, 73.1, and 47.0%, respectively. Univariate analysis revealed that significant prognostic factors for poorer survival were male gender ( P  = 0.026), age older than 65 years ( P  = 0.013), the presence of inflammation ( P  = 0.009), moderately or poorly differentiated tumor ( P  < 0.001), nonpolypoid gross type ( P  = 0.003), and pT stage ( P  < 0.001). Tumor differentiation was a significantly independent predictor of poor prognosis. Conclusions Male patients exhibited aggressive tumor characteristics. Laparoscopic cholecystectomy is an adequate treatment for pT1 tumors. For pT2 and pT3 patients, additional radical surgery might be needed to achieve a tumor-free surgical margin, along with lymph node dissection.

Surgical resection is the treatment of choice for bile duct cancers. The aim of this study was to investigate disease recurrence patterns and prognostic factors for recurrence of distal bile duct cancers after surgical resection. A retrospective study was performed on 122 patients with distal bile duct cancers who underwent R0 or R1 surgical resection at Korea University Guro Hospital from 1991 to 2010. Sites of initial disease recurrence were classified as locoregional or distant. Univariate and multivariate analyses were performed to investigate the factors affecting recurrence. Of the 122 patients, 80 patients developed recurrence. The disease-free survival rate was 63.1 per cent at one year and 36.4 per cent at three years. The patterns of recurrence at diagnosis were locoregional in 25 patients, locoregional and distant metastasis in 14 patients, and distant metastasis in 41 patients. Multivariate analyses revealed that recurrence pattern, lymph node metastasis, and differentiation are independent prognostic factors affecting disease-free survival. R status (marginal significance) and tumor differentiation were independent prognostic factors associated with locoregional recurrence. Differentiation and lymph node metastasis were independent prognostic factors associated with distant metastasis. The prognosis after recurrence was poor with a 1-year survival rate after recurrence of 26.1 per cent. Adjuvant chemo- or radiation therapy, delivered in patients mainly with R1 resection or with presence of lymph node metastasis, did not demonstrate the survival benefit. Significant factors for recurrence were tumor differentiation and lymph node metastasis. Therefore, close follow-up and adjuvant therapy will be necessary in patients with lymph node metastasis or poorly differentiated tumor.