Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy. External drainage of pancreatic duct with a stent has been shown to reduce pancreatic fistula rate of pancreaticojejunostomy in a few retrospective or prospective nonrandomized studies, but no randomized controlled trial has been reported thus far. This single-center prospective randomized trial compared the results of pancreaticoduodenectomy with external drainage stent versus no stent for pancreaticojejunal anastomosis. A total of 120 patients undergoing pancreaticoduodenectomy with end-to-side pancreaticojejunal anastomosis were randomized to have either an external stent inserted across the anastomosis to drain the pancreatic duct (n = 60) or no stent (n = 60). Duct-to-mucosa anastomosis was performed in all cases. The 2 groups were comparable in demographic data, underlying pathologies, pancreatic consistency, and duct diameter. Stented group had a significantly lower pancreatic fistula rate compared with nonstented group (6.7% vs. 20%, P = 0.032). Radiologic or surgical intervention for pancreatic fistula was required in 1 patient in the stented group and 4 patients in the nonstented group. There were no significant differences in overall morbidity (31.7% vs. 38.3%, P = 0.444) and hospital mortality (1.7% vs. 5%, P = 0.309). Two patients in the nonstented group and none in the stented group died of pancreatic fistula. Hospital stay was significantly shorter in the stented group (mean 17 vs. 23 days, P = 0.039). On multivariate analysis, no stenting and pancreatic duct diameter <3 mm were significant risk factors of pancreatic fistula. External drainage of pancreatic duct with a stent reduced leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy.

To investigate the trend of the posthepatectomy survival outcomes of hepatocellular carcinoma (HCC) patients by analysis of a prospective cohort of 1198 patients over a 20-year period. The hospital mortality rate of hepatectomy for HCC has improved but the long-term survival rate remains unsatisfactory. We reported an improvement of survival results 10 years ago. It was not known whether there has been further improvement of results in recent years. The patients were categorized into two 10-year periods: period 1, before 1999 (group 1, n = 390) and period 2, after 1999 (group 2, n = 808). Patients in group 2 were managed according to a modified protocol and technique established in previous years. The patients in group 2 were older and had a higher incidence of comorbid illness and cirrhosis. They had a lower hospital mortality rate (3.1% vs 6.2%, P = 0.012) and longer 5-year overall survival (54.8% vs 42.1%, P < 0.001) and disease-free survival rates (34.8% vs 24%, P = 0.0024). An improvement in the overall survival rate was observed in patients with cirrhosis, those undergoing major hepatectomy, and those with tumors of tumor-node-metastasis stages II, IIIA, and IVA. A significant increase in the survival rates was also seen in patients whose tumors were considered transplantable by the Milan criteria (72.5% vs 62.7%, P = 0.0237). Multivariate analysis showed a significantly more favorable patient survival for hepatectomy in period 2. A continuous improvement of survival outcomes after hepatectomy for HCC was achieved in the past 20 years even in patients with advanced diseases. Hepatectomy remains the treatment of choice for resectable HCC in a predominantly hepatitis B virus-based Asian population.

This study aims to evaluate the effect of operator experience on the treatment outcomes of radiofrequency ablation (RFA) for malignant liver tumors. RFA is gaining popularity as the ablative therapy of choice for liver tumors. It is generally considered a simple and safe technique, and little attention has been paid to the importance of operator experience in this treatment. A learning curve in this treatment modality has not been documented before. The clinical data and treatment outcomes of the initial 100 patients undergoing RFA for liver tumors (hepatocellular carcinoma, n = 84; metastasis, n = 15; cholangiocarcinoma n = 1) were collected prospectively. All patients were managed by a single team of surgeons and interventional radiologists. The data of the first 50 patients (group I) and the second 50 patients (group II) were compared. RFA was performed by percutaneous (group I, n = 22; group II, n = 19), open (group I, n = 26; group II, n = 30) or laparoscopic (group I, n = 2; group II, n = 1) approach. In group I, 30 patients (60%) had a solitary tumor and 20 (40%) had multiple tumors; in group II, 35 patients (70%) had a solitary tumor and 15 (30%) had multiple tumors (P = 0.295). The size of the largest tumor was comparable between groups I and II (median, 2.8 cm in both groups; P = 0.508). Group II had significantly shorter hospital stay (median, 4.0 versus 5.5 days; P = 0.048), lower morbidity rate (4% versus 16%; P = 0.046) and higher complete ablation rate (100% versus 85.7%; P = 0.006) than group I. There was 1 hospital death (2%) in group I and 0 in group II. By multivariate analysis, treatment period (group I versus group II) was an independent significant factor affecting the morbidity rate and complete ablation rate. A low complication rate and a high complete ablation rate could be achieved with the accumulated experience from the first 50 cases of RFA for liver tumors by a specialized team. This study demonstrates that there is a significant learning curve in RFA for liver tumors.