Background/Aims: Various lumen-apposing metal stents (LAMS) have been used for the endoscopic ultrasound-guided transmural drainage (EUS-TD) of postoperative pancreatic fluid collections (POPFC) and peripancreatic fluid collections (PFC). In this study, we aimed to assess the efficacy and safety of novel electrocautery-enhanced LAMSs (Hot-Plumber with Z-EUS IT) with different inter-flange lengths (13 to 33 mm) for managing POPFC and PFC. Methods: We reviewed the interventional EUS database of Asan Medical Center to identify consecutive patients with POPFC or PFC who underwent EUS-TD with the novel LAMSs between April 2023 and December 2023. Technical success, clinical success, and adverse events were evaluated. Results: Ten patients (5 with POPFCs and 5 with PFCs) were included in the analysis. The technical and clinical success rates were 100% and 90%, respectively. The LAMS was placed using either the freehand technique (n=5) or the over-the-guide wire technique (n=5). One patient successfully underwent endoscopic necrosectomy for walled-off necrosis through a novel LAMS.Two patients experienced adverse events (one stent migration and one infection). The LAMS was removed in 7 out of 10 patients after resolution of the fluid collection at a median of 61 days (interquartile range, 31 to 69 days) post-LAMS placement. Conclusions EUS-TD using the novel LAMS for POPFC and PFC demonstrated high efficacy and an acceptable safety profile. This novel LAMS represents a viable option when selecting stents for EUS-guided drainage of the POPFC and PFC.

Background/Aims: Various lumen-apposing metal stents (LAMS) have been used for the endoscopic ultrasound-guided transmural drainage (EUS-TD) of postoperative pancreatic fluid collections (POPFC) and peripancreatic fluid collections (PFC). In this study, we aimed to assess the efficacy and safety of novel electrocautery-enhanced LAMSs (Hot-Plumber with Z-EUS IT) with different inter-flange lengths (13 to 33 mm) for managing POPFC and PFC. Methods: We reviewed the interventional EUS database of Asan Medical Center to identify consecutive patients with POPFC or PFC who underwent EUS-TD with the novel LAMSs between April 2023 and December 2023. Technical success, clinical success, and adverse events were evaluated. Results: Ten patients (5 with POPFCs and 5 with PFCs) were included in the analysis. The technical and clinical success rates were 100% and 90%, respectively. The LAMS was placed using either the freehand technique (n=5) or the over-the-guide wire technique (n=5). One patient successfully underwent endoscopic necrosectomy for walled-off necrosis through a novel LAMS.Two patients experienced adverse events (one stent migration and one infection). The LAMS was removed in 7 out of 10 patients after resolution of the fluid collection at a median of 61 days (interquartile range, 31 to 69 days) post-LAMS placement. Conclusions EUS-TD using the novel LAMS for POPFC and PFC demonstrated high efficacy and an acceptable safety profile. This novel LAMS represents a viable option when selecting stents for EUS-guided drainage of the POPFC and PFC.

Background/Aims: Various lumen-apposing metal stents (LAMS) have been used for the endoscopic ultrasound-guided transmural drainage (EUS-TD) of postoperative pancreatic fluid collections (POPFC) and peripancreatic fluid collections (PFC). In this study, we aimed to assess the efficacy and safety of novel electrocautery-enhanced LAMSs (Hot-Plumber with Z-EUS IT) with different inter-flange lengths (13 to 33 mm) for managing POPFC and PFC. Methods: We reviewed the interventional EUS database of Asan Medical Center to identify consecutive patients with POPFC or PFC who underwent EUS-TD with the novel LAMSs between April 2023 and December 2023. Technical success, clinical success, and adverse events were evaluated. Results: Ten patients (5 with POPFCs and 5 with PFCs) were included in the analysis. The technical and clinical success rates were 100% and 90%, respectively. The LAMS was placed using either the freehand technique (n=5) or the over-the-guide wire technique (n=5). One patient successfully underwent endoscopic necrosectomy for walled-off necrosis through a novel LAMS.Two patients experienced adverse events (one stent migration and one infection). The LAMS was removed in 7 out of 10 patients after resolution of the fluid collection at a median of 61 days (interquartile range, 31 to 69 days) post-LAMS placement. Conclusions EUS-TD using the novel LAMS for POPFC and PFC demonstrated high efficacy and an acceptable safety profile. This novel LAMS represents a viable option when selecting stents for EUS-guided drainage of the POPFC and PFC.

Background/Aims: Various lumen-apposing metal stents (LAMS) have been used for the endoscopic ultrasound-guided transmural drainage (EUS-TD) of postoperative pancreatic fluid collections (POPFC) and peripancreatic fluid collections (PFC). In this study, we aimed to assess the efficacy and safety of novel electrocautery-enhanced LAMSs (Hot-Plumber with Z-EUS IT) with different inter-flange lengths (13 to 33 mm) for managing POPFC and PFC. Methods: We reviewed the interventional EUS database of Asan Medical Center to identify consecutive patients with POPFC or PFC who underwent EUS-TD with the novel LAMSs between April 2023 and December 2023. Technical success, clinical success, and adverse events were evaluated. Results: Ten patients (5 with POPFCs and 5 with PFCs) were included in the analysis. The technical and clinical success rates were 100% and 90%, respectively. The LAMS was placed using either the freehand technique (n=5) or the over-the-guide wire technique (n=5). One patient successfully underwent endoscopic necrosectomy for walled-off necrosis through a novel LAMS.Two patients experienced adverse events (one stent migration and one infection). The LAMS was removed in 7 out of 10 patients after resolution of the fluid collection at a median of 61 days (interquartile range, 31 to 69 days) post-LAMS placement. Conclusions EUS-TD using the novel LAMS for POPFC and PFC demonstrated high efficacy and an acceptable safety profile. This novel LAMS represents a viable option when selecting stents for EUS-guided drainage of the POPFC and PFC.

Background: Modern neurosurgery has undergone significant evolution to include minimally inva-sive procedures, with the supraorbital approach (SOA) being a prime example. In this study, we aim to explore the surgical techniques and outcomes of this approach in the surgical treatment of frontal lobe, anterior skull base, and parasellar lesions. Methods: This study included 33 patients aged 36–83 years who underwent surgery using theSOA for lesions in the inferior frontal lobe, anterior skull base, and parasellar area between 2015 and 2024. There were 25 cases of meningioma, 2 cases of brain abscess, 2 cases of glioma, and one case each of craniopharyngioma, hemangioma, metastasis, and Rathke’s cleft cyst. The medical data and follow-up results were retrospectively analyzed. Results: The mean size of lesion was 3.38±3.05 cm. The mean follow-up period was 48.8months. Gross total resection was achieved in 25 patients (75.8%). There were no perioperative deaths, cases of cerebrospinal fluid rhinorrhea, or infections. Two cases of morbidity were reported as complications: one case of delayed intracerebral hemorrhage and one case of infarction due to vascular injury. All patients exhibited satisfactory cosmetic results. Conclusion In comparison to the conventional pterional approach, the SOA represents a safe and effective keyhole method for the removal of both extra-axial and intra-axial skull base tumors. This is particularly beneficial for lesions in the orbitofrontal region and parasellar area, as it allows for minimal disruption of normal brain parenchyma. Moreover, the SOA promotes a swift recovery and short hospital stay. Additionally, the SOA yields superior cosmetic results, including the prevention of temporalis muscle atrophy.

Background/Aims: Endoscopic papillectomy (EP) is increasingly used as an alternative to surgery for managing benign ampullary neoplasms. However, post-EP resection margins are often positive or indeterminate, and there is no consensus on the management of ampullary adenomas with positive or indeterminate margins after EP. This study was designed to compare the longterm outcomes between resected margin-negative (RMN) and resected margin-positive/indeterminate (RMPI) groups and to identify factors associated with clinical outcomes. Methods: This retrospective analysis included patients with ampullary adenoma without evidence of adenocarcinoma who underwent EP between 2004 and 2016. The RMN and RMPI groups were compared for recurrence rates and recurrence-free duration during a mean followup duration of 71.7±39.8 months. Factors related to clinical outcomes were identified using multivariate analysis. Results: Of the 129 patients who underwent EP, 82 were in the RMN group and 47 were in the RMPI group. The RMPI group exhibited a higher recurrence rate compared to the RMN group (14.6% vs 34.0%, p=0.019). However, the recurrence-free duration was not significantly different between the groups (34.7±32.6 months vs 36.2±27.4 months, p=0.900). Endoscopic treatment successfully managed recurrence in both groups (75% vs 75%). Submucosal injection was a significant risk factor for residual lesions (hazard ratio, 4.11; p=0.009) and recurrence (hazard ratio, 2.57; p=0.021). Conclusions Although ampullary adenomas with positive or indeterminate margins after EP showed a higher rate of recurrence at long-term follow-up, endoscopic treatment was effective with favorable long-term outcomes. Submucosal injection prior to resection was associated with increased risk of recurrence and residual lesions.

Purpose: The benefit of adjuvant chemotherapy following curative-intent surgery in pancreatic ductal adenocarcinoma (PDAC) patients who had received neoadjuvant FOLFIRINOX is unclear. This study aimed to assess the survival benefit of adjuvant chemotherapy in this patient population. Materials and Methods: This retrospective study included 218 patients with localized non-metastatic PDAC who received neoadjuvant FOLFIRINOX and underwent curative-intent surgery (R0 or R1) between January 2017 and December 2020. The association of adjuvant chemotherapy with disease-free survival (DFS) and overall survival (OS) was evaluated in overall patients and in the propensity score matched (PSM) cohort. Subgroup analysis was conducted according to the pathology-proven lymph node status. Results: Adjuvant chemotherapy was administered to 149 patients (68.3%). In the overall cohort, the adjuvant chemotherapy group had significantly improved DFS and OS compared to the observation group (DFS: median, 13.8 months [95% confidence interval (CI), 11.0 to 19.1] vs. 8.2 months [95% CI, 6.5 to 12.0]; p < 0.001; and OS: median, 38.0 months [95% CI, 32.2 to not assessable] vs. 25.7 months [95% CI, 18.3 to not assessable]; p=0.005). In the PSM cohort of 57 matched pairs of patients, DFS and OS were better in the adjuvant chemotherapy group than in the observation group (p < 0.001 and p=0.038, respectively). In the multivariate analysis, adjuvant chemotherapy was a significant favorable prognostic factor (vs. observation; DFS: hazard ratio [HR], 0.51 [95% CI, 0.36 to 0.71; p < 0.001]; OS: HR, 0.45 [95% CI, 0.29 to 0.71; p < 0.001]). Conclusion Among PDAC patients who underwent surgery following neoadjuvant FOLFIRINOX, adjuvant chemotherapy may be associated with improved survival. Randomized studies should be conducted to validate this finding.

Background/Aims: There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension. Methods: Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated. Results: A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of IDRFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures. Conclusions Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure.

Objective: : Nontraumatic subdural hematoma (SDH) is a common disease, and spinal cerebrospinal fluid (CSF) leakage is a possible etiology of unknown significance, which is commonly investigated by several invasive studies. This study demonstrates that heavily T2-weighted magnetic resonance myelography (HT2W-MRM) is a safe and clinically effective imaging modality for detecting CSF leakage in patients with nontraumatic SDH. Methods: : All patients who underwent HT2W-MRM for nontraumatic SDH workup at our institution were searched and enrolled in this study. Several parameters were measured and analyzed, including patient demographic data, initial modified Rankin Scale (mRS) score upon presentation, SDH bilaterality, hematoma thickness upon presentation, CSF leakage sites, treatment modalities, followup hematoma thickness, and follow-up mRS score. Results: : Forty patients were identified, of which 22 (55.0%) had CSF leakage at various spinal locations. Five patients (12.5%) showed no change in mRS score, whereas the remaining (87.5%) showed decreases in follow-up mRS scores. In terms of the overall hematoma thickness, four patients (10.0%) showed increased thickness, two (5.0%) showed no change, 32 (80.0%) showed decreased thickness, and two (5.0%) did not undergo follow-up imaging for hematoma thickness measurement. Conclusion : HT2W-MRM is not only safe but also clinically effective as a primary diagnostic imaging modality to investigate CSF leakage in patients with nontraumatic SDH. Moreover, this study suggests that CSF leakage is a common etiology for nontraumatic SDH, which warrants changes in the diagnosis and treatment strategies.

Purpose: This study evaluated the efficacy of adjuvant chemotherapy (AC) in patients with resected ampulla of Vater (AoV) carcinoma. Materials and Methods: Data from 646 patients who underwent surgical resection at Asan Medical Center between 2000 and 2017 were retrospectively reviewed. Results: The median age of the patients was 62 years, and 54.2% were male. Patients were classified into AC group (n=165, 25.5%) and no AC group (n=481, 74.5%). With a median follow-up duration of 88 months, in patients with stage I, II, III, median recurrence-free survival (RFS) was not reached, 44 months, and 15 months, respectively, and the median overall survival (OS) were not reached, 88 months and 35 months, respectively. Despite no statistical significance, RFS and OS were better in stage II patients with AC than in those without AC (median RFS, 151 months vs. 38 months; p=0.156 and median OS, 153 months vs. 74 months; p=0.299). In multivariate analysis for RFS and OS, TNM stage, R1 resection status, presence of lymphovascular invasion, and perineural invasion remained significant factors, whereas AC (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.54 to 1.00; p=0.052) was marginally related with RFS. After propensity score matching in only stage II/III patients, RFS and OS with AC were numerically longer than those without AC (HR, 0.80; 95% CI, 0.60 to 1.06; p=0.116 and HR, 0.77; 95% CI, 0.56 to 1.06; p=0.111). Conclusion AC with fluoropyrimidine did not improve survival of patients with resected AoV carcinoma. However, multivariate analysis with prognostic factors showed a marginally significant survival benefit with AC.