Rapid Staining Using the Shorr Method for Intraoperative Peritoneal Washing Cytology in Advanced Gastric Cancer: a Pilot Study from a Single Institution

PURPOSE: Intraoperative peritoneal washing cytology (PWC) is used to determine treatment strategies for gastric cancer with suspected serosal invasion. However, a standard staining method for intraoperative PWC remains to be established. We evaluated the feasibility of a rapid and simple staining method using Shorr's stain for intraoperative PWC in advanced gastric cancer. MATERIALS AND METHODS: Between November 2012 and December 2014, 77 patients with clinical T3 or higher gastric cancer were enrolled. The sensitivity, specificity, and concordance between the Shorr staining method and conventional Papanicolaou (Pap) staining with carcinoembryonic antigen (CEA) immunohistochemistry (IHC) were analyzed. RESULTS: Intraoperative PWC was performed laparoscopically in 69 patients (89.6%). The average time of the procedure was 8.3 minutes, and the average amount of aspirated fluids was 83.3 mL. The average time for Shorr staining and pathologic review was 21.0 minutes. Of the 77 patients, 16 (20.7%) had positive cytology and 7 (9.1%) showed atypical findings; sensitivity and specificity were 73.6% and 98.2% for the Shorr method, and 78.9% and 98.2% for the Pap method with CEA IHC, respectively. Concordance of diagnosis between the 2 methods was observed in 90.9% of cases (weighted κ statistic=0.875) and most disagreements in diagnoses occurred in atypical findings (6/7). In overall survival, there was no significant difference in C-index between the 2 methods (0.459 in Shorr method vs. 0.458 in Pap with CEA IHC method, P=0.987). CONCLUSIONS: Shorr staining could be a rapid and reliable method for intraoperative PWC in advanced gastric cancer.

Soft Tissue Hemangioendothelioma in Children / 소아외과

PURPOSE: Soft tissue hemangioendothelioma (STHE) is a rare vascular tumor, which has a similar prognosis to borderline malignancy. The disease is poorly understood in pediatric cases because of its low incidence; therefore, we investigated treatment strategies for STHE in children. METHODS: We retrospectively analyzed 8 patients with STHE, who were pathologically confirmed between January 1995 and June 2015. The median duration of follow-up was 72 months. RESULTS: Five were male and the median age at the time of surgery was 1.2 years. Six patients presented with a palpable mass, and 2 patients experienced facial paralysis. The median tumor size was 4.0 cm. The following tumor locations were observed head (2 patients), neck (2 patients), chest wall (1 patient), sacrococcyx (1 patient), upper limb (1 patient), and lower limb (1 patient). The patients underwent either microscopic complete resection (R0) (3 patients), macroscopic complete resection (R1) (2 patients), or macroscopic incomplete resection (R2) (3 patients). After histopathological examination, 6 patients were diagnosed with kaposiform hemangioendothelioma (HE), one with retiform HE, and one with epithelioid HE. Postoperative sequelae occurred as gait disturbance, hearing impairment, and vocal cord palsy. Tumor recurrence or regrowth occurred in 4 patients. These patients underwent reoperation and IFN therapy; however, in the patient with epithelioid HE, metastasis to the scalp occurred after these therapies. The patient with the head tumor who underwent R2 resection, underwent resection three more times, but died 11 months after the first surgery. CONCLUSION: When treating STHE in children, R0 resection should be first considered, but recurrence and metastasis should be monitored depending on the size, pathology, and location of the lesion. When major sequelae are expected, function-preserving surgery could be considered, depending on tumor location, size, and nearby organs.

Long-term Follow-up for Type 2 Diabetes Mellitus after Gastrectomy in Non-morbidly Obese Patients with Gastric Cancer: the Legitimacy of Onco-metabolic Surgery

PURPOSE: This study primarily aimed to investigate the short- and long-term remission rates of type 2 diabetes (T2D) in patients who underwent surgical treatment for gastric cancer, especially patients who were non-obese, and secondarily to determine the potential factors associated with remission. MATERIALS AND METHODS: We retrospectively reviewed the clinical records of patients with T2D who underwent radical gastrectomy for gastric cancer, from January 2008 to December 2012. RESULTS: T2D improved in 39 out of 70 (55.7%) patients at the postoperative 2-year follow-up and 21 of 42 (50.0%) at the 5-year follow-up. In the 2-year data analysis, preoperative body mass index (BMI) (P=0.043), glycated hemoglobin (A1C) level (P=0.039), number of anti-diabetic medications at baseline (P=0.040), reconstruction method (statistical difference was noted between Roux-en-Y reconstruction and Billroth I; P=0.035) were significantly related to the improvement in glycemic control. Unlike the results at 2 years, the 5-year data analysis revealed that only preoperative BMI (P=0.043) and A1C level (P=0.039) were statistically significant for the improvement in glycemic control; however, the reconstruction method was not. CONCLUSIONS: All types of gastric cancer surgery can be effective in short- and long-term T2D control in non-obese patients. In addition, unless long-limb bypass is considered in gastric cancer surgery, the long-term glycemic control is not expected to be different between the reconstruction methods.

Laparoscopic gastrojejunostomy versus duodenal stenting in unresectable gastric cancer with gastric outlet obstruction

PURPOSE: To compare the outcome between laparoscopic gastrojejunostomy (LapGJ) and duodenal stenting (DS) in terms of oral intake, nutritional status, patency duration, effect on chemotherapy and survival. METHODS: Medical records of 115 patients, who had LapGJ or duodenal stent placement between July 2005 and September 2015 in Seoul National University Bundang Hospital, have been reviewed retrospectively. Oral intake was measured with Gastric Outlet Obstruction Scoring System. Serum albumin and body weight was measured as indicators of nutritional status. The duration of patency was measured until the date of reintervention. Chemotherapy effect was calculated after the procedures. Survival period and oral intake was analyzed by propensity score matching age, sex, T-stage, comorbidities, and chemotherapy status. RESULTS: Forty-three LapGJ patients and 58 DS patients were enrolled. Improvement in oral intake was shown in LapGJ group versus DS group (88% vs. 59%, P = 0.011). Serum albumin showed slight but significant increase after LapGJ (+0.75 mg/dL vs. −0.15 mg/dL, P = 0.002); however, there was no difference in their body weight (+5.1 kg vs. −1.0 kg, P = 0.670). Patients tolerated chemotherapy longer without dosage reduction after LapGJ (243 days vs. 74 days, P = 0.006) and maintained the entire chemotherapy regimen after the procedure longer in LapGJ group (247 days vs. 137 days, P = 0.042). LapGJ showed significantly longer survival than DS (220 vs. 114 days, P = 0.004). CONCLUSION: DS can provide faster symptom relief but LapGJ can provide improved oral intake, better compliance to chemotherapy, and longer survival. Therefore, LapGJ should be the first choice in gastric outlet obstruction patients for long-term and better quality of life.

Impact of perioperative nutrition and transfusion on postoperative complication in gastric surgery

PURPOSE: The aim of this study was to evaluate the impact of perioperative nutrition and transfusion affecting postoperative complications in gastric surgery.METHODS: From January through December in 2013, 181 patients who underwent curative gastrectomy for gastric adenocarcinoma at Korea University Guro Hospital were included. We collected general information, nutritional parameters (serum hemoglobin, albumin, total lymphocyte counts, and body mass index), operative method, perioperative transfusion and postoperative complications. The patients were divided into two groups by Clavien-Dindo classification: group I, no complication and Grade I complication; group II, above Grade II complication.RESULTS: The mean age of patients was 62.06 years, and 119 (65.7%) patients were men. The number of patients who suffered complications was 81 (44.8%), group I was 38 (21.0%) and group II was 33 (18.2%). According to the results of univariate analysis, sex, age, comorbidities, the American Society Anesthesiologists (ASA) classification and operative method had no significant effect on postoperative complications. Also in nutritional factors, serum hemoglobin, albumin, total lymphocyte counts, body mass index had no significant correlation with postoperative complications. The only independent factor correlated with postoperative complications was perioperative transfusion (odds ratio [OR], 2.424, 95% confidence interval [CI], 1.064–5.525; P=0.035) and operation time (OR, 1.007; 95% CI, 1.001–1.013; P=0.027) according to univariate analysis as well as multivariate analysis.CONCLUSION: This study suggests that perioperative transfusion may play a significant role in the development of postoperative complications.

Single-Port Laparoscopic Proximal Gastrectomy with Double Tract Reconstruction for Early Gastric Cancer: Report of a Case

In Korea, proximal gastrectomy has recently attracted attention as a better choice of function-preserving surgery for proximal early gastric cancer than total gastrectomy. Of the various strategies to overcome reflux symptoms from remnant stomach, double tract reconstruction not only reduces the incidence of anastomosis-related complications, but is also sufficiently reproducible as a laparoscopic procedure. Catching up with the recent rise of single-port laparoscopic surgeries, we performed a pure single-port laparoscopic proximal gastrectomy with DTR. This procedure was designed by merging the function-preserving concept of proximal gastrectomy with single-port laparoscopic total gastrectomy.

Laparoscopic Total Gastrectomy for Gastric Cancer

Laparoscopic total gastrectomy (LTG) has been more widely performed in the last decade because of improvements in the techniques and safety of laparoscopic distal gastrectomy. However, due to its technical difficulty, there are still concerns regarding the safety of LTG. Meta-analyses have shown that LTG is technically feasible, safe, and may offer advantages over open total gastrectomy for treatment of gastric cancer. Various methods of performing esophagojejunostomy have been developed in an effort to decrease the rate of anastomosis-related complications, and have ultimately improved the safety and acceptance of LTG. However, there is still a lack of level-one evidence in support of LTG. Conduct of large-scale, randomized clinical trials will be needed in order to verify the safety and efficacy of LTG. Therefore, we reviewed the current status and some of the controversies surrounding LTG.

Proximal Gastrectomy for Gastric Cancer

Laparoscopic proximal gastrectomy (LPG) is theoretically a superior choice of minimally-invasive surgery and function-preserving surgery for the treatment of proximal early gastric cancer (EGC) over procedures such as laparoscopic total gastrectomy (LTG), open total gastrectomy (OTG) and open proximal gastrectomy (OPG). However, LPG and OPG are not popular surgical options due to three main concerns: the first, oncological safety; the second, functional benefits; and the third, anastomosis-related late complications (reflux symptoms and anastomotic stricture). Numerous recent studies have concluded that OPG and LPG present similar oncological safety profiles and improved functional benefits when compared with OTG and LTG. While OPG with modified esophagogastrostomy does not provide satisfactory results, OPG with modified esophagojejunostomy showed similar rates of anastomosis-related late complications when compared to OTG. At this stage, no standard reconstruction method post-LPG exists in the clinical setting. We recently showed that LPG with double tract reconstruction (DTR) is a superior choice over LTG for proximal EGC in terms of maintaining body weight and preventing anemia. However, as there is no definitive evidence in favor of LPG with DTR, a randomized clinical trial comparing LPG with DTR to LTG was recommended. This trial, the Korean Laparoscopic Gastrointestinal Surgery Study-05 (NCT01433861), is expected to assist surgeons in choice of surgical approach and strategy for patients with proximal EGC.

Solo Intracorporeal Esophagojejunostomy Reconstruction Using a Laparoscopic Scope Holder in Single-Port Laparoscopic Total Gastrectomy for Early Gastric Cancer

Single-incision laparoscopic total gastrectomy for gastric cancer has recently been reported by Seoul National University Bundang Hospital. However, this is not a popular procedure primarily because of the technical difficulties involved in achieving consistent intracorporeal esophagojejunostomy. At Seoul National University Bundang Hospital, we recently introduced a simple, easy-to-use, low-profile laparoscopic manual scope holder that enables the maintenance of a stable field of view, the most demanding condition in single-port gastrectomy. In this technical report, we describe in detail the world's first solo single-incision laparoscopic total gastrectomy with D1+ lymph node dissection and intracorporeal esophagojejunostomy for proximal early gastric cancer.

Clinical Relevance of the Tumor Location-Modified Lauren Classification System of Gastric Cancer

PURPOSE: The Lauren classification system is a very commonly used pathological classification system of gastric adenocarcinoma. A recent study proposed that the Lauren classification should be modified to include the anatomical location of the tumor. The resulting three types were found to differ significantly in terms of genomic expression profiles. This retrospective cohort study aimed to evaluate the clinical significance of the modified Lauren classification (MLC). MATERIALS AND METHODS: A total of 677 consecutive patients who underwent curative gastrectomy from January 2005 to December 2007 for histologically confirmed gastric cancer were included. The patients were divided according to the MLC into proximal non-diffuse (PND), diffuse (D), and distal non-diffuse (DND) type. The groups were compared in terms of clinical features and overall survival. Multivariate analysis served to assess the association between MLC and prognosis. RESULTS: Of the 677 patients, 48, 358, and 271 had PND, D, and DND, respectively. Their 5-year overall survival rates were 77.1%, 77.7%, and 90.4%. Compared to D and PND, DND was associated with significantly better overall survival (both P<0.01). Multivariate analysis showed that age, differentiation, lympho-vascular invasion, T and N stage, but not MLC, were independent prognostic factors for overall survival. Multivariate analysis of early gastric cancer patients showed that MLC was an independent prognostic factor for overall survival (odds ratio, 5.946; 95% confidence intervals, 1.524~23.197; P=0.010). CONCLUSIONS: MLC is prognostic for survival in patients with gastric adenocarcinoma, in early gastric cancer. DND was associated with an improved prognosis compared to PND or D.

Pure single-incision laparoscopic D2 lymphadenectomy for gastric cancer: a novel approach to 11p lymph node dissection (midpancreas mobilization)

We developed a novel approach to perform a perfect 11p lymph node dissection (LND), the so-called 'midpancreas mobilization' (MPM) method. Briefly, in pure single-incision laparoscopic distal gastrectomy (SIDG), after the completion of 7, 8a/12a, and 9 LND in the suprapancreatic portion, we started 11p LND after midpancreas mobilization. After mobilization of the entire midpancreas from the white line of Toldt, two gauzes were inserted behind the pancreas. This maneuver facilitated exposure of the splenic vein and complete detachment of soft tissue, including 11p lymph nodes, from the white line of Toldt, which was possible because of the tilting of the pancreas. The dissection plane along the splenic artery and vein for 11p LND could be visualized just through control of the operator's grasper without the need of an assistant. Fourteen patients underwent the procedure without intraoperative events, conversion to conventional laparoscopy, or surgery-related complications, including postoperative pancreatic fistula. All patients underwent D2 LND by exposure of the splenic vein. The mean numbers of retrieved lymph node and 11p lymph node were 61.3 +/- 9.0 (range, 49-70), and 4.00 +/- 3.38 (range, 1-10). Thus, we concluded that MPM for 11p LND in pure SIDG appears feasible and embryologically ideal; this method can be used in conventional laparoscopic gastrectomy.

Risk Factors of Postoperative Pancreatic Fistula in Curative Gastric Cancer Surgery

PURPOSE: Postoperative pancreatic fistula is a dreadful complication after gastric cancer surgery. The purpose of this study is to evaluate the actual incidence and risk factors of postoperative pancreatic fistula after curative gastrectomy for gastric cancer. MATERIALS AND METHODS: A total of 900 patients who underwent gastrectomy for gastric cancer (laparoscopic gastrectomy, 594 patients; open gastrectomy 306 patients) were enrolled between January 2009 and December 2010. Clinical outcomes, including postoperative pancreatic fistula grade based on the International Study Group on Pancreatic Fistula, were investigated. RESULTS: Overall, the postoperative pancreatic fistula rate was 3.3% (30/900) (1.5% in laparoscopic gastrectomy versus 6.9% in open gastrectomy, P<0.001). Patients who underwent D2 lymphadenectomy, total gastrectomy, splenectomy or distal pancreatectomy showed higher postoperative pancreatic fistula rates (4.7%, 13.8%, 13.6%, or 57.1%, respectively, P<0.001). Patients with postoperative pancreatic fistula had higher morbidity (46.7% versus 13.1%, P<0.001), delayed gas out (4.9 days versus 3.8 days, P<0.001), belated diet start (5.8 days versus 3.5 days, P<0.001) and longer postoperative hospital stay (13.7 days versus 6.8 days, P<0.001). On the multivariate analysis, total gastrectomy (odds ratio 9.751, 95% confidence interval: 3.348 to 28.397, P<0.001), distal pancreatectomy (odds ratio 7.637, 95% confidence interval: 1.668 to 34.961, P=0.009) and open gastrectomy (odds ratio 2.934, 95% confidence interval: 1.100 to 7.826, P=0.032) were the independent risk factors of postoperative pancreatic fistula. CONCLUSIONS: Laparoscopic gastrectomy had an advantage over open gastrectomy in terms of the lower postoperative pancreatic fistula rate. Total gastrectomy and combined resection, such as distal pancreatectomy, should be performed carefully to minimize postoperative pancreatic fistula in gastric cancer surgery.

Simplified Approach to Repair of Complete Atrioventricular Septal Defect / 대한흉부외과학회지

Recent advances in understanding the anatomy of complete atrioventricular septal defect have led to alternative methods of repairing these defects. Here we report two cases of complete atrioventricular septal defect repair by direct closure of the ventricular element of the defect. Follow-up for average of 3 months suggests that, when direct closure can be performed, the results can be comparable with those of the standard technique. Our initial success with this approach is encouraging; however, longer follow-up and more experiences are required to establish whether it will be broadly applicable.

Minimally Invasive Coronary Artery Bypass Grafting / 대한흉부외과학회지

Minimally invasive coronary artery bypass grafting without using cardiopulmonary bypass (CPB) is a recently accepted modality of myocardial revascularization prcedures which is particularly suitable to the patients with lesions in the left anterior descending (LAD) and the right coronary arteries. Of the consecutive 35 patients of coronary artery bypass grafting performed at Sejong General Hospital from March to August 1996, six patients underwent minimally invasive coronary artery bypass grafting without CPB. All had stenotic lesions of the LAD more than 90%. Bypass grafting of the LAD was approached through midline sternotomy in one, through ministernotomy in two, and through limited left anterior thoracotomy in three patients, respectively. The internal mammary arteries were prepared without the use of thoracoscope. The mobilized mammary arteries were connected directly to the LAD in 5 patients, and the anastomosis required interposition of a segment of the radial artery in the remaining one. The diagonal branch was revascularized with the saphenous vein graft at the same time in one patient. No blood transfusion was necessary in 2 patients, and average blood required during surgery was 800ml in 4 patients. All patients were extubated from 4 to 14 hours (mean 9 hours) after operation. Early postoperative coronary angiography in 5 patients between 7 and 10 days after surgery has proved full patency of the grafts. With these limited clinical experiences, the clinical results demonstrated that minimally invasive coronary artery bypass grafting without CPB is an useful procedure especially in patients with isolated lesion in the proximal LAD.

Surgical Repair of Ebstein's anomaly by Modified Carpentier's Method: 2 cases report / 대한흉부외과학회지

Ebstein's anomaly is a complex malformation that can be treated by various surgical techniques, either repair or replacement of the abnormal tricuspid valve, with variable results. The essence of the malformation is the downward displacement of the septal and posterior leaflets into the ventricle, resulting in the formation of an atrialized portion of the right ventricle. The aim of surgical repair is to correct the tricuspid valve dysfunction and to plicate the atrialized portion of the right ventricle A 12-months old female was admitted with the diagnosis of Carpentier type A of Ebstein's anomaly with severe tricuspid regurgitation. She successfully underwent operation with vertical plication of right ventricle and reimplantation of tricuspid leaflets. Postoperatively cardiac size was significantly reduced and tricuspid regurgitation was trivial in echocardiography. She was diacharged the 14th postoperative day.

Use of the Native Aortic Valve as the Pulmonary Valve in the Ross Procedure / 대한흉부외과학회지

Aortic valve replacement in young patients has its problems. Biologic prosthetic valves degenerate and need replacement. Metalic prosthetic valves are more durable, however, anticoagulation which has its inherent problems is inevitable. The use of Ross procedure in young patients is gaining wider acceptance. The need of foreign pulmonary valve in right ventricular outflow tract (RVOT) will require reoperation due to RVOT obstruction, later. To overcome this problem, we reimplanted the native aortic valve in the pulmonary position in 21 year old female patient operated on utilizing the Ross procedure for aortic insufficiency. We experienced that the diseased aortic valve worked well in the pulmoanry position because of low pulmonary artery pressure and resistance.

Early Results of Extracardiac Fontan Operation / 대한흉부외과학회지

Between August 1996 and August 1997, 22 patients underwent extracardiac Fontan operations. The basic diagnoses included univentricular heart of the right ventricular type (n=12); univentricular heart of the left ventricular type (n=4); tricuspid atresia (n=4); left isomerism, transposition of great arteries, ventricular septal defect and pulmonary stenosis (n=1); and criss-cross heart with uneven ventricle (n=1). The median age of the 14 men and 8 women was 29 months (range from 21 months to 26 years). Previous procedures included bidirectional cavopulmonary shunt (n=15, interval=15.6+/-3.4 months), Kawashima operation (n=4, interval=37.5+/-20 months), and classic Glenn shunt (n=1, interval=14 years). In 2 patients, extracardiac Fontan operations were done without any previous procedures. A 16-to 22-mm flexible Gore-Tex tube graft (n=18), Hemashield graft (n=3), or, alternatively, a nonvalved aortic allograft (n=1) was cut and anastomosed end-to-end between inferior vena cava and undersurface of pulmonary artery using Gore-Tex or Prolene suture in a running fashion. In risk Fontan patients (n=12), a communication between the extracardiac conduit and the right atrium was constructed. In the most 13 recent patients, the procedures were done without cross-clamping of the aorta and with a beating heart. Operative mortality was 9.1% (n=2). Complications included persistent chest tube drainage for more than 7 days (n=5), chorea (n=2), and low cardiac output (n=1). There were no late deaths. Follow-up echocardiogram (mean: 6 months) demonstrated satisfactory hemodynamic results in the surviving 20 patients. Potential advantages of this technique consist of minimization of surgical manipulation of atrial tissue, reduction or elimination of myocardial ischemia, creationof a uniform and stable inferior vena cava-to-pulmonary artery conduit, and increased flexibility and safety in certain high-risk patients such as those with increased pulmonary vascular resistance, pulmonary hypertension, and impaired ventricular function. Further investigations during a longer follow-up are needed to confirm the intermediate and long-term results, especially the reduction of late atrial arrhythmias.

Pulmonary Autograft Replacement in Native Aortic Root Abscess / 대한흉부외과학회지

Bacterial endocarditis of the native aortic valve is associated with significant morbidity and mortality despite aggressive medical and surgical treatment, especially when perivalvular tissue was invaded and destructed. The pulmonary autograft is full viable and immune compatible tissue. This paper describes successful Ross operation as total root replacement in 38 years old native valve endocarditis patient with aortic root abscess.

Aortoventriculoplasty with The Pulmonary Autograft: The "Ross-Konno" Procedure: 1 case report / 대한흉부외과학회지

In small children with left ventricular outflow tract obstruction, a few methods of surgical treatment could be considrred. The pulmonary autogrart provides a promising options for aortic valve replacement as part of the aortoventriculoplasty procedure in children. We report a successfully treated congenital aortic stcnoinsufricicncy with severe left ventricular dysfunction in an early infant with the aortoventriculoplasty using thc pulmonary autograft (the Ross-Konno procedure).