Randomized Phase III Trial of Cisplatin, Epirubicin, Leucovorin, 5-Fluorouracil (PELF) Combination versus 5-fluorouracil Alone as Adjuvant Chemotherapy in Curative Resected Stage III Gastric Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The combination of cisplatin, epirubicin, leucovorin and 5-fluorouracil (PELF) administration, as adjuvant chemotherapy after curative resection for gastirc cancer, was compared with 5-fluorouracil (5-FU) administration alone. This paper reports the results of a prospective randomized comparison of the two regimens, PELF and 5-FU. METHODS: From August 1996 to July 1999, 54 patients were selected subsequent to being diagnosed with stage III cancer after a curative resection for gastric cancer. The patients were stratified according to stage IIIA/IIIB and subtotal/total gastrectomy, and then they were randomized into each treatment group, i.e. the PELF or 5-FU alone groups. RESULTS: 54 assessable patients were enrolled in this study: 28 received PELF and 26 received 5-FU alone. 12 patients relapsed in each group and the median follow-up duration was 42 months (range: 10~77 months). The overall survival rate and disease-free survival rate (DFS) were not significantly different between two groups, (5-year survival of PELF vs. 5-FU: 57% vs. 64%, 5-year DFS: 54% vs. 51%). The PELF combination was more toxic in terms of anemia, anorexia, nausea and diarrhea than the 5-FU. CONCLUSIONS: This study showed that the PELF combination, as an adjuvant therapy for gastric cancer after a curative resection, was a less effective treatment, and it had more toxic effects than the 5-FU.

New Tension-free Hernioplasty Using Umbrella- Shaped Mesh

PURPOSE: Lichtenstein`s tension-free repair & mesh-plug hernia repair are the most frequently used procedures for inguinal hernia repair by american surgeons. A new tension- free hernioplasty procedure, maintaining the advantages of both of these procedures, was invented by an experienced surgeon in our hospital. In this procedure, an umbrella- shaped mesh is applied to the entire posterior wall, not only to the defective area. We analyzed the results of this procedure in comparison with those from conventional repair (Bassini procedure). METHODS: From March 1998 to March 2001, 69 cases of hernioplasty were performed by one staff surgeon. Among these cases, we excluded 2 cases of bilateral inguinal hernia, 1 case of femoral hernia, and 6 cases which were impossible to follow up. In addition, we analyzed 29 cases of tension-free hernioplasty using an umbrella-shaped mesh (U group) and 31 cases of conventional repair (B group). Retrospective chart reviews and telephone interviews were carried out. Operation duration, length of hospital stay, period of analgesics use, complications, time required to return to usual activity, and recurrence were compared between these two groups. RESULTS: No significant differences were found concerning operation duration, period of hospital stay, complications, and time for return to usual activity. The period of analgesic use was significantly shorter in the U group than in the B group (p=0.001, 2.0 days vs 2.9 days). Only one recurrence occurred in B group. CONCLUSION: This new procedure has all the properties of tension free hernioplasty and plug hernia repair. This procedure can be used for all types of inguinal hernia and for a much lower cost than the preformed plug method. No incidence of recurrence was found folling the use of this procedure.

Clinical Trial Comparing Pain and Clinical Function after Conventional Semi-open Milligan Hemorrhoidectomy vs Open Ultrasonic Dissector Hemorrhoidectomy

PURPOSE:Hemorrhoidectomy is considered to be a painful operation, therefore some patients with symptomatic hemorrhoids conceal their symptoms to defer a much-needed surgical procedure. Patients who have undergone hemorrhoidectomy have experienced constipation or urinary retention due to postoperative pain. Several interventions have been used to relieve postoperative pain after hemorrhoidectomy. Nevertheless, the results are unsatisfactory. Hemorrhoidectomy with ultrasonic dissector have less thermal injury and can avoid ligation and suture. This study compared conventional semi-open Milligan hemorrhoidectomy with open ultrasonic dissector hemorrhoidectomy. METHODS:One hundred patients with prolapsed symptomatic hemorrhoids were randomly assigned to semi-open Milligan (n=50) or open ultrasonic dissector (n=50) hemorrhoidectomy. Operation time, postoperative complication, hospital stay, degree and duration of postoperative pain, pain on bowel movement, and urinary retention were recorded and analyzed. RESULTS:There was no significant difference in excised pile number. Operation time of open ultrasonic dissector hemorrhoidectomy was shorter than that of semi-open Milligan hemorrhoidectomy (P<0.05). The open ultrasonic dissector hemorrhoidectomy group resulted in less postoperative pain (P<0.05) and shorter duration of pain (P<0.05) and postoperative hospital stay (P<0.05) than semi-open Milligan hemorrhoidectomy. Urinary retention did not occur in both groups. CONCLUSIONS:Despite the higher cost, open ultrasonic dissector hemorrhoidectomy results in less postoperative pain, shorter operation time and hospital stay than the conventional hemorrhoidectomy.

A Study of the Quality of Life Following after Curative Surgery for Gastric Cancer

PURPOSE: The quality of life of patients who have undergone surgery for carcinoma of the esophagus, breast, or lung has been discussed, however, little is known of the results following radical surgery for gastric cancer. We evaluated the quality of life of patients who had undergone radical surgery for gastric cancer and clarified the factors that influenced the quality of life for patients with gastric cancer. METHODS: We surveyed one hundred and thirty seven patients without recurrence of disease or chronic diseases following gastrectomy for gastric cancer. A questionnaire based on the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 was used to analyse the correlations between six functional scales and nine symptom scales and stage, surgical methods, chemotherapy, and performance status by scoring system. RESULTS: The quality of life following gastrectomy was determined by the stage of the disease at surgery, the surgical method, the application of anticancer chemotherapy, and the patient's own performance status. Patients with more advanced stages had a lower quality of life, and those who underwent total gastrectomy were expected to have a lower quality of life than patients who received subtotal gastrectomy. However there were no differences in the quality of life between patients with gastrojejunostomy and gastroduodenostomy following subtotal gastrectomy. The severity of postoperative weight loss had no influence on the quality of life. Patients undergoing chemotherapy showed higher points in the symptom scale rather than the functional scale. The functional scale and the symptom scale both showed asignificant difference according to the patient's performance status as assessed by the surgeon after a survey of the patient. CONCLUSION: We consider the periodic evaluation of the quality of life following gastrectomy in patients with gastric cancer to be useful in obtaining information concerning the patient's postoperative course and in assessing the therapeutic efficiency of the patient.

Risk Factors Affecting Lymph Node Metastasis and Recurrence in Early Gastric Cancer

PURPOSE: The prognosis of operated early gastric cancer is quite excellent and the 5-year survival rate shows to be over 90%. The less extensive treatment has been considered to be attractive. However, lymph node metastasis remains a main risk factor for recurrence of early gastric cancer. The author performed this study in order to determine which clinicopathologic factors of early gastric cancer influence lymph node metastasis and recurrence. MATENRIALS AND METHODS: A retrospective study was conducted on 222 patients with early gastric cancer who had been treated by gastrectomy combined with D2 or more extended lymph node dissection between January 1991 and December 1997 at the Department of Surgery, Kyunghee University Hospital. RESULTS: Lymph node metastasis was observed in 26 patients (11.7%), and the depth of tumor invasion and tumor size among clinicopathologic factors affected lymph node metastasis. The 5-year recurrence rate was 4.4%, and it was revealed that lymph node metastasis and depth of tumor invasion had a greater effect on recurrence than other clinicopathologic factors. CONCLUSION: The high risk factors of early gastric cancer in recurrence were submucosal tumor invasion, tumor size more than 2 cm, and lymph node metastasis. Patients of early gastric cancer with such high risk factors should undergo radical gastric resection than limited surgery.

Role of Surgery in the Management of Primary Lymphoma of the Gastrointestinal Tract

BACKGROUND: Primary lymphoma of the gastrointestinal tract is an unusual disease for which the optimal management strategy has not been clearly defined. The role of surgery in the management of primary gastrointestinal lymphoma remains controversial. METHODS: We retrospectively reviewed the management and the outcome of 55 patients a diagnosis of gastrointestinal lymphoma who were treated at Kyung-Hee University Medical Center during the period 1986-1997. Thirty-seven of them underwent a resection for cure, and 23 patients of them underwent chemotherapy. 18 patients underwent chemotherapy only. Radiation therapy was excluded due to the small number of patients. Surgery consisted of wide local resection of the primary tumor (curative for stages I and II, and palliative for stages III and IV), and regional lymph nodes, with re-establishment of bowel continuity. Chemotherapy involved 6-10 courses of CHOP-B (cyclophosphamide, adriamicin, vincristine, prednisone, and bleomycin). Survival curves were calculated by using the Kaplan and Meier method. RESULTS: The mean age was 51 years (range: 3-82), the peak incidence of age was the fifth decades (34%), and the male-to-female ratio was 1.3:1. Common signs and symptoms at presentation were abdo minal pain (n=46), palpable mass (n=28), nausea/vomiting (n=26), and weight loss (n=18). The diagnostic sensitivities of ultrasound, contrast radiography, endoscopic biopsy, and computed tomography were 52%, 57%, 76%, and 78%, respectively. The primary tumor sites were the stomach (n=18), the terminal ileum & cecum (n=15), the small bowel (n=13), and the large bowel (n=9). The respective cumulative overall 5-year survival rates for stage I, II, III tumors were 89%, 74%, and 43% (p<0.05). The respective overall 5-year survival rate for resection only, resection with chemotherapy, and chemotherapy only were 100%, 78%, and 40% (p<0.05). By the Kaplan-Meier method, the prognostic factors of survival were stage and curative resection (p<0.05). CONCLUSION: A curative resection in a stage I, II lymphoma confined to the gastrointestinal tract and to regional involvement may improve patient survival.

Surgical Approach to Cystic Neoplasm of the Pancreas / 한국간담췌외과학회지

BACKGROUND: Cystic neoplasms of the pancreas are rare tumor with malignant potential. Preoperative differentiation of a benign versus malignant tumor is unreliable and routine testing for this purpose is questionable. Therefore an aggressive resectional approach for cystic tumor of the pancreas was a recent trend and anticipate good prognosis. METHODS: This is a retrospective analysis of 23 patients with cystic neoplasm of the pancreas between Jun.1990 and Dec.1999. Data include patient demographics, presenting symptom, operative procedure, pathologic diagnosis, perioperative morbidity and mortality, survival follow-up data. RESULTS: The mean age of patients was 33.48 years and twenty one patients were women. There were 3 serous cystadenoma, 4 mucinous cystadenoma, 2 mucinous cystadenocarcinoma, 13 SPEN, 1 ductal ectasia. Major symptoms were abdominal pain(39.1%), palpable mass(30.4%), incidental(21.7%), melena( 4.3%), hematemesis(4.3%). Tumor site were 6 head(26.1%), 3 body(13.4%), 14 tail(60.9%). Main investigations were ultrasonography and CT. Other investigation were ERCP, MRCP, cytology. Operative procedure were 12 distal pancreatectomy and splenectomy, 4 PPPD, 2 mass enucleation, 2 distal pancreatectomy, 1 PD, 1 subtotal pancreatectomy, 1 cystojejunostomy. An accurate preoperative diagnosis of tumor type was proposed 65% pancreatic cystic tumor. Mean follow-up was 27 months(range 0.8 months to 90 months). Of these 23 patients, 20 patients were alive without recurrence during mean follow-up. One patient was died due to postoperative sepsis. Two patients was dead of unrelated cause. CONCLUSION: An aggressive resectional approach for cystic tumor of the pancreas is recommend in cystic tumor of the pancreas, if medically fit to tolerate surgery.

Expression of Glucose Transporter Gene in Colorectal Cancer

PURPOSE: The primary metabolic characteristic of malignant cells is an increased uptake of glucose and its anaerobic glycolysis. Recent studies have demonstrated that facilitative glucose transport across the plasma membrane is mediated by a family of proteins, i.e., glucose transporters. PURPOSE: In order to evaluate the clinicopathologic correlations of glucose transporter genes expressed in colorectal cancer, the author studied the expression of glucose transporter genes in human colorectal cancer and analyzed their expression in normal and malignant colorectal tissues. METHODS: A reverse transcriptase-polymerase chain reaction (RT-PCR) was applied to quantitatively determine the levels of the glucose transporter genes, GLUT1 and GLUT3, from Crohnes diseases (N=2), adenomatous polyps (N=4), and colorectal cancers (N=40) and their normal counterparts. RESULTS: The expresssion of the GLUT1 gene was detected in 50% of the inflammatory colonic mucosae and adenomatous polyp tissues, but the levels of expression were not significantly different from their normal counterparts. Among the 40 colorectal cancer patients, 23 patients (57.5%) showed GLUT1 gene expression and the levels of expression were increaed by 1.8 as compared to their normal counterparts (p<0.05). The expression of the GLUT3 gene was detected in almost all tissues examined, and the levels of expression were not significantly different from their normal counterparts. In colorectal cancers, there was correlation between GLUT1 expression, the extent of lymph node involvement and the stage of colorectal cancers (p<0.05). But, the correlation between the expressions of the GLUT3 gene and the clinicopathologic prognostic factors of colorectal cancers could not be determined because almost all tissues showed a GLUT3 gene expression. CONCLUSIONS: In conclusion, the GLUT1 glucose transporter expression in colorectal cancer was associated with high possibilities of lymph node metastases and poorer prognosis, and the assessment of GLUT1 expression in colorectal cancer would be useful in identifying high risk patients.

Early Versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis

PURPOSE: The laparoscopic cholecystectomy has increasingly been accepted as the procedure of choice for treatment of symptomatic gall stones and chronic cholecystitis. However, its role and its timing in the management of patients with acute cholecystitis remain controversial. This retrospective study was undertaken to compare on early laparoscopic cholecystectomy with a delay one for patients with acute cholecystitis. METHODS: Between January 1995 and June 1999, 15 patients were operated on within 72 hours of symptom onset. Those patients were classified as the early laparoscopic cholecystectomy group. The 18 patients who underwent a delayed laparoscopic cholecystectomy after a percutaneous transhepatic cholecystostomy (PTCS) and conservative management were classified as the delayed laparoscopic cholecystectomy group. RESULTS: No significant differences were seen in the conversion rate (1 case in the delayed group), the operation time (early group 107.3 min., delayed group 118.6 min.), postoperative complications (early group 20.0%, delayed group 16.7%), and the postoperative hospital stay (early group 4.7 days, delayed group 7.1 days). The early group had significantly more frequent operation modifications and decreased total hospital stays than the delayed group: 86.7% and 7.0 days, for the early group and 44.4% and 22.8 days for the delayed group. CONCLUSION: Early laparoscopic cholecystectomy for acute cholecystitis did not increase the operation time, the morbidity, or the conversion rate. Although this study was not a randomized study and the sample size was small, an early laparoscopic cholecystectomy seems to be safe and feasible for patients with acute cholecystitis, having the benefit of a decreased total hospital stay.

Morphological Study of Effects of Oxidized Low Density Lipoprotein on Three Dimensionally Constructed Vascular Wall

PURPOSE: The purpose of this experiment was to study the effects of Ox-LDL (oxidized low density lipoprotein) and Ox-VLDL (oxidized very low density lipoprotein) with or without probucol treatment on the proliferation of human vascular endothelial cells (EC) which were three dimensionally constructed vascular wall model. METHOD: The thiobarbituric acid reactive substance content of LDL and VLDL oxidized by incubation with copper irons was consistently greater than 10 nM malondialdehyde (MDA)/mg protein compared with less than 3 nM MDA/mg for unmodified lipoprotein immediately after isolation. On agarose gel electrophoresis, Ox-LDL and Ox-VLDL were shown to have greater cationic charge than unmodified lipoprotein. RESULT: In Ox-LDL stimulated ECs, the cellular enzymatic activity was markedly decreased in 50 mug/ml concentration of Ox-LDL and was protected by 10 nM probucol. And in Ox-VLDL stimulated ECs, the cellular enzymatic activity was markedly decreased in 25 and 50 mug/ml concentration of ox-VLDL and was not protected by 10 nM probucol. On scanning electron microscopy (SEM) and transmission electron microscopy (TEM), endothelial layers of control, unmodified LDL and unmodified VLDL groups showed similar appearance. But in Ox-LDL and Ox-VLDL groups, cellular edema, loosened cell-to-cell contact and loss of microvilli were shown on SEM, and marked cellular edema, distortion of cell membrane, loss of intracellular organelles and destruction of nulcleus were shown on TEM. And the protective effect of probucol was definite in Ox-LDL group but in 25 and 50 mug/ml concentration of Ox-VLDL group, there were no protective effects of probucol. CONCLLUSION: As a conclusion, three dimensionally constructed vascular wall model is to be a good experimental model for vascular research. And Ox-LDL and Ox-VLDL have toxic effects on vascular endothelial cell layer and its toxic effects are partially prevented by probucol.

Intrahepatic Cholangiocarcinoma in Hepatolithiasis

BACKGROUND: Hepatolithiasis is rarely associated with a cholangiocarcinoma and the etiologic relationship between them has not been proved. Hepatolithiasis is a risk factor for cholangiocarcinoma. Accurate preoperative diagnosis remains low, and the survival outcome is still dismal, despite improvements in imaging studies. METHODS: Eighteen cases of intrahepatic cholangiocarcinomas among the 522 cases undergoing treatments from Jan. 1984 to May 1998 for hepatolithiasis at the Department of Surgery, Kyung Hee University Hospital were reviewed. RESULTS: The patients had a significantly long duration of symptoms, a high incidence of previous biliary surgery, and a lower rate of preoperative diagnosis. The eighteen cases accounted for 3.4% of the hepatolithiasis cases and 8.5% of the cholangiocarcinomas. There were 17 women and 1 man, and the most prevalent age group was in the 5th and the 6th decades. HBsAg was positive in one case who had chronic hepatitis, 3 patients had clonorchiasis, and 2 patients had liver cirrhosis. CEA and CA19-9 were elevated in 42.9% (3/7) and 27.3% (3/11) of the patients. Various imaging studies, including ultrasonography, CT, choangiography, angiography, and ERCP were performed for diagnosis. The malignant lesions could not be detected preoperatively in 9 patients, and the presence of a coexisting malignant tumor was confirmed by frozen section or by permanent tissue pathology. The operative methods were as follows; a lobectomy in 4 patients, a segmentectomy in 4 patients, and a CBD resection for palliation or explo-laparotomy only in 4 patients because of multiple hepatic metastases. During the operation, the exact location of the stones and the gross pathology of the tumor were recorded in each case. The left side was more prevalent than the right. The mean survival was 15 months for resection group and 9 months for non resection group. CONCLUSIONS: The lower survival rates may be attributed to delayed diagnosis, lower diagnostic accuracy, and relatively fewer curative resections in the patients with stone-containing cholangiocarcinomas. Hepatolithiasis is one of the risk factors of a cholangiocarcinoma. During the diagnostic and operative procedures, we should not overlook a cholangiocarcinoma which can coexist with hepatolithiasis, and we should examine tumor markers, the results of imaging studies and tissue examinations, and the operative findings.

Laparoscopic Cholecystectomy after an Endoscopic Sphincterotomy for Patients with Choledocholithiasis

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic gallbladder (GB) stones. About 10% of patients with symptomatic GB stones may have common duct (CD) stones at the same time. For patients with symptomatic GB stones and suspected CD stones, an endoscopic retrograde cholangiopancreaticography (ERCP) should be performed. The preferred approach to these patients is an ERCP, an endoscopic sphincterotomy (EST), and removal of the CD stones, followed by a LC. The aims of this study were to test the safety and to evaluate the efficacy of the endoscopic and laparoscopic procedure in patients with symptomatic GB stones associated with CD stones. MATERIAL AND METHODS: A retrospective review was conducted on 522 patients who had been treated surgically for GB stones with or without CD stones between Jul. 1994 and Jun 1997. Among them, an ERCP followed by a LC was performed in 57 (67.1%) of the 85 patients who had CD stones, a LC in 377, an open cholecystectomy in 60, and an open cholecystectomy and CD exploration in 28. RESULTS: There were significant differences in operation times, hospital stays, and postoperative complications between the group with an EST followed by a LC and the group with an open cholecystectomy and CD exploration, but no significant differences between the LC group and the group with an EST followed by a LC. CONCLUSIONS: An EST followed by a LC is a good and safe treatment mordality for patients with symptomatic GB stones associated with CD stones.

A Survey II for Satisfaction for Stoma on Ostomates

PURPOSE: This survey was designed to acknowledge that it is necessary to rehabilitate ostomates. METHODS: This medical survey attempted to make an analysis of the types and causes of stoma, the problems stemming from the stoma, the degree to which ostomates are satisfied with their life quality, and the extent to which they are affected in doing their jobs, on the basis of the examinations conducted for eighty eight ostomates, who responded to the questionnaire at the 3rd Workshop for Stoma Rehabilitation for Ostomates on August 29, 1998 by the Department of Surgery, Kyung-Hee University Hospital, or who replied back to the questionnaire that was sent by mail. RESULTS: On examination, it was found that the ratio of male to female was nearly 1.5:1 (53:35); by age distribution, the ostomates in their 50 and 60's constituted 65.9%; by stoma pattern, colostomy was made up of 81 cases (92%), ileostomy 4 cases (4.5%), urostomy 2 cases (2.3%); by duration, permanent stoma was 81 cases (92%), temporary stoma 6 cases (6.8%); by the cause of stoma operation, malignancy consisted of 78 cases (88.6%), IBD 4 cases (4.5%), congenital anomaly 1 case, car accident 1 case, benign bladder disease 1 case, intestinal obstruction after radiation therapy 1 case, but 2 cases were not identified. Besides, it was also examined that, regarding the degree of post-operation satisfaction for stoma, dissatisfaction amounted to 58 cases (65.9%); as for the problems stemming from the stoma, skin irritation or injury reached 30 cases (34.1%), discomfort for stoma location 17 cases (19.35%), parastomal hernia 8 cases (9.1%), stoma retraction 4 cases (4.5%) and disease recurrence 3 cases (3.4%); as for the degree of the satisfaction of ostomates for their life quality, dissatisfaction revealed 70 cases (79.5%); regarding the extent to which the ostomates are affected in doing their jobs, fifty four out of eighty eight ostomates (62.0%) had a disturbance. CONCLUSIONS: This medical survey clearly shows that most of ostomates suffered from stoma in their daily lives and doing their occupations, thus they need helps from the experts such as colorectal surgeons and enterostomal therapists, or the ostomy association. In addition, it is also necessary to pay a more deliberate attention to determining the location of stoma.

Proliferation and MCP-1 Expression of Vascular Smooth Muscle Cells in Response to Lipoproteins

No abstract available.

Treatment of Acute Arterial Thromboembolism

BACKGROUND: Arterial emboli remain an important cause of acute arterial ischemia. Despite simplification of operative techniques, the substantial morbidity and mortality still associated with an acute embolus remain a challenge to the vascular surgeon. We wanted to know the adequate evaluation and treatment modality for this limb threatened condition, and to evaluate the results according to etiology, location, time interval before starting treatment, clinical conditions, and limb survival rate. MATERIAL AND METHODS: A retrospective review was conducted on 91 patients who treated for acute lower leg thromboembolism between Jan. 1992 and Dec. 1997. RESULTS: There were 73 men and 18 women and most prevalent age group was in the 5th and 6th decades (53.8%). Over all amputation rate was 25.3% and mortality rate was 5.5%. Cardiac problem was the most common etiologic factor. Associated diseases were cardiac problem (37.4%), hypertension (35.2%), cerebrovascular accident (17.6%), and diabetes (15.4%). Interval from attack to definite therapy, within 24 hours in 14 cases (15.4%), 1~3 days in 23 (25.3%), after 4 days in 54 (59.3%) were noted. The locations were aorta and iliac in 25.3%, femoral in 38.5%, popliteal in 19.8%, tibial in 4.4%, and 15.4% in graft site in other of frequency. Clinical categories were grade I in 9.9%, IIa in 40.7%, IIb in 30.8%, and III in 18.7%. According to Eagle's criteria, low risk group were 34 cases (37.4%), moderate risk group were 39 cases (42.9%), and high risk group were 18 cases (19.8%). Of the 91 patients, conservative treatment in 2 (2.2%), thrombolytic therapy in 33 (36.3%), thromboembolectomy in 56 (61.5%), bypass in 16 (17.6%), endarterectomy and vessel ligation were performed. The 1-month and 1-year limb salvage rates were 73.4% and 71.1%, respectively. Especially, salvage rates in the Department of Vascular Surgery were 84.9% and 83.7%, whereas that of Thoracic and Orthopedic Surgery were 44.4% and 33.0% (p=0.0001). CONCLUSIONS: Cardiac problem especially atrial fibrillation was the most common etiologic factor. Prompt balloon catheter embolectomy performed under local anesthesia is a safe, simple, and effective method of treatment and the preferred mode of management in the great majority of patients. Nonoperative management with thrombolytic agents or high-dose heparin therapy alone is occasionally indicated in highly selected patients. The prognosis of acute arterial thromboembolism of lower extremity can be improved by early detection, early adequate treatment, and the involvement of a qualified vascular surgeon.

Multivariate Analysis of Prognostic Factors in Gastric Cancer

BACKGROUND: Worldwide stomach cancer death rates have been steadily declining in most countries since World War II, but in Korea the incidence of stomach cancer is still high and is a major concern for public health. Surgical resection is the best method of treatment and offers a chance for cure, but the overall results of surgical treatment have been dismal. METHODS: The authors performed a retrospective study of 958 patients treated for adenocarcinomas of the stomach with curative intent over the period from March 1986 through December 1994 at Kyung Hee University Hospital. The study examined the prognostic influence of 2 host factors (age and sex of the patients), 7 tumor factors (location of tumor, number of lesions, size of tumor, depth of invasion, extent of lymph-node involvement, number of metastatic lymph nodes, and TNM stage), and 4 treatment factors (type of gastrectomy, combined resection, extent of lymph-node dissection, and adjuvant chemotherapy) by univariate and multivariate analysis. RESULTS: In univariate analysis, 9 prognostic factors - the age of the patients, the size of lesions, the depth of invasion, the extent of lymph-node involvement, the number of metastatic lymph nodes, the TNM stage, the type of gastrectomy, the extent of lymph-node dissection, and combined resection - were significantly correlated with survival. In multivariate analysis using the Cox proportional hazard model, 5 independent prognostic factors significantly correlated with survival: the age of the patients (RR = 1.480), the depth of invasion (RR = 1.287), the number of metastatic lymph nodes (RR = 2.700), the TNM stage (RR = 1.592), and the extent of lymph-node dissection (RR = 1.390). CONCLUSIONS: The authors can make a prognosis for stomach cancer more precisely on the basis of these independent prognostic factors, and an extended D2 operation (D2 alpha operation) may be a valuable means to treat gastric cancer.

Perioperative Risk Factors of the Hepatic Resection

This study was conducted to investigate the risk factors for postoperative mortality and morbidity in 322 consecutive hepatic resections. The indications for the hepatic resection were 178 intrahepatic stones, 81 hepatocellular carcinomas, 21 cholangiocarcinomas, 16 benign liver tumors, 12 metastatic liver cancers, 7 liver abscesses, and 7 other diseases. The overall in-hospital mortality and morbidity rates were 0.9% and 39.4%, respectively. Various postoperative complications developed, including 60 wound infections (18.6%), 49 pulmonary complications (15.2%), 19 bile leakages (5.9%), 13 intraabdominal abscesses (4.0%), 13 ascites (4.0%), 4 bleedings (1.2%), 3 hepatic failures (0.9%), 3 cholangitis (0.9%) and 28 other complications (8.7%). Among the risk factors, perioperative transfusion was significantly associated with more frequent wound infections (p=0.004), pulmonary complications(p=0.008), and bile leakages (p=0.039). Coexisting hepatitis was related to increased pulmonary complication rate (p=0.0223) and ascites formation (p=0.0157). Diabetes, was associated with increased wound infection rate (p=0.0433), and preexisting heart disease was associated with higher pulmonary complication rate (p= 0.0213). However, age, presence of liver cirrhosis, extent of resection, operative time, pulmonary disease or combined bowel surgery had no influence on the outcome. In conclusion, minimizing perioperative blood loss and transfusion is essential to reduce postoperative complications in hepatectomy.

Multiple Primary Colorectal Cancer

To assess the clinico-pathological characteristics of patients with multiple primary colorectal cancer, 458 patients who underwent curative surgery and being followed-up at our institution between Jan. 1987 and Dec. 1993 were evaluated in this study. The median follow-up period was 42 months. Synchronous cancer was defined as distinct lesions separated by a distance of greater than 4cm with the invasion of the tumor below the muscularis mucosa at the time of diagnosis or within 6 months after initial treatment, and metachronous cancer was defined as the development of colon cancers more than 6 months after the initial treatment without evidence of the recurrence or metastases from primary tumor. There were 29 cases of multiple primary colorectal cancer(6.3%). Eighteen cases(3.9%) of them were synchronous, 11 cases(2.4%) were metachronous cancers. Seven cases(1.5%) were related to 5 hereditary non-polyposis colorectal cancer(HNPCC) families. During the follow-up period, 11 patients(2.4%) developed cancers in other organs. Adenomatous polyps were identified 14 cases of 29 patients with multiple primary colorectal cancers(48.3%), compared to 43 cases(10%) in 429 patients with solitary colorectal cancer(p0.05). In aspect of family history, there was close-relationship with this regarding in the group of multiple primary colorectal cancers. However, authors were unable to make analysis this regarding in the group of solitary primaries because of lack of the information. Conclusively, authors guess the frequent association of the adenomatous polyps in multiple primary colorectal cancers as the evidence of the adenoma-carcinoma sequence. In addition, authors emphasized the importance of the total colonoscopic examinations in pre-and post-operation in order to make diagnosis of the multiple primary colorectal cancers and paying attention as to the family history of colorectal cancer patients because we have good therapeutic results after operation of early stage in synchronous cancers and co-existent adenomatous polyps.

A Survey on Ostomates With the special reference to physical, psychosocial and sexual problems

The survey was undertaken among the 105 ostomates who attended the 2nd Workshop for Stoma Rehabilitation on Aug. 30th, 1997 by the Department of Surgery, Kyung-Hee University Hospital to assess the physical, psychosocial and sexual problems with a stoma. The 97% of ostomates had permanent colostomies following abdominoperineal resection. The 67% of ostomates had one or more physical problems caused by stoma. Frequent bowel movement (94.3%), impairment of irrigation (64.6%), unpleasant odor (27.3%), and urinary frequency (21.3%) were common problems encountered by ostomates. Concerning the psychosocial problems, 3.8% of them suffered from profound restriction of social activities and 1.9% of them had psychologic problems such as depression. 42 of 58 ostomates (72.4%) who were employed before operation returned to their work. Among 71 men, 44 (62%) were impaired by sexual function. Most ostomates suffered physical, social, psychologic and sexual problems in their daily life and needed helps of experts such colorectal surgeons, enterostomal therapists, and ostomy association. Attention is needed more to improve the quality of life for the ostomates.

Clinical Analysis of Primary Hyperparathyroidism

Primary hyperparathyroidism is a rare disease that can be accurately diagnosed and effectively treated in most patients. The diagnosis is established by a persistent elevation of serum calcium and parathyroid hormone and by clinical evaluation. With the introduction of a biochemical screening test for calcium and the development of radiologic techniques, the detection of hyperparathyroidism has increased slightly. However, the parathyroidectomy is still not a common operation in Korea.Twenty-eight patients with primary hyperparathyroidism comprised of 14 males and 14 females, were treated by operation from January 1986 to December 1995 at Kyunghee University Hospital and the data were analyzed retrospectively. The results are as follows: 1) The sex distribution was 14 males & 14 females, and the age distribution was from 14 to 79 years. 2) The clincal manifestations were renal symptoms (42.9%), skeletal symptoms (28.6%), a neck mass (10.7%), pancreatitis (7.1%), no symptoms (7.1%), polydipsia (3.6%) in order of frequency. 3) Most of the patients showed hypercalcemia above 11mg/dl, but five patients had calcium levels which were either slightly increased or in the upper normal range . 4) The preoperative localization methods were mainly combinations of sonography, C.T.,and Tl-Tc subtraction scans and showed high sensitivity & specificity (above 90%). 5) The main tumor locations were the Rt. lower pole in 10 cases, the Rt. upper pole in 5 cases, the Lt. upper pole in 3 cases, the Lt. lower pole in 7 cases; there were 2 cases of ectopic location and 1case of hyperplasia at the Rt. upper & the Lt. lower pole. 6) The pathologic findings revealed a solitary adenoma in 25 patients, a carcinoma in two patients, and hyperplasia associated with MEN2a in 1 patient. 7) We experienced one case of recurrence after primary excision at the Rt. lower pole. Reoperation for a missed gland, after the primary operation, was performed in one patient; the excision of the tumor was performed successsfully. 8) We performed surgical excisions and 17 patients showed hypocalcemia postoperatively. Most of the hypocalcemia was transient and disappeared after ingestion of oral calcium agents or usuage of Vit. D3.