The Role of Hand-Assisted Laparoscopic Surgery in a Right Hemicolectomy for Right-Sided Colon Cancer

PURPOSE: The purpose of this study is to evaluate the perioperative and long-term oncologic outcomes of hand-assisted laparoscopic surgery (HALS) and standard laparoscopic surgery (SLS) and assess the role of HALS in the management of right-sided colon cancer. METHODS: The study group included 53 patients who underwent HALS and 45 patients who underwent SLS for right-sided colon cancer between April 2002 and December 2008. RESULTS: The patients in each group were similar in age, American Society of Anesthesiologist (ASA) score, body mass index, and history of previous abdominal surgeries. Eight patients in the HALS group and no patient in the SLS group exhibited signs of tumor invasion into adjacent structures. No differences were noted in the time to return of normal bowel function, time to toleration of diet, lengths of hospital stay and narcotic usage, and rate of postoperative complications. The median incision length was longer in the HALS group (HALS: 7.0 cm vs. SLS: 4.8 cm, P < 0.001). The HALS group had a significantly higher pathologic TNM stage and significantly larger tumor size (HALS: 6.0 cm vs. SLS: 3.3 cm, P < 0.001). The 5-year overall, disease-free, and cancer-specific survival rates of the HALS and the SLS groups were 87.3%, 75.2%, and 93.9% and 86.4%, 78.0%, and 90.7%, respectively (P = 0.826, P = 0.574, and P = 0.826). CONCLUSION: Although patients in the HALS group had more advanced disease and underwent more complex procedures than those in the SLS group, the short-term benefits and the oncologic outcomes between the two groups were comparable. HALS can, therefore, be considered an alternative to SLS for bulky and fixed right-sided colon cancer.

Phototoxic effect of blue light on the planktonic and biofilm state of anaerobic periodontal pathogens

PURPOSE: The purpose of this study was to compare the phototoxic effects of blue light exposure on periodontal pathogens in both planktonic and biofilm cultures. METHODS: Strains of Aggregatibacter actinomycetemcomitans, Fusobacterium nucleatum, and Porphyromonas gingivalis, in planktonic or biofilm states, were exposed to visible light at wavelengths of 400.520 nm. A quartz-tungsten-halogen lamp at a power density of 500 mW/cm2 was used for the light source. Each sample was exposed to 15, 30, 60, 90, or 120 seconds of each bacterial strain in the planktonic or biofilm state. Confocal scanning laser microscopy (CSLM) was used to observe the distribution of live/dead bacterial cells in biofilms. After light exposure, the bacterial killing rates were calculated from colony forming unit (CFU) counts. RESULTS: CLSM images that were obtained from biofilms showed a mixture of dead and live bacterial cells extending to a depth of 30-45 microm. Obvious differences in the live-to-dead bacterial cell ratio were found in P. gingivalis biofilm according to light exposure time. In the planktonic state, almost all bacteria were killed with 60 seconds of light exposure to F. nucleatum (99.1%) and with 15 seconds to P. gingivalis (100%). In the biofilm state, however, only the CFU of P. gingivalis demonstrated a decreasing tendency with increasing light exposure time, and there was a lower efficacy of phototoxicity to P. gingivalis as biofilm than in the planktonic state. CONCLUSIONS: Blue light exposure using a dental halogen curing unit is effective in reducing periodontal pathogens in the planktonic state. It is recommended that an adjunctive exogenous photosensitizer be used and that pathogens be exposed to visible light for clinical antimicrobial periodontal therapy.

The effect of implant shape and bone preparation on primary stability

PURPOSE: The purpose of this study was to evaluate the effects of implant shape and bone preparation on the primary stability of the implants using resonance frequency analysis. METHODS: Sixty bovine rib blocks were used for soft and hard bone models. Each rib block received two types of dental implant fixtures; a straight-screw type and tapered-screw type. Final drilling was done at three different depths for each implant type; 1 mm under-preparation, standard preparation, and 1 mm over-preparation. Immediately after fixture insertion, the implant stability quotient (ISQ) was measured for each implant. RESULTS: Regardless of the bone type, the ISQ values of the straight-screw type and tapered-screw type implants were not significantly different (P > 0.05). Depth of bone preparation had no significant effect on the ISQ value of straight-screw type implants (P > 0.05). For the tapered-screw type implants, under-preparation significantly increased the ISQ value (P < 0.05), whereas overpreparation significantly decreased the ISQ value (P < 0.05). CONCLUSIONS: Within the limitations of this study, it is concluded that bone density seemed to have a prevailing effect over implant shape on primary stability. The primary stability of the tapered-screw type implants might be enhanced by delicate surgical techniques.

Marginal bony changes in relation to different vertical positions of dental implants

PURPOSE: The purpose of this study was to radiographically evaluate marginal bony changes in relation to different vertical positions of dental implants. METHODS: Two hundred implants placed in 107 patients were examined. The implants were classified by the vertical positions of the fixture-abutment connection (microgap): 'bone level,' 'above bone level,' or 'below bone level.' Marginal bone levels were examined in the radiographs taken immediately after fixture insertion, immediately after second-stage surgery, 6 months after prosthesis insertion, and 1 year after prosthesis insertion. Radiographic evaluation was carried out by measuring the distance between the microgap and the most coronal bone-to-implant contact (BIC). RESULTS: Immediately after fixture insertion, the distance between the microgap and most coronal BIC was 0.06 +/- 0.68 mm; at second surgery, 0.43 +/- 0.83 mm; 6 months after loading, 1.36 +/- 0.56 mm; and 1 year after loading, 1.53 +/- 0.51 mm (mean +/- SD). All bony changes were statistically significant but the difference between the second surgery and the 6-month loading was greater than between other periods. In the 'below bone level' group, the marginal bony change between fixture insertion and 1 year after loading was about 2.25 mm, and in the 'bone level' group, 1.47 mm, and in 'above bone level' group, 0.89 mm. Therefore, the marginal bony change was smaller than other groups in the 'above bone level' group and larger than other groups in the 'below bone level' group. CONCLUSIONS: Our results demonstrated that marginal bony changes occur during the early phase of healing after implant placement. These changes are dependent on the vertical positions of implants.

Impact of PTGBD on Patients with Acute Complicated Cholecystitis: Consecutive 4,000 Cases of Laparoscopic Cholecystectomy / 대한내시경복강경외과학회지

PURPOSE: The aim of this study was to determine the advantages of adequate PTGBD in patients with acute complicated cholecystitis. METHODS: We performed a retrospective review of a database that was collected from September 2001 to July 2008. Acute cholecystitis with gangrene or perforation was defined as acute complicated cholecystitis. A PTGBD was performed for the patients immediately after the diagnosis using US or CT and then a tubogram was performed after 5~7 days. After evaluating the gallbladder (GB) and common bile duct (CBD) with a tubogram, we removed the drainage and the patients underwent a LC after readmission. RESULTS: Three hundred seventy four of the 893 patients who were diagnosed with acute cholecystitis underwent PTGBD. While 19 (3.2%) of the total acute cholecystitis patients were converted to open cholecystectomy due to severe inflammation, 14 (3.7%) acute complicated patients were converted to open cholecystectomy. In 79 patients, the pre-operative tubogram showed the presence of CBD stone and so ERCP was performed. There was no post-operative death. CONCLUSION: Performing PTBGD in patients with acute complicated cholecystitis allows the early relief of the symptoms of acute cholecystitis. This allows for sufficient evaluation and treatment for CBD during the PTGBD state. Further, PTBGD decreases the mortality and morbidity in the high-risk patients due to sufficient evaluation and management of the underlying critical disease. PTBGD allows for performing elective cholecystectomy when the patient is in a better condition for surgery. Therefore, PTGBD can be useful for treating acute complicated cholecystitis.

Gastric Schwannoma Treated by Laparoscopic Surgery

Gastric schwannoma is a very rare gastrointestinal mesenchymal tumor. Schwannoma in the gastrointestinal tract is usually not symptomatic, and preoperative abdominal CT or endoscopic evaluation cannot distinguish it from gastrointestinal stromal tumor. Surgical resection of this tumor is adequate to achieve a good prognosis. We performed laparoscopic gastric wedge resection in two patients who had the preoperative diagnosis of gastric gastrointestinal stromal tumor. In both cases, the postoperative immunohistochemistry staining was positive for S-100 protein and it was negative for CD34, which is consistent with gastric schwannoma. We report here on two cases of gastric schwannoma along with a review of the literatures.

Changes of Symptoms and Manometric Results after Hemorrhoidectomy for Hemorrhoids with Difficulty in Evacuation

PURPOSE: We aimed to identify the need for an adjunctive internal sphincterotomy based on an evaluation of the changes in the symptoms and manometric results after a hemorrhoidectomy for hemorrhoids with difficulty in evacuation. METHODS: Twenty-five (25) patients who had hemorrhoids with difficulty in evacuation and 13 patients who had hemorrhoids without difficulty in evacuation were prospectively evaluated. Patients were interviewed about symptoms and underwent anorectal manometry before and 2 months after surgery. Difficulty in evacuation is defined as the difficulty that a patient has when trying to evacuate the rectum. RESULTS: There were significant differences in the sex ratio, the frequency of bowel movements, and the duration of bowel movements between the two groups (P<0.05). In cases with difficulty in evacuation, the frequency of bowel movements was significantly higher postoperatively and the duration of bowel movements was significantly shorter (P<0.05). The symptom of difficulty in evacuation disappeared in 21 of the as patients experiencing such a symptom, and was improved in the remaining of patients (P<0.05). Following the hemorrhoidectomy for the patients with difficulty in evacuation in the mean and the maximum resting pressure, and the maximum squeeze pressure decreased significantly (P<0.05). CONCLUSIONS: An adjunctive internal sphincterotomy was not necessary for patients who had hemorrhoids with difficulty in evacuation because following the hemorrhoidectomy, the resting pressure was significantly decreased, and the difficulty in evacuation had nearly subsided.

Clinical Review of the Hepatic Resection for Hepatolithiasis: Factors Affecting Postoperative Complications / 한국간담췌외과학회지

PURPOSE: The hepatolithiasis and associated cholangitis result in liver atropy, biliary stricture, liver abscess and intrahepatic malignancy, and a hepatic resection should be performed in such cases. The technical difficulty and accompanied inflammation with a hepatic resection frequently cause postoperative complications. Therefore, the factors affecting the postoperative complications were evaluated. METHODS: Twenty one patients, with hepatolithiasis that had received a hepatectomy at the Department of Surgery, Eulji University Hospital between March 2001 and January 2003, were reviewed. RESULTS: The postoperative complications were intraabdominal abscess (7 cases), pleural effusion (3 cases), wound complication (3 cases), T-tube site leakage (1 case), cardiac arrest (1 case), acute pancreatitis (1 case), hepatitis A (1 case) and delayed gastric emptying (1 case). The overall complication rate was 57% (12/21 patients) and the most common complication was an intraabdominal abscess (7 cases). The factors that may affect these complications were analyzed. Preoperative percutaneous transhepatic biliary drainage (PTBD) increased the postoperative complications, which was statistically significant (p=0.027). Especially, preoperative PTBD and hepaticojejunostomy increased the rate of an intraabdominal abscess, which was statistically significant (p=0.026, p=0.008). CONCLUSION: With hepatolithiasis requiring hepatic resection there is a need to avoid unnecessary preoperative PTBD and bypass surgery for the reduction of postoperative complications, including an intraabdominal abscess. Conversely, it is considered important to remove every stone and avoid needless bypass surgery under an operation and for a hepatic resection to be performed after removing PTBD, where possible.

Usefulness of Preoperative Percutaneous Transhepatic GB Drainge on Laparoscopic Cholecystectomy in Patients with Acute Cholecystitis / 한국간담췌외과학회지

BACKGROUND/AIMS: A laparoscopic cholecystectomy (LC) has many clinical advantages and is now recognize as the choice of treatment for gallstones. However a laparoscopic cholecystectomy is often not feasible or is converted to the conventional open method in patients with acute cholecystitis because of inflammation around the gallbladder, adhesion, unclear anatomy, or intraoperative complications. Recent studies recommended that acute cholecystitis patients or gallbladder empyema patients undergo a percutaneous transhepatic GB drainage (PTGBD) first and a laparoscopic cholecystectomy later because PTGBD can be very helpful for improving the patient's state. METHODS: This study was carried out on 99 patients with acute cholecystitis or GB empyema who underwent a laparoscopic cholecystectomy after PTGBD at Eulji University School of Medicine from January 1996. These cases were compared with a control group of 41 patients who showed similar symptoms, ultrasonographic finding, operative finding, and pathologic results. RESULTS: There were no differences in the age and the sex distributions, the symptom duration, laboratory finding except alkaline phosphatase and leucocytosis. Among PTGBD group, a successful laparoscopic cholecystectomy was possible in 63 patients (63.6%), the other 36 patients were converted to open cholecystectomy. In control group, only 15 patients (36.6%) out of 41 underwent a successful laparoscopic cholecystectomy. This difference was statistically significant (P= 0.003). We analyze two groups about factors that can affect open conversion during laparoscopic cholecystectomy. In multivariate analysis, preoperative PTGBD and degree of wall thickening are the independent risk factors that can convert LC into open cholecystectomy. CONCLUSION: We think that a laparoscopic cholecystectomy performed some time after PTGBD to improve the patient's condition by eliminating acute inflammation or decompressing the gallbladder may be recommended for management of acute cholecystitis patients with severe clinical symptoms and ultrasonographic findings of marked gallbladder dilatation or pericholecystic fluid collection.

The Significance of Whole Blood Tacrolimus Level on the Development of Acute Rejection in Liver Transplantation / 대한이식학회지

PURPOSE: Tacrolimus has been widely used to prevent acute rejection in liver transplantation and it requires drug concentration monitoring due to narrow therapeutic index. The aim of this study is to define an adequate whole blood tacrolimus level to prevent acute rejection and drug toxicity in early postoperative days. METHODS: We reviewed 27 patients who underwent liver transplantation from November 1998 to January 2000 at the Department of Surgery, Seoul National University, College of Medicine. Tacrolimus plus steroid were used as initial immunosuppressive drugs. The trough whole blood tacrolimus level had been checked everyday from 2 days after transplantation by microparticle enzyme immunoassay (IMX Tacrolimus II assay). Acute rejection was confirmed by liver biopsy. We divided the patients into low level group (below median, n=13) and high level group (above median, n=14) according to average tacrolimus level within 30 days after transplantation. We compared the incidence of side effects between two groups. The average whole blood tacrolimus levels of the patients according to development of acute rejection were compared. The ratio of sex, age, donor status were also compared. RESULTS: 17 patients (63.0%) showed acute rejection within 30 days after transplantation. The median tacrolimus level of all patients within 30 days after transplantation was 11.39 ng/ml. The incidence of acute rejection in low level group (84.6%) was significantly higher than in high level group (42.9%) (P=0.046). The incidence of side effects between two groups was not different. Mean tacrolimus level of the patients without acute rejection within 30 days after transplantation (12.43+/-1.78 ng/ml) was significantly higher than that of the patients with acute rejection (10.81+/-1.17 ng/ml) (P=0.022). Daily average levels were different statistically on 7th (18.4+/-6.7 vs 10.7+/-3.3 ng/ml, P=0.009), 8th (16.0+/-6.7 vs 11.0+/-3.1 ng/ml, P=0.016), 23th (12.2+/-4.5 vs 9.0+/-2.5 ng/ml, P=0.030), 24th (13.7+/-3.2 vs 9.5+/-2.5 ng/ml, P= 0.009), 25th (13.5+/-3.0 vs 8.9+/-4.0 ng/ml, P=0.009) days after transplantation. Sex, age (adult or child) and donor status (living or cadevaric) didn't affect the development of acute rejection. CONCLUSION: The whole blood tacrolimus level should be kept near 15 ng/ml around 7 and 8 days after transplantation to prevent acute rejection in liver transplantation.

Clinical Features of Intrahepatic Cholangiocarcinoma according to Gross Morphology

PURPOSE: Recently, the Liver Cancer Study Group of Japan classified intrahepatic cholangiocarcinoma into three types: mass forming type, periductal infiltrating type and intraductal growth type. The clinical features of these three types are not well known. The purpose of this study was to define the clinical features of intrahepatic cholangiocarcinoma according to gross morphology. METHODS: We retrospectively reviewed the clinical records of 98 patients with intrahepatic cholangiocarcinoma who had undergone surgery at the Department of Surgery, Seoul National University Hospital from January 1980 to December 1998. The tumors were classified into mass forming type (MF, n=42), periductal infiltrating type (PI, n=22), intraductal growth type (IG, n=21) and Mixed type (n=13) by gross appearance. RESULTS: There were no differences in age, sex ratio, symptoms or laboratory findings. Intrahepatic stones were highly associated with the PI type (31.8% vs 2.4% in MF p=0.02). Hepatitis B surface antigen was more frequently found in the MF type (21.4% vs 4.5% in PI, 4.8% in IG, p=0.04). The size of tumor in the MF type was larger than those of the PI and IG types. In PI type, the rate of lymph node metastasis was higher (45.5% vs 19% in MF, 0% in IG, p=0.01). In IG type, the tumors were associated with adenomatous hyperplasia at a 95% rate. The cumulative five year survival rate of the MF and IG types were 23.3% and 76.2% (p<0.001), respectively. There were no five year survivors in the PI type. CONCLUSION: Intrahepatic cholangiocarcinoma has quite different clinical features and prognoses according to the grosstypes. Therefore we must choose appropriate treatment strategies according to gross type.

Clinical Significance of Preoperative Transcatheter Arterial Embolization in Hepatocellular Carcinoma

PURPOSE: Transcatheter arterial embolization (TAE) is widely used as a diagnostic and therapeutic tool for hepatocellular carcinomas (HCC). Although there are many controversies about the effect of preoperative TAE, in some centers, it has been done in most patients with HCC. We investigated the effect of preoperative TAE on the prognosis for the patients who had undergone curative hepatic resection for HCC. METHODS: We retrospectively studied 541 patients who had undergone curative hepatic resection for HCC at the Department of Surgery in Seoul National University Hospital between 1988 and 1995. Among those, preoperative TAE was done in 489 patients (TAE (+) group) and was not done in 52 patients (TAE (-) group). We examined demographics, tumor-free survival rate, overall survival rate, and complications. RESULTS: There were no statistical differences of demographic data between TAE (+) and TAE (-) groups. The 1-year, 3-year and 5-year tumor-free survival rates for TAE (+)/TAE (-) groups were 72.9%/70.6%, 43.8%/36.7% and 35.7%/30.5%, respectively. There was no statistical difference. The 1-year, 3-year and 5-year overall survival rates for TAE (+)/TAE (-) group were 85.5%/86.0%, 69.1%/63.3% and 56.6%/51.7%, respectively. These differences were not statistically significant (p>0.05). The postoperative complication rates were 26.6% for patients undergoing pre operative TAE and 26.9% for patients not undergoing it; these differences were not statistically significant (p>0.05). In the patients who had preoperative TAE, the hospital stay was prolonged (24.4+/-11.4 days vs. 17.8+/-8.8 days) and cost increased significantly (about 1,300,000 won). CONCLUSION: Preoperative TAE shows no advantages in the treatment of resectable HCC. Rather, it prolongs hospital stay and increases cost. Therefore, preoperative TAE should be done only in selected patients.

Comparison of the Clinicopathologic Features and Surgical Outcomes of Hepatocellular Carcinoma Related with Hepatitis B and C / 한국간담췌외과학회지

BACKGROUND AND AIM: Hepatitis B virus and hepatitis C virus were known as risk factors of hepatocellular carcinoma( HCC). Through past epidemiological and molecular biologic studies, the pathogenesis of HCC related with hepatitis viruses has been investigated. However the clinical features of the patients with HCC according to viral infections have not been established well. The aim of this study was to evaluate the clinical features and surgical outcomes in hepatocellular carcinoma related with hepatitis B and/or C. METHODS: We retrospectively reviewed the medical records of 411 patients who underwent the hepatic resections for hepatocellular carcinoma at Seoul National University Hospital between 1990 and 1997. We checked preoperative clinical features, preoperative laboratory tests, operative findings, postoperative pathologic reports, recurrences and survivals. According to the presence of hepatitis B surface antigen(HbsAg) and antibody of heptitis C virus(anti-HCV Ab), we divided into 4 groups: Non B C group(HbsAg(-) and anti-HCV Ab (-) n=61), B group (HBsAg (+) and anti-HCV Ab (-) n=275), C group(HBsAg (-) and anti-HCV Ab (+) n=62), B C group(HBsAg (+) and anti-HCV Ab (+) n=13). RESULTS: C group were older than B group (62.6+/-6.0 years vs. 50.5+/-9.3 years, p=0.005) and had poorer hepatic functions than B group; serum albumin level(3.52+/-0.32 g/dl vs. 3.69+/-0.40 g/dl, p=0.006), aspatate aminotransferase (108.50+/-114.36 IU/L vs. 59.63+/-60.80 IU/L, p=0.015), alanine aminotransferase (99.477+/- 7.82 IU/L vs. 65.59+/-86.39 IU/L, p=0.032), prothrombin time (83.2+/-16.4% vs. 91.3+/-14.4%, p=0.006), ICG R15 ( 18.83+/-9.02% vs. 9.19+/-7.98%, p=0.001). Pathologic results showed that C group has smaller sizes(3.5+/-2.6 cm vs. 4.6+/-3.0 cm, p<0.05), less encapsulated (68.2% vs. 80.9%, p=0.001), more multiple lesions(27.4% vs. 9.1%, p=0.001) than B group. The survival rate of B,C group was significantly lower than that of B group(5- year cumulative survival rate: 32.0% vs. 58.0%, p=0.029). Otherwise, there were no differences in recurrence rates, disease free survival rates and overall survival rates among four groups. CONCLUSION: The patients with anti-HCV Ab positive had poorer hepatic functions and older age than other patients. And the patients who had combined infections with hepatitis B and C had poorer outcome. More careful pre- and post- operative follow-up is needed in these patients.

Flexible Intramedullary Nailing for Femoral Fractures / 대한정형외과학회잡지

Various methods of internal fixation have been used for the treatment of femoral fractures. In 1970, Ender and Simon-Weidner described their method of flexible intramedullary nailing for the treatment interterochanteric and subtrochteric fractures. This method was widely used and obtained good result but Pankovich described that the intertrochsnteric fraeture, particullary unstable, is the worst indication due to many complications and difficulties in the procedure, We used flexible intramedullary nailing fot 115 cases of the femoral fractures from Jan. 1985 to Mar, 1988 at the Department of Orthopedir Surgery, Soonchunhyang University Hopsital with following results. 1. The intertrochanteric, subtrochanteric and shaft fractures were healed within 12.6 weeks, 15.8 weeks and 17.3 weeks respectively, however, unstable or comminuted fractures took more time to be healed. 2. The most frequent complication was shortening (20 cases), flollowed by nail migration, broken nail, delayed and non-union in orders. 3. Nonunion and delayed union were frequently occured at the distal shaft fractures and developed broken nail. the healing time is longer than those of other sites, So, the flexible intramedullary nailing on the distal shaft fractures of femur may be inappropriate. 4. In 8 cases of unstable or comminuted fractures of subtrochanteric and shaft, open reduction and cerclage wiring were done before nail insertion. We could prevent shortening and start early weight bearing and obtain the good result of bone union. 5. In 8 cases of locking with screw through the nail eyes, there was no nail migration and knee joint pain was almost none. 6. Among 4 cases of secondary Ender nailing and bone graft, one case was infected and the others were united after 11.7 weeks. In nonunion, this method may be useful. 7. Varization and shortening were developed in the unstable intertrochanteric fractures but clinically they were not significant. We recommed ender nailing for the unstable intertrochanteric fractures for experienced surgeons.