Port-site Metastasis Following Laparoscopic Cholecystectomy

The application of laparoscopy for the resection of a malignancy has been a question for debate among many active surgeons. Cases of unapparent GB cancer especially, following a laparoscopic cholecystectomy, can occasionally be diagnosed. We add another case, which occurred in a 60- year-old male, at 22 and 45 months following a laparoscopic cholecystectomy for gallstone, where there had been no evidence of a malignancy from a previous examination. The patient's metastatic port-site nodules were excised widely, and the patient is still alive.

Detection of Micrometastases in the Sentinel Lymph Node from Patients with Early Gastric Cancer

PURPOSE: If the SLN (sentinel lymph node) is an accurate predictor of the lymph node status it should eliminate unnecessary lymph node dissection, resulting in a lower morbidity and mortality in patients with an early gastric cancer. The aim of this study was to investigate the feasibility of SLN biopsy for its location, accuracy and ability to sensitize the tumor cell detection, using reverse transcriptase-polymerase chain reactions (RT-PCR) for the cytokeratin 19 and CD44 variants. METHODS: SLN biopsies were performed in patients with early gastric cancer (n=33). After a gastrectomy to the apposite site, isosulfan blue dye (0.5-1.0 ml) was injected submucosal medially, laterally, superiorly and inferiorly, adjacent to the tumor site. Lymphatic channels were immediately apparent. Sentinel nodes were separately submitted, and evaluated with RT-PCR, using the cytokeratin 19 and CD44 variants. Following the removal of the sentinel node, the adjacent regional nodes were also removed. Both SLN and non-SLN were examined with H&E stain and RT- PCR. RESULTS: Sentinel nodes could be identified in 26 of 33 patients (79%). The average number of sentinel nodes detected was 1.4 and were chiefly perigastric nodes. Of these 26 patients, 6 had micrometastasis in their sentinel nodes by RT-PCR detection using the cytokeratin 19 and CD44 variants. The specificity of the SLN status in the diagnosis of the lymph node status was 95% (20/21). One patient (4%) had skip metastasis. CONCLUSION: A SLN biopsy, using indocyanine green, can be performed with a high success rate. A focused examination of the sentinel nodes detected by indocyanine green with RT-PCR will resolve the underestimation of micrometastasis in regional lymph nodes, and improve the accuracy of the pathological staging. If the sentinel node concept is clinically feasible for early gastric cancer, we would perform not only accurate staging, but also effective surgical treatment, with minimally invasive techniques.

The Clinical Experience of Juxtarenal Aortic Occlusion

PURPOSE: Juxtarenal aortic occlusion (JRAO) was defined as those that extended adjacent to the renal arteries, whereas suprarenal aortic occlusion involved the orifice of at least one main renal artery. The risk of JRAO is due to vital organ ischemic complications involving the kidneys, bowel, or spinal cord. METHOD: During the period from January, 1991 to March, 2000, we experienced 240 patients with chronic aortoiliac occlusive disease at Department of Surgery, Kangnam St. Mary's Hospital, The Catholic University of Korea. Among them, JRAO confirmed by preoperative transbrachial aortography were 19 cases. RESULT: The age of the patients ranged from 42 to 75 years with the mean age of 60 years. All but two were male. Clinical manifestations were presented from intermittent claudication to gangrene with vital organ ischemic changes. The treatment of choice for JRAO is aorto-iliac or aorto-femoral bypass by Dacron graft, with preserving the function of vital organs and preventing the risk of proximal propagation of aortic thrombus. CONCLUSION: The level of aortic clamping was suprarenal aortic segment in all with the protection of renal arteries by vessel loop and aortic clamping time was 42+/-19 min. Our method of clamping was that advocated by Liddicoat without permanent renal insufficiency.

Complicated Nonspecific Small-Bowel Ulcers

BACKGROUND: Nonspecific small-bowel ulcers occurring beyond the duodenum are relatively uncommon, and it is difficult to make an exact diagnosis preoperatively. The majority of patients require surgical treatment for complications such as bleeding, perforation, or stenosis. METHODS: Fifteen cases (11 males and 5 females) of complicated nonspecific small-bowel ulcers occurring between 1990 and 1999 were retrospectively analyzed at the Department of Surgery, Holy Family Hospital, the Catholic University of Korea. RESULTS: The mean age of the patients was 52.4 years, and the most prevalent age was in the 4th decade (30%). The ratio of males to females was 2.8:1, and the predominant presenting symptoms were blood loss (13.3%), intestinal obstruction (20%), and an acute abdomen (66.7%). Two had chronic gastrointestinal hemorrhages, three had strictures, resulting in intestinal obstruction, and ten had perforations. The majority of ulcerations were located in the ileum (80%), and perforation was by far more common in the jejunum (100%) than in the ileum (58.3%). A small-bowel enema was a more reliable diagnostic technique than other radiologic modalities, such as sonography or computerized tomography, for delineating the bleeding or the stenotic foci. Surgical resections of the involved segments of the small bowels were curative in all but one perforation case, an 81-year-old female with postoperative multiple-organ failure. CONCLUSIONS: The exact diagnosis was rarely made preoperatively although abnormalities were noted roentgenographically in 80% (four out of five bleeding and stricture cases). Resection of the involved small bowel was the treatment of choice and was usually curative. Operative mortality was 6.7%. No etiologic causes could be determined pathologically.