Diagnostic value of peripheral blood immune profiling in colorectal cancer

PURPOSE: Little is known about the clinical value of peripheral blood immune profiling. Here, we aimed to identify colorectal cancer (CRC)-related peripheral blood immune cells and develop liquid biopsy-based immune profiling models for CRC diagnosis. METHODS: Peripheral blood from 131 preoperative patients with CRC and 174 healthy controls was analyzed by flow cytometry and automated hematology. CRC-related immune factors were identified by comparing the mean values of immune cell percentages and counts. Subsequently, CRC diagnostic algorithms were constructed using binary logistic regression. RESULTS: Significant differences were observed in percentages and counts of white blood cells, lymphocytes, neutrophils, regulatory T cells, and myeloid-derived suppressor cells (MDSCs) of patients and controls. The neutrophil/lymphocyte and Th1/Th2 ratios were also significantly different. Likewise, the percentages and counts of peripheral blood programed death 1, cytotoxic T lymphocyte antigen 4, B-and T-lymphocyte attenuator, and lymphocyte activation gene-3 were higher in patients with CRC. The binary logistic regression model included 12 variables, age, CD3+%, NK%, CD4+CD279+%, CD4+CD25+%, CD4+CD152+%, CD3+CD366+%, CD3+CD272+%, CD3+CD223+%, CD158b−CD314+CD3−CD56+%, Th2%, and MDSCs cells/µL, for the prediction of cancer. Results of retrospective and prospective evaluation of the area under the curve, sensitivity, and specificity were 0.980 and 0.940, 91.53% and 85.80%, and 93.50% and 86.20%, respectively. CONCLUSION: Peripheral blood immune profiling may be valuable in evaluating the immunity of CRC patients. Our liquid biopsy-based immune diagnostic method and its algorithms may serve as a novel tool for CRC diagnosis. Future largescale studies are needed for better characterization of its diagnostic value and potential for clinical application.

The Present and Future of Surgery

Surgery is a field of the medical science that aims to treat disease with the best possible medical skill. Until recently, surgeons have had a fixed idea that an adequate big incision is needed to perform a satisfactory operation and to get a good result. As we say in Korea, "Great surgeon, big incision was the traditional rule when training a surgeon. However, we are now at turning point and transition period for the surgical Department of medical science. Almost every day we are experiencing the change that the surgeon can perform a minimally invasive procedure for people with disease, and the present high technical procedures are less invasive have less complications, superior cosmetic results and faster recovery. This is partially because the consumers, i.e., the patients, demand this more advanced medical service and so surgeons, are, making strenuous efforts to achieve a more humanistic medical approach to treatment. Of course, minimally invasive surgery has some limitations and pitfalls for its technical and, economical, aspects. We cannot oppose to this general trend in spite of possible obstacles. We can anticipate rather major changes in surgery, such as "individualized minimally invasive surgery" or "tailored surgery". So, we should prepare ourselves with study and education to receive this new paradigm.

Comparison of Clinical and Surgical Outcomes between Unilateral and Bilateral Intrahepatic Duct Stone Disease

PURPOSE: Intrahepatic duct stone (IHD) disease, especially bilateral lesion, is difficult to management for complete cure. The purpose of this study is to analyze the clinical manifestations and treatment outcomes and is to consider adequate strategy of treatment between unilateral and bilateral IHD stones. METHODS: From October 1993 to July 2004, 218 patients with IHD stone were performed by surgical management at Ewha Womans University Mokdong Hospital. The medical records of these patients were reviewed retrospectively. We classified into two groups, such as unilateral group (U group) and bilateral group (B group), and compared two groups for clinical manifestations and outcomes. RESULTS: Of the 218 IHD stone patients, 188 cases underwent conventional open surgery, 20 cases underwent laparoscopic surgery, and 10 cases underwent laparoscopic assisted surgery. U group and B group was composed 162 and 56 cases, respectively. IHD stones were more common in left lobe of liver than right lobe in U group (P<0.001). IHD stricture were more common in U group (P=0.048). On the other hand, remnant stones were more common in B group (P<0.001). There was no statistical significance for postoperative complication and method of operation include liver resection between two groups. CONCLUSION: We presume that the pathogenesis may be different between unilateral and bilateral IHD stone. To cure or reduce the remnant stone rate, more aggressive treatment such as liver resection should be also considered in the patients with bilateral as well as unilateral IHD stone because of no difference of complication rate of two groups.

Laparoscopic Spleen Preserving Distal Pancreatectomy with the Conservation of the Splenic Artery and the Vein

Until now, there have been few reports of laparoscopic spleen preserving distal pancreatectomies with the conservation of the splenic vessels. We experienced two cases of a laparoscopic spleen preserving distal pancreatectomy, with the conservation of the splenic artery, vein and short gastric vessels. One case was in a 52 years old woman. The patient was preoperatively diagnosed with a nonsymptomatic cystadenoma, which measured 7 cm in diameter at the tail of pancreas. The procedure used was a 70% distal pancreatectomy, with preservation of the spleen, including the splenic vessels. Three 10 mm ports, one 15mm port and one linear stapler (EndoGIA60(R)) were used for the procedure. A 3 cm incision, extending 15 mm to the trocar site, was used for the extraction of the specimen. The total operative time was 435 minutes. The patient was discharged on the 8th postoperative day with no problems. The other case was in a 61 years old woman. The patient was preoperatively diagnosed with a symptomatic cystadenoma, which measured 3 cm in size at the body of the pancreas. The procedure used was an 85% distal pancreatectomy, employed the same method as the previous case, with the exception that an EndoGIA30(R) was used for the resection of pancreas in place of the EndoGIA60(R). The total operative time was 400 minutes. The patient was discharged on 9th postoperatvie day, with no problems. There was no morbidity and mortality during hospitalization. A laparoscopic spleen splenic vessels, could be an alternative treatment in selective preserving distal pancreatectomy with the conservation of the patients with benign pancreatic neoplasms.

Totally Laparoscopic Anatomic Liver Resection

PURPOSE: There have been several recent reports of laparoscopy-assisted procedure for limited, or a laparoscopic, resections of small lesion of the liver. However, there are few reports on total laparoscopic surgery in anatomic resections, which is due to high level of skill required for the procedure and the risk of an air embolism. The aim of this study was to determine the safety of total laparoscopic surgery in anatomic liver resections during our early experiences. METHODS: The 6 patients included in this study were all treated with a totally laparoscopic anatomic resection of the liver at Ewha Womans University, Mokdong Hospital between September 2002 and January 2003. All 6 cases were diagnosed with an intrahepatic duct (IHD) stone, with stricture and/or common bile duct (CBD) stones. Of these 6 cases, 2 underwent a totally laparoscopic left lateral segmentectomy of the liver. In the remaining 4 cases, totally laparoscopic left lobectomies and CBD explorations, with T-tube insertion, were performed. In all cases, 4 trocars were used. During the operation, the intraperitoneal pressure of the pneumoperitoneum was maintained between 8 and 12 mmHg using CO2. The instruments used included Ligasure(R), Autosonix(R), 0 degrees and 30 degrees camera, fan retractor, Endo(vascular)- GIA 30 , and a large LapBag(R). All cases were managed in the supine position, with 15 degrees of left tilting. The specimen were extracted through a 4 to 5 cm extension of the upper trocar site. The T-tube exited through a 12mm site in the right upper port, and a drain was inserted into the sub-hepatic area. RESULTS: The patients comprised of 5 women and a man, with a mean age of 50.2 years old. The mean operative time was 469.2 (+/-141.4) minutes. In one case, 2 pints of packed red blood cells had to be transfused during the operation. The mean time to diet was 3.3 days. The mean postoperaitve hospital stay was 11.7 days. There was no conversion to open surgery, morbidity or mortality. The mean extensional incision size for the extraction of the specimen was 4.3 cm. CONCLUSION: In the anatomic resection of the liver, especially for benign liver disease, a total laparoscopic resection could be another relatively safe option for selected cases.

The Safety of a Laparoscopic Cholecystectomy in Acute Cholecystitis in High Risk Patients Older than Sixty

PURPOSE: To evaluate the safety of a laparoscopic cholecystectomy in acute, or complicated, cholecystitis in patients older than sixty. METHODS: A prospective study was performed, at the Ewha Womans University Mokdong Hospital, on a series of elderly patients (>60 years; n=137) who had undergone a laparoscopic cholecystectomy due to acute, or complicated, cholecystitis between March 1997 and December 2001. We divided the patients into 3 groups; ASA 1 (n=33, 24.1%), ASA 2 (n=79, 57.7%) and ASA 3 (n=25, 18.3%), according to their ASA (American Society of Anesthesiologist) classification. No patient was categorized as either ASA 4, 5 or 6. RESULTS: The mean age of the ASA 3 patients was 71.9+/-6.9 years, which was older than the 65.7+/-6.0 years of the ASA 1 patients (P0.05). One death, due to acute myocardial infarction, occurred in one of the ASA 3 patients. CONCLUSION: A laparoscopic cholecystectomy in acute, or complicated, cholecystitis could be an option in elderly-high risk patients.

Application of Laparoscopic Cholecystectomy in Patients with Previous Abdominal Surgery

PURPOSE: Previous abdominal surgery has been one of the relative contraindications of laparoscopic cholecystectomy (LC). Recently, the accumulation of experience and the development of skill have widened the indications of LC. The aim of this study was to elucidate the effectiveness and safety of LC in patients with a history of previous abdominal surgery. METHODS: The medical records of patients treated with LC at Ewha Womans University, Mokdong Hospital from March 1997 to December 2000 were reviewed. Operative results were compared between the previous abdominal-surgery group (Group A) and the non-operative history group (Group B). Group A consisted of 99 cases: 91 cases with one operation history, 7 with two, and 1 with three. Group B consisted of 99 cases randomly selected out of 437 cases without a history of previous abdominal surgery in the same period. We compared the mean operative time, conversion rate, rate of drain insertion, starting day of postoperative diet and hospital stay. RESULTS: In groups A and B, the mean ages were 52 and 51.4 years olds, the male to female ratios 1 : 2.7 and 1 : 1.08, and the mean operative times 88.8 and 91.1minutes (P=0.740), respectively. The conversion rates were 3% and the time of postoperative diet was 2.3 days in both groups. The rates of drain insertion were 21% and 15% (P=0.372), the hospital stay was 5.4 days and 5.6 days (P=0.769), the morbidity was 4% and 1% (P=0.371), respectively. There were no cases of mortality in either group. CONCLUSION: The operative results of the patients with a history of previous abdominal surgery were similar to those of the patients without an operative history. Laparoscopic cholecystectomy was an effective and safe method in the patients with a history of previous abdominal surgery.

Central Segmental Resection of Pancreas for Cystic Neoplasms in Head and Neck of Pancreas

PURPOSE: Pancreatic cystic neoplasm is a rare disease. It should be resected regardless of the presence of symptoms due to the possibility of malignancy. Standard pancreatic resection such as PPPD or distal pancreatectomy accompanies the loss of a significant amount of normal pancreatic parenchyma and may cause an impairment of normal pancreatic functions. On the contrary, pancreatic enucleation is known to have risks of pancreactic fistula or abscess. The aim of this study is to elucidate whether segmental resection of the pancreas is a safe and effective treatment in cystic neoplasms in the head and neck of the pancreas. METHODS: We reviewed the medical records of seven patients treated with central segmental resection of the pancreas for cystadenoma at Ewha Womans University Mokdong Hospital from December 2000 to April 2001. All lesions were located at the head and neck of the pancreas. A cephalic stump was sutured for closure of minute pancreatic ductal leakage and hemostasis, and the distal stump was anastomosed with a Roux-en-Y jejunal loop. Postoperative pancreatic functions, complications, and follow up results were analysed. RESULTS: The mean age of the patients was 48.14 (+/-9.55) years old. The pathological diagnoses were 4 cases of serous cystadenoma and 3 cases of mucinous cystadenoma. The mean size was 2.03 (+/-0.7) cm. The average operating time was 299.3 (+/-44.2) minutes. There were two cases of minor complications that were mild pancreatic fistulas without symptoms. There was no operative mortality, impairment of pancreatic function, or recurrence. The mean postoperative hospital stay was 23.6 days. CONCLUSION: Segmental resection of the pancreas can be a rational therapeutic option for cystic neoplasms in the head and neck of the pancreas in terms of the potential benefit of preserving pancreatic function.

Prognostic Factors in Traumatic Liver Injury

PURPOSE: The liver is one of the most commonly injured organs in abdominal trauma. Surgery has played a major role in treating traumatic liver injury. Recently, it was reported that conservative treatment could be the first-line management for the hemodynamically stable patients without combined intraabdominal surgical problems. However, the risk of mortality remains high in this type of injury. The aim of this study was to examine the prognostic factors intraumatic liver injury. METHODS: The medical records of 132 patients who were treated for traumatic liver injury at Ewha Womans University, Mokdong Hospital from March 1994 to June 2001 were reviewed. The initial systolic blood pressure, prehospital transportation time, the number of associated organ injury, the level of initial hemoglobin, the grade of liver injury, the treatment method, the preoperative preparation time, the amount of estimated intraoperative blood loss, and the amount of intraoperative transfusion were analyzed with a univariate analysis and a multivariate analysis. RESULTS: Among the 132 patients, 76 cases (57.6%) were managed non-surgically, and 56 cases (42.4%) underwent surgery. Out of the 17 cases (12.9%) of mortality, 14 (82.4%) were encountered in those who underwent surgery and 3 cases (17.6%) were encountered in those who were treated nonsurgically. Univariate analysis revealed that the initial systolic blood pressure, prehospital transportation time, initial hemoglobin level, the number of associated organ injury, the surgical treatment, the grade of liver injury and the amount of intraoperative transfusion were significant prognostic factors for the survival. Multivariate analysis indicated that the initial systolic blood pressure and the extent of associated organ injury were the independent prognostic factors. CONCLUSION: The patients with unstable vital signs initially and multiple associated organ injuries have a poor prognosis. Aggressive management might be helpful for improving the survival rate in these patients.

The Role of Intraoperative Choledochoscopy for Diagnosis and Treatment in Biliary Surgery

PURPOSE: A choledochoscopy is useful for treating stone disease in the biliary tract. In the era of laparoscopic surgery, this method is expected to be used more widely. Its use during surgery may not only aid disease treatment, but may also help in making a differential diagnosis and a decision on the appropriate operative method. The aim of this study was to determine the role of intraoperative choledochoscopy in biliary surgery. METHODS: This study was a prospective analysis for 119 cases of biliary surgery where a choledochoscopy was used at the Ewha Womans University Mokdong Hospital from June, 1999 to February, 2001. An attempt was made to determine if the use of choledochoscopy altered the preoperative diagnosis, added another diagnosis and influenced the surgical treatment. In addition, the frequency of the remnant stones in biliary stone disease, and the complications related with this procedure were evaluated. RESULTS: The male to female ratio was 1:1.53, and the mean age was 61.1 (+/-14.53) years. A choledochoscopy was used in 82 cases (69%) in open surgery, and 37 cases (31%) in laparoscopic surgery. In 31 cases (26.1%), the diagnosis was changed by the choledochoscopic findings. In 9 cases (7.5%), new finding that was not recognized in the preoperative state was added with the use of choledochoscopy. The surgical method was influenced by the use of a choledochoscopy in 39 cases (32.8%). The remnant stones in patients with an intrahepatic duct stone and common bile duct stone were detected in 8 cases and 3 cases, respectively. The respective clearance rate of the stones were 79.5% (31/39) and 94.5% (52/55). There was no complications and side effects associated with the use of choledochoscopy. The mean time for diagnostic use was 14.6 (+/-10.0) minutes and for therapeutic use was 47 (+/-60.4) minutes. CONCLUSION: Intraoperative choledochoscopy provided useful information for a precise diagnosis and assisted in determining the appropriate treatment for biliary disease. Furthermore, it is very important for making a differential diagnosis in patients with an undetermined malignancy.

Ischemia-reperfusion Injury after Canine Liver Allo-transplantation: The Effect of Gadolinium Chloride

PURPOSE: The effective suppression of Kupffer cell function is believed to contribute to the prevention of preservation/ reperfusion injury. In this study, the effect of Gadolinium, a synthetic Kupffer cell suppressor, on the reperfusion injury was examined using a canine partial liver transplant model. METHODS: About 70% of the liver was harvested and reimplanted in a mongrel recipient dog weighing 20~25 kg. Gadolinium Chloride (10 mg/kg) was infused via the cephalic vein 24 hour before harvesting the partial liver (Gadolinium group, n=5). Serum Aspartate Aminotransferase (AST) Alkaline phosphatase (ALP), Lactate dehydrogenase (LDH), and morphological grading of the graft were compared with the control group (n=5). Statistical analysis was done with an independent T-test. RESULTS: The total ischemic time was 4 hours and 27 minutes on average. One hour after reperfusion, there were no significant differences in the AST, ALP and LDH level, and the pathologic scores. At 48 hours after reperfusion, the AST (P=0.03) and LDH (P=0.05) levels were significantly lower in Gadolinium group. CONCLUSION: Kupffer cell blockage using the Gadolinium chloride might be an effective way of reducing ischemia reperfusion injury. However, this effect was not evident in the early stages of reperfusion.

Comparative Study of Laparoscopic Common Bile Duct Exploration vs Open Method for the Treatment of CBD Stone

PURPOSE: To compare a laparoscopic common bile duct (CBD) exploration with the open method with regards to the clinical outcome in the treatment of a CBD stone. METHODS: A comparative study was performed on 88 patients who underwent surgical treatment for a CBD stone at Ewha Womans University Mokdong Hospital from February 1997 to December 2001. The patients were divided into three groups; a group treated by a laparoscopic CBD exploration (group L, n=59), a group treated by open surgery (group O, n=22), and a group converted to open surgery during laparoscopic treatment (group C, n=7). The medical records were reviewed, and the follow-ups study of the quality of life was assessed with a questionnaire on the symptoms associated with cholangitis. RESULTS: Among the 3 groups, there was no difference in the preoperative status of the patients (age, sex, preoperative comorbidity and previous abdominal operation history). The mean operating time were 230.7 minutes in group L, 182.0 minutes in group O, and 247.9 minutes in group C (P>0.05). The time to diet and hospital stay was longer in group C than the others (P<0.05). The postoperative complications were 10.5% in group L, 40.9% in group O and 14.3% in group C. The symptoms of cholangitis by the questionnaire during the follow-up period were 2.7% in group L, 33.3% in group O, and 66.7% in group C. CONCLUSION: Laparoscopic CBD exploration has acceptable operative difficulties, less morbidity, and good follow-up quality of life compared to the open method in treating CBD stones.

Intrahepatic Duct Stones in Young Patients

PURPOSE: The etiology of intrahepatic duct stone has not yet been elucidated. This disease is more prevalent in older patients, but it can occur in young patient, too. The study of intrahepatic duct stones in young patients may provide clues to the pathogenesis of this disease. METHODS: We analyzed the anatomic distribution of stones and the presence of ductal strictures, as well as the operative methods and the results of treatment. We treated 125 patients with intrahepatic duct stones, of which 15 patients were under 40 years of age and 110 patients were over 40. RESULTS: The average age was 32.9 in young patients and 58.4 in older patients. The anatomic distributions of stones in young patients were even between the right and the left lobes, 4 in the right lobe, 8 in both lobes and 3 in the left lobe. However, the distributions in older patients showed predominance in the left lobe, 61 in the left lobe, 31 in both lobes and 18 in the right lobe. Strictures of duct were present in 7 (46.7%) patients in the young group and 35 (31.8%) in the older group. Hepatic resections were done in 7 (46.7%) and 35 (52.7%) in young and older patients, respectively. The incidence of remnant stones was similar between the two group, 40% in young patients and 31.8% in older ones. The complication rate was less in young patients (6.7%) than in older patients (24.5%). CONCLUSION: Intrahepatic duct stones in young patients had a tendency to develop in the right lobe and to have strictures in the duct. More aggressive treatment is recommended for this group of patients.

Application of Laparoscopic Cholecystectomy in Acute Cholecystitis

PURPOSE: Acute cholecystitis has been a general contraindication of laparoscopic cholecystectomy, and complicated cholecystitis is a challenging disease even in open surgery. The purpose of this study is to evaluate the effectiveness and safety of laparoscopic cholecystectomy in acute and complicated cholecystitis. METHODS: We retrospectively reviewed the medical records of 233 cases treated with laparoscopic cholecystectomy for acute and complicated cholecystitis at Ewha Mokdong hospital from March 1997 to February 2001. Postoperative outcomes were compared between simple acute cholecystitis and complicated cases. The uncomplicated simple acute cholecystitis group (simple acute group) comprised 161 cases (69%) and the complicated cholecystitis group, which included hydrops, empyema, and pericholecystic abscess (complicated group), included 72 cases (31%). RESULTS: In the acute and complicated cholecystitis groups, the length of postoperative diet was 2.19 days and 2.46 days, the conversion rate was 8.07% and 8.3%, and the complication rate was 4.97% and 12.5%, respectively. There was no statistical difference for these three factors (p>0.05). The hospital stay was 6.19 days and 7.57 days, and the mean time of operation was 97.09 minute and 116.5 minute, respectively. These two factors were significantly different (p<0.05). CONCLUSION: Laparoscopic cholecystectomy was shown to be a safe and effective treatment for simple acute cholecystitis and complicated acute cholecystitis. Even in severecomplicated cholecystitis, laparoscopic cholecystectomy can be a primary treatment modality.

Hand-Assisted Laparoscopic Surgery (HALS) with the HandPort System

PURPOSE: The purpose of this study was to evaluate the feasibility and potential benefits of Hand-Assisted Laparoscopic Surgery (HALS) with the HandPort system. The surgeon inserts the nondominant hand into the abdomen while the pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic surgery. This approach provides an excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. METHODS: A prospective study was performed in patients who had undergone surgical intervention with the HandPort system at Ewha Womans University Mok-Dong Hospital. The surgeon was free to test the device in any situation where they expected a potential advantage over conventional laparoscopy. The surgeon inserted the nondominant hand into the abdomen while the pneumoperitoneum was generally maintained at 13 mmHg. RESULTS: Thirteen patients were entered in the study. Operations included radical gastrectomy in 8 cases, subtotal gastrectomy in 1 case, hemicolecotmy in 2, distal pancreatectomy with splenectomy in 1, nephrectomy with splenectomy in 1. The mean incision size for the HandPort device was 7.5 cm for the nondominant hand. None of the patients required conversion to open surgery as a result of an unmanageable air leak. There were no postoperative problems and no cases of mortality. CONCLUSION: HALS with the HandPort system is helpful in complex laparoscopic surgery and appeared to be useful in minimally invasive procedures considered too complex for,a laparoscopic approach.

Laparoscopy-assisted Billroth I Gastrectomy Compared with Open Gastrectomy

PURPOSE: To compare laparoscopy-assisted Billroth I gastrectomy (LABIG) including standard lymph node dissection for patients with early gastric cancer was compared with open gastrectomy as a treatment method. METHODS: A prospective nonrandomized study was performed of early gastric cancer patients at Ewha Womans University Mok-Dong hospital from July 1999 to May 2001. Twenty patients (Group L) underwent LABIG including standard lymph node dissection. The control group (Group O) comprised 14 patients with conventional open radical subtotal gastrectomy and Billroth I anastomosis. RESULTS: In group L, pathologic reports revealed 18 early gastric cancers (stage IA 17 cases, IB 1 case), and 2 pm cancers (stage IB 1 case, stage II 1 case). In group O, there were 13 early gastric cancers (stage IA 12 cases, IB 1 case), and 1 pm cancer (stage IB). Significant differences (p<0.05) were present between group L and O in regards to mean operation time (277.5 vs 215.0 minutes), proximal margin (4.8 vs 7.0 cm), distal margin (4.4 vs 3.9 cm), number of harvested lymph nodes (25.6 vs 37.9), frequencies for pain control (7.2 vs 11.0 times), wound size (7.6 vs 20.0 cm) and postoperative hospital stay (13.7 vs 21.9 days). There were no differences in blood loss, transfusion, leukocyte count, time to diet, serum protein, or weight loss. Complications were seen in 2 cases in group L (enterocutaneous fistula, gastric atony), and 2 cases in group O (gastric atony, marginal ulcer with bleeding). CONCLUSION: LABIG with standard lymph node dissections is a safe and useful technique for the treatment of early gastric cancer with improved postoperative recovery as compared to open conventional gastrectomy.

Hand-assisted Laparoscopic Total Gastrectomy

Although the standard treatment of gastric cancer is still radical subtotal or total gatrectomy, minimal invasive surgery is a primary issue in early gastric cancer, because quality of life is very important if the disease is curable. Laparoscopic total gastrectomy has not yet met widspread acceptance owing to the technical difficulties and has not been reported in Korea. The authors used the Handport system(TM), which enables introducing one of the surgeon's hands into the abdominal cavity while maintaining pneumoperitoneum. The patient was a 38-year old man. His chief complaint was hematemesis. Emergency esophagogatroscopy revealed cardiac ulcer with active bleeding. Sclerotherapy was successfully done and the patient was stabilized. Follow-up gastroscopic examination and biopsy demonstrated moderately differentiated adenocarcinoma in the ulcer area. The surgery was done electively. The operator's left hand was inserted into the abdomen through the right upper quadrant via the Handport system. An additional 10 mm working port was made in the left upper quadrant. Laparoscopy was inserted through the umbilical port. An Ultrashear(R) was used for dissection of omentum and perigastric vessels. D1 plus alpha lymph node dissection was performed completely. Roux-en-Y esophagojejunostomy was done for reconstruction through the Handport site. Opeation time was 6 hours and blood loss was 500 ml. No transfusion was required. The patient recovered uneventfully and was discharged at 16 postoperative days. In terms of recovery and quality of life laparoscopic total gastrectomy is a technically feasible and reasonable option for the treatment of early gastric cancer.

Perigastric Devascularization with or without Fundectomy for Gastric Variceal Bleeding

PURPOSE: Catastrophic bleeding of the gastric varices has been considered a life threatening emergency. Sclerotherapy cannot easily control the bleeding, and there is a high risk of rebleeding despite successful intervention. Surgery is often necessary to save the life. The purpose of this study was to elucidate the role of surgery and analyze the factors determining operative mortality in gastric variceal bleeding. METHODS: A retrospective study was performed of 30 patients who underwent operation for gastric variceal bleeding with portal hypertension at Ewha Womans University Mok-Dong Hospital from Jul. 1994 to Feb. 2001. Among them, 23 patients received perigastric devascularization with fundectomy and the remainder received perigastric devascularization alone. RESULTS: There was one case of recurrent bleeding from esophageal varix at 8 months postoperative. This was controlled with sclerotherapy. The overall operative mortality rate was 30.0%. Preoperative hepatic functional reserve was a significant factor. The mortality rate was 0% (0/5) in Child-Pugh group A, 27.8% (5/18) in group B, and 57.1% (4/7) in group C (p<0.05). The preoperative success of intervention influenced postoperative outcomes. There was no mortality in the successfully controlled group (0/5). In the failure group, 5 of 7 patients expired (p<0.05). Preoperative transfusion amount was also a significant factor in determining survival. There was 15.8% (3/19) mortality rate in patients trans fused less than 10 units, and a 54.5% (6/11)rate in those receiving more than 10 units (p<0.05). CONCLUSION: This operative approach was effective for saving lives from an otherwise uniformly fatal disease. The rebleeding rate at the follow-up period was low. Proper selection of patients and an early surgical decision could lower the operative mortality.

Laparoscopic Surgery for Common Bile Duct Stone

PURPOSE: Application of a laparoscopic technique to common bile duct explorations has been limited due to technical difficulty. With increased experience and technique, laparoscopic surgery has become a possible option for the treatment of common bile duct stones. The purpose of this study was to assess the usefulness of laparoscopic surgery in the treatment of common bile duct stones. METHODS: Between March 1997 and August 1999, 35 patients with choledocholithiasis were treated with laparoscopic common bile duct exploration (4 had a previous biliary operative history). Intraoperative choledochoscopy was used to remove common bile duct stones. The stones were retrieved by using a saline flush, a basket, or a Fogarty catheter. The impacted stones were destroyed using electrohydraulic lithotripsy. RESULTS: Successful laparoscopic stone clearance was achieved in 33 cases (94.3%), and conversion to open surgery occurred in one case (2.9%). The morbidity was 5.7% without mortality. Two cases of retained stone were treated with postoperative choledochoscopic removal via fistula tract and postoperative endoscopic extraction. CONCLUSION: Laparoscopic common bile duct exploration is feasible and safe in most patients. With increased of experience, laparoscopic common bile duct exploration could be used widely.

Preduodenal Portal Vein and Left Sided Gallbladder in Hepatolithiasis Patient: A case report

A preduodenal portal vein is a rare anomaly. A left-sided gallbladder is also a rare anatomical variant that may be occasionally combined with a preduodenal portal vein. We report here a patient with multiple biliary stones whose preduodenal portal vein was discovered at operation. The anomaly was a preduodenal portal vein associated with a left-sided gallbladder, which is very rare. This is the first case reported in Korea. An abnormal location of the round ligament to the right side can make the gallbladder appear to be a left-sided gallbladder. Our case belongs to this category. This patient had multiple biliary stones in the intrahepatic duct, the common bile duct, and the gallbladder. We treated him with a cholecystec tomy, choledochotomy, and choledochoscopic stone extraction using a basket, and electrohydraulic lithotripter. All procedures were done using a laparoscopic method. The patient was treated well with no complication.