Four-channel single incision laparoscopic cholecystectomy using a snake retractor: comparison between 3- and 4-channel SILC 4-channel single incision cholecystectomy

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is a widely used method of performing cholecystectomy. A common technique used in SILC is a 3-channel method. However, exposure of Calot's triangle is limited in conventional 3-channel SILC. Therefore, we herein report the adequacy and feasibility of 4-channel SILC using a snake retractor. METHODS: Four hundred and fifteen SILC cases were performed between April 2010 and February 2013. We performed 326 SILC cases between April 2010 and September 2012 using the 3-channel method. We introduced a snake retractor for liver traction in October 2012, and 89 cases of 4-channel SILC using snake retractor have been performed since. RESULTS: Thirty patients (9.2%) in the 3-channel SILC group, and 23 patients (25.8%) in the 4-channel SILC group, were treated with percutaneous transhepatic gallbladder drainage insertion because of acute inflammation of the gallbladder (GB) before operation (P < 0.001). The mean operating time was 53.0 +/- 25.8 minutes in the 3-channel SILC group and 51.9 +/- 18.6 minutes in the 4-channel SILC group (P = 0.709). In the 3-channel SILC group, mean hospital stay was 3.0 +/- 3.3 days whereas it was 2.6 +/- 0.9 days in the 4-channel SILC group (P = 0.043). There were a total 9 cases (2.1%) of additional port usages, 6 cases (1.8%) in the 3-channel SILC group and 3 cases (3.4%) in the 4-channel SILC group (P = 0.411), due to cystic artery bleeding and bile leakage from gallbladder bed, but there were no open conversions. CONCLUSION: Benign diseases of the GB can be operated on using SILC with the 4-channel method using a snake retractor.

Single incision laparoscopic cholecystectomy using Konyang Standard Method

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is a minimally invasive surgery that is growing rapidly among surgical procedures. However, there is no standard method for SILC. Therefore, we evaluated the adequacy and feasibility of SILC using Konyang Standard Method. METHODS: We retrospectively reviewed our series of 307 SILCs performed between April 2010 and August 2012. Initially we excluded the patients who were more than 70 years old, had cardiologic or pulmonologic problems and complications of acute cholecystitis. After 50 cases, we did not apply the exclusion criteria. We performed SILC by Konyang Standard Method using three-trocar single port (hand-made) and long articulated instruments. RESULTS: Three hundred and seven patients underwent SILC. Male were 131 patients and female were 176 patients. Mean age was 51.6 +/- 13.7 years old and mean body mass index was 24.8 +/- 3.6 kg/m2. Ninety-three patients had histories of previous abdominal operation. Patient's pathologies included: chronic cholecystitis (247 cases), acute cholecystitis (30 cases), gall bladder (GB) polyps (24 cases), and GB empyema (6 cases). Mean operating time was 53.1 +/- 25.4 minutes and mean hospital stay was 2.9 +/- 3.4 days. There were four cases of 3-4 ports conversion due to cystic artery bleeding. Complications occurred in 5 cases including wound infection (2 cases), bile duct injury (1 case), duodenal perforation (1 case), and umbilical hernia (1 case). CONCLUSION: SILC using Konyang Standard Method is safe and feasible. Therefore, our standard procedure can be applied to almost all benign GB disease.

Comparison of Single Incision and Three Port Laparoscopic Cholecystectomy

PURPOSE: Laparoscopic surgery is a minimally invasive surgery which has been widely used in abdominal surgery, such as appendectomy and cholecystectomy. There were several strong points in single incision laparoscopic cholecystectomy (SILC). However, no definite study comparing SILC with three port laparoscopic cholecystectomy (TPLC) has been reported. Therefore, this study focused on feasibility and safety of SILC in comparison with conventional TPLC. METHODS: This study included 86 cases of SILC and 230 cases of TPLC from April, 2010 to February, 2011. The patients were divided into two groups according to the surgical procedure, group 1 was SILC and group 2 was TPLC. All operations were performed by a single surgeon, and the retrograde approach was the fundamental surgical procedure used in both groups. RESULTS: Eighty five patients in group 1 underwent SILC and 229 patients in group 2 underwent TPLC. In comparison of preoperative data, statistical significance regarding age, gender, and preoperative PTGBD insertion was observed between the two groups. In comparison of intraoperative data, the average operation time and average hospital day did not show any statistical significance. Intraoperative multiple port conversion was performed in group 1 to TPLC due to cystic artery bleeding, and in group 2, TPLC was changed into a four port operation due to the same reason. CONCLUSION: In this study, no significant difference in operation result, time, and acute complication was observed between SILC and conventional TPLC. Besides the cancers, SILC could definitely be applied without exclusion criteria mentioned above if improvement of instruments and accumulation of surgeon's experience were satisfied.

Is Biliary Drainage Really Necessary after Laparoscopic Common Bile Duct Exploration?

PURPOSE: Laparoscopic common bile duct exploration (LCBDE) has been the alternative treatment in patients who have failed endoscopic removal. Until now, biliary drainage has been performed as a customary practice after LCBDE in order to prevent complication or to prevent remnant stones from draining out; however, the drainage was often caused by other complications. For this reason, we have been performing LCBDE with primary closure. The aim of this study was to report on the efficacy and safety of primary closure. METHODS: Of 207 cases of common bile duct stones with performance of LCBDE from March 2001 to January 2013, 199 cases were included. Eight cases were excluded due to the open conversion. The 199 patients were subdivided into the primary closure group (P-group) and the drainage group (D-group). RESULTS: Of 199 patients, there were 36 (18.1%) with primary closure, and 163 (81.9%) with drainage. No significant difference in characteristics was observed between the two groups, except for smaller stones in the P-group (11.4+/-6.0 mm, 16.2+/-8.0 mm, p<0.01). Mean number of postoperative hospital days was significantly shorter in the P-group (6.0+/-3.1 days, 7.6+/-3.8 days, p=0.019). The rate of postoperative complications was higher in the D-group, but showed no statistical significance. There were six cases of bile leakage in the D-group, and two cases in the P-group, but without statistical significance (p=0.638). The recurrence rate was significantly lower in the P-group (5.6%, 22.1%, p=0.02). CONCLUSION: In the P-group, the number of mean postoperative hospital days was lower, and a lower rate of recurrence was observed. Compared with other types of drainage after LCBDE, the primary closure would be a sufficient method. Therefore, it can be regarded as safe enough and feasible.

Mesenteric Pseudocyst of the Small Bowel in Gastric Cancer Patient: A Case Report

Mesenteric pseudocyst is rare. This term is used to describe the abdominal cystic mass, without the origin of abdominal organ. We presented a case of mesenteric pseudocyst of the small bowel in a 70-year-old man. Esophago-gastro-duodenoscopy showed a 3.5 cm sized excavated lesion on the posterior wall of angle. Endocopic biopsy confirmed a histologic diagnosis of the poorly differentiated adenocarcinoma, which includes the signet ring cell component. Abdominal computed tomography scan showed a focal mucosal enhancement in the posterior wall of angle of the stomach, a 2.4 cm sized enhancing mass on the distal small bowel loop, without distant metastases or ascites in rectal shelf, and multiple gallbladder stones. The patient underwent subtotal gastrectomy with gastroduodenostomy, segmental resection of the small bowel, and cholecystectomy. The final pathological diagnosis was mesenteric pseudocyst. This is the first case report describing incidentally detected mesenteric pseudocyst of the small bowel in gastric cancer patients.

The learning curve for laparoscopic totally extraperitoneal herniorrhaphy by moving average / 대한외과학회지

PURPOSE: Laparoscopic totally extraperitoneal (TEP) herniorrhaphy has been recognized as a treatment option for inguinal hernia. The objective of this study was to clarify the learning curve for laparoscopic TEP herniorrhaphy using the moving average method. METHODS: A total of 90 patients underwent laparoscopic TEP herniorrhaphy by a single surgeon between March 2009 and March 2011. We analyzed medical records including the demographic data, operating time, hospital stay, and postoperative complications. RESULTS: The mean operating time of the initial 30 cases (learning period group) was 66.3 minutes. After the initial 30 cases were performed, the time decreased to 52.8 minutes in the later 60 cases (experienced period group, P = 0.015). This represents the operating time becoming stabilized and then decreasing as the number of performed cases accumulates. Hospital stay was shorter and frequency of pain control, and complication rate were lower in the experienced period, however, there was no statistical significance. CONCLUSION: We suggest that number of patients needed for the learning curve for laparoscopic TEP herniorrhaphy should be 30 cases. The operating time for laparoscopic TEP herniorrhaphy stabilizes after 40 cases in moving average analysis.

Extensive Visceral Vein Thrombosis Associated with Deep Vein Thrombosis

Extensive visceral vein thrombosis, including the femoral vein, iliac vein, superior mesenteric vein, splenic vein and portal vein, is an uncommon type of thrombosis that is associated with significant mortality and morbidity. Making an early diagnosis and adequate management are very important. We present here the case of a 39-year-old woman with extensive visceral vein thrombosis and complicated small bowel necrosis and perforation. She had no known prothrombotic conditions, but the laboratory findings showed an elevated level of factor VIII. The patient's condition improved without complication after resection of the infarcted and perforated small bowel along with immediate postoperative anticoagulant therapy. On the follow up, the size of the thrombosis was decreased and there was no complication.

Comparison of Bile Drainage Methods after Laparoscopic CBD Exploration

PURPOSE: T-tube is a major procedure that prevents complication by biliary decompression, but which is accompanied by complications. Therefore, several procedures such as ENBD, PTBD, and antegrade biliary stent have been attempted, but with controversies as to which procedure is superior. Also, there are no standard procedures after laparoscopic CBD exploration. We performed this study to ascertain the most appropriate biliary drainage procedure after laparoscopic CBD exploration. METHODS: From March 2001 to December 2009, 121 patients who underwent Laparoscopic CBD exploration in Gunyang University were included for retrospective analysis. The patients were divided to 4 groups according to type of procedure, and we compared clinical parameters including age and gender, operation time, hospital stay, start of post-operative diet, and complications. RESULTS: There was no difference in age, gender, mean operation time, postoperative diet between the 4 groups. Hospital stay in the Stent group was shorter than T-tube group. There were 10 (7%) complications that occurred. Two 2 occurred in the T-tube, 3 in PTBD, and 5 in the Antegrade stent group. There were more complications in Stent group but no significant statistical difference. In 5 cases with remnant CBD stone, a total of 4 (3 PTBD, 1 Stent) was performed by endoscopic CBD stone removal. One T-tube case was removed easily by choledochoscopy through the T-tube. Three migrated and the impacted stents were removed by additional endoscopy. Perioperative biliary leakage (1) and peritonitis (1) post t-tube removal were resolved by conservative treatment. CONCLUSION: T-tube appears to be an appropriate method to patients who are suspected to have remnant CBD stones. Multiple procedures may be performed on a case by case basis such as performing PTBD first in a suspected cholangitis patient.

Torsion of Appendix Misdiagnosed as Ovarian Tumor / 대한내시경복강경외과학회지

Acute appendicitis is the most common cause of an acute abdomen. But torsion of the appendix is a rare disorder that causes abdominal symptoms that are indistinguishable from acute appendicitis. So, making the preoperative diagnosis of torsion of the appendix is difficult. In 1918, Payne et al. reported the first case of torsion of the appendix in a 37 years old woman. Since then, more than thirty cases have been reported. Torsion of the appendix can occur at any age & gender. Here, we report on a case of secondary torsion of appendix with mucinous cystadenoma in a 52 year-old woman, which was initially thought to be a right adnexal mass. Abdomen CT showed an 11x5 cm sized intra-abdominal mass growing along the right fallopian tube. On the small bowel series, an extra-luminal mass was found and this was pushing aside the small intestine. We performed diagnostic laparoscopic exploration and found inflammation of appendix with torsion. It was twisted 720degrees in a clockwise direction with ischemic change. The histological result was mucinous cystadenoma.

Extension of Nonoperative Management on Spleen Injury with Judicious Selection and Embolization; 10 Years of Experience

PURPOSE: We describe clinical outcomes of NOM on spleen injuries with judicious selection and embolization during the past 10 years. METHODS: From March 2000 to November 2009, 151 patients with splenic injury were included. Eighteen patients were excluded because of incomplete data. Patients' medical records were reviewed to examine admission demographics, laboratory results, radiologic findings as well as transfusion requirement, hospital stay, and ultimate outcomes. RESULTS: Twenty patients were chosen for non-operative management (NOM) after splenic embolization and 1/20 (5%) patient failed. There were 32 patients more than 55 years old (range, 55~87 years). Of these patients, 26 (81%) patients were chosen for NOM and 3 (11.5%) patients failed. According to OIS, 51 patients were grade 3; 26 patients, grade 4; and 6 patients, grade 5. Among grade 3, 49 (96%) were chosen for NOM with or without embolization and 1 (2%) patient failed; grade 4, 19 (73%) with NOM, 2 (7.6%) patients failed. Of all 133 patients with NOM or failed NOM (FNOM), there was 0 mortality in grade 3; 2, in grade 4; 2, in grade 5, excluding other causes of death. The mean ISS was significantly higher in the failed NOM group compared with successful NOM group (P=0.01). The group of failed NOM had a significantly higher mean OIS (P=0.00). CONCLUSION: Aggressive but highly selective NOM on the base of clinicoradiologic parameters with the aid of angioembolization would result in a low failure rate and complication in the management of high grades (grade 3 or 4).

The Outcome of Laparoscopic Common Bile Duct Exploration (LCBDE) with Stone Removal in Common Bile Duct Stone / 대한내시경복강경외과학회지

PURPOSE: ERCP (Endoscopic retrograde cholangiopancreatigraphy) and ES (endoscopic sphicterotomy) have become the main treatments for common bile duct (CBD) stone. However, when ERCP with ES fails to remove CBD stone, an operation is needed for stone removal. The aim of this study was to investigate the outcomes of laparoscopic CBD exploration (LCBDE) for the management of difficult choledocholothoasis. METHODS: This study was a retrospective analysis of 106 LCBDE cases that were performed from March 2001 to December, 2009. RESULTS: Of the 106 patients who underwent laparoscopic procedures, 74 were combined with gallstone and 105 underwent the choledochotomy approach. The mean operation time and mean hospital stay were 146.9+/-74.5 minutes and 11.0+/-6.4 days, respectively. The open conversion and stone clearance rates were 3.8% (4 cases) and 96% (102/106 cases). There were 10 complications with 3 cases of bile leakage, 2 cases of pulmonary complications, 4 cases of remnant stone and 1 case of subhepatic seroma. CONCLUSION: The LCBDE is a safe and feasible procedure. If ERCP is difficult or stone retrieval is incomplete, then LCBDE could be an alternative treatment for difficult CBD stone.

Clinicopathologic Review of the Intraductal Papilloma of Breast / 한국유방암학회지

PURPOSE: Intraductal papilloma of the breast (IDP) is the most common causes of nipple discharge and it is often a solitary, centrally located tumor that most commonly occurs in the fifth and sixth decades of life. There have been many conflicting reports on the malignant potential of IDP. METHODS: From February 2003 to November 2008, we operated 161 patients who were diagnosed with IDP at Konyang University Hospital. A retrospective review of all the pathologic reports and the corresponding radiological reports was undertaken. RESULTS: The mean age of the patients was 43.23 years (SD, +/-10.1). Eighty-three (51.6%) had nipple discharge, 37 (44.6%) had bloody discharge and 46 (55.4%) had yellowish serous discharge. Twenty-four had a mass and 2 had both bloody discharge and a mass. Radiologic significant findings were shown on 20 mammography exams, 71 ductography exams and 157 breast ultrasound exams. Onehundred forty-four (89.4%) patients with IDP or papillomatosis had surrounding pathologic lesions in the operated specimen according to the final pathology, 107 (66.5%) had fibrocystic change, 26 (16.1%) had fibroadenoma, 30 (18.6%) had atypical ductal hyperplasia (ADH), 11 (6.8%) had carcinoma in situ and 4 (2.5%) had invasive ductal carcinoma. During the follow up, 7 patients (4.3%) developed recurrent IDP, 3 patients developed ADH and 5 patients developed carcinoma in situ (4 patients had ductal carcinoma in situ and 1 patient had lobular carcinoma in situ). CONCLUSION: Intraductal papilloma should be closely followed up due to its malignant potential and the surrounding breast tissue with IDP should be carefully evaluated due to the high rate of developing other precancerous lesions.

Clinicopathologic Review of the Intraductal Papilloma of Breast / 한국유방암학회지

PURPOSE: Intraductal papilloma of the breast (IDP) is the most common causes of nipple discharge and it is often a solitary, centrally located tumor that most commonly occurs in the fifth and sixth decades of life. There have been many conflicting reports on the malignant potential of IDP. METHODS: From February 2003 to November 2008, we operated 161 patients who were diagnosed with IDP at Konyang University Hospital. A retrospective review of all the pathologic reports and the corresponding radiological reports was undertaken. RESULTS: The mean age of the patients was 43.23 years (SD, +/-10.1). Eighty-three (51.6%) had nipple discharge, 37 (44.6%) had bloody discharge and 46 (55.4%) had yellowish serous discharge. Twenty-four had a mass and 2 had both bloody discharge and a mass. Radiologic significant findings were shown on 20 mammography exams, 71 ductography exams and 157 breast ultrasound exams. Onehundred forty-four (89.4%) patients with IDP or papillomatosis had surrounding pathologic lesions in the operated specimen according to the final pathology, 107 (66.5%) had fibrocystic change, 26 (16.1%) had fibroadenoma, 30 (18.6%) had atypical ductal hyperplasia (ADH), 11 (6.8%) had carcinoma in situ and 4 (2.5%) had invasive ductal carcinoma. During the follow up, 7 patients (4.3%) developed recurrent IDP, 3 patients developed ADH and 5 patients developed carcinoma in situ (4 patients had ductal carcinoma in situ and 1 patient had lobular carcinoma in situ). CONCLUSION: Intraductal papilloma should be closely followed up due to its malignant potential and the surrounding breast tissue with IDP should be carefully evaluated due to the high rate of developing other precancerous lesions.

A Case of Thyroid Hematoma Complicated with Unexpected Airway Obstruction by Blunt Cervical Trauma / 대한내분비외과학회지

Traumatic thyroid hematoma is a rare problem in cases of blunt trauma, but it can be a life-threatening condition. We report here on a case of thyroid hematoma that was complicated with unexpected airway obstruction due to blunt trauma on the anterior neck. A 23-year-old man who developed neck painful swelling and dyspnea was admitted to the emergency room with a blunt neck injury after motor-bicycle accident, and he hit his anterior neck against the handle-bar. He had no previous thyroid pathology and other medical problems. On the initial examination, his vital signs were stable and the oxygen saturation was 97.8%. A computed tomography (CT) scan of the neck showed fragmentation and extensive hematoma within the right thyroid gland and dislocation of the trachea. No definite bleeding focus was identified on the angiography that was done through the carotid artery. Two hours later, the patient experienced sudden respiratory distress and the oxygen saturation dropped rapidly. The patient needed emerg encyendotracheal intubation and surgical intervention. He successfully underwent right lobectomy of the thyroid gland, and was discharged on the 6th hospital day without any complications. The thyroid function was normal after 3 months.

Adenomatous Polyposis Coli and Ras Association Domain Family 1A Gene Methylation in Breast Cancer Patients / 한국유방암학회지

PURPOSE: Of the many carcinogenic mechanisms, DNA methylation is a strong factor in various cancers, including cancer of the breast. The genes related to breast cancer include 14.3.3 sigma, Cyclin D2, RARbeta, Twist, Ras association domain family 1A gene (BASSF1A), HIN-1, p16, and Adenomatous polyposis coli (APC). Of these, hypermethylation of the APC and RASSF1A genes is, found in breast cancer patients, and especially in those with a poor prognosis. This study investigated whether hypermethylation of the APC and RASSF1A genes is related with breast cancer metastasis. METHODS: Of the 110 patients who received surgical operation at our hospital's department of surgery from January 2001 to December 2003, 16 patients with metastatic lesion found during the follow-up period were selected. Seventeen patients without metastasis selected as the tissue group after considering their age, cancer stage, and physical state. Forty seven patients were selected as the serum group, including 6 patients with metastasis, and they were evaluated for metastasis and methylation. Serum and tissue were collected and after being processed by the methylation specific PCR (MSP), and the methylation of the APC and RASSF1A genes was observed. RESULTS: In the tissue study group, the APC gene methylation ratio of the patients whose stages are between the stage 2 and 3 was 50:94%, and that of RASSF1A gene methylation was 68.7:65% respectively. Methylation rates of both genes was found in 42.9% of the stage 2 recurrent patients (non-recurrent patients: 22%) and in 77.8% (non-recurrent patients: 50%) in stage 3 recurrent patients. In the serum study group, a statistical correlation was shown (p=0.013) between methylation of RASSF1A and recurrence, where 5 of the 16 patients with methylation showed recurrences and only 1 patient of the 31 nonmethylated patients showed recurrence. CONCLUSION: We determined the correlation between APC and RASSF1A methylation and recurrence of breast cancer. Further studies with large sample populations and more advanced method are needed to confirm our findings.

The Effects of Genistein to Expression of Fatty Acid Synthase in Breast Cancer Cells / 한국유방암학회지

PURPOSE: The relatively low incidence of breast cancer in Asian countries with cultures which traditionally eat a large amount of soy is worth noticing in research fields. Genistein is a isoflavone phytoestrogen found in soy and its consumption may have a role in cancer etiology. We have established a hypothesis that a diet high in soy consumption is related to a low incidence of breast cancer. Fatty acid synthase (FAS) is a multi-protein enzyme responsible for de novo biosynthesis of fatty acids. Recent studies have demonstrated that high levels of FAS occurs in a subset of human cancers, such as breast cancer, ovarian cancer, and prostate cancer. High level of FAS are associated with a poor prognosis. Sterol regulatory element binding proteins (SREBPs) are a family of transcription factors that regulate genes involved in lipid metabolism, including FAS. Recent studies show that expression of SREBP1c is correlates with FAS expression. The aim of this study is to investigate the effect of genistein on the expression of FAS in breast cancer cells. METHODS: We performed immunofluorescent staining to examine the expression of FAS under different concentration of genistein. RT-PCR was also performed to investigate the mRNA expression of FAS and SREBP1c in different conditioned breast cancer cells treated with different concentration of FAS inhibitor and genistein. RESULTS: By immunofluorescent staining, the FAS expression after treatment with the FAS inhibitor, C75, decreased at a micron10 M concentration. However the expression of FAS decreased at all concentrations of genistein (0.5, 1, 5, 10 micronM). The mRNA levels of FAS and SREBP1c after treatment with C75 decreased constantly according to time and concentration. However the effect was noted only after 12 hr. The mRNA level of FAS and SREBP1c following treatment with genistein decreased at only a 10 micronM concentration (p<0.005). CONCLUSION: Genistein may down regulate FAS expression in breast cancer cells through modulation of SREBP-1c. This finding may account for the relatively low incidence of breast cancer in Asians who consume a large amount of soy in their diet.

Introduction of Electrochemical Therapy (EChT) and Application of EChT to The Breast Tumor / 한국유방암학회지

PURPOSE: To introduce the history and principle mechanism of electrochemical treatment (EChT) with animal study and report two cases successfully treated breast cancer and hemangioma by EChT. METHODS: In animal study, the breast cancer tumor in nude mouse treated with EChT (100 Coulomb/cm3) were reviewed for histologic changes. In the case studies, we reported method of EChT and clinical results after EChT. Case 1: 74 yr old female with locally advanced breast cancer received 3 times EChT with 1,000 Coulomb/time, 8 Volt. Case 2: 51 yr old female with breast hemagioma received one time EChT with 80 Coulomb, 8 Volt. RESULTS: In animal study, There were destructive change including vaculated cell fragment and extensive coagulative necrosis. Case 1 showed no local recurrence during 18 monthes after EChT. Case 2 also showed no evidence of recurrence of hemangioma. CONCLUSION: The EChT is easy to use. It is effective, safe, less traumatic and makes patients recover quickly. This is a new and effective method to treat patients with tumours that are inoperable and can not receive chemotherapy or radiotherapy.