Clinical Experiences of Pancreatic Tumors in Children

Pancreatic tumors in children are very rare but have a better prognosis compared with that in adult. Pediatric pancreatic tumors are more often benign and easier to resect. To evaluate the characteristics and prognosis, the records of 13 patients who underwent pancreatic resection, from June 1997 to May 2005, at Samsung Medical Center were reviewed. The mean follow up period was 48 months. The male to female ratio was 1: 1.6. Mean age was 10.3 years. Signs and symptoms included abdominal pain (7), abdominal palpable mass (5), jaundice (1), hypoglycemic (1), and non-specific GI symptoms (4). The commonly used diagnostic tools were CT and abdominal sonography. In addition, MRI, ERCP, EEG, and hormone test were also done when indicated. Surgical procedures included distal pancreatectomy (5), pylorus preserving pancreaticoduodenectomy (4), tumor excision (3), and subtotal pancreatectomy (1). Locations of lesions in pancreas were head (4), tail (5), and body and tail (4). Postoperative complications developed in 3 cases; postoperative ileus (1), wound problem (1), and pancreatitis (1). The pathologic diagnosis included solid-pseudopapillary tumor (6), congenital simple cyst (1), pancreatic duplication cyst (1), serous oligocystic adenoma (1), mucinous cystadenocarcinoma (1), rhabdomyosarcoma (1), insulinoma (1), and pancreatoblastoma (1). Three cases received adjuvant chemotherapy and radiotherapy. Overall survival rate was 81%. One patient with a mucinous cystadenocarcinoma died. In this study, pancreatic tumors in children were resectable in all patients and had good survival. Surgery of pancreatic tumors should be regarded as the gold standard of treatment and a good prognosis can be anticipated in most cases of benign and malignant tumors.

Comparison of Early Complications after Peritoneal Dialysis Catheter Implantation by Laparoscopic Surgery and Conventional Surgery in Children

PURPOSE: To assess the early complication of laparoscopic peritoneal dialysis catheter implantation in children. METHODS: Medical record review was carried out on 21 laparoscopic and 16 conventional peritoneal dialysis catheter implantations which were performed in 31 children under 18 years of age between 2002 and 2006. All medical records were retrospectively analyzed. The patients were followed until 2 months after catheter placement. Patient characteristics and catheter-related complications, such as significant bleeding, leakage, obstruction, migration, insertion site infection and peritonitis during the first 60 days after implantation were recorded. RESULTS: After conventional operation, dialysate leakage occurred in 2 of 16 cases and all cases improved after conservative management. In 1 case, significant bleeding occurred and re-operation was performed. Three cases of obstruction due to migration were reported, 2 cases underwent reoperation and 1 case improved without intervention. After laparoscopic surgery, outflow obstruction occurred in 1 out of 21 cases, which was caused by adhesion after several reinsertions of the catheter and recurrent peritonitis. No migration was noted after laparoscopic surgery. There was no significant difference in the complication rate between the two groups. CONCLUSION: Laparoscopic peritoneal dialysis catheter placement is feasible in children of all age groups, with at least equivalent functional results compared to conventional surgery. The additional advantage of laparoscopic catheter insertion is the option to identify and eliminate anatomical risk factors, such as intra-abdominal adhesions, and to perform partial omentectomy without additional incisions.

Laparoscopic vs. Open Appendectomy in Children: a Retrospective Study

Pediatric laparoscopic appendectomy is controversial particularly in complicated appendicitis. We evaluated the outcomes of laparoscopic appendectomy (LA) and open appendectomy (OA) in simple appendicitis and complicated appendicitis respectively. Since June 2004, initial LA has been our policy in all appendicitis including complicated ones. A total of 160 patients were included in this study, consisting of 80 OA (August 2001 . August 2003) and 80 LA (June 2004 . June 2006). We compared the operating time, the length of hospital stay, the length of antibiotics use, and the postoperative complications between LA and OA. In simple appendicitis (73), there were no differences between LA and OA. However in the 87 patients with complicated appendicitis, the operating time was longer in LA (64.8 min vs. 50.2 min) but the length of hospital stay was shorter in LA than OA (8.5 days vs. 9.6 days). There was one complication in simple appendicitis group and six in complicated appendicitis group (3 cases in LA, 3 cases in OA). There was no difference in the results of LA versus OA in simple appendicitis. Therefore for simple appendicitis, LA is recommended in consideration of the cosmetic effect (fewer scar). In complicated appendicitis, early discharge was an advantage and there were no differences in complications in LA despite a longer operative time. So we conclude LA can be considered as the first choice of treatment for all pediatric appendicitis including complicated appendicitis. To confirm our impressions, more well controlled randomized prospective studied need to be done.

Diagnostic and Therapeutic Strategies for Insulinomas of Pancreas

PURPOSE: The diagnosis and treatment of insulinoma are very important because the tumor can induce critical and permanent neurological deficit. The purpose of this study was to gain an understanding of the clinical features of insulinomas and to establish the diagnostic and therapeutic strategies. METHODS: 17 patients, preoperatively diagnosed with insulinomas and who had undergone surgical management between January, 1998 and March 2004, at the Department of Surgery, Samsung Medical Center, were analyzed. RESULTS: After the operation the 17 patients were diagnosed pathologically; 13 insulinoma, 2 nesidioblastosis, 1 endocrine tumor and 1 endocrine carcinoma. The male to female ratio was 7: 10, with a mean age of 52.3 years. All the patients had symptoms of Whipple triad. The mean duration of symptoms to surgery was 18 months. The preoperative mean blood sugar, plasma insulin, C-peptide and insulin to glucose ratio were 39.6 mg/dl, 47.4muU/ml, 4.8 ng/ml and 1.02 respectively. Preoperative localization was achieved in 15 patients by combining ultrasonography, angiography, abdominal CT and intra-arterial calcium stimulated venous sampling and sensitivity of those examinations were 60, 61.5, 73.3 and 91.7%, respectively. Intraoperative localization was also performed by a combination of manual palpation and intraoperative ultrasonography in 15 patients, with retrospective sensitivities of 86.6 and 100% respectively. The frequenies of head, body and tail were 6: 3: 6. In 2 nesidioblastosis patients, the localization failed both pre- and intraperatively. The types of operations included 11 enucleations, 3 distal pancreatectomies, 2 blind subtotal pancreatectomies and a distal pancreatectomy combined with an extended left hemihepatectomy and intraoperative radiofrequency ablation (RFA) for one patient accompanied by multiple liver metastase. 13 insulinomas were benign, small (mean diameter 1.5 cm, maximum 2.3 cm) and solitary, with the exception of one patient with MEN I. The symptoms of hypoglycemia and the laboratory values were improved in all patients after the operation. CONCLUSION: Insulinomas may be readily localized using sensitive diagnostic tools, such as intra-arterial stimulated venous sampling or intraoperative ultrasonography with manual palpation. If possible, enucleation may be a curative and feasible procedure for benign insulinomas. However, in the case of a highly suspicious nesidioblastosis, a blind partial pancreatectomy may be used as a trail method.

Clinical Study of Synchronous Multiple Gastric Cancer

PURPOSE: Gastric cancer is the most common cancer in Korea, occurring in 20.8% of all cancer patients, most frequently at the antrum, followed by the body and fundus. Multiple synchronous gastric cancers are reported in 0.8 to 8.3% of all gastric cancers. This study aimed to investigate their clinicopathological features and prognosis. METHODS: Out of 6068 patients that underwent a gastrectomy for gastric cancers at the Department of Surgery, Samsung Medical Center between September 1994 and December 2002, 108 multiple synchronous gastric cancers patients, with more than two lesions, were investigated using a clinicopathological evaluation. RESULTS: The mean age of the subjects was 59.8 years with a male to female ratio of 4.68: 1. The majority of subjects had two lesions , but some had as many as five. A subtotal gastrectomy was performed in 67 and a total gastrectomy in 41 cases. Early stage and advanced gastric cancers were present in 164 and 68 patients, respectively. Fifty-four patients had multiple lesions only at an early stage, 10 at an advanced stage and 44 at both stages. The average tumor sizes of the main and secondary lesions were 39.1 and 23.5 mm, respectively. The lesions were mostly located in the lower two-thirds of the stomach, with 54 having different regions for the main and accessory lesions; one in the each of the upper, middle and lower regions, and seven in the upper and lower regions only. The overall five year survival rate was 89.8%. CONCLUSION: With the generalization of an endoscopic diagnosis, gastric cancers can be diagnosed more quickly and accurately. Despite the rare occurrence of multiple synchronous gastric cancers, the possibility of further lesion, especially in early gastric cancers, should be considered.