Laparoscopic total extraperitoneal repair of lumbar hernia / 대한외과학회지

Lumbar hernia is a rare surgical entity without a standard method of repair. With advancements in laparoscopic techniques, successful lumbar herniorrhaphy can be achieved by the creation of a completely extraperitoneal working space and secure fixation of a wide posterior mesh. We present a total extraperitoneal laparoendoscopic repair of lumbar hernia, which allowed for minimal invasiveness while providing excellent anatomical identification, easy mobilization of contents and wide secure mesh fixation. A total extraperitoneal method of lumbar hernia repair by laparoscopic approach is feasible and may be an ideal option.

Trans-Sacral Local Resection as a Posterior Approach

PURPOSE: Surgical removal for a mass in the pre-sacral space or mid rectum through a posterior approach is not frequent. We would like to present the technique of trans-sacral local resection as a posterior approach. We analyzed the follow up of patients who underwent surgery using the proposed technique. METHODS: A total of 21 patients who had undergone a trans-sacral local resection with lower sacrectomy between January 1997 and December 2006 were enrolled in this study. The diagnoses were large epidermal cyst, gastrointestinal stromal tumor, high grade adenoma, and early cancers in the mid rectum. We analyzed the surgical complications and disease recurrences. The mean follow up for tumors of the rectum was 53+/-35 mo. RESULTS: Epidural anesthesia was appropriate for all whole procedures. Among the 21 cases, there was one case of a rectocutaneous fistula as a postoperative complication (4.9%). In one case among the submucosal cancers, there was a systemic metastasis at 24 mo without local recurrence. CONCLUSION: In our experience, a trans-sacral resection with a lower sacrectomy is a good option and provides a wide and direct surgical exposure for the removal of a pre-sacral or a mid-rectal mass. Good bowel preparation is mandatory.

Intersphincteric Resection versus Stapled Coloanal Anastomosis for Low Rectal Cancer

PURPOSE: Local control and functional results of an intersphincteric resection are controversial in Asian, low BMI patients, even though it might a provide a chance to avoid a permanent colostomy. We tried to evaluate the potential risk of an intersphincteric resection, compared with a stapled coloanal anastomosis, in patients with low rectal cancer. METHODS: Patients with low rectal cancer, who underwent a intersphincteric resection with a hand-sewn anastomosis (ISR) or a coloanal anstomosis with staples (stapled CAA), were analyzed. RESULTS: From 1999 to 2006, 85 patients were enrolled. The distance between the anal verge and the lower margin of the tumor was 3.4+/-0.8 cm (range: 2~5 cm) in the ISR group and 4.9+/-0.8 cm (range: 3~7 cm) in the stapled CAA. The mean body mass index was 23 (range: 18~32). The patients complained postoperatively of intolerable anal incontinence (Kirwan's class > 2) in 35% of the ISR group and in 9% as the stapled CAA group, (P<0.02). The local recurrence rate was greater in the ISR group (15%) than in the stapled CAA group (2%, P<0.04). There was no significant difference in distant metastasis between the two groups. The disease-free survival rates were 80.8% and 91.2% at three years in the ISR group and the stapled CAA group, respectively. Complications, such as urinary incontinence and sexual dysfunction in male patients, were not significantly different between the two groups. CONCLUSIONS: An intersphincteric resection with hand-sewn anastomosis could be worse than a stapled coloanal anastomosis in function and local recurrence. This may indicate that careful selection is required for a intersphincteric resection even when a stapled anastomosis cannot be applied due to a narrow margin.

Laparoscopic Assisted Distal Rectal Cancer Resection with Preoperative Concurrent Chemoradiotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Anatomy of deep pelvis, narrow distal margin and tumor invasion into neighbor organ are obstacles for curative radical resection for advanced cancer of distal rectum. Technically, laparoscopic application after downstaging the tumor with preoperative concurrent chemotherapy (CCRT) may give a solution to overcome the anatomical difficulties. We compared the results of laparoscopic surgery in the patients who received CCRT with those of patients who had conventional surgery. MATERIALS AND METHODS: A continuous infusion of 5FU plus leucovorin and radiotherapy (50.4 Gy) in 28 fractions was given each patient as CCRT. They underwent D2 radical resection with TME and ANP for the rectal cancer in 4 weeks. RESULTS: Thirty three patients had laparoscopic resection such as LAR, colo-anal anastomosis and APR. The results were compared with 12 cases of the conventional resections. As a result of preoperative CCRT, the cancer was down-staged in 71%. Two year disease free survival was 75% and 74% in the group of conventional and laparoscopic resection, respectively (p=0.427). Ileus, voiding difficulty and leakage after surgery were not different between two groups. Weakness of ejaculation was noted in 9~11% of both groups. The DFS of the preoperative CCRT followed by radical resection in the groups with a response was more favorable than that in the group with progressive or stable disease. CONCLUSION: Radical resection of advanced distal rectal cancer could be done with performing a laparoscopic assisted operation after CCRT induced down-staging. We may suggest that laparoscopic assisted resection is a good treatment option as it doesn't increase the complications and it has a compatible survival rate to conventional surgery.

The Significance of Metastatic Lymph Node Ratio in the Survival Rate of pT2 Gastric Cancer

PURPOSE: The number of resected lymph nodes can influence the current N staging. This study examined the significance of the metastatic lymph node ratio on the survival of patients with pT2 gastric cancer. METHODS: The records of 176 patients who had undergone curative gastrectomy and diagnosed with pT2 gastric cancer by pathology, between February 1990 and October 2002 were retrospectively reviewed. Those patients with other organ metastases or those who had undergone a dissection of less than 15 lymph nodes were excluded. The clinicopathologic prognostic variables were evaluated using the SPSS statistical program. RESULTS: There were 115 men and 61 women with a mean age of 59 years. The median survival period was 93 months (2~184 months). Metastatic lymph nodes were found in 100 cases (56.8%), a mean of 34.6 lymph nodes were dissected, a mean of 3.2 lymph nodes metastasized, and a mean metastatic lymph node ratio of 0.09 was found. According to the UICC TNM classification, the number of stage IB (N0) cases was 76 (43.2%), stage II (N1) was 74 (42.0%), stage IIIA (N2) was 18 (10.2%), and stage IV (N3) was 8 (4.5%). The overall 5-year survival rate was 75.2%. According to the UICC TNM classification, the 5-year survival rate was stage IB, II, IIIA, and IV was 88.6%, 74.3%, 39.5%, and 33.3%, respectively. The metastatic lymph node ratio (nR) was divided into 4 categories; nR0 (76) = 0, 0

Clinical Analysis of the Infantile Hypertrophic Pyloric Stenosis

PURPOSE: Infantile hypertrophic pyloric stenosis (IHPS) is a common surgical emergency of infants that exhibits clearly unique characteristic symptoms, but its etiology and pathogenesis are still obscure. The Fredet-Ramstedt pyloromyotomy has gained worldwide acceptance. The advantages of this operation are immediate solution of the problem and few complication. Cosmetically circumumbilical incision or laparoscopic pyloromytomy can be used. METHODS: Forty cases of IHPS admitted to the Chuncheon Sacred Heart Hospital from Jan 1997. to Dec 2002 were reviewed retrospectively. These cases underwent Fredet-Ramstedt's operation. RESULTS: The most prevalent age group was 21~30 days (10 cases: 25%), mean age was 41.4+/-9.9 days, and the males to females ratio was 4.7: 1. Among the 40 cases, 24 (60%) involved the first baby. The mean gestation age was 39.9+/-1.7 weeks and mean birth weight was 3.3+/-0.5 Kg. The mean duration of symptom was 4.1+/-1.6 days. The common symptoms were non-bile stained, projectile vomiting in all cases, an olive-shaped mass in the right upper quadrant abdomen in 21 cases (52.5%), visible peristalsis on epigastrium in 16 cases (40%), and jaundice in 1 case (2.5%). Hypokalemic alkalosis was observed in 3 cases (7.5%). The mean length and thickness of the stenotic canal, as measured in the operation, were 28.8+/-8.5 mm and 4.9+/-0.6 mm, respectively. Postoperative complications were one case each (2.5%) pneumonia, wound seroma, and recurrence. Conclusion: Fredet-Ramstedt's pyloromyotomy for IHPS is an effective operation after the correction of dehydration and electrolyte imbalance.

A Case of Cecal Volvulus Diagnosed with Abdominal Computed Tomography

Cecal volvulus is a rare disease of the colon, which occurs in less than 2% of adult intestinal obstruction cases. Precipitating factors can be identified in some patients, including adhesions, a recent abdominal operation, congenital bands, pregnancy, violent exercise, malrotation, obstructing lesions of the left colon and colonoscopy, etc. A right colectomy is a definitive treatment for the best long term control of symptoms, and is the treatment of choice when gangrenous changes are present in the bowel. However, in the presence of viable bowel, the preferred treatment is a controversial matter, with options including; detorsion, cecopexy and cecostomy, etc. We experienced a case of cecal vovulus, which had been treated for COPD at ICU. A diagnosis was made with abdominal computed tomography, and a right hemicolectomy was performed.

Immunoreactivity of CD99 in Stomach Cancer

CD99 is characteristically expressed in Ewing's sarcoma/primitive neuroectodermal tumor. Recently its immunoreactivity has also been reported in other tumors. However, the significance of CD99 isoforms expressed in these tumors has not been elucidated. In this study, we evaluated the expression of CD99 isoforms and its relationship with histopathologic parameters in gastric adenocarcinomas. Paraffin sections of 46 gastric adenocarcinomas were stained with an anti-CD99 monoclonal antibody, YG32. Twelve (26.1%) cases of 46 gastric adenocarcinomas showed immunoreactivity to YG32. The CD99 expression was also seen both in non-neoplastic foveolar epithelial cells and infiltrating lymphocytes. In addition, Western blot and RT-PCR analyses revealed that the type I is the predominant isoform of CD99 in non-neoplastic and neoplastic gastric tissues. The CD99 expression was usually seen in the intestinal type adenocarcinoma, while rarely in the diffuse type. The CD99 immunoreactivity decreased in MMP-2-overexpressing adenocarcinomas (p=0.028). Our results suggest that the type I is the major isoform of CD99 expressed in non-neoplastic gastric mucosa and gastric adenocarcinomas and its downregulation in gastric adenocarcinoma may be associated with cellular dedifferentiation and/or MMP-2 overexpression.

Multiple Ulcerating Malignant Lymphoma of the Gastrointestinal Tract with Perforation

Malignant lymphoma of the gastrointestinal tract is a rare lesion, which comprises 1~4% of the malignant neoplasms of the gastrointestinal tract. Abdominal pain and weight loss are the most common symptoms and an abdominal mass, the most common physical finding. This tumor is often discovered at a late stage; a diagnosis should be done on all patients undergoing an emergency operation for an obstruction, hemorrhage, or perforation. We report a case of a multiple ulcerating malignant lymphoma of the gastrointestinal tract with perforation in a 60 year-old male. The patient visited our hospital because of a sudden onset of acute abdominal pain. The operative finding was multiple masses on the small bowel, sigmoid colon, and stomach, plus multiple perforations of the small bowel. We performed a multiple small bowel segmental resection and an anastomosis at the site of the perforated lesion. The pathologic evaluation diagnosed it as a malignant lymphoma and the patient was treated with cyclophosphamide, adreiamycin, and vincristine. We report this rare disease with a review of the literature.

Osteogenic Sarcoma of the Breast

Osteogenic sarcoma is a rare breast tumor. The first report of a malignant mammary neoplasm composed of bone and cartilage was that of Bonet in 1700. Meanwhile in Korea, Kim et al reported one case of osteosarcoma of the breast in 1999. A 44 year old woman visited our hospital because of a mass on her right breast. The mass was fixed on the skin and 5 5 cm in size. Following a frozen biopsy result of malignancy. A modified radical mastectomy was performed. The tumor was confirmed histologically and immunohistochemically as an osteogenic sarcoma. This study presents one case of an osteogenic sarcoma of the breast, and the report of this rare breast tumor is accompanied by a review of the literature.

Adenosquamous Cell Carcinoma of the Gallbladder: A case report

Primary adenosquamous carcinoma of the gallbladder is an extremely uncommon neoplasm which accounts for approximately 2% of carcinomas of the gallbladder. According to a recent extensive review of carcinomas of the gallbladder, the dismal outlook for this carcinoma still prevails in spite of recent advances in diagnostic and surgical techniques because of late diagnosis and ineffectual treatment. A sixty-one-year-old female patient visited the Department of Internal Medicine due to postprandial epigastric discomfort. Abdominal sonography, abdominal computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) were performed. We treated the patient with a cholecystectomy and chemotherapy with FAM. However, five months after discharge, the patient revisited, complaining of epigastric discomfort. We performed abdominal CT and gastrofiberscopy. The result was a recurrence of the cancer in the bed of the gallbladder and in the liver. However, the patient and her family did not want more treatment for the metastase of the cancer. We experienced one case of an adenosquamous-cell carcinoma of the gallbladder, and we report this rare cancer with a review of the literature.

Expression of EGF Receptor Family Genes and Proteins in Gastric Cacner ( EGFR , c-erbB-2 , c-erbB-3 , c-erbB-4 ) / 대한암학회지

PURPOSE: to evaluate the relationship between the expression of EGF receptor gene family and clinico-pathologic parameters. MATERIALS AND METHODS: We compared adenocarcinoma tissue with normal mucosa obtained from same patients in 60 cases. The amplifications of DNA was examined by slot blot, while the expression of mRNA by ribonuclease protection assay, and that of protein by immunohistochemistry. RESULTS: Expression of EGFR mRNA was observed in 9 of 59, that of c-erbB-2 mRNA in 8 of 57, that of c-erbB-3 mRNA in 4 of 60, and that of c-erbB-4 mRNA in 13 of 59. The expression of EGFR in expanding type showed a higher tendency than that in infiltrative type. The expression of c-erbB-2 in poorly differentiated adenocarcinoma showed a higher tendency than that in well differentiated adenocarcinoma. And expression of c-erbB-2 was correlated with presence of endolymphatic tumor emboli. No significant correlation was observed between expression of EGFR mRNA and that of its protein or amplification of its DNA. Similarly, No clear relationship between c-erbB-2 gene amplification and expression of mRNA or proteins was detected. CONCLUSION: EGFR, c-erbB-2, c-erbB-3, and c-erbB-4 were expressed in gastric adenocarcinoma in Korea. The presence of EGF receptor gene family by various tumor cells suggested that it may play an important role in adenocarcinoma. Therefore further studies are currently being carried out to clarify the role of these oncogenes in tumor behavior and gastric carcinogenesis.

Clinical Characteristics of Mesenteric Infarction

BACKGROUND: Mesenteric infarction is a significant cause of death in elderly patients, and is being reported with increasing frequency. The diagnosis seldom is made prior to the onset of gangrene, despite an increased awareness of the lethality of mesenteric ischemia. The outcome for patients with mesenteric ischemia depends on the age of the patient, the extent and the severity of the ischemia and the effectiveness of the collateral blood supply. METHODS: We retrospectively reviewed the cases of 23 patient with mesenteric infarction who had been treated at the Department of Surgery, Hallym University, Chunchon Sacred Heart Hospital, between September 1988 and August 1977. RESULTS: The mean age was 52.3 years and the ratio of males to females was 1:1.6. The most frequent underlying diseases were hypertension, congestive heart failure, atrial fibrillation, and myocardial infarction. The radiologic study of a simple plain abdomen revealed a paralytic ileus in 87% of the cases; a partial vascular occlusion was shown under angiogram. The mean time lapse from onset of symptom to operation was 38.3 hours. Eight (34.8%) patients died when renal failure, ARDS or peritonitis developed. CONCLUSIONS: The cause of the persistently high mortality in patients with mesenteric in farction and to define a more effective form of management based on our results and recent clinical or laboratory findings. This study was concluded that early detection of the mesenteric infarction was reduced postoperative complications.

Clinical Usefulness of Laparoscopic Cholangiography Compared to Endoscopic Retrograde Cholangiography in a Laparoscopic Cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy has become the gold-tandard treatment for symptomatic gallbladder diseases. The evaluation and the treatment of common duct pathology is an essential component in the surgical management of biliary tract disease. The purpose of the present study was to identify the value and the importance of laparoscopic cholangiography compared to endoscopic retrograde cholangiography (ERC) in a laparoscopic cholecystectomy and to suggest the role of laparoscopic cholangiography in the management of patients undergoing laparoscopic cholecystectomy. METHODS: A laparoscopic cholecystectomy was attempted in two hundred six consecutive patients treated at Hallym University between January 1993 and December 1996. Patients were divided into three groups: In group I, 167 patients were examined with preoperative ERC while in group II, 17 patients were examined with laparoscopic cholangiography; Group III included 22 patients who were not examined with preoperative ERC or laparoscopic cholangiography. RESULTS: The average age was 52.78 years in group I, 45.62 years in group II, and 49.22 years in group III. The average operative time was 76.88 minutes in group I, 131.47 minutes in group II, and 85.22 minutes in group III. The operative time in group II was longer than that in group I (p<0.001). The duration of postoperative hospitalization was 4.9 days in group I and 4.11 days in group II, but this difference was not statistically significant (p=0.166). Conversion to an open cholecystectomy was 17/167 (10%) in group I, 1/17 (5%) in group II and 5/22 (22%). No complications or deaths occurred that were due to laparoscopic cholangiography. The postoperative complications in group I/II/III included bile leakage (3/0/2), bleeding in the bed of the gallbladder (5/0/0), wound bleeding (2/1/1), recurrent common duct stones (2/0/0), subcutaneous emphysema (4/1/0), shoulder pain (12/3/0), and wound infections (15/2/1). CONCLUSIONS: Although cholangiography may not be indicated for all patients undergoing a laparoscopic cholecystectomy, it will eventually be required. We conclude that laparoscopic cholangiography, as well as ERC, is a good method for evaluating the biliary tree. Laparoscopic cholangiography is clinically useful in patients who have negative ultrasonography and a dilated bile duct. Also, laparoscopic cholangiography has many advantages, especially at a teaching hospital: it outlines the anatomy of the extrahepatic biliary tree, identifies anomalies of surgical importance in time before iatrogenic damage is inflicted, detects stones in the cystic duct, discovers unsuspected stones, and develops experience with the technique. However, it is technically diffult to cannulate cystic duct and extends the operating time.

Traumatic Liver Injury

One hundres and two cases of traumatic liver injury were treated during 11 years from January 1986 to December 1996 at the department of surgery, Chunchon Sacred-Heart Hospital, Hallym University, and analysis of clinical manifestation and factors affecting to the mortality were carried out, and the results were as follows. The male to female ratio was 2.6:1. The liver is most commonly injuried following blunt trauma, and the most common cause of blunt trauma was automobile accidents(83.3%). Right lobe injuries consisted of 82.4% of the cases, left lobe injuries were 11.8%, and injuries affecting both lobes were 5.9%. Among the clinical symptoms, peritoneal irritation sign was most common(52.9%). Other symptoms consisted of adominal distension(46.1%), chest pain or dyspnea(42.2%), abdominal wound(12.8%). Arriving at emergency room, patients with shock symptoms were present in 10.8% of all cases. Needle abdominal, paracentesis was performed in 44 cases, and a positive tap showed in 33 cases. In 44.1% of the cases, the liver injury was accompanied with rib fracture, 36.3% with hemothorax or pneumothorax, 32.4% with fracture of long-bone, 17.7% with head injury. Accompaning injuried intraabdominal organs that occured in order from highest to lowest percentage were the kidneys, spleen, small intestines, large intestines, stomach, diaphragm, pancreas and duodenum. Using the AAST Organ Injury Severity Classification, Grade II injuries were 31.4%, Grade I injuires were 28.4%, and Grade III injuries were 19.6%. Conservative management was the preferred method in 26 cases, and operations were performed in 76 cases. Suture and drainage were performed in 66 cases. Hepatic resection procedures were perfromed in three cases. The incidence of complication was 44.1%. The most common post-operative complications were respiratory problems, such as atelectasis, pneumonia, pleural effusion, and ARDS. The mortality rate was 15.7%, and the most common cause of death was hypovolemic shock due to massive bleeding. Accompanying head injuries, renal failue, and ARDS were also cause of death. Factors affecting to the mortality were the severity of the injury, the prescence of shock, systolic blood pressure at arrival, initial value of hematocrit, and the prescence of the abdominal distension.

Expression of the EGF Receptor Gene Family in Gastric Cancer

Growth factor receptors play critical roles in the regulation of normal growth and developement. Some of these molecules have been implicated in the neoplastic process as well. In this study, We examined the expression of the EGF receptor gene family in gastric carcinoma by Ribonuclease protection assay and investigated the relationship between the expression of using a mRNA and clinicopathologic parameters. Expression of EGFR mRNA was found in 34 of 59 cases (57.6%), expression of c-erbB-2 mRNA was found in 27 of 57 cases (64.9%), expression of c-erbB-3 mRNA was found in 47 of 60 cases (78.3%), and expression of c-erbB-4 mRNA was found in 39 of 59 cases (66.1%). The expression of EGFR was correlated with the size of the tumor. The expression of c-erbB-2 was correlated with the presence of endolymphatic tumor emboli, Ming's classification, and lymph node matastasis. The expression of c-erbB-3 was correlated with the macroscopic type. Coexpression of c-erbB-2 and c-erbB-3 was correlated with age. These results suggest that the production of the EGF receptor gene family by various tumor cells it may play an important role in the cellular function. Therefore, further studies are currently being carried out to clarify the role of these oncogenes in tumor behavior and gastric carcinogenesis.

Clinical Effects of a Braun Enteroenterostomy in Patients with a Subtotal Gastrectomy

BACKGROUNDS:During the past two decades, a dramatic increase has been seen in the diagnosis and treatment of alkaline reflux gastritis (ARG). Recently, the number of symptomatic, medically resistant postgastrectomy patients with ARG experiencing enterogastric reflux has increased as documented by clinical symptoms, gastroscopy, quantitative radionuclide biliary scanning, and biochemical study. Even the number of asymptomatic patients experiencing enterogastris refluy or ARG after gastrectomy has increased. METHODS: In a retrospective study, we evaluated an efficacy of an additional Braun enteroenterostomy (BEE) in preventing the ARG by diverting bile away from the stomach in 72 patients with gastric cancer (51 with BEE and a control of 21 without BEE) who underwent a subtotal gastrectomy. The BEE was performed about 20 to 30 cm from the gastrojejunostomy. Seventy-two patients had their clinical symptoms recorded and underwent radiologic study, gastroscopy, and biopsy. RESULTS: The present study demonstrated the following:1) Of the 51 patients who underwent BEE, twelve (23.5%) developed ARG symptoms and required medication. Of the 21 control patients without BEE, twelve (54.6%) developed ARG symptoms and required medical treatment. 2) The postoperative gastroendoscopic findings in the 51 patients who underwent BEE were grade 1 in 27 (52.9%) patients, grade 2 in 16 (31.4%) patients and grade 3 in only one patient versus grade 1 in 5 (22.7%) patients, grade 2 in 13 (59.1%) patients and grade 3 (9.1%) patients without BEE. CONCLUSIONS: BEE was an effective procedure for reducing the risk of ARG caused by reflux of bile.

Clinical Analysis of PTFE Graft Arteriovenous Fistula: The long-term patency rate and factors affecting the patency rate

Expanded polytetrafluoroethylene(PTFE) graft fistulas are widely used as secondary vascular access for patients receiving long-term hemodialysis. It is well known also that several factors should be considered in order to maintain PTFE graft fistula adequately. To elucidate these factors, we reviewed 71 cases of PTFE graft arteriovenous fistula that performed at Hallym University Hospitals from March 1991 to December 1995 and analysed it for regard to age, serum creatinine level, diabetes mellitus, hypertension, diameter of graft and operation site and method. The resultes were as follows: 1) The mean duration of patency of PTFE graft fistula was 10month and the 6 month, 12 month and 24 month patency rate was 64.9%, 39.4% and 36.1% respectively. 2) The complication rate was 45%. 3) Of these factors, diabetes mellitus was the only factor that decreased the patency rate(P<0.05).

Early postoperative results with EEA stapler in total gastrectomy

No abstract available.

A clinical analysis and evaluation of long term effect of surgical treatment of peptic ulcer

No abstract available.