Synchronous, Orthotopic Occurrence of Early Gastric Cancer with Gastrointestinal Stromal Tumor that Mimicked Advanced Gastric Cancer

In recent years, the synchronous occurrence of two adjacent but histologically distinct tumors arising in the same organ has been reported. The simultaneous development of gastric adenocarcinoma and gastrointestinal stromal tumor (GIST) is very uncommon. The question raised was whether such a coexistence is a simple incidental finding or whether the two neighboring tumors are caused by a same unknown carcinogenic agent. Many doctors may have an interest in this rare condition and we expect further studies will be done in order to determine if there is any association between the two different tumors. We report a unique case of a synchronous, orthotopic occurrence of an early gastric cancer with GIST in the same location that mimicked advanced gastric cancer.

Endovascular Therapy to Salvage Hemodialysis Access / 대한혈관외과학회지

PURPOSE: Maintaining function of dialysis access is very important to end stage renal disease patients, and it is critical for these patients' overall well-bing. This study was performed to evaluate the success rate of endovascular interventions, risk factors and patencies of interventions. METHODS: From January 2008 to June 2010, 315 interventions were performed on 189 patients with malfunctioning hemodialysis access. Angioplastic intervention (n=147), and percutaneous mechanical thrombectomies (n=168) were done to restore flow of vascular access. RESULTS: Most common cause of malfunctioning hemodialysis accesses was stenosis (71%) in autogenous fistula group (AFG) and thrombosis (73%) in prosthetic graft group (PGG). Common stenotic site was juxta-anastomotic area (48%) in AFG, and venous anastomotic area (42%) in PGG, primary patencies of interventions at 6, 12, and 18 months were 67%, 45%, and 37% and secondary patencies were 83%, 66%, and 49%, respectively. Finally, thrombotic events (P=0.005) and numbers of procedure (P=0.000) were independent predictive factors of shorter access patency after endovascular treatment. CONCLUSION: Endovascular treatment in malfunctioning hemodialysis access is highly successful procedure with acceptable primary and secondary patency results. Especially, in the cases of stenotic lesion without thrombosis, percutaneous transluminal angioplasty was successfully done in AFG and PGG.

Clinical Analysis and Laparoscopic Surgical Experience for an Appendiceal Mucocele / 대한내시경복강경외과학회지

PURPOSE: A mucocele of the appendix is an infrequent entity of appendiceal pathology. A preoperative diagnosis is important to determine for appropriate treatment and to avoid unintended rupture of the mucocele during surgery. The purpose of our study was to identify the clinical features of an appendiceal mucocele (AM) and to describe the experience of the use of the laparoscopic approach for an AM. METHODS: Between July 1998 and July 2008, 32 cases of AM were diagnosed. We reviewed the clinicopathological characteristics and surgical experience for an AM. RESULTS: The incidence of an AM was 0.66% for 4825 performed appendectomies. Most cases manifested with symptoms of abdominal pain (84.4%), but two cases were determined based on CT incidental findings. A preoperative diagnosis of a mucocele was determined for 34.4% of the cases. The use of ultrasonography, CT and colonoscopy helped to achieve a correct diagnosis. Open surgery was performed in 15 cases and laparoscopic surgery was performed in 17 cases. For patients that underwent an appendectomy, the mean operation time and diet-start date were significantly shorter for patients that underwent laparoscopic surgery as compared to patients that underwent open surgery (p=0.030, p=0.007, respectively). Pathology identified mucosal hyperplasia (25%), mucinous cystadenoma (59.4%) and a simple mucocele (15.6%). The mean duration of follow-up was 46 months. Recurrence or development of pseudomyxoma peritonei and complications after laparoscopic surgery were not seen. CONCLUSION: Laparoscopic resection of an AM was feasible when there was no mucinous spillage. Close follow-up is recommended in all patients due to the risk of recurrence in the form of pseudomyxoma peritonei or a gastrointestinal neoplasm.

Clinical Experiences of Laparoscopic Surgery in Children

PURPOSE: The indications for pediatric laparoscopic surgery are increasing according to the improvement of laparoscopic procedures and instruments and the increased knowledge of its safety and benefits. We summarized the analysis of the outcomes and the feasibility of performing laparoscopic surgery in children. METHODS: We retrospectively analyzed 183 consecutive children (114 males and 69 females) who underwent laparoscopic surgery between June 2001 and July 2007. The following information was obtained: the surgical indications, operative procedures and surgical outcomes. RESULTS: The laparoscopic procedures for each disease were as follows, appendectomy for acute appendicitis (n=143), reduction for barium reduction-failed intussusceptions (n=15), splenectomy for symptomatic hereditary spherocytosis (n=5), salphingoophorectomy for torsion of a parovarian cyst and ovarian tumor (n=2), diverticulectomy or segmental resection for symptomatic Meckel's diverticulum (n=3), cholecystectomy for symptomatic gall stones & adenomyomatosis (n-4), repair for Morgagni hernia (n=1), Nissen's fundoplication for paraesophageal hernia (n=1), Heller myotomy and Dor fundoplication for achalasia (n=1), diagnostic purpose for peritoneal tuberculosis (n=3) and lymphoma (n=1), excision for retroperitoneal neuroblastoma (n=1), peritoneal drainage for postoperative abscess (n=1) and removal of a foreign body in the peritoneal cavity (n=2). The mean age was 9.9 years (range: 4 months to 15 years). There was one conversion for a perforated appendicitis. There were 3 cases of laparoscopic assisted reductions for intussusception. There were three wound infections in the patients with complicated appendicitis. CONCLUSION: Laparoscopic procedures for various pediatric surgical disorders were feasible under the appropriate indications.

Laparoscopic Appendectomy for Acute Appendicitis in Children: A Comparison with Open Appendectomy

PURPOSE: The advantage of a laparoscopic appendectomy for acute appendicitis in children is controversial, with no consensus among most pediatric surgeons, particularly with regard to the operative time and hospital costs in complicated cases. The objective of this study was to examine the safety, efficacy and complications of a laparoscopic appendectomy in children compared with an open appendectomy. METHODS: Our clinical experiences of laparoscopic appendectomy (LA) and open appendectomy (OA) for simple appendicitis (SA), complicated appendicitis (CA) and no evidence of appendicitis (NA) in children, between November, 2003 and October, 2006, were reviewed. Ninety- three (93) patients underwent a LA (58 boys, 35 girls) and 194 patients an OA (128 boys, 66 girls). The mean ages of the patients having undergone LA and OA were 9.6 and 8.9 years, respectively. RESULTS: The mean operation times were similar between the LA and OA in the SA and NA groups, but was shorter for a LA than an OA in the CA group, which was also statistically significant (P=0.007). There were statistically significant differences in the postoperative duration of hospital stay between a LA and an OA in all groups (in SA, 2.8 versus 4.5 days, P<0.001 and in CA, 4.5 versus 8.4 days, P<0.001). The rates of postoperative complications were different between a LA and an OA were: for the SA group, 1.7 versus 1.0%, P=1.000; for the CA group, 0 versus 22.4%, P=0.006. CONCLUSION: Our experiences suggest that a laparoscopic appendectomy was a safe and effective procedure for any type of appendicitis in children, with a shorter hospital stay and lower rate of postoperative complications.

Laparoscopic Surgery in Children; Early Experience

PURPOSE: The application of laparoscopic surgery in children has expanded tremendously in recent years. However, the feasibility of the technique is somewhat controversial. We summarize our experience of laparoscopy in children and describe the surgical techniques used in these cases. METHODS: Between June 2001 and May 2004, 58 children (33 male, 25 female) underwent laparoscopic surgery at the Department of Surgery, Daegu Fatima hospital. All the clinical data was collected retrospectively. RESULTS: The laparoscopic procedures for each indications were a laparoscopic reduction for a barium reduction failed intussuception (n=15), laparoscopic appendectomy for acute appendicitis (n=30), laparoscopic splenectomy for symptomatic hereditary spherocytosis (n=4), laparoscopic salphin-go-ophorectomy for torsion of parovarian cyst and ovarian tumor (n=2), laparoscopic diverticulectomy for symptomatic Meckel's diverticulum (n=2), laparoscopic Hellor myotomy and Dor fundoplication for achalasia (n=1), diagnostic purpose for peritoneal tuberculosis (n=2) and the laparoscopic removal of a foreign body in the peritoneal cavity (n=2). The mean age was 7.9 years (range from 4 months to 14 years). In intussusception, the laparoscopic reduction was successful in 12 patients (80%), with a conversion to an open procedure occurring in 3 cases (20%). There were no other open con-versions. There were no postoperative wound complications except for two wound problems in patients with acute perforated appendicitis. The operative time and duration of the hospital stay was suitable. CONCLUSION: The laparoscopic procedure in various disorders of infants and children is safe and avoids the necessity of open surgery under the appropriate indication.

Two Cases of Heparin-Induced Thrombocytopenia in Hemodialysis Patients / 대한신장학회잡지

Heparin, a widely used anticoagulant, is currently the anticoagulant of choice in long-term hemodialysis (HD). Heparin-induced thrombocytopenia (HIT) is one of the most serious side effects of heparin which can cause arterial or venous thromboembolism associated with substantial morbidity and mortality. We experienced two patients who had thrombocytopenia and vascular access occlusion during the induction period of HD with the use of unfractionated heparin. Thrombocytopenia was improved after discontinuation of heparin. HIT was confirmed with anti-heparin/platelet factor 4 antibody test. HD was conducted and arteriovenous fistula was created successfully after switch of heparin to argatroban (Novastan(R)) or nafamostat mesilate (Futhan(R)). Nephrologist should rule out HIT first when thrombocytopenia and thromboembolic complications occur after use of heparin, especially during the induction period of HD. For suspicious patients, immediate cessation of heparin and switch to alternative anticoagulant is very important to avoid serious complications.

Report of Nation-wide Questionnaire Survey for Abdominal Aortic Aneurysm Treatment in Korea

While endovascular aneurysm repair (EVAR) is prevailing for the treatment of abdominal aortic aneurysm (AAA) in modern vascular practice, PURPOSE: we conducted nationwide questionnaire survey to investigate the current status of AAA treatment and their results in Korea. METHOD: We reviewed the replies from 28 hospitals (33 departments) to the questionnaire inquiring annual number, clinical features, mode of treatment and results of AAA patients during the period from Jan. 2000 to Jul. 2004. Results: 980 AAA patients were reported including 292 ruptured AAA (29.8%) and 688 non-ruptured AAA (70.2%). For treatment of AAA, 834 (85.1%) surgical repairs (SRs) and 111 (11.3%) endovascualr aneurysm repairs (EVARs) were performed while 35 patients (3.6%) died of AAA rupture before operation. The locations of AAA were infrarenal in 889 (90.7%), juxtarenal in 62 (6.3%), and suprarenal in 29 patients (3.0%). Among 834 patients undergoing SR, 577 patients (69.2%) had non-ruptured AAAs and 257 patients (30.8%) had ruptured AAAs. Mean operative mortality rate was 4.1% after elective SRs, 30.7% after SR for ruptured AAAs, and 2.3% after EVARs. The reported brand name of stent graft devices were various including domestic custom-made in 56 (50.5%), imported brand in 18 (16.2%) while 37 (33.3%) stent grafts were not reported their brand name. The frequencies of type I and III endoleaks after EVAR were reported 5.8% and 5.8% respectively in 86 patients with an available data. CONCLUSION: SR has been used as a major treatment option in Korea for the treatment of AAA patients while EVAR is increasing. The mortality rate of SR of AAA was comparable to western multi-center trial reports but mortality or morbidity rates of EVAR were unable to know in this questionnaire survey.

Usefulness of Laparoscopic-assisted Surgery for the Treatment of Colonic Diverticulitis

PURPOSE: Colonic diverticulitis was rare in Korea in the past. However, it is progressively increasing probably because of a prolonged life span and a westernized diet pattern. Especially, right-sided colonic diverticulitis is difficult to differentiated from acute appendicitis. The purpose of this study was to verify the usefulness of laparoscopic-assisted surgery for the diagnosis and treatment of colonic diverticulitis. METHODS: We retrospectively reviewed 65 patients with colonic diverticulitis who underwent surgery from January 1998 to December 2002. RESULTS: The mean age of the patients was 36.3 years. Males were more prevalent than females (1.6:1). Abdominal ultrasonography (USG) was used as a diagnostic tool in 40 cases (61.5%), abdominal USG with colon enema in 8 cases (12.3%), and abdominal USG with abdominal CT in 4 cases (6.2%). The preoperative diagnosis was acute appendicitis in 52 patients (80.0%), perforated diverticulitis in 10 patients (15.4%), peritonitis in 2 patients (3.5%), and peptic ulcer perforation in 1 patient (1.5%). The postoperative diagnosis was simple diverticulitis in 47 cases (72.3%). The cecum was the most commonly involved area (55 cases, 84.6%). The types of open surgery were an appendectomy in 17 cases (26.1%), a right hemicolectomy in 17 cases (26.1%), a cecectomy in 6 cases (9.2%). The types of laparoscopic- assisted surgery were an appendectomy in 17 cases (26.1%), a laparoscopic-assisted right hemicolectomy in 4 cases (6.2%), and an anterior resection in 1 case (1.5%). The postoperative complication rate was 11.9% (5 cases). All of these occurred with the open technique, but no statistically significant difference existed between the complication rates for the two operative procedures (P=0.158). The mortality rate was zero for both operative procedures. The length of hospital stay (4.72+/-4.3 vs 10.1+/-6.2)(P=0.001) was significantly shorter in the laparoscopic-assisted group than in the open group. CONCLUSIONS: Preoperative diagnosis is sometimes difficult in patients with colonic diverticulitis. We consider laparoscopic-assisted surgery to be a useful diagnostic and therapeutic modality in such cases. The laparoscopic technique offers particular advantages to diverticulitis patients because of the short hospital stay and the low morbidity and mortality rates.

Laparoscopic Reduction for Intussusception in Children; Early Experience

PURPOSE: The objective of this study was to evaluate the advantages of a laparoscopic technique for the treatment of intussusception in children with repeated hydrostatic reduction failure. METHODS: Between April 2001 and March 2002, twenty one children with intussusception were treated. Eleven patients, with repeated barium reduction failure, underwent a laparoscopic reduction. The type of intussusception, operative time, postoperative hospital stay, and conversion rate, were prospectively examined. RESULTS: The laparoscopic reduction was successful in 8 patients (72.7%), with a conversion to an open procedure occurring in 3 (27.3%). In the 8 successful laparoscopic reduction cases, the average operative time and postoperative hospital stay were 66 minutes and 3 days, respectively. Seven cases were of the ileo-colic type of intussusception and remaining one was of the ileo-ileo-colic type. There were no mortalities or intraoperative complications. CONCLUSION: Intussusception in number of children with hydrostatic reduction failure could be reduced with the laparoscopic technique. The laparoscopic procedure for intussusception was safe and resulted in the avoidance of open surgery.

Interactions of Nitric Oxide and Antioxidants in Hypoxia-Reoxygenation Injury

PURPOSE: An ischemia-reperfusion injury leads to profound functional and structural alterations of vascular smooth muscle cells (VSMC). It is still not clear whether hypoxia- reoxygenation and antioxidants affect the nitric oxide (NO) synthesis of VSMC. This study tried to investigate the effects of antioxidants on NO production, inducible nitric oxide synthase (iNOS) and the expression of NFkappaB p65, during the hypoxia-reoxygenation of VSMC cultures. METHODS: The VSMCs were primarily cultured from rat aortae, and confirmed by immunoreaction with the anti- smooth muscle myosin antibody. The condition of the hypoxia was verified by measuring the PO2 and PCO2 of the culture media. The concentrations of nitrite in the culture media were measured by the Griess reaction. Western blottings for the iNOS and NFkappaB p65 proteins were performed. L-NAME was used as an NOS inhibitor. Vitamins C and E, Glutathione (GSH), lipoic acid and dihydrolipoic acid (DHLA) were used as antioxidants. RESULTS: The iNOS protein was induced in the VSMC by 24 hours of hypoxia, which increased the nitrite in the VSMC culture medium. The reoxygenation profoundly increased the iNOS protein expression and nitrite concentration. The L- NAME, vitamins C and E, GSH, lipoic acid and DHLA decreased the nitrite productions during hypoxia and the hypoxia-reoxygenation, whereas, the expressions of the iNOS and NFkappaB p65 proteins were not influenced. CONCLUSION: We concluded that hypoxia-reoxygenation induced the iNOS protein, and the subsequent production of NO in the VSMC. The antioxidants and the NOS inhibitor decreased the NO production during the hypoxia-reoxygenation, but did not affect the expressions of the iNOS and NFkappaB p65 proteins

Lichtenstein's Tension-Free Repair of Groin Hernias: A Single-Surgeon Experience with 321 Cases

PURPOSE: Tension-free hernioplasty has become the most popular procedure for the repair of groin hernias in the United States and United Kingdom. The purpose of this study is to describe a 7-year personal experience with Lichtenstein's tension-free groin hernia repair under local anesthesia. METHODS: We retrospectively studied the clinical outcome of 321 cases of Lichtenstein repairs, performed consecutively by an experienced surgeon between Jan. 1994 and Dec. 2000. RESULTS: Of the 321 cases, 242 (75.4%) were indirect, 34 (10.6%) were direct, 8 (2.5%) were femoral, 7 (2.2%) were pantaloon, and 30 (9.3%) were recurred hernias. The mean age was 55 years; 91% were male. The mean number of injections of analgesics required in the postoperative period was 3.2. The mean hospital stay following repair was 2.7 days. Complications occurred in 23 cases (7.1%). Most of these were minor, consisting of five cases of bruising or hematomas (1.6%), four superficial infections (1.3%), three seromas (0.9%), two hydroceles (0.6%), six patients with persisting groin pain for more than a month (1.8%), one foreign body granuloma, one urinary retention, and one testicular atrophy. There were no recurrences or operative deaths. CONCLUSION: Lichtenstein's tension-free hernioplasty is an easy and simple technique with less pain, minor complications and only rare instances of recurrence. This procedure can be performed on a same-day basis under local anesthesia. Lichtenstein repair may be the most promising technique for the repair of groin hernias.