Rationale and surgical technique of laparoscopic left lateral sectionectomy using endoscopic staples

PURPOSE: Laparoscopic left lateral sectionectomy (LLLS) has been widely accepted due to benefits of minimally invasive surgery. Some surgeons prefer to isolate glissonian pedicles to segments II and III and to control individual pedicles with surgical clips, whereas opt like to control glissonian pedicles simultaneously using endoscopic stapling devices. The aim of this study was to find the rationale of LLLS using endoscopic staples. METHODS: We retrospectively analyzed and compared the clinical outcomes (operation time, drainage length, transfusion, hospital stay, and complication rate) of 35 patients that underwent LLLS between April 2004 and February 2012. Patients were dichotomized by surgical technique based on whether glissonian pedicles were isolated and controlled (the individual group, n = 21) or controlled using endoscopic staples at once (the batch group, n = 14). RESULTS: Mean operation time was 265.3 +/- 21.3 minutes (mean +/- standard deviation) in the individual group and 170 +/- 22.9 minutes in the batch group. Operation time in the batch group was significantly shorter than the individual group (P = 0.007). Mean drainage length was 4.8 +/- 1.6 and 2.6 +/- 1.5 days in the individual and the batch group. There was significantly shorter in the batch group, also (P = 0.006). No transfusion was required in the batch group, but 4 patients in the individual group needed transfusion. Mean hospital stay was 10.7 +/- 1.1 and 9.4 +/- 0.8 days in the individual and the batch groups (P = 0.460). There were no significant complications or mortality in both groups. CONCLUSION: LLLS using endoscopic staples (batch group) was found to be an easier and safer technique without morbidity or mortality.

FDG Uptake Pattern of a Prosthetic Graft without Infection on a PET/CT Scan

PURPOSE: A prosthetic graft infection is a rare but often disastrous complication during vascular surgery. Diagnosis of a prosthetic graft infection is not always easy, particularly with a low virulent bacterial infection or in a deeply placed graft in the retroperitoneal space. Recently, fludeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) has been proposed as a diagnostic modality for prosthetic graft infection. However, some reports have indicated that high FDG uptake occur in grafts without infections. This study analyzed FDG uptake patterns in prosthetic grafts of asymptomatic patients. METHODS: We reviewed 14,545 patients who had received PET/CT in a tertiary hospital between July 2007 and March 2010. Of them, 11 patients who had undergone previous bypass surgery with a prosthetic graft were identified. Four underwent an aortic bypass and the others received lower extremity bypass grafting. PET/CT images and patient clinical data were reviewed retrospectively. The maximum standardized uptake value (SUVmax, A) in the graft, the mean SUV (SUVmean, B) of the blood-pool, and the target-to-background ratio (T/B, A/B) were calculated. RESULTS: The mean duration between bypass grafting and the PET/CT scan was 21 months (range, 1~80 months). No clinical evidence of graft infection was observed in any of the patients. PET/CT revealed an uneven, diffuse FDG uptake pattern on the grafts, and the mean T/B was 2.0 (range, 0.9~4.6). T/B was greater than 2.0 in six patients (55%). CONCLUSION: A prosthetic graft without an infection can result in increased FDG uptake during PET/CT. A further prospective study is necessary to evaluate the usefulness of FDG PET/CT for diagnosing a prosthetic graft infection.

Macrophage Migration Inhibitory Factor (MIF) Concentration in the Serum of Patients with Ovarian Cysts for Differential Diagnosis of Endometrioma / 대한불임학회지

OBJECTIVE: To evaluate the usefulness of serum concentrations of macrophage migration inhibitory factor (MIF) of patients with ovarian cysts for differential diagnosis of endometrioama. METHOD: From Jan. 2003 to Dec. 2004, preoperative serum MIF levels were assessed in 28 women with endometrioma, 32 with benign epithelial tumor, 23 with functional and simple cysts, 22 with benign mature cystic teratoma, and 25 women without ovarian tumor as control. MIF levels were determined using an ELISA (Quantikine Human MIF immunoassay, R&D Systems, Inc., USA). RESULTS: Mean MIF levels were higher in all groups with benign tumors than control (all p<0.01), but there was no significant difference between benign tumor groups (p=0.95). There was no significant correlation between MIF levels and tumor volume, body mass index (BMI) (p=0.635, 0.674 respectively) Serum MIF level had significant correlation with count of WBC and neutrophils (p=0.008, 0.024 respectively), but had no correlation with count of lymhocytes and monocytes (p=0.688, 0.294 respectively). CONCLUSIONS: This study showed a marked increase in MIF concentrations in the peripheral blood of patients with endometrioma, but there was no significant difference with other benign tumors. Serum MIF level had significant correlation with count of WBC and neutrophils. These suggest serum MIF level has no usefulness for differential diagnosis of endometrioma from other benign ovarian cysts.

The Necessity for Mechanical Bowel Preparation before Colonic Resection and Primary Anastomosis

BACKGROUND: The results of recent reports suggest that mechanical bowel preparation before colonic resection and primary anastomosis may be unnecessary. To determine whether mechanical bowel preparation influences the incidence of postoperative complications following colorectal surgery, the records of patients who had undergone colonic or rectal resection were retrospectively reviewed. METHODS: Between March 1992 and October 1997, colonic resection and primary anastomosis without colostomy was performed on 56 patients. Among these, 27 patients had undergone mechanical bowel preparation (MBP) before surgery, and 29 patients had not. We compared the data from both groups with respect to wound infection, anastomotic leak, intra-abdominal sepsis and death. RESULTS: The postoperative complication and mortality rates were similar in the two groups. Wound infection occurred in seven patients (four with MBP, three without), and the incidence of wound infection was similar in the two groups (14.8% versus 10.3%, P=0.700). Wound disruption occurred in two patients (one with MBP, one without). Anastomotic leaks occurred in two patients who had undergone bowel preparation. The overall anastomotic leak rate was 3.6% (7.4% versus 0%), but the incidence of anastomotic leaks was not significantly different between the two groups (P=0.228). No intra-abdominal sepsis was clinically apparent in either group. There was one death, a patient who had undergone bowel preparation. The mortality rate was not significantly different between the two groups (P=0.482). CONCLUSIONS: We believe that mechanical bowel preparation before colonic resection and primary anastomosis may be unnecessary, so routine MBP should be further scrutinized.

Laparoscopic Versus Open for Complicated Appendicitis

BACKGROUND: For complicated appendicitis, in contrast to simple appendicitis, laparoscopic appendectomy (LA) is considered a relative or absolute contraindication because of the higher postoperative complication rate than that of open appendectomy (OA), especially, high incidence of intra-abdominal abscess. The purpose of this article is to assess the feasibility of LA for complicated appendicitis. METHODS: A retrospective review of 35 LA and 128 OA for the cases of gangrenous, perforated appendicitis, and periappendiceal abscess between May 1995 and June 1997 was performed. Patients were identified through the hospital pathology registry. We compared data from both groups with respect to operative times, postoperative pain, duration of ileus, length of hospital stay, and complication rate, with special attention to the incidence of intra-abdominal abscess. RESULTS: 1) The male:female ratio of LA (1:1.2) was significantly lower than that of OA (1:0.45) (p0.05). But LA was associated with higher incidence of postoperative intra-abdominal abscess (3/35, 8.6%) than OA (3/128, 2.3%) (p=0.114). There was one serious intra-abdominal abscess in the LA, which required reoperation. The rest 2 cases in the LA and all 3 cases in the OA were treated conservatively. CONCLUSIONS: LA for complicated appendicitis could afford the merits of shorter hospital stay, reduced incidenceof wound infection, and comparable incidence of overall complication rate. To reduce the incidence of postoperative intra-abdominal abscess, copious irrigation and adequate drainage should be recommended.

Experience of stapled Unbalanced Uncut Roux-Y Gastrojejunostomy

Roux-en-Y reconstruction is an occasional occurrence of Roux-Y stasis syndrome, characterized by chronic abdominal pain, persistent nausea, and intermittent vomiting. Construction of the Roux limb requires transection of the jejunum, which disturbs normal propagation of pacesetter potential and evokes development of ectopic pacemakers in the Roux limb. Ectopic pacemakers in the Roux limb generate pacesetter potentials, which with their associated orally propagating contractions, result in slower transit through the Roux limb.To prevent the Roux stasis syndrome, a new operation has been designed that is similar to the standard Roux-en-Y gastrojejunostomy construction but theoretically without inherent motor pathophysiology. The authors designed a new unbalanced " Uncut Roux-en-Y" procedure to avoid postoperative blind loop syndrome and performed the procedures with staple occlusion of the afferent loop in 11 patients who required gastric resection and reconstruction, during a period of 6 months from April 1995 to September 1995. Results were summarized as follows. 1) 9 of the 11 patients( 81%) had excellent results with stable or increased weight and no stasis syndrome. 2) 2 patients(19%) had poor results with alkaline reflux gastritis or esophagitis. Both had documented staple line dehiscence. One of them was operated on and converted to a standard Roux operation, but died. The other one continued to loose weight but maintained a normal dietary pattern. 3) Unbalanced Roux technique worked well without harmful complications. 4) Reinforcing serosal sutures on the staple line could prevent a possible jejunal leakage in the case of staple line dehiscence and might prevent dehiscence of staple lines.

Clinical Analysis of Actinomycosis: 66 Cases of Korean Experience

Abdominal actinomycosis is a rare entity which presents some difficulty in establishing a correct preoperative diagnosis. The diagnosis is usually based on histologic demonstration of sulfur granules in pus or surgically resected specimen. Treatment has consisted of longterm antibiotic therapy coupled with surgery in complicated cases. The authors analyzed 66 patients of proven abdominal actinomycosis, who consisted of 53 cases previously reported in Korean literatures since 1966 and 13 cases treated at the department of General Surgery, Sae Gang General Hospital since 1990. The results were as follows. 1) Females were more frequently involved. The male to female ratio of abdominal actinomycosis was 1:2.1 and the mean age was 40.3 years-old. 2) Clinical features were different with each involved organ. However, most of the clinical symptoms were nonspecific to suspect actinomycosis. 3) The frequently involved sites were mainly located in the lower abdomen, such as the appendix, omentum, uterus and adnexa, ileocecum, colon, rectum, and small bowel. 4) In 59% of the patients, predisposing factors were identifiable. Identified possible factors were previous appendectomy, IUD, abdominal trauma, abortion, and perforative disorders of the GIT. 5) The preoperative diagnoses were intra-abdominal tumors or abscesses in 67% of the patients. Correct pre-exploratory diagnoses were made in 15% of the patients by using fine needle aspiration cytologic study, culture of drained pus, or direct tissue biopsy. 6) Explorations were performed in 88% of the patients to afford a proper surgical treatment and a correct diagnosis. After operation, almost all patients were treated with oral antibiotics for long periods. The authors conclude that pre-exploratory cytologic or culture study in patients who show uncomplicated low abdominal tumors or abscesses may increase the rate of correct diagnosis and could eliminate unnecessary explorations.