Postcholecystectomy syndrome: symptom clusters after laparoscopic cholecystectomy

PURPOSE: Postcholecystectomy syndrome (PCS) is characterized by abdominal symptoms following gallbladder removal. However, there is no consensus for the definition or treatment for PCS. The purpose of this study was to define PCS among various symptoms after laparoscopic cholecystectomy, and to identify risk factors affecting PCS. METHODS: This study was conducted at Dongguk University Ilsan Hospital and Chung-Ang University Hospital (2012–2013). Outcomes were assessed using European Organization for Research and Treatment of Cancer QLQ–C30 questionnaire. Symptom cluster for determining PCS was made by factor analysis. Cluster analysis evaluating risk factors of PCS was made by Ward methods and Dentogram. RESULTS: Factor analysis revealed three distinct symptom clusters, those are ‘insomnia and financial difficulties (eigenvalue, 1.707; Cronbach α, 0.190),’‘appetite loss and constipation (eigenvalue, 1.413; Cronbach α, 0.480),’ and ‘right upper quadrant (RUQ) pain and diarrhea (eigenvalue, 1.245; Cronbach α, 0.315).’ Among these symptom clusters, the cluster of ‘RUQ pain and diarrhea’ was determined as PCS. However, we could not find any risk factors between high symptomatic group and low symptomatic group. CONCLUSION: PCS could consist of RUQ pain and diarrhea. Well-designed prospective trials are needed to determine risk factors of PCS.

The Learning Curve for Laparoscopic Totally Extraperitoneal Herniorrhaphy by Logarithmic Function

PURPOSE: Totally extraperitoneal (TEP) hernia repair has gained in popularity in the past two decades. Despite the advantages TEP hernia repair, the approach is hindered by the relatively long learning curve of the surgery. We tried to estimate the necessary number of repetitions of TEP hernia repair in the learning curve using logarithmic and exponential function models. METHODS: We performed a retrospective review of all patients who underwent TEP hernia repair by a single surgeon consecutively at a single center. We calculated how many operations were needed to achieve a reduction in the expected operating time to mean operating time using logarithmic and exponential function models. RESULTS: In the 91 patients, the logarithmic function model predicted that 37 cases were needed to overcome the learning curve for TEP hernia repair while the exponential model predicted that 39 cases were needed. CONCLUSION: According to this study, at least 37 to 39 cases are needed in the overcome learning curve of TEP hernia repair. Further studies are needed to optimize surgical education and maximize quality.

What Are the Risk Factors for Complication in Transumbilical Single-Port Appendectomy?

PURPOSE: Along with the development of minimally invasive surgery, laparoscopic surgery has recently been adopted worldwide. In cases of laparoscopic appendectomy, single port appendectomy is increasingly being adopted due to its cosmetic advantages and reduced pain. This study was conducted to evaluate the risk factors associated with post-operative complications in single port appendectomy. METHODS: Forty-nine consecutive patients who underwent transumbilical single port appendectomy (TUSPLA) were enrolled in this study. We reviewed the initial WBC count, hsCRP, position of the appendix, and intra operative findings and then analyzed the data by univariate and multivariate analysis. RESULTS: Complications were observed in five of the 49 patients (10.2%). Specifically, wound complications were observed in three patients (6.1%), and periappendiceal fluid collection occurred in two patients (4.1%). Univariate analysis revealed a retrocecal type appendix (p=0.046) and overweight (BMI> or =23, p=0.034) as risk factors significantly correlated with the occurrence of complications. Conversely, retrocecal type appendix (p=0.121) and overweight (BMI> or =23, p=0.329) were not significantly correlated with complications upon multivariate analysis. CONCLUSION: For patients with a high risk of postoperative complications, including those with retrocecal appendix undergoing TUSPLA and obese patients, sufficient informed consent is necessary, and intensive monitoring for the incidence of complications must be considered postoperatively. However, further studies enrolling larger groups of patients should be conducted to confirm these findings.

What are Risk Factors Associated with Conversion to Open Appendectomy in Laparoscopic Appendectomy? / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic appendectomy has recently been performed more frequently than open appendectomy because of its advantages. Yet laparoscopic appendectomy has the risk of converting to open appendectomy. We evaluated the preoperative evaluation factors that can influence the rate of conversion to open appendectomy. METHODS: For the 255 patients admitted to our hospital, we reviewed their medical history, their clinical and laboratory examination etc. and the final diagnosis was made by CT scan. The preoperative characteristics of the patients who underwent laparoscopic appendectomy and the patients who were converted to open appendectomy were compared using univariate and multivariate analysis. RESULTS: Out of 255 patients who underwent laparoscopic appendectomy, 15 patients (5.8%) were converted to open appendectomy. The main reasons were adhesion and periappendiceal abscess formation. Periappendiceal fat infiltration (p=0.030) seen in the CT scan and perforation (p=0.019) were significant risk factors associated with converting to open appendectomy. CONCLUSION: Periappendiceal fat infiltration and perforation seen on preoperative CT scanning are important when considering performing laparoscopic appendectomy. Identifying the potential preoperative factors for conversion may assist surgeons when making decisions concerning the management of patients with appendicitis and for the judicious use of LA.

Bilaterality of Papillary Thyroid Carcinoma: Analysis of Clinicopathologic Factors and the Value of Preoperative Ultrasonography / 대한내분비외과학회지

PURPOSE: Papillary thyroid carcinoma (PTC) is the most common endocrine malignancy. The extent of the initial surgical treatment for PTC is still controversial and the bilaterality of PTC is an important factor for determining the extent of surgical resection. The aim of this study was to analyze clinicopathologic factors and the value of preoperative ultrasonography (PU) for bilateral tumor. METHODS: We retrospectively reviewed clinicopathologic factors and PU findings of 91 patients who underwent total thyroidectomy for PTC at the Dongguk University Ilsan Hospital from January 2006 to April 2009. RESULTS: Of the 91 patients, 28 (30.7%) had bilateral PTC in postoperative pathology. Of these 28 patients, only 18 patients (64.3%) were checked for bilateral PTC by PU findings and fine needle aspiration cytology. Sensitivity and specificity for bilaterality of PTC were 64.3% and 85.7%, respectively. The presence of benign nodules or malignant nodules in the same lobe in PU (P=0.008) and post-operative pathology (P=0.014) were statistically correlated with bilaterality. CONCLUSION: For the surgical care of PTC, bilaterality must always be considered, even though the tumor is diagnosed unilateral small PTC. PU in PTC patients has limited diagnostic value for bilateral PTC.

Strangulated Obturator Hernia: Mesh-Plug Technique

Although obturator herniae are rare, they are associated with a high mortality, as diagnosis is often delayed and the condition tends to occur in the elderly. The preoperative diagnosis is difficult because of nonspecific symptoms and sign. They often produce a small bowel obstruction. The treatment is always surgical. Several repair techniques have been described: a sac ligation alone, a direct suture repair, and the use of autologous tissue or prosthetic repair. Recently, the placement of permanent mesh prostheses, in a clean contaminated operative field, has been performed due to the minimal wound-related morbidity and patient mortality. Thus, utilization of a permanent mesh in an obturator hernia is a new, simple and effective method for repair. Two cases of a strangulated obturator hernia were experienced in elderly women. The peritoneal cavity was not overly contaminated, with only necrotic foci on the herniated small bowel wall noted. A segmental resection of the small bowel was performed. Consequently, the hernia defect was closed with mesh- plug between the peritoneum and periosteum of the obturator foramen. Here, two cases of obturator herniae treated by use of a mesh-plug are reported, with a brief review of the literature.

Clinical Significance of the Colorectal Polyps

The aim of this study was to investigate the association of colorectal polyps with carcinoma of the colon and rectum. METHODS: Between January 1995 and December 1998, 203 consecutive patients with 423 colorectal polyps retrospectively documented at the Department of General Surgery and College of Medicine in Dongguk University. RESULTS: The peak age group of the colorectal polyp was in the fifth decades (33.5%). The proportions of malignant polyps were as follows: for size, 5.2% of polyps less than 1.0 cm and 19.5% of polyps larger than 1 cm (P0.05); for number of polyp, 4.5% in cases of single polyp and 25.0% in cases of multiple polyps (P<0.05); for underlying histology, 9.2% in cases of tubular adenoma and 19.2% in cases of villous adenoma (p<0.05). The presence of distal adenomatous polyp was increased the risk of presence of the proximal adenomas (59.7%), whereas the presence of hyperplastic polyp did not (16.7%). CONCLUSIONS: The malignant potential of colorectal polyps are correlated with size, histologic type, morphologic shape, multiplicity and distal location. The presence of hyperpalstic polyp should not be indication for colonoscopy because they are not associated with proximal adenoma when adjusting for patient characteristics and presence of distal adenoma.

The Significance of Serum Carcinoembryonic Antigen in Curative Surgery of Colorectal Cancer

Carcinoembryonic antigen (CEA) in now the most widely used and the most useful marker for many cancers, including those of the colon, lung, pancreas, and breast. Also CEA is widely used for detection, staging, recurrence, and assessing the response to therapy in colorectal cancer. METHODS: From 1992 to 1998 the clinical value of the pre- and postoperative serum levels of CEA who underwent curative surgery at Department of General Surgery, College of Medicine, Dongguk University KyungJu Hospital, in 140 s patient with colorectal cancer with abnormal levels of CEA (>or=5 ng/ml) was investigated. RESULTS: The results are as follows: 1) The positive rate of preoperative CEA level was 47%, so preoperative CEA level measurement was not useful as screening test for colorectal cancer. 2) There was no significant association between abnormal CEA level and the location of tumor. 3) There was significant association between increased levels of preoperative serum CEA and lymph node metastases. 4) The incidence of preoperatively elevated CEA levels in Dukes stages A, B, C, and D was 0%, 27%, 63%, 71%, respectively. There was significant association between increased levels of the preoperative serum CEA and the progressive stages of colorectal cancers. 5) There was no significant association between abnormal CEA level and histologic differentiation of tumor. In addition, there was no significant association between abnormal CEA level and ploidy status of tumor. 6) The recurrence rate was 20% and 77% in patients with preoperative levels of CEA5 ng/ml, respectively. 7) The recurrence rate was 11% and 64% in patients with postoperative levels of CEA 5 ng/ml, respectively. 8) Considering as normal CEA levels up to 5.0 ng/ml, sensitivity was found to be 77%, specificity, 80%, and predictive value of an elevated CEA concentration, 77%. CONCLUSIONS: In conclusion, it is suggested that measurement of preoperative and serial postoperative CEA is very useful in assessing the prognosis and in detecting recurrences in colorectal cancer.

Significance of Heat Shock Protein 70 and Sulphomucin Expression in Gastric Adenocarcinomas

BACKGROUND: The heat shock proteins (HSPs) are stress-responsive genes present in all species and play a major role in many cellular processes. These proteins are highly conserved molecules whose expression is induced in eukaryotic cells by a variety of environmental stresses. These proteins can also be expressed in virally transformed cells and cancer cells. Especially, HSP70 is found at a higher level in growing cells than in resting cells. Sulphomucin is secreted by immature foveolar cells of stomach and expressed in gastric adenocarcinomas. Also, it is known that the population of sulphomucin-producing cells increases with long-lasting stress. The purpose of this study was to determine HSP70 and sulphomucin expressions in gastric adenocarcinoma and the significance of expressions. METHODS: Thirty-one paraffin-embeded surgical specimens of gastric adenocarcinomas were obtained from April 1992 to March 1995 and were selected for analysis. The expressions of HSP70 and sulphomucin were analyzed by immunohistochemical staining with HSP70 monoclonal antibody and the Spicer (HID) method. RESULTS: The expressions of HSP70 and sulphomucin were positive in 13 (42%) cases and 11 (35%) cases, respectively. The expression of HSP70 correlated with neither clinopathological factors nor sulphomucin expression. There was a significant correlation not only between sulphomucin expression and histologic differentiation (p=0.001) but also between disease-free survival and sulphomucin expression. CONCLUSIONS: Sulphomucin expression in gastric adenocarcinoma may be useful as a prognostic factor of gastric adenocarcinomas.

A Case of Ulceroglandular Tularemia

Tularemia is a zoonosis caused by Francisella tularensis. It is primarily a disease of wild animals. Human infection is incidental and usually results from interaction with biting or blood-sucking insects, wild or domestic animals, or the environment. An increasing number of cases have been reported in several countries. However, in Korea it has not been reported until now. A 40-year old male patient visited our department on Jan 13, 1997, complaining of multiple swollen lymph-nodes on his axillae and reddish swollen left upper arm which contained an abscess at its central portion for about ten days. On Dec 25, 1996, he found a dead wild rabbit on a nearby mountainside, ate it after cooking it by himself with his hands injured. His abscess was drained and microbiologic examination was done. However no microorganism was isolated. His lymph nodes were surgically removed from both axillae, and we investigated them microbiologically and pathologically. On microbiologic examination, small aerobic gram negative coccobacilli were grown on a chocolate agar plate in an aerobic condition with 5% CO2 at 37 degrees centigrade. On H & E staining, the lymph node showed chronic granulomatous inflammation. We sent the microorganism and lymph nodes to the Centers for Disease Control and Prevention in the United States of America for the definitive diagnosis. Finally the microorganism was identified as F. tularensis by culture morphology, biological tests and immunohistochemical staining. We report the first case of F. tularensis in Korea.

Comparison of Laparoscopic Cholecystectomy and Minilaparotomy Cholecystectomy

BACKGROUND: Cholecystectomy is the standard treatment for gallbladder stones and at present is performed in minimally invasive procedures. There are several advantages to a laparoscopic cholecystectomy, so now it is a popular procedure for use in a cholecystectomy. Also, a minilaparotomy cholecystectomy is an alternative method to a traditional open cholecystectomy and results in a smaller incision than a traditional open cholecystectomy. METHODS: We analyzed outcomes following laparoscopic and minilaparotomy cholecystectomy. 74 patients with gallstones were included. 45 patients were treated by a laparoscopic cholecystectomy and 29 patients were treated by a minilaparotomy cholecystectomy. RESULTS: Compared to the minilaparotomy cholecystectomy, the laparoscopic cholecystectomy resulted in a shorter mean hospital stay, a faster mean time to diet, and a longer mean operating time. During the first postoperative 24 hours more analgesics were used in the minilaparotomy cholecystectomy than in the laparoscopic cholecystectomy, and the laparoscopic cholecystectomy was more expensive than the minilaparotomy cholecystectomy. Postoperative complications occurred in 3 patients receiving a lapaaroscopic cholecystectomy and 1 patient receiving a minilaparotomy cholecystectomy. Conversion from a laparoscopic cholecystectomy to a traditional open cholecystectomy was necessary in 2 patients; no conversion to a traditional cholecystectomy was necessary in the minilaparotomy cholecystectomy. CONCLUSIONS: This study has proven the advantages of a laparoscopic cholecystectomy to be shorter hospitalization, less pain, and better cosmetic effect. Also, a minilaparotomy cholecystectomy has the advantages of a laparoscopic cholecystectomy and can be performed more safely.