High rates of complications in advanced stage gastric cancer after laparoscopic gastrectomy

PURPOSE: The inclusion criteria for laparoscopic gastrectomy have recently been expanded, and this has led to an increase in the number of publications describing the laparoscopic treatment of advanced gastric cancer. The aim of this study was to evaluate morbidity in advanced stage gastric cancer (ASGC; tumor, node, metastasis [TNM] stage II–III) compared with that in early stage gastric cancer (ESGC; TNM stage I) in patients undergoing laparoscopic assisted distal gastrectomy (LADG).METHODS: The clinical data of 448 consecutive patients who underwent LADG with R0 resection for gastric cancer at the Gyeongsang National University Hospital were retrospectively analyzed.RESULTS: The morbidity and mortality rates for radical distal gastrectomy were 20.3% (91/448) and 0.2% (1/448), respectively. Wound problems were the most common complication (4.7%, n=21), followed by leakage (4.5%, n=20), and postoperative bleeding (3.8%, n=17). We found ASGC had higher frequencies of postoperative ileus (0.8% vs. 5.4%), wound problems (3.1% vs. 10.9%), and pulmonary complications (4% vs. 7%) than ESGC in the LADG (P < 0.05).CONCLUSION: Among patients who underwent LADG, ASGC patients had higher rates of postoperative ileus and wound and pulmonary complications than ESGC patients. ASGC patients should be closely monitored for these complications after LADG.

Overexpression of Neuron-Specific Enolase as a Prognostic Factor in Patients with Gastric Cancer

PURPOSE: Enolase is a cytoplasmic enzyme that catalyzes the conversion of 2-phosphoglycerate to phosphoenolpyruvate in the glycolytic pathway. The aim of this study was to investigate whether the overexpression of neuron-specific enolase (NSE) can serve as a prognostic factor in patients with gastric cancer (GC). MATERIALS AND METHODS: To assess its prognostic value in GC, NSE expression was measured by immunohistochemistry in a clinically annotated tissue microarray comprising of 327 human GC specimens. Cytoplasmic NSE expression was scored from 0 to 4, reflecting the percentage of NSE-positive cells. RESULTS: In terms of histology as per the World Health Organization criteria (P=0.340), there were no differences between the NSE overexpression (NSE-OE) and NSE underexpression (NSE-UE) groups. The NSE-OE group showed a significantly lower rate of advanced GC (P<0.010), lymph node metastasis (P=0.010), advanced stage group (P<0.010), cancer-related death (P<0.010), and cancer recurrence (P<0.010). Additionally, a Kaplan-Meier survival analysis revealed that the NSE-OE group had longer cumulative survival times than the NSE-UE group (log-rank test, P<0.010). However, there were no significant differences in the serum levels of NSE expression in patients with GC and healthy volunteers (P=0.280). CONCLUSIONS: Patients with NSE overexpressing GC tissues showed better prognostic results, implying that NSE could be a candidate biomarker of GC.

A Case of Advanced Gastric Cancer with Para-Aortic Lymph Node Metastasis from Co-Occurring Prostate Cancer

An 84-year-old man was diagnosed with two synchronous adenocarcinomas, a Borrmann type IV advanced gastric adenocarcinoma in his antrum and a well-differentiated Borrmann type I carcinoma on the anterior wall of the higher body of his stomach. Pre-operatively, computed tomography of the abdomen revealed the presence of advanced gastric cancer with peri-gastric and para-aortic lymph node (LN) metastasis. He planned for palliative total gastrectomy owing to the risk of obstruction by the antral lesion. We performed a frozen biopsy of a para-aortic LN during surgery and found that the origin of the para-aortic LN metastasis was from undiagnosed prostate cancer. Thus, we performed radical total gastrectomy and D2 LN dissection. Post-operatively, his total prostate-specific antigen levels were high (227 ng/mL) and he was discharged 8 days after surgery without any complications.

Unsuspected Duplicated Gallbladder in a Patient Presenting with Acute Cholecystitis

Duplicated gallbladder (GB) is a rare congenital disease. Surgical management of a duplicated GB needs special care because of concurrent bile duct anomalies and the risk of injuring adjacent arteries during surgery. An 80-year-old man visited an emergency room with right upper quadrant abdominal pain. Computed tomography (CT) revealed cholecystitis with a 2-bodied GB. Because of this unusual finding, magnetic resonance choledochopancreatography was performed to detect possible biliary anomalies. The 2 GB bodies were unified at the neck with a common cystic duct, a so-called V-shaped duplicated GB. The patient's right posterior hepatic duct joined the common bile duct (CBD) near the cystic duct. The patient underwent laparoscopic cholecystectomy without adjacent organ injury, and was discharged uneventfully. Surgeons should carefully evaluate the patient preoperatively and select adequate surgical procedures in patients with suspected duplicated GB because of the risk of concurrent biliary anomalies.

Relationship between low body mass index and morbidity after gastrectomy for gastric cancer

PURPOSE: This study aimed to evaluate the association between low body mass index (BMI) and morbidity after gastric cancer surgery. METHODS: A total of 1,805 patients were included in the study. These subjects had undergone gastric cancer surgery at a single institution between January 1997 and December 2013. Clinicopathologic and morbidity data were analyzed by dividing the patients into 2 groups: underweight patients (BMI < 18.5 kg/m2) and nonunderweight patients (BMI ≥ 18.5 kg/m2). RESULTS: The overall complication rate as determined by our study was 24.4%. Pulmonary complications occurred more frequently in the underweight group (UWG) than in the non-UWG (10.5% vs. 3.8%, respectively; P = 0.012). Multivariate analysis revealed two independent factors responsible for postoperative pulmonary complications—weight of the patients (UWG vs. non-UWG, 10.8% vs. 3.8%; P < 0.007) and stage of gastric cancer (early stage vs. advanced stage, 3.1% vs. 6.8%; P < 0.023). Multivariate analysis revealed that underweight (UWG vs. non-UWG, 10.8% vs. 3.8%, respectively, P < 0.007) and advanced cancer stage (early stage vs. advanced stage, 3.1% vs. 6.8%, respectively, P = 0.023) were significant risk factors for postoperative pulmonary complications. CONCLUSION: We concluded that underweight patients had a higher pulmonary complication rate. Additionally, underweight and advanced cancer stage were determined to be independent risk factors for the development of postoperative pulmonary complications.

Lateral Lymph Node Metastasis Prediction in Papillary Thyroid Cancer Patients with Suspicious Preoperative Imaging Findings / 대한내분비외과학회지

PURPOSE: Lateral lymph node metastasis of papillary thyroid cancer (PTC) is indicative of tumor aggressiveness and can determine treatment strategies. However, the role of prophylactic lateral lymph node dissection in the management of PTC is unclear. This study evaluated factors predictive of lateral lymph node metastasis in patients with suspicious lymph node enlargement in preoperative imaging. METHODS: This retrospective study included 728 patients with newly diagnosed PTC who underwent therapeutic surgery. Clinicopathologic results were reviewed, and factors predictive of lateral lymph node metastasis were analyzed. RESULTS: Of the 242 patients with lymph node metastasis, 50 had lateral lymph node metastasis. Lateral lymph node metastasis was associated with sex, tumor size, preoperative thyroid stimulating hormone (TSH) concentration and presence of central lymph node metastasis. Among patients with suspicious lateral lymph node metastasis by ultrasonography, high TSH level (odds ratio 3.833, P=0.031) and number of metastatic central lymph nodes (odds ratio 3.68, P=0.025) were significantly predictive of lateral lymph node metastasis. CONCLUSION: High serum TSH level and central lymph node metastasis were predictive of lateral lymph node metastasis in PTC patients with suspicious preoperative imaging findings. These predictive factors might help reduce unnecessary therapeutic lateral lymph node dissection.

A case of gallbladder cancer combined with ectopic individual opening of pancreatic and bile ducts to the duodenal bulb

Ectopic opening of the pancreatic and bile ducts (EOPBD) into the duodenal bulb is an extremely rare congenital anomaly with unknown clinical implications. We presented a case of gallbladder cancer with EOPBD into the duodenal bulb. A 57-year-old male was referred to our hospital with intermittent right upper abdominal pain. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography showed individual EOPBD into the duodenal bulb with no papillary structure, and a focal nodular lesion in the gallbladder. A follow-up abdominal computed tomography scan 9 months later revealed a slight increase in the size of the fundal nodule, which was suspected as gallbladder cancer. An intraoperative frozen biopsy identified the nodular lesion as adenocarcinoma involving the cystic duct, and the patient underwent radical cholecystectomy including bile duct resection with hepaticojejunostomy. EOPBD is an extremely rare condition that can be associated with gallbladder malignancy as well as benign disease. Clinicians should follow up carefully and consider surgical treatment for suspected malignant lesions.

Surgical Strategy for Colonic Intussusception Caused by a Giant Colonic Lipoma: A Report of Two Cases and a Review of the Literature

A colon lipoma is a remarkably rare tumor. In most cases, the tumors are asymptomatic and small in size, need to be differentiated from malignant tumors, and do not need any special treatment. Selection of the right surgical strategy depends on the status of bowel, as well as the size and the location of tumor. We encountered two patients with giant submucosal lipomas that had induced intussusceptions: one with a lipoma in the transverse colon and the other with a lipoma in the ascending colon. The diagnoses were made by using histological examinations. We report the clinical features, diagnoses, and treatments of, as well as our experience with, these two uncommon cases, and we present a review of the literature on this subject.

Current status of the use of antiadhesive agents for gastric cancer surgery: a questionnaire survey in South Korea / 대한외과학회지

PURPOSE: The aim of this study was to investigate the current status of the use of antiadhesive agents (AAdAs) via a questionnaire and to discuss the availability of AAdAs. METHODS: The survey was sent to a list of members that was approved by the Korean Gastric Association. The survey included questions on AAdA use by surgeons, the type of AAdAs used, and the reasons for not using AAdAs. Surgeons were also asked to describe complications related to AAdAs, and the reliability of its use. RESULTS: The response rate was 21%. The rates of frequent use stratified by procedure were 26.9% (14/52) for open gastrectomy, 5.9% (3/51) for laparoscopic gastrectomy, and 31.5% (17/54) for surgery for postoperative bowel obstruction (P < 0.01). After including data from the occasional use group, the corresponding values were 51.9% (27/52), 19.6% (10/51), and 70.4% (38/54), respectively (P < 0.01). Sefrafilm and Guardix were most commonly used for open procedures. Guardix and Interceed were most commonly used for laparoscopic surgery. The primary reasons for nonuse of AAdAs were ineffectiveness and high cost. Ten percent (4/40) of surgeons observed complications associated with AAdAs. A minority (17.3%, 9/52) had positive attitudes toward AAdAs. The majority of respondents expressed neutral (73.1%, 38/52) or negative (9.6%, 5/52) attitudes toward AAdAs. CONCLUSION: The low use rates of AAdAs in gastric cancer surgery may be attributable to perceptions that AAdAs are ineffective, unreliable, and costly. We anticipate the emergence of promising antiadhesive strategies that reach far beyond the limitations of current products.

Acute gastric volvulus treated with laparoscopic reduction and percutaneous endoscopic gastrostomy / 대한외과학회지

Acute gastric volvulus requires emergency surgery, and a laparoscopic approach for both acute and chronic gastric volvulus was reported recently to give good results. The case of a 50-year-old patient with acute primary gastric volvulus who was treated by laparoscopic reduction and percutaneous endoscopic gastrostomy is described here. This approach seems to be feasible and safe for not only chronic gastric volvulus, but also acute gastric volvulus.

Effectiveness of endoscopic clipping and computed tomography gastroscopy for the preoperative localization of gastric cancer / 대한외과학회지

PURPOSE: Before laparoscopic gastrectomy for gastric cancer can be planned, it is very important to know the precise location of the tumor. The aim of this study was to evaluate 3 methods of predicting the exact location of the tumor: preoperative gastrofibroscopy (GFS), preoperative computed tomography gastroscopy (CT), and intraoperative gastroscopy-guided laparoscopy (Lap). METHODS: In this study, 15 patients were prospectively identified, and endoscopic clips were preoperatively placed on the proximal 1 cm of the tumor, at the angle on the greater curvature and opposite the angle on the greater curvature. The distances between the pylorus and the proximal tumor clip (PT), the angle clip (PA), the greater curvature clip (PG), and the gastroesophageal junction were measured by preoperative GFS, preoperative CT, intraoperative Lap, and visual inspection (Vis). RESULTS: PT, PA, and PG values measured by preoperative GFS differed significantly from the Vis values (P < 0.01). However, preoperative CT measurements of PT, PA, and PG did not differ from the Vis values (P = 0.78, P = 0.48, and P = 0.53, respectively). Intraoperative Lap and Vis PT values differed by only 1.1 cm on an average (P = 0.10), but PA and PG values varied by 1.9 and 3.4 cm, respectively (P = 0.01 for both). CONCLUSION: Endoscopic clipping combined with preoperative CT gastroscopy is more useful than preoperative GFS for preoperatively predicting the location of early gastric cancers and will be helpful for planning laparoscopic gastrectomy.

The Effect of Subconjunctival Bevacizumab Injection after Primary Pterygium Surgery

PURPOSE: To evaluate the effect and safety of subconjunctival bevacizumab injection immediately after primary pterygium surgery. METHODS: From October 2010 to June 2011, 54 patients (54 eyes) with primary pterygium who had received pterygium excision with the bare sclera technique were evaluated. Twenty-seven patients (27 eyes) in the bevacizumab group received a subconjunctival injection of 5 mg (0.2 ml) bevacizumab and 27 patients (27 eyes) in the control group received a subconjunctival injection of 0.2 ml balanced salt solution immediately after surgery. At the 6-month follow-up, the degree of fibrovascular tissue proliferation, the recurrence rate of pterygium and the effect of wound healing were analyzed prospectively. RESULTS: One month after the surgery, the degree of fibrovascular tissue proliferation was inhibited in the bevacizumab group compared to the control group (p = 0.028). However, 3 to 6 months after surgery, there was no significant difference between the 2 groups. In addition, there was no significant difference between the 2 groups in the recurrence rate of pterygium and wound healing after surgery. CONCLUSIONS: Subconjunctival bevacizumab injection after primary pterygium surgery inhibited the degree of fibrovascular tissue proliferation for 1 month and safe for wound healing. Subconjunctival bevacizumab injection has the potential for adjunctive therapy after pterygium surgery.

Totally Laparoscopic Distal Gastrectomy after Learning Curve Completion: Comparison with Laparoscopy-Assisted Distal Gastrectomy

PURPOSE: The aims are to: (i) display the multidimensional learning curve of totally laparoscopic distal gastrectomy, and (ii) verify the feasibility of totally laparoscopic distal gastrectomy after learning curve completion by comparing it with laparoscopy-assisted distal gastrectomy. MATERIALS AND METHODS: From January 2005 to June 2012, 247 patients who underwent laparoscopy-assisted distal gastrectomy (n=136) and totally laparoscopic distal gastrectomy (n=111) for early gastric cancer were enrolled. Their clinicopathological characteristics and early surgical outcomes were analyzed. Analysis of the totally laparoscopic distal gastrectomy learning curve was conducted using the moving average method and the cumulative sum method on 180 patients who underwent totally laparoscopic distal gastrectomy. RESULTS: Our study indicated that experience with 40 and 20 totally laparoscopic distal gastrectomy cases, is required in order to achieve optimum proficiency by two surgeons. There were no remarkable differences in the clinicopathological characteristics between laparoscopy-assisted distal gastrectomy and totally laparoscopic distal gastrectomy groups. The two groups were comparable in terms of open conversion, combined resection, morbidities, reoperation rate, hospital stay and time to first flatus (P>0.05). However, totally laparoscopic distal gastrectomy had a significantly shorter mean operation time than laparoscopy-assisted distal gastrectomy (P<0.01). We also found that intra-abdominal abscess and overall complication rates were significantly higher before the learning curve than after the learning curve (P<0.05). CONCLUSIONS: Experience with 20~40 cases of totally laparoscopic distal gastrectomy is required to complete the learning curve. The use of totally laparoscopic distal gastrectomy after learning curve completion is a feasible and timesaving method compared to laparoscopy-assisted distal gastrectomy.

A Stercoral Perforation of the Rectum

A stercoral perforation of the rectum due to a fecaloma is a rare disease with a high mortality rate. Although multiple case reports of colonic perforations have been published, the data regarding rectal perforations are limited. This case report will highlight one such case of a stercoral rectal perforation that was successfully treated with a laparoscopic operation.

Identification of Prognostic Factors for In-Hospital Mortality in Acute Mesenteric Ischemia / 대한혈관외과학회지

PURPOSE: The purpose of this study was to determine the prognostic factors and risk scorings that could have an impact on the in-hospital mortality of acute mesenteric ischemia (AMI). METHODS: Forty consecutive patients received an operation due to AMI between January 2001 and June 2009. The hospital medical charts and clinical records were retrospectively reviewed. Clinical features, laboratory findings, operative findings, surgical procedure, and prognostic scoring system were collected and assessed as possible the prognostic factors for in-hospital mortality. RESULTS: The overall hospital mortality rate was 32.5% (13/40). In a univariate analysis, significant predictors of in-hospital mortality were decreased mentality (P=0.029), shock at admission (P=0.006), symptom duration (P=0.011), blood urea nitrogen (P=0.029), serum creatinine (PII) (P=0.02) were identified as independent prognostic factors of in-hospital mortality. CONCLUSION: In conclusion, the prognostic factors in AMI who have hyperglycemia (>200 mg/dL) and high ASA grading (>II) are truly associated with very high in-hospital mortality.

Laparoscopic left hemihepatectomy for left intrahepatic duct stones / 대한외과학회지

PURPOSE: The feasibility of laparoscopic left hemihepatectomy for the management of intrahepatic duct (IHD) stones was evaluated. METHODS: The clinical data of 26 consecutive patients who underwent total laparoscopic left hemihepatectomy for IHD stones at Gyeongsang National University Hospital between January 2009 and June 2011 were reviewed retrospectively. RESULTS: The mean operation time was 312.1 +/- 63.4 minutes and the mean postoperative hospital stay was 11.8 +/- 5.0 days. There were 2 cases of postoperative bile leakage and 3 cases of intra-abdominal fluid collection, which were successfully managed conservatively. Remnant stones were detected in 2 patients. The initial success rate of stone clearance was 92.3% (24 of 26). The remnant stones were located in the common bile duct in both cases and were removed by endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Therefore, the final success rate of stone clearance was 100% (26 of 26). During a mean follow-up of 22 months (range, 7 to 36 months), there was no patient with recurrent stone. CONCLUSION: Laparoscopic surgery could be an effective treatment modality for the management of IHD stones in select patients.

Two Cases of Bone Metastasis from Follicular Thyroid Carcinoma Several Years after Initial Thyroidectomy / 대한내분비외과학회지

A 78-year-old woman presented with epigastric discomfort with nausea, and an abdominal CT revealed a rib mass and gall bladder polyp. She had had a subtotal thyroidectomy of a 4.2×3 cm-sized follicular thyroid carcinoma 19 years ago. The rib mass was excised and its histological examination showed a metastatic carcinoma from a follicular thyroid carcinoma. One month later we carried out a completion thyroidectomy, and we will perform radioactive ablation with ¹³¹I. A 64-year-old woman presented to our clinic for leg motor weakness and we found a T7 pathologic fracture by X-ray and MRI. She had had a left thyroid lobectomy for a minimal invasive follicular thyroid carcinoma measuring 4 cm at the greatest diameter. Anterior-decompression and fusion were carried out, and histological examination showed a metastatic lesion from the thyroid. Then we performed a completion thyroidectomy and 131I radioactive ablation one month later. Radioactive ablation should be performed for large-sized follicular carcinomas to prevent recurrences.

Analysis of Risk Factors for Postoperative Morbidity in Perforated Peptic Ulcer

PURPOSE: Emergency operations for perforated peptic ulcer are associated with a high incidence of postoperative complications. While several studies have investigated the impact of perioperative risk factors and underlying diseases on the postoperative morbidity after abdominal surgery, only a few have analyzed their role in perforated peptic ulcer disease. The purpose of this study was to determine any possible associations between postoperative morbidity and comorbid disease or perioperative risk factors in perforated peptic ulcer. MATERIALS AND METHODS: In total, 142 consecutive patients, who underwent surgery for perforated peptic ulcer, at a single institution, between January 2005 and October 2010 were included in this study. The clinical data concerning the patient characteristics, operative methods, and complications were collected retrospectively. RESULTS: The postoperative morbidity rate associated with perforated peptic ulcer operations was 36.6% (52/142). Univariate analysis revealed that a long operating time, the open surgical method, age (> or =60), sex (female), high American Society of Anesthesiologists (ASA) score and presence of preoperative shock were significant perioperative risk factors for postoperative morbidity. Significant comorbid risk factors included hypertension, diabetes mellitus and pulmonary disease. Multivariate analysis revealed a long operating time, the open surgical method, high ASA score and the presence of preoperative shock were all independent risk factors for the postoperative morbidity in perforated peptic ulcer. CONCLUSIONS: A high ASA score, preoperative shock, open surgery and long operating time of more than 150 minutes are high risk factors for morbidity. However, there is no association between postoperative morbidity and comorbid disease in patients with a perforated peptic ulcer.

Diagnosis of a Trocar Site Mass as Omental Herniation after Laparoscopic Gastrectomy

A trocar site hernia is a rare complication. We report a patient who had an abdominal wall mass at a previous trocar site after laparoscopic distal gastrectomy. It was diagnosed as omental herniation and fat necrosis. We conclude that patients with trocar site masses exhibiting fat density on a computed tomography scan could be followed up without surgery, and that fascial defects located at 10-mm or larger trocar sites should be closed whenever possible to prevent hernia formation.

Clinical features and prognostic factors in papillary thyroid microcarcinoma depends on age / 대한외과학회지

PURPOSE: Clinical outcomes of papillary thyroid microcarcinoma (PTMC) vary. In general, age at diagnosis is an independent prognostic factor in conventional papillary thyroid carcinoma. However, it is unclear in patients of PTMC. The purpose of this study was to identify clinicopathologic features and prognostic factors of PTMC according to patients' age. METHODS: Five hundred twenty-seven patients who received thyroid surgery and diagnosed as having PTC between January 2001 and December 2009 were included. The clinical data were retrospectively analyzed. RESULTS: We divided the patients into two groups; group I who were younger than 45 years, and group II who were 45 years old or older. The mean tumor size and incidences of neck lymph nodes involvement of group I was larger than group II. In group II, however, there were more patients who had multiple cancer foci and were body mass index > or = 25 kg/m2. The overall incidence of recurrent disease was 3.2%. The incidence of recurrence was higher in group II (2.0% vs. 4.0%), without a statistical difference. In multivariate analysis, the significant risk factors of recurrence were male gender and multifocality in group I, and lymph node metastasis and multifocality in group II. In particular, the male gender and multifocality showed the highest odds ratio (OR) on each group (OR, 4.721 and 6.177). CONCLUSION: The patients with PTMCs had different clinical features and prognostic factors according to age. Hence, clinicians should consider a different strategy for therapy and plan for follow-up according to age.