Postoperative Shoulder Pain after Laparoscopic Surgery

We often encounter patients complaining of shoulder pain after laparoscopic surgery. The pain mechanism is believed to be due to the diaphragmatic overstretching under pressure in a pneumoperitoneum, which causes referred pain to the shoulder, but the exact mechanism has not been clarified.

Laparoscopic Pediatric Inguinal Hernia Repair; Intracorporeal Purse-String Suture Using Needlescopic 2-mm Instruments

Purpose@#Two-millimeter needlescopic instruments induce minimal damage to the abdominal wall and have excellent cosmetic benefits. We aimed to evaluate the feasibility of a laparoscopic intracorporeal suture using 2-mm instruments for pediatric inguinal hernia. @*Methods@#We retrospectively reviewed 131 patients who underwent laparoscopic repair between March 2011 and February 2017. Three trocars were used: a 5-mm umbilical trocar for a needle holder and two 2-mm trocars for a camera and a grasper. The internal ring was closed with an intracorporeal purse-string suture. A telephone interview was conducted to confirm recurrence. @*Results@#In the 131 patients, 169 procedures were successfully performed. The ages ranged from 2 months to 14 years (mean, 52.5 months), and the mean body weight was 18.0 kg (range, 6.7~49 kg). The mean operating time was 42 minutes for the unilateral cases and 46 minutes for the bilateral inguinal hernia repairs. All the cases were completed laparoscopically without intraoperative complications. Herniotomy was not performed in all the patients except nine. A contralateral patent processus vaginalis was present in 27.3% (35/128) of the patients. During the mean follow-up period of 54.6 months, 3 recurrences (2.3%) were observed. Two recurrences were treated using laparoscopy and one using open herniorrhaphy. Hydrocele occurred in one male patient. No wound complications or umbilical hernias developed. No testicular atrophy was observed. @*Conclusion@#This study showed that laparoscopic intracorporeal internal ring suture using 2-mm instruments for pediatric inguinal hernia was technically feasible and safe, with excellent cosmetic results.

Laparoscopic Surgery for Colorectal Cancer in Korea: Nationwide Data from 2013 to 2018 / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#We report nationwide data on the current status of laparoscopic surgery for colorectal cancer (CRC) in Korea. @*Materials and Methods@#Nationwide data of patients who underwent surgery for CRC from 2013 to 2018 were obtained from the Health Insurance Review & Assessment Service database. Data and trends of laparoscopy use for colorectal resection over six years were examined. @*Results@#In Korea, a total of 117,320 patients underwent surgical resection for CRC from 2013 to 2018. The proportion of laparoscopic resection increased from 64.9% in 2013 to 78.5% in 2018. The rate of laparoscopic resection for colon cancer increased from 64.7% in 2013 to 77.4% in 2018. For rectal cancer, the rate of laparoscopic resection increased from 65.4% to 81.6%. Males accounted for 59.8% of all patients, but females surpassed males at over 80 years of age. The age of peak incidence was in the 60s for males and in the 70s for females. A steady increase in the number of patients undergoing surgery for CRC was observed over 80 years of age. @*Conclusion@#The laparoscopic penetration rate for CRC in Korea continued to increase annually and reached 78.5% in 2018.

Postoperative Outcomes of Stoma Takedown: Results of Long-term Follow-up

PURPOSE: Stoma takedown is a frequently performed procedure with considerable postoperative morbidities. Various skin closure techniques have been introduced to reduce surgical site infections. The aim of this study was to assess postoperative outcomes after stoma takedown during a long-term follow-up period. METHODS: Between October 2006 and December 2015, 84 consecutive patients underwent a colostomy or ileostomy takedown at our institution. Baseline characteristics and perioperative outcomes were analyzed through retrospective reviews of medical records. RESULTS: The proportion of male patients was 60.7%, and the mean age of the patients was 59.0 years. The overall complication rate was 28.6%, with the most common complication being prolonged ileus, followed by incisional hernia, anastomotic leakage, surgical site infection, anastomotic stenosis, and entero-cutaneous fistula. The mean follow-up period was 64.3 months. The univariate analysis revealed no risk factors related to overall complications or prolonged ileus. CONCLUSION: The postoperative clinical course and long-term outcomes following stoma takedown were acceptable. Stoma takedown is a procedure that can be performed safely.

Impact of Adjuvant Therapy Type on Survival in Stage II/III Rectal Cancer Without Preoperative Chemoradiation: A Korean Multicenter Retrospective Study

PURPOSE: This study compared the oncologic impact of postoperative chemotherapy and chemoradiotherapy on patients with rectal cancer without preoperative chemoradiation. METHODS: This retrospective study analyzed 713 patients with a mean follow-up of 58 months who had undergone radical resection for stage II/III rectal cancer without preoperative treatment in nine hospitals from January 2004 to December 2009. The study population was categorized a chemotherapy group (CG, n = 460) and a chemoradiotherapy group (CRG, n = 253). Five-year overall survival (OS) and disease-free survival (DFS) were analyzed, and independent factors predicting survival were identified. RESULTS: The patients in the CRG were significantly younger (P < 0.001) and had greater incidences of low rectal cancer (P < 0.001) and stage III disease (P < 0.001). Five-year OS (P = 0.024) and DFS (P = 0.012) were significantly higher in the CG for stage II disease; however, they were not significantly different for stage III disease. In the multivariate analysis, independent predictive factors were male sex, low rectal cancer and stage III disease for OS and male sex, abdominoperineal resection, stage III disease and tumor-positive circumferential margin for DFS. However, adjuvant therapy type did not independently affect OS (hazard ratio [HR], 1.243; 95% confidence interval [CI], 0.794–1.945; P = 0.341) and DFS (HR, 1.091; 95% CI, 0.810–1.470; P = 0.566). CONCLUSION: Adjuvant therapy type did not affect survival of stage II/III rectal cancer patients without neoadjuvant chemoradiotherapy. These results suggest that adjuvant therapy can be chosen based on the patient’s condition and the policies of the surgeons and hospital facilities.

Three Dimensional Laparoscopy Improves Surgical Performance: Comparative Study in a Cadaver

PURPOSE: Conventional laparoscopy using a two-dimensional (2D) has limited performance because of insufficient representation of the stereoscopic effect. Development of three-dimensional (3D) imaging technology has improved depth perception, shortened the execution time and reduced error number. This study was designed to identify the effects of 3D imaging on surgical performance for skilled professionals and surgical residents. METHODS: Two laparoscopic skills tasks, each with three repetitions, were performed by seven experienced laparoscopic surgeons, two minimally experienced laparoscopic surgeons, and three inexperienced surgical residents under both 2D and 3D conditions with two cadavers. Outcome measures were time for task completion and subjective assessment of performance. RESULTS: Suturing was completed by all participants and anchoring with V-Loc was performed by 10 participants. Suturing and anchoring time were significantly shorter with 3D laparoscopic in all participants (suturing time, p=0.011; anchoring time, p=0.005). Significant differences were observed between experienced and minimally experienced surgeons (suture time, p=0.021; anchoring time, p=0.018). There was no significant difference among inexperienced surgical residents, but they preferred 3D imaging over 2D. CONCLUSION: 3D laparoscopy is associated with a significantly shorter time for performance by experienced surgeons. Our results suggest that 3D laparoscopy will be helpful for surgeons conducting laparoscopic procedures.

Transanal Total Mesorectal Excision for Low Rectal Cancer

A 70-year-old female patient was diagnosed with low rectal adenocarcinoma (cT3N2) based on the initial CT and MRI. The patient underwent neoadjuvant chemoradiotherapy consisting of short course radiotherapy with 5-fluorouracil (5-FU) and leucovorin (LV) chemotherapy. Three additional cycles of simplified infusional 5-FU/LV were given every 2 weeks to the patient during the resting period (8 weeks) before surgery. For transanal TME, a purse-string suture of the distal rectum was performed just above the dentate line. Transanal circumferential dissection including the mesorectum was performed from the dentate line until the peritoneal reflection. Thereafter, laparoscopic dissection was conducted using the medial to lateral approach and the inferior mesenteric artery was ligated at the pedicle. Lateral detachment and splenic flexure mobilization were completed. After full mobilization of the distal transverse colon and rectum, the specimen was retrieved through the anus and resected. Colo-anal anastomosis was performed by the hand-sewn method. A closed suction drain was inserted into the pelvis. We also demonstrate our procedure for transanal TME using a short video clip.

Massive Hemoptysis due to Acute Mitral Regurgitation with Sporadic Primary Mitral Valve Prolapse / 대한구급학회지

The most common cardiac cause of massive hemoptysis is mitral stenosis. Mitral regurgitation is rarely complicated by massive hemoptysis. A 48-year-old man with no significant medical history was admitted to our hospital with hemoptysis and production of 500 mL of blood within 24 hours. A pan-systolic murmur was found on chest examination. A chest computed tomography showed airspace consolidation in the right upper and middle lobes, with faint bilateral ground glass opacity. Echocardiography revealed mitral valve prolapse and grade IV mitral regurgitation. The patient was diagnosed with sporadic primary mitral valve prolapse. After mitral valve repair surgery, the patient recovered fully.

A preliminary study for the development of indices and the current state of surgical site infections (SSIs) in Korea: the Korean Surgical Site Infection Surveillance (KOSSIS) program

PURPOSE: We aimed to develop an effective system for surgical site infection (SSI) surveillance and examine the current domestic state of SSIs for common abdominal surgeries in Korea. METHODS: The Korean Surgical Site Infection Surveillance (KOSSIS) program was developed as an SSI surveillance system. A prospective multicenter study in nine university-affiliated or general hospitals was conducted for patients who underwent gastrectomy, cholecystectomy, appendectomy, colectomy, or proctectomy between August 16 and September 30 in 2012. Patients were monitored for up to 30 days by combining direct observation and a postdischarge surgeon survey. Data on SSIs were prospectively collected with KOSSIS secretarial support according to a common protocol. Operation-specific SSI rates were stratified according to risk factors and compared with data from the Korean Nosocomial Infections Surveillance System (KONIS) and National Healthcare Safety Network. A focus group interview was conducted with participating hospitals for feedback. RESULTS: A total of 1,088 operations were monitored: 207 gastrectomies, 318 cholecystectomies, 270 appendectomies, 197 colectomies, and 96 proctectomies. Operation-specific SSI rates determined by the KOSSIS program were substantially higher than those found in KONIS (7.73% [95% confidence interval, 4.5%-12.3%] vs. 3.4% for gastrectomies, 10.15% [95% confidence interval, 6.1%-15.2%] vs. 4.0% for colectomy, and 13.5% [95% confidence interval, 7.4%-22.0%] vs. 4.2% for proctectomy). CONCLUSION: Despite a short surveillance period and heterogenous group of hospitals, our results suggest that KOSSIS could be a useful program to enhance SSI surveillance in Korea.

Laparoscopic Surgery for Colorectal Cancer in Korea: Nationwide Data from 2008~2013

The aim of this study was to report nationwide data on the current practice of laparoscopic colorectal cancer (CRC) surgery in Korea. Nationwide surgical data for colorectal cancer from 2008 to 2013 were obtained from the Health Insurance Review & Assessment Service database and a retrospective analysis of CRC surgery patients was conducted. The trends in laparoscopy use for each procedure of colorectal resection over six years were evaluated. From 2008 to 2013, a total of 105,305 patients nationwide underwent resection for CRC, and 55.3% of the cases underwent laparoscopic surgery. The proportion of laparoscopic resection increased from 42.6% in 2008 to 64.7% in 2013. The most common site of colon cancer was sigmoid, followed by ascending, and rectosigmoid junction, which together accounted for 64.9% of all colon cancer cases. The three leading procedures were low anterior resection, hemicolectomy, and anterior resection, which together accounted for 87.3% of all CRCs. For low anterior resection, the rate of laparoscopy increased from 44.8% in 2008 to 69.8% in 2013. The percentage of abdominoperineal resection for rectal cancer continued to decrease from 10.6% in 2008 to 7.5% in 2013. Over the six years, a total of 2520 robotic surgeries for CRC were performed. The number of robotic surgeries for rectal cancer showed a steady increase, whereas that for colon cancer decreased. Overall, the rate of minimally invasive surgeries for CRC was 43.5% in 2008 and increased to 65.7% in 2013. The laparoscopic resection rate for CRC in Korea is very high and continues to show a steady increase.

Massive Hemoptysis due to Acute Mitral Regurgitation with Sporadic Primary Mitral Valve Prolapse / 대한중환자의학회지

The most common cardiac cause of massive hemoptysis is mitral stenosis. Mitral regurgitation is rarely complicated by massive hemoptysis. A 48-year-old man with no significant medical history was admitted to our hospital with hemoptysis and production of 500 mL of blood within 24 hours. A pan-systolic murmur was found on chest examination. A chest computed tomography showed airspace consolidation in the right upper and middle lobes, with faint bilateral ground glass opacity. Echocardiography revealed mitral valve prolapse and grade IV mitral regurgitation. The patient was diagnosed with sporadic primary mitral valve prolapse. After mitral valve repair surgery, the patient recovered fully.

Influence of Shorter Duration of Prophylactic Antibiotic Use on the Incidence of Surgical Site Infection Following Colorectal Cancer Surgery

PURPOSE: This study aimed to identify the risk factors for surgical site infections (SSIs) in patients undergoing colorectal cancer surgery and to determine whether significantly different SSI rates existed between the short prophylactic antibiotic use group (within 24 hours) and the long prophylactic antibiotic use group (beyond 24 hours). METHODS: The medical records of 327 patients who underwent colorectal resection due to colorectal cancer from January 2010 to May 2014 at a single center were retrospectively reviewed, and their characteristics as well as the surgical factors known to be risk factors for SSIs, were identified. RESULTS: Among the 327 patients, 45 patients (13.8%) developed SSIs. The patients were divided into two groups according to the duration of antibiotic use: group S (within 24 hours) and group L (beyond 24 hours). Of the 327 patients, 114 (34.9%) were in group S, and 213 (65.1%) were in group L. Twelve patients (10.5%) in group S developed SSIs while 33 patients (15.5%) in group L developed SSIs (P = 0.242). History of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were independent risk factors for SSIs. CONCLUSION: This study shows that discontinuation of prophylactic antibiotics within 24 hours after colorectal surgery has no significant influence on the incidence of SSIs. This study also showed that history of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were associated with increased SSI rates.

Transanal natural orifice transluminal endoscopic surgery total mesorectal excision in animal models: endoscopic inferior mesenteric artery dissection made easier by a retroperitoneal approach

PURPOSE: We report the performance of natural orifice transluminal endoscopic surgery (NOTES) low anterior resection in animals using transanal total mesorectal excision (TME) with laparoscopic assistance and endoscopic inferior mesenteric artery (IMA) dissection. METHODS: Four pigs weighing 45 kg each, and one dog weighing 25 kg, underwent surgery via a transanal approach. The rectum was occluded transanally using a purse-string suture, approximately 3-4 cm from the anal verge. The rectal mucosa was incised circumferentially just distal to the purse-string. A SILS or GelPOINT port was inserted transanally. Transanal TME was assisted by laparoscopy and proceeded up to the peritoneal reflection. More proximal dissection, including IMA dissection, was performed along the retroperitoneal avascular plane by endoscopy alone and facilitated by CO2 insufflation. The IMA was clipped and divided endoscopically. The mobilized rectosigmoid were exteriorized transanally and transected. A colorectal anastomosis was performed using a circular stapler with a single stapling technique. RESULTS: Endoscopic dissection of the IMA was successful in all five animals. The mean operation time was 125 minutes (range, 90-170 minutes). There were no intraoperative complications or hemodynamic instability. The mean length of the resected specimen was 14.4 cm (range, 12-16 cm). CONCLUSION: A NOTES retroperitoneal approach to the IMA with CO2 insufflation and intact peritoneal covering overcame the difficulties of retraction and exposure of endoscopic dissection in animals.

Erratum: The Effects of Bronchiectasis on Asthma Exacerbation / 결핵및호흡기질환

In the reference list, reference 16 should be omitted. Reference numbers in the text and in the reference list must be changed accordingly.

The Effects of Bronchiectasis on Asthma Exacerbation / 결핵및호흡기질환

BACKGROUND: Bronchiectasis and asthma are different in many respects, but some patients have both conditions. Studies assessing the effect of bronchiectasis on asthma exacerbation are rare. The aim of this study is to investigate the effect of bronchiectasis on asthma exacerbation. METHODS: We enrolled 2,270 asthma patients who were followed up in our hospital. Fifty patients had bronchiectasis and asthma. We selected fifty age- and sex-matched controls from the 2,220 asthma patients without bronchiectasis, and assessed asthma exacerbation and its severity based on the annual incidence of total asthma exacerbation, annual prevalence of steroid use, and frequency of emergency room visits and hospitalizations due to asthma exacerbation in each group. RESULTS: Fifty patients (2.2%) had bronchiectasis and asthma. The annual incidence of asthma exacerbation was higher in patients with asthma and bronchiectasis than in patients with asthma alone (1.08+/-1.68 vs. 0.35+/-0.42, p=0.004). The annual prevalence of steroid use (0.9+/-1.54 vs. 0.26+/-0.36, p=0.006) and the frequency of emergency room visits (0.46+/-0.84 vs. 0.02+/-0.13, p=0.001) due to asthma exacerbation were also higher in patients with asthma and bronchiectasis than in patients with asthma alone. CONCLUSION: Bronchiectasis is associated with difficult asthma control.

Increase in the Serum Parathyroid Hormone Level During a Bisphosphonate Drug Holiday

After discontinuation of bisphosphonate therapy, an antiresorptive effect and antifracture protection persist for an undefined period. Patients are encouraged to continue calcium and vitamin D supplementation, during a bisphosphonate drug holiday. However, assessment of adequate calcium intake during the bisphosphonate drug holiday is difficult. Therefore, we measured the serum intact parathyroid hormone (PTH) level as a surrogate marker. A premenopausal woman discontinued bisphosphonate therapy, after 7.5 years of treatment. Two months later, blood calcium and phosphorus levels were normal, serum 25-hydroxyvitamin D level was 31.3 ng/mL, but serum PTH level had increased to 94.9 pg/mL. The elemental calcium supplement dose was increased to 600 mg/day, with no change in the cholecalciferol dose (400 IU). Her serum PTH levels decreased to 49.1 after 4 months and 32.9 pg/mL after 5 months. The serum PTH level may be helpful in assessing adequate calcium intake during a bisphosphonate drug holiday.

Clinical Application of Electrogastrography in Patients with Stomach Cancer Who Undergo Distal Gastrectomy

PURPOSE: Electrogastrography is a method of measuring action potentials of the stomach. The purpose of this study was to investigate early postoperative changes in the electrogastrography and determine the correlation between electrogastrography and quality of life of patients with stomach cancer who underwent distal gastrectomy. MATERIALS AND METHODS: This study analyzed 20 patients with stomach cancer who underwent electrogastrography and quality of life was measured 1, 12, and 24 weeks after the operation. Quality of life-C30 version 3.0 and quality of life-STO22, were used. RESULTS: Fasting and postprandial mean dominant frequency at 1 week after the operation was 2.7 and 2.7 cycles per minute, and 2.8 and 2.7 cycles per minute at 12 weeks, 2.6 and 2.8 cycles per minute at 24 weeks. Fasting and postprandial mean dominant power at 1 week was 36.5 and 36.4 dB, 36.3 and 40.1 dB at 12 weeks and 40.9 and 42.3 dB at 24 weeks. The percentage of tachygastria was increased whereas the percentage of bradygradia was decreased during the postoperative periods (P0.05). CONCLUSIONS: These may suggest that electrogastrography is a simple and noninvasive method and may be applicated for evaluating motility and autonomic functions of the remnant stomach.

Mechanical Bowel Preparation and Prophylactic Antibiotic Administration in Colorectal Surgery: A Survey of the Current Status in Korea

PURPOSE: The usefulness of mechanical bowel preparation (MBP) in colon surgery was recently challenged by many multicenter clinical trials and meta-analyses. The objectives of this study were to investigate current national opinions about MBP and prophylactic antibiotics (PA) and to provide preliminary data for developing future Korean guidelines for MBP and PA administration in colorectal surgery. METHODS: A questionnaire was mailed to 129 colorectal specialists. The questionnaires addressed the characteristics of the hospital, the MBP methods, and the uses of oral and intravenous antibiotics. RESULTS: A total of 73 questionnaires (56.6%) were returned. First, in regard to MBP methods, most surgeons (97.3%) used MBP for a mean of 1.36 days. Most surgeons (98.6%) implemented whole bowel irrigation and used polyethylene glycol (83.3%). Oral antibiotic use was indicated in over half (52.1%) of the responses, the average number of preoperative doses was three, and the mean time of administration was 24.2 hours prior to the operation. Finally, the majority of responders stated that they used intravenous antibiotics (95.9%). The responses demonstrated that second-generation cephalosporin-based regimens were most commonly prescribed, and 75% of the surgeons administered these regimens until three days after the operation. CONCLUSION: The results indicate that most surgeons used MBP and intravenous antibiotics and that half of them administered oral PA in colorectal surgery preparations. The study recommends that the current Korean guidelines should be adapted to adequately reflect the medical status in Korea, to consider the medical environment of the various hospitals, and to establish more accurate and relevant guidelines.

Laparoscopic Colorectal Surgery Is Safe for Elderly Patients over the Age of 70 / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic surgery is used in elderly patients to maximize the benefits of improved postoperative recovery but this supposition lacks proper evidence. The aims of this study were to assess the safety and feasibility of laparoscopic colorectal surgery in elderly patients (group A, age > or =70 years, n=77) by a comparison with those in younger patients (group B, age 200 minutes), ICU stay and rectal surgery. CONCLUSION: Laparoscopic colorectal surgery in elderly patients is safe and does not compromise the postoperative outcomes despite the comorbid conditions of the elderly patients.

Local Perianal Block in Anal Surgery: The Disadvantage of Pain during Injection despite High Patient Satisfaction

PURPOSE: We evaluated the usefulness of anal surgery using local perianal block and assessed patient satisfaction. METHODS: From January to October 2008, a total of 41 consecutive patients consented to anal operation with local perianal block for stapled hemorrhoidopexy (n=15), excisional hemorrhoidectomy (n=9), fistulotomy (n=13), or abscess drainage (n=4). Postoperative pain was evaluated on a visual analogue scale (VAS) from 0 to 10. Patient satisfaction was evaluated through telephone interviews. RESULTS: The mean peak VAS scores on the day of operation were 3.3 after stapled hemorrhoidopexy, 2.9 after excisional hemorrhoidectomy, 2.6 after fistulotomy, and 3.5 after abscess drainage; on postoperative day 1, the scores were 1.3, 1, 0.9, and 2.3, respectively. The majority of patients (31; 86.1%) were satisfied with the postoperative results (very satisfied 12, satisfied 19, only fair 5, unsatisfied 0). More than half of the patients (23; 63.9%) were satisfied with the use of local anesthesia (very satisfied 4, satisfied 19, only fair 12, unsatisfied 1). The mean VAS scores during injection were significantly different between the satisfied group (very satisfied and satisfied) and not-satisfied group (only fair and unsatisfied) treated with the local anesthesia (satisfied group: 3.5 and not-satisfied group: 5.4, P=0.04). Most patients (30; 83.3%) would undergo this anesthetic procedure again if future anal surgeries were necessary. CONCLUSION: Local perianal block is feasible for various anal operations and results in a high degree of satisfaction among patients. However, the pain associated with injection has an adverse effect on patient satisfaction.