The Multifaceted Clinical Characteristics of Congenital Cytomegalovirus Infection: From Pregnancy to Long-Term Outcomes

Background@#The aim of this study was to capture multifaceted clinical characteristics of congenital cytomegalovirus (CMV) infection from diagnosis to treatment using a multidisciplinary approach including obstetrics, pediatrics, pathology, and otorhinolaryngology-head and neck surgery. @*Methods@#This is a retrospective study including 30 consecutive cases of congenital CMV infection that were diagnosed at a single tertiary hospital located in Seoul, Korea from January 2009 to December 2020. Congenital CMV infection was defined as a positive result by polymerase chain reaction from urine, saliva or cerebrospinal fluid or positive CMV IgM from neonatal blood sampled within 3 weeks after birth. All cases were analyzed with respect to whole clinical characteristics from diagnosis to treatment of congenital CMV by a multidisciplinary approach including prenatal sonographic findings, maternal immune status regarding CMV infection, detailed placental pathology, neonatal clinical manifestation, auditory brainstem response test, and antiviral treatment (ganciclovir or valganciclovir). Long-term outcomes including developmental delay and hearing loss were also investigated. @*Results@#The total number of births during the study period in our institution was 19,385, with the prevalence of congenital infection estimated to be 0.15%. Among 30 cases of congenital CMV, the median gestational age at delivery was 32.2 weeks [range, 22.6–40.0] and 66.7% of these infants were delivered preterm at less than 37 weeks. Suspected fetal growth restriction was the most common prenatal ultrasound finding (50%) followed by ventriculomegaly (17.9%) and abnormal placenta (17.9%), defined as thick placenta with calcification. No abnormal findings on ultrasound examination were observed in one-third of births. Maternal CMV serology tests were conducted in only 8 cases, and one case each of positive and equivocal IgM were found. The most common placental pathologic findings were chronic villitis (66.7%) and calcification (63.0%), whereas viral inclusions were identified in only 22.2%. The most common neonatal manifestations were jaundice (58.6%) followed by elevation of aspartate aminotransferase (55.2%) and thrombocytopenia (51.7%). After excluding cases for which long-term outcomes were unavailable due to death (n = 4) or subsequent follow up loss (n = 3), developmental delay was confirmed in 43.5% of infants (10/23), and hearing loss was confirmed in 42.9% (9/21) during the follow-up period. In our cohort, 56.7% (17/30) of neonates were treated for congenital CMV with ganciclovir or valganciclovir. @*Conclusion@#Our data show that prenatal findings including maternal serologic tests and ultrasound have limited ability to detect congenital CMV in Korea. Given that CMV is associated with high rates of developmental delay and hearing loss in infants, there is an urgent need to develop specific strategies for the definite diagnosis of congenital CMV infection during the perinatal period by a multidisciplinary approach to decrease the risks of neurologic impairment and hearing loss through early antiviral treatment.

Impact of Coronavirus Disease 2019 on Gastric Cancer Diagnosis and Stage:A Single-Institute Study in South Korea

Purpose@#Gastric cancer (GC) is among the most prevalent and fatal cancers worldwide.National cancer screening programs in countries with high incidences of this disease provide medical aid beneficiaries with free-of-charge screening involving upper endoscopy to detect early-stage GC. However, the coronavirus disease 2019 (COVID-19) pandemic has caused major disruptions to routine healthcare access. Thus, this study aimed to assess the impact of COVID-19 on the diagnosis, overall incidence, and stage distribution of GC. @*Materials and Methods@#We identified patients in our hospital cancer registry who were diagnosed with GC between January 2018 and December 2021 and compared the cancer stage at diagnosis before and during the COVID-19 pandemic. Subgroup analyses were conducted according to age and sex. The years 2018 and 2019 were defined as the “before COVID” period, and the years 2020 and 2021 as the “during COVID” period. @*Results@#Overall, 10,875 patients were evaluated; 6,535 and 4,340 patients were diagnosed before and during the COVID-19 period, respectively. The number of diagnoses was lower during the COVID-19 pandemic (189 patients/month vs. 264 patients/month) than before it.Notably, the proportion of patients with stages 3 or 4 GC in 2021 was higher among men and patients aged ≥40 years. @*Conclusions@#During the COVID-19 pandemic, the overall number of GC diagnoses decreased significantly in a single institute. Moreover, GCs were in more advanced stages at the time of diagnosis. Further studies are required to elucidate the relationship between the COVID-19 pandemic and the delay in the detection of GC worldwide.

Chylous Ascites After Gastric Cancer Surgery: Risk Factors and Treatment Results

Purpose@#Although chylous ascites is a frequent complication of radical gastrectomy for gastric cancer, proper diagnostic criteria and optimal treatment strategies have not been established. This study aimed to identify the clinical features of chylous ascites and evaluate the treatment outcomes. @*Materials and Methods@#We retrospectively analyzed the data of patients who underwent radical gastrectomy between 2013 and 2019. Diagnosis was made when milky fluid or elevated triglyceride levels (≥100 mg/dL) appeared in the drains without a preceding infection. The clinical features, risk factors, and treatment outcomes were assessed according to the initial treatment modalities for fasting and non-fasting groups. @*Results@#Among the 7,388 patients who underwent radical gastrectomy for gastric cancer, 156 (2.1%) experienced chylous ascites. The median length of hospital stay was longer in patients with chylous ascites than in those without (median [interquartile range]: 8.0 [6.0–12.0] vs. 6.0 [5.0–8.0], P<0.001). Low body mass index (adjusted odds ratio [aOR]=0.9; P<0.001), advanced gastric cancer (aOR=1.51, P=0.024), open surgery (reference: laparoscopic surgery; aOR=1.87, P=0.003), and extent of surgical resection (reference: subtotal gastrectomy, total gastrectomy, aOR=1.5, P=0.029; proximal gastrectomy, aOR=2.93, P=0.002) were associated with the occurrence of chylous ascites. The fasting group (n=12) was hospitalized for a longer period than the non-fasting group (n=144) (15.0 [12.5–19.5] vs. 8.0 [6.0–10.0], P<0.001). There was no difference in grade III complication rate (16.7% vs. 4.2%, P=0.117) or readmission rate (16.7% vs. 11.1%, P=0.632) between the groups. @*Conclusions@#A fat-controlled diet and medication without fasting provided adequate initial treatment for chylous ascites after radical gastrectomy for gastric cancer.

Intracorporeal modified delta-shaped gastroduodenostomy during 2-port distal gastrectomy:technical aspects and short-term outcomes

Purpose@#Surgeons have become increasingly interested in reduced-port gastrectomy to minimize trauma while maintaining oncologic safety. Although gastroduodenostomy has the benefits of better nutritional outcomes and fewer postoperative complications than other types of reconstruction, gastroduodenostomy is not a preferred option for reducedport distal gastrectomy because of technical difficulties. In this study, we describe our intracorporeal modified deltashaped gastroduodenostomy technique, which is easily applicable during 2-port distal gastrectomy. @*Methods@#We retrospectively reviewed our database of 30 consecutive patients with gastric cancer who underwent 2-port distal gastrectomy with intracorporeal modified delta-shaped gastroduodenostomy from October 2016 to May 2021. In this reduced-port approach, we used a Tropian Single port (TROPIAN TECH) via a 25-mm transumbilical incision and a 12-mm port at the right flank. All anastomoses were performed using a 60-mm endolinear stapler. We used 3 additional sutures to provide proper traction and support for the anastomosis. @*Results@#Mean ± standard deviation of operation time was 148.9 ± 34.7 minutes; reconstruction time was 13.2 ± 4.6 minutes; estimated blood loss was 29.3 ± 44.4 mL; and length of hospital stay was 4.5 ± 1.2 postoperative days. A total of 11 patients (36.7%) had a Clavien-Dindo grade I or grade II complication, and there were no grade IIIa or higher complications. @*Conclusion@#Intracorporeal modified delta-shaped gastroduodenostomy was safely performed via a 2-port approach, resulting in acceptable surgical outcomes and no major complications.

Obstructive Sleep Apnea Is Associated With Late-Onset Preeclampsia in Overweight Pregnant Women in Korea

Background@#Obstructive sleep apnea (OSA) is closely related to maternal obesity in pregnant women, and the association increases with later pregnancy. Obesity and OSA are risk factors of pregnancy-related complications, including gestational hypertension, gestational diabetes mellitus (GDM), and fetal morbidities. We aimed to determine the prevalence of OSA and to assess the impact of OSA on pregnancy-related disorders in overweight pregnant women. @*Methods@#Eligible participants who were overweight [body mass index (BMI) ≥ 23 kg/m 2 ] in gestational age 30 weeks or more, assessed OSA using a portable polysomnography at home.Clinical data were collected from pregnant women and their babies. @*Results@#The average age of 51 participants was 34.5 years (27–44 years). The number of primipara was 25 (49%) and that of multipara was 26 (51%). Eight cases of GDM (15.7%) and five cases of preeclampsia (9.8%) were reported, and six patients (11.8%) experienced preterm delivery. In results of polysomnography, 14 patients (27.5%) were diagnosed as OSA. Apnea-hypopnea index moderately correlated with BMI (r = 0.515, P < 0.001). The BMI (P < 0.005) and preeclampsia rate (P < 0.017) were higher in the OSA group compared to the control group. Odds ratios (ORs) adjusting age, BMI, parity, and abortion history were calculated. The presence of OSA increased OR of preeclampsia (OR, 13.1; 95% confidence interval, 1.1–171.3). The majority of preeclampsia patients (4/5, 80%) underwent preterm delivery. @*Conclusion@#OSA is an important risk factor for preeclampsia, resulting in preterm delivery.For overweight pregnant women, an OSA evaluation should be mandatory.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Adverse Effects of Ligation of an Aberrant Left Hepatic Artery Arising from the Left Gastric Artery during Radical Gastrectomy for Gastric Cancer: a Propensity Score Matching Analysis

Purpose@#No consensus exists on whether to preserve or ligate an aberrant left hepatic artery (ALHA), which is the most commonly encountered hepatic arterial variation during gastric surgery. Therefore, we aimed to evaluate the clinical effects of ALHA ligation by analyzing the perioperative outcomes. @*Materials and Methods@#We retrospectively reviewed the data of 5,310 patients who underwent subtotal/total gastrectomy for gastric cancer. Patients in whom the ALHA was ligated (n=486) were categorized into 2 groups according to peak aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels: moderate-to-severe (MS) elevation (≥5 times the upper limit of normal [ULN]; MS group, n=42) and no-to-mild (NM) elevation (<5 times the ULN; NM group, n=444). The groups were matched 1:3 using propensity score-matching analysis to minimize confounding factors that can affect the perioperative outcomes. @*Results@#The mean operation time (P=0.646) and blood loss amount (P=0.937) were similar between the 2 groups. The length of hospital stay was longer in the MS group (13.0 vs.7.8 days, P=0.022). No postoperative mortality occurred. The incidence of grade ≥ IIIa postoperative complications (19.0% vs. 5.1%, P=0.001), especially pulmonary complications (11.9% vs. 2.5%, P=0.003), was significantly higher in the MS group. This group also showed a higher Comprehensive Complication Index (29.0 vs. 13.9, P<0.001). @*Conclusions@#Among patients with a ligated ALHA, those with peak AST/ALT ≥5 times the ULN showed worse perioperative outcomes in terms of hospital stay and severity of complications. More precise perioperative decision-making tools are needed to better determine whether to preserve or ligate an ALHA.

Intracorporeal Esophagojejunostomy during Reduced-port Totally Robotic Gastrectomy for Proximal Gastric Cancer: a Novel Application of the Single-Site ® Plus 2-port System

Purpose@#Intracorporeal esophagojejunostomy during reduced-port gastrectomy for proximal gastric cancer is a technically challenging technique. No study has yet reported a robotic technique for anastomosis. Therefore, to address this gap, we describe our reduced-port technique and the short-term outcomes of intracorporeal esophagojejunostomy. @*Materials and Methods@#We conducted a retrospective review of patients who underwent a totally robotic reduced-port total or proximal gastrectomy between August 2016 and March 2020. We used an infra-umbilical Single-Site® port with two additional ports on both sides of the abdomen. To transect the esophagus, a 45-mm endolinear stapler was inserted via the right abdominal port. The common channel of the esophagojejunostomy was created between the apertures in the esophagus and proximal jejunum using a 45-mm linear stapler. The entry hole was closed with a 45-mm linear stapler or robot-sewn continuous suture. All anastomoses were performed without the aid of an assistant or placement of stay sutures. @*Results@#Among the 40 patients, there were no conversions to open, laparoscopic, or conventional 5-port robotic surgery. The median operation time and blood loss were 254 min and 50 mL, respectively. The median number of retrieved lymph nodes was 40.5. The median time to first flatus, soft diet intake, and length of hospital stay were 3, 5, and 7 days, respectively. Three (7.5%) major complications, including two anastomosis-related complications and a case of small bowel obstruction, were treated with an endoscopic procedure and re-operation, respectively. No mortality occurred during the study period. @*Conclusions@#Intracorporeal esophagojejunostomy during reduced-port gastrectomy can be safely performed and is feasible with acceptable surgical outcomes.

The effects of maternal body mass index and plurality on maternal and umbilical cord serum magnesium levels in preterm birth at less than 32 weeks of gestation

Objective@#To evaluate the effects of maternal body mass index (BMI) and plurality on maternal and umbilical cord serum magnesium levels after antenatal magnesium sulfate treatment. @*Methods@#This was a retrospective cohort analysis of 135 women treated with antenatal magnesium sulfate at less than 32 weeks of gestation between January 2012 and June 2018. Subjects were stratified into groups according to maternal BMI (group I [18.5–22.9 kg/m²], group II [23.0–24.9 kg/m²], and group III [≥25.0 kg/m²]) and plurality (singleton and twin). Univariable and multivariable analyses were performed to compare the umbilical cord serum magnesium levels between the groups. @*Results@#Maternal serum magnesium levels were not significantly different between the maternal BMI groups and singleton and twin pregnancies. Umbilical cord serum magnesium levels were significantly different among the maternal BMI groups (3.3±1.2 mg/dL in group I, 3.3±1.2 mg/dL in group II, and 4.0±1.4 mg/dL in group III, P=0.003). The trend of increase in magnesium levels was statistically significant (P=0.001, Jonckheere-Terpstra test). Umbilical cord serum magnesium levels were not significantly different according to plurality. However, in the multivariable analysis, maternal BMI and plurality were not significantly associated with umbilical cord serum magnesium levels after adjusting for indication and total dose of magnesium sulfate treatment, gestational age at delivery, mode of delivery, neonatal sex, and birth weight. @*Conclusion@#Maternal BMI and plurality were not significantly associated with maternal or umbilical cord serum magnesium levels after exposure to antenatal magnesium sulfate treatment.

D2 Lymph Node Dissections during Reduced-port Robotic Distal Subtotal Gastrectomy and Conventional Laparoscopic Surgery Performed by a Single Surgeon in a High-volume Center: a Propensity Score-matched Analysis

Purpose@#Various studies have indicated that reduced-port robotic gastrectomies are safe and feasible for treating patients with early gastric cancer. However, there have not been any comparative studies conducted that have evaluated patients with clinically advanced gastric cancer. Therefore, we aimed to compare the perioperative outcomes of D2 lymph node dissections during reduced-port robotic distal subtotal gastrectomies (RRDGs) and conventional 5-port laparoscopic distal subtotal gastrectomies (CLDGs). @*Materials and Methods@#We retrospectively evaluated 118 patients with clinically advanced gastric cancer who underwent minimally invasive distal subtotal gastrectomies with D2 lymph node dissections between February 2016 and November 2019. To evaluate the patient data, we performed a 1:1 propensity score matching (PSM) according to age, sex, body mass index, American Society of Anesthesiologists physical status classification score, and clinical T status. The short-term surgical outcomes were also compared between the two groups. @*Results@#The PSM identified 40 pairs of patients who underwent RRDG or CLDG. The RRDG group experienced a significantly longer operation time than the CLDG group (P<0.001), although the RRDG group had significantly less estimated blood loss (P=0.034). The number of retrieved extraperigastric lymph nodes in the RRDG group was significantly higher than that of the CLDG group (P=0.008). The rate of postoperative complications was not significantly different between the two groups (P=0.115). @*Conclusions@#D2 lymph node dissections can be safely performed during RRDGs and the perioperative outcomes appear to be comparable to those of conventional laparoscopic surgeries. Further studies are needed to compare long-term survival outcomes.

D2 Lymph Node Dissections during Reduced-port Robotic Distal Subtotal Gastrectomy and Conventional Laparoscopic Surgery Performed by a Single Surgeon in a High-volume Center: a Propensity Score-matched Analysis

Purpose@#Various studies have indicated that reduced-port robotic gastrectomies are safe and feasible for treating patients with early gastric cancer. However, there have not been any comparative studies conducted that have evaluated patients with clinically advanced gastric cancer. Therefore, we aimed to compare the perioperative outcomes of D2 lymph node dissections during reduced-port robotic distal subtotal gastrectomies (RRDGs) and conventional 5-port laparoscopic distal subtotal gastrectomies (CLDGs). @*Materials and Methods@#We retrospectively evaluated 118 patients with clinically advanced gastric cancer who underwent minimally invasive distal subtotal gastrectomies with D2 lymph node dissections between February 2016 and November 2019. To evaluate the patient data, we performed a 1:1 propensity score matching (PSM) according to age, sex, body mass index, American Society of Anesthesiologists physical status classification score, and clinical T status. The short-term surgical outcomes were also compared between the two groups. @*Results@#The PSM identified 40 pairs of patients who underwent RRDG or CLDG. The RRDG group experienced a significantly longer operation time than the CLDG group (P<0.001), although the RRDG group had significantly less estimated blood loss (P=0.034). The number of retrieved extraperigastric lymph nodes in the RRDG group was significantly higher than that of the CLDG group (P=0.008). The rate of postoperative complications was not significantly different between the two groups (P=0.115). @*Conclusions@#D2 lymph node dissections can be safely performed during RRDGs and the perioperative outcomes appear to be comparable to those of conventional laparoscopic surgeries. Further studies are needed to compare long-term survival outcomes.

Perinatal outcome of twin pregnancies according to maternal age

OBJECTIVE: To investigate the perinatal outcomes of twin pregnancies according to maternal age. METHODS: This is a retrospective cohort study of twin pregnancies delivered ≥24 weeks' gestation at a tertiary academic hospital from 1995 to 2016. Subjects were categorized into 5 groups according to maternal age: < 25, 25–29, 30–34, 35–39, and ≥40 years. Maternal and neonatal outcomes of each maternal age group were analyzed using the Jonckheere-Terpstra test and the linear-by-linear association test. RESULTS: A total of 1,936 twin pregnant women were included, of which 47 (2.4%), 470 (24.3%), 948 (49.0%), 417 (21.5%), and 54 (2.7%) women were aged < 25, 25–29, 30–34, 35–39, and ≥40 years, respectively. Higher maternal age was significantly associated with a higher rate of dichorionic twins and a higher risk of gestational diabetes and placenta previa. However, rates of preterm labor, preterm premature rupture of membranes, cervical incompetence, preterm delivery, preeclampsia, placenta abruption, and cesarean section were not associated with maternal age. Birth weight increased and the rate of admission to the neonatal intensive care unit (NICU) decreased with older maternal age, but other neonatal outcomes did not change with age. Maternal age was significantly associated with a lower rate of NICU admission after controlling for potential confounding factors in multivariable analysis. CONCLUSION: Advanced maternal age in twin pregnancies was associated with increased risk of gestational diabetes, placenta previa, and higher birth weight but a lower rate of NICU admission. However, other outcomes were not significantly associated with maternal age.

The trends and risk factors to predict adverse outcomes in gestational diabetes mellitus: a 10-year experience from 2006 to 2015 in a single tertiary center

OBJECTIVE: To investigate the change of maternal characteristics, delivery and neonatal outcomes in gestational diabetes mellitus (GDM) over recent 10 years and to identify the risk factors associated with adverse outcome. METHODS: Consecutive GDM patients (n=947) delivered in our institution were included. Research period was arbitrarily divided into 2 periods (period 1: from 2006 to 2010, period 2: from 2011 to 2015). Multiple pregnancies or preexisting diabetes were excluded. Maternal baseline characteristics, delivery and neonatal outcomes were reviewed. Fetal biometric findings by prenatal ultrasonography were collected. Adverse pregnancy outcome (APO) was defined by the presence of one of the followings; shoulder dystocia, neonatal macrosomia (>4 kg), neonatal hypoglycemia (< 35 mg/dL), respiratory distress syndrome (RDS), and admission to the neonatal intensive care unit (NICU) in term pregnancy. RESULTS: Period 2 was associated with older maternal age (34 vs. 33, P < 0.001) and higher proportion of GDM A2 compared to period 1 (30.9% vs. 23.0%, P=0.009). By univariate analysis, APO was associated with increased body mass index (BMI) at pre-pregnancy (23.4 kg/m² vs. 21.8 kg/m², P=0.001) or delivery (27.9 kg/m² vs. 25.8 kg/m², P < 0.001), higher HbA1c at diagnosis (5.6% vs. 5.3%, P < 0.001) or delivery (5.8% vs. 5.5%, P=0.044), and larger fetal biometric findings (abdominal circumference [AC] and estimated fetal weight, P=0.029 and P=0.007, respectively). Multivariate analysis showed pre-pregnancy BMI (odds ratio [OR], 1.101; 90% confidence interval [CI], 1.028–1.180) and fetal AC (OR, 1.218; 90% CI, 1.012–1.466) were independently associated with adverse outcomes. CONCLUSION: Our study demonstrated the trends and relevant factors associated with the adverse outcomes.

Prevalence of vaginal microorganisms among pregnant women according to trimester and association with preterm birth

OBJECTIVE: The aim of this study was to investigate the prevalence of abnormal vaginal microorganisms in pregnant women according to trimester, and to determine whether the presence of abnormal vaginal colonization is associated with higher risk of miscarriage or preterm delivery. Furthermore, we analyzed delivery outcomes according to individual microorganism species. METHODS: We included pregnant women who underwent vaginal culture during routine prenatal check-up between January 2011 and June 2016. We compared delivery outcomes according to the presence or absence of abnormal vaginal flora grouped by trimester. RESULTS: This study included 593 singleton pregnancies. We classified participants into 3 groups, according to the trimester in which vaginal culture was performed; 1st trimester (n=221), 2nd trimester (n=138), and 3rd trimester (n=234). Abnormal vaginal colonization rate significantly decreased with advancing trimester of pregnancy (21.7% for 1st, 21.0% for 2nd, 14.5% for 3rd; P=0.048). Abnormal vaginal colonization detected in the 2nd trimester but not in 1st trimester was associated with a significant increase in preterm delivery before 28 weeks of gestation (6.9% vs. 0%; P=0.006). Among abnormal vaginal flora isolated in the 2nd trimester, the presence of Klebsiella pneumonia was identified as significant microorganism associated with preterm delivery before 28 weeks of gestation (50% vs. 0.7% for K. pneumonia; P=0.029). CONCLUSION: There is an association between abnormal vaginal colonization detected in the 2nd trimester and preterm delivery before 28 weeks. K. pneumonia has been identified as the likely causative microorganisms.

Laparoendoscopic single-site radical hysterectomy for early stage cervical cancer

Technical developments have made laparoendoscopic single-site (LESS) surgery increasingly more feasible for treating gynecological conditions, including cancer. However, complex surgeries such as radical hysterectomy have rarely been performed with single-port access because of technical difficulties. The majority of the difficulties are due to the inefficient retraction of tissue during dissection. Here, we report a detailed description of LESS radical hysterectomy plus pelvic lymph node dissection that was successfully performed in two patients with stage IB1 cervical cancer. We used our expertise with LESS to perform space development as much as possible before the ligaments were resected. The oncologic clearance was comparable to that of conventional laparoscopic radical hysterectomy.

Predicting factors for success of vaginal delivery in preterm induction with prostaglandin E₂

OBJECTIVE: To evaluate the efficacy and safety of prostaglandin (PG) E₂ for preterm labor induction and to investigate the predictive factors for the success of vaginal delivery. METHODS: A retrospective cohort study was performed in women (n=155) at 24+0 to 36+6 weeks of gestation who underwent induction of labor using a PGE₂ vaginal pessary (10 mg, Propess) from January 2009 to December 2015. Success rates of vaginal delivery according to gestational age at induction and incidence of intrapartum complications such as tachysystole and nonreassuring fetal heart rate were investigated. Multivariable logistic regression analysis was performed to evaluate the predictive factors for success of labor induction. RESULTS: The vaginal delivery rate was 57% (n=89) and the rate of cesarean delivery after induction was 43% (n=66). According to gestational age, labor induction was successful in 16.7%, 50.0%, and 62.8% of patients at 24 to 31, 32 to 33, and 34 to 36 weeks, showing a stepwise increase (P=0.006). There were 18 cases (11%) of fetal distress, 9 cases (5.8%) of tachysystole, and 6 cases (3.8%) of massive postpartum bleeding (>1,000 mL). After adjusting for confounding factors, multiparity (odds ratio [OR], 8.47; 95% confidence interval [CI], 3.10 to 23.14), younger maternal age (OR, 0.84; 95% CI, 0.75 to 0.94), advanced gestational age at induction (OR, 1.06; 95% CI, 1.02 to 1.09), rupture of membranes (OR, 11.83; 95% CI, 3.55 to 39.40), and the Bishop score change after removal of PGE₂ (OR, 2.19; 95% CI, 1.0 to 4.8) were significant predictors of successful preterm vaginal delivery. CONCLUSION: An understanding of the principal predictive factors of successful preterm labor induction, as well as the safety of PGE₂, will provide useful information when clinicians consult with preterm pregnant women requiring premature delivery.

A rare pseudomyxoma peritonei with a MSH2 variation of unknown significance and two mutation carrier family members

Pseudomyxoma peritonei (PMP) is a rare tumor that usually originates in the appendix, but a small number of cases originate in the ovary. Lynch syndrome (LS) is an autosomal dominant hereditary condition that increases the risk of cancer, particularly in the colon and endometrium. Mutations in the mismatch repair genes (MSH2, MLH1, MSH6, and PMS2) increase the risk of LS. Reported PMP cases with hereditary gene mutations of unknown significance are also rare. Here, we investigated a PMP patient and her family members, who have an MSH2 variant of unknown significance. Physicians have an important role in counseling, management, and surveillance based on genetics and pathogenicity.

Effect of visceral fat area on outcomes of laparoscopyassisted distal gastrectomy for gastric cancer: subgroup analysis by gender and parameters of obesity

PURPOSE: The aim of this study was to investigate the impact of the visceral fat area (VFA) of patients with gastric cancer undergoing laparoscopic surgery on operative outcomes such as number of retrieved lymph nodes (LNs) and operative time. METHODS: We retrospectively reviewed the medical records and the CT scans of 597 patients with gastric cancer who underwent laparoscopy assisted distal gastrectomy (LADG) with partial omentectomy and LN dissection (>D1 plus beta). Patients were stratified by gender, VFA, and body mass index (BMI), and the clinicopathologic characteristics and operative outcomes were evaluated. Multiple linear regression analysis was used to assess the effects of VFA and BMI on the number of retrieved LNs and operative time in male and female patients. RESULTS: The mean number of retrieved LNs was significantly decreased for both male and female patients with high VFA. The operative time was significantly longer for both male and female patients with high VFA. The number of retrieved LNs had a statistically significant negative correlation with VFA in both men and women, but not with BMI. The operative time had a statistically significant positive correlation with VFA in men, whereas the operative time had a statistically significant positive correlation with BMI in women. CONCLUSION: The preoperative VFA of male patients with gastric cancer who undergo LADG may affect the number of retrieved LNs and operative time. VFA was more useful than BMI for predicting outcomes of LADG.

Beginner Surgeon's Initial Experience with Distal Subtotal Gastrectomy for Gastric Cancer Using a Minimally Invasive Approach

PURPOSE: Minimally invasive gastrectomy (MIG), including laparoscopic distal subtotal gastrectomy (LDG) and robotic distal subtotal gastrectomy (RDG), is performed for gastric cancer, and requires a learning period. However, there are few reports regarding MIG by a beginner surgeon trained in MIG for gastric cancer during surgical residency and fellowship. The aim of this study was to report our initial experience with MIG, LDG, and RDG by a trained beginner surgeon. MATERIALS AND METHODS: Between January 2014 and February 2015, a total of 36 patients (20 LDGs and 16 RDGs) underwent MIG by a beginner surgeon during the learning period, and 13 underwent open distal subtotal gastrectomy (ODG) by an experienced surgeon in Bundang CHA Medical Center. Demographic characteristics, operative findings, and short-term outcomes were evaluated for the groups. RESULTS: MIG was safely performed without open conversion in all patients and there was no mortality in either group. There was no significant difference between the groups in demographic factors except for body mass index. There were significant differences in extent of lymph node dissection (LND) (D2 LND: ODG 8.3% vs. MIG 55.6%, P=0.004) and mean operative time (ODG 178.8 minutes vs. MIG 254.7 minutes, P<0.001). The serial changes in postoperative hemoglobin level (P=0.464) and white blood cell count (P=0.644) did not show significant differences between the groups. There were no significant differences in morbidity. CONCLUSIONS: This study showed that the operative and short-term outcomes of MIG for gastric cancer by a trained beginner surgeon were comparable with those of ODG performed by an experienced surgeon.

Totally Laparoscopic Roux-en-Y Gastrojejunostomy after Laparoscopic Distal Gastrectomy: Analysis of Initial 50 Consecutive Cases of Single Surgeon in Comparison with Totally Laparoscopic Billroth I Reconstruction

PURPOSE: Roux-en-Y reconstruction (RY) in laparoscopic distal gastrectomy for gastric cancer is a more complicated procedure than Billroth-I (BI) or Billroth-II. Here, we offer a totally laparoscopic simple RY using linear staplers. MATERIALS AND METHODS: Each 50 consecutive patients with totally laparoscopic distal gastrectomy with RY and BI were enrolled in this study. Technical safety and surgical outcomes of RY were evaluated in comparison with BI. RESULTS: In all patients, RY gastrectomy using linear staplers was safely performed without any events during surgery. The mean operation time and anastomosis time were 177.0+/-37.6 min and 14.4+/-5.6 min for RY, respectively, which were significantly longer than those for BI (150.4+/-34.0 min and 5.9+/-2.2 min, respectively). There were no differences in amount of blood loss, time to flatus passage, diet start, length of hospital stay, and postoperative inflammatory response between the two groups. Although there was no significant difference in surgical complications between RY and BI (6.0% and 14.0%), the RY group showed no anastomosis site-related complications. CONCLUSION: The double stapling method using linear staplers in totally laparoscopic RY reconstruction is a simple and safe procedure.