Solid Pseudopapillary Neoplasm of the Pancreas with Lymph Node Metastasis in a Young Male Patient / 대한소화기학회지

Solid pseudopapillary pancreatic neoplasms are rare. The male-to-female ratio is 1:9, and metastasis occurs only in a few cases. A 39-year-old male with a solid pseudopapillary neoplasm (SPN) with lymph node metastasis underwent ultrasonography, CT, and MRI, which revealed a mass (8 cm) in the pancreatic head. Fluorodeoxyglucose (FDG)-PET showed a hypermetabolic lymph node in the root area of the superior mesenteric artery (SMA). The patient underwent pylorus-preserving pancreaticoduodenectomy, which confirmed a peripancreatic lymph node metastasis. The lymph node of the SMA root area remained because of the encasing of the superior mesenteric artery. After 14 months of follow-up (with no adjuvant therapy initiated), the residual metastatic lymph nodes showed no change and no recurrence. In conclusion, surgery of the primary tumor for patients with SPN is recommended, even in cases with metastatic lymph nodes remaining.

Single Port Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis: A Case Report

The use and application of a laparoscopic cholecystectomy has been regarded as a first-choice treatment option for benign gallbladder disease, even if patients have situs inversus totalis. Furthermore, surgical procedures in general are becoming less invasive, because of both patient and surgeon preferences for reduced trauma and improved cosmetic outcomes attributable to minimized incisions. A 37 years old man was aware of situs inversus totalis with chronic cholecystitis. The operation was successfully performed without any specific complications. Single port laparoscopic cholecystectomy, in an experienced operator, is possible even in patients with situs inversus totalis.

Validation of the 8th AJCC Cancer Staging System for Pancreas Neuroendocrine Tumors Using Korean Nationwide Surgery Database / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic neuroendocrine tumor (PNET) included several significant changes. We aim to evaluate this staging system compared to the 7th edition AJCC staging system and European Neuroendocrine Tumors Society (ENETS) system. MATERIALS AND METHODS: We used Korean nationwide surgery database (2000-2014). Of 972 patients who had undergone surgery for PNET, excluding patients diagnosed with ENETS/World Health Organization 2010 grade 3 (G3), only 472 patients with accurate stage were included. RESULTS: Poor discrimination in overall survival rate (OSR) was noted between AJCC 8th stage III and IV (p=0.180). The disease-free survival (DFS) curves of 8th AJCC classification were well separated between all stages. Compared with stage I, the hazard ratio of II, III, and IV was 3.808, 13.928, and 30.618, respectively (p=0.007, p < 0.001, and p < 0.001). The curves of OSR and DFS of certain prognostic group in AJCC 7th and ENETS overlapped. In ENETS staging system, no significant difference in DFS between stage IIB versus IIIA (p=0.909) and IIIA versus IIIB (p=0.291). In multivariable analysis, lymphovascular invasion (p=0.002), perineural invasion (p=0.003), and grade (p < 0.001) were identified as independent prognostic factors for DFS. CONCLUSION: This is the first large-scale validation of the AJCC 8th edition staging system for PNET. The revised 8th system provides better discrimination compared to that of the 7th edition and ENETS TNM system. This supports the clinical use of the system.

Mushroom Poisoning by Macrolepiota neomastoidea / 대한소화기학회지

There are currently over 5,000-known species of mushrooms worldwide. Only 20–25% of mushrooms have been named, and 3% of these are poisonous. More than 95% of mushroom poisoning cases occur due to difficulties associated with the identification of mushroom species. Most of the fatal mushroom poisoning cases recorded to date have been related to the Amanita species. Until now, a case of fatal poisoning caused by Macrolepiota neomastoidea (M. neomastoidea) has not been reported in Asia. A 57-year-old male patient was admitted to the emergency room with nausea, vomiting, diarrhea, and abdominal pain. He reported ingesting wild mushrooms with his mother and sister about 2 days ago. His mother and sister were treated with only supportive care, but he was admitted to the intensive care unit and underwent liver transplantation due to acute liver failure. We are reporting a case of fatal M. neomastoidea intoxication from wild mushrooms, a rare case of mushroom poisoning.

Are prophylactic antibiotics necessary in elective laparoscopic cholecystectomy, regardless of patient risk?

PURPOSE: The average rate of surgical site infections (SSIs) for laparoscopic cholecystectomy (LC) has been reported in the literature to be between 0.4% and 6.3%. Also, these recent reviews have concluded that a prophylactic antibiotics for elective LCs in low-risk patients is not useful, but there were no results in high-risk patients. METHODS: The aim of this study was to investigate the role of a single dose of first-generation cephalosporin as a prophylactic antibiotic for patients undergoing elective LC, regardless of patient risk. This randomized clinical trial was conducted from October 2013 to December 2014 by single surgeon at our hospital. Patients were randomized into two groups by following method. Odd-numbered patients (group A) received 1-g cefazolin intravenously within 30 minutes before incision, whereas even-numbered patients (group B) received normal saline intravenously instead of prophylactic antibiotics, with the aim of including 100 patients in each group. SSIs were recorded and compared between the groups. RESULTS: There were no differences in preoperative demographics and postoperative findings between the groups. There were no superficial and deep SSIs in either group, 9 cases of superficial seromas developed (4.5%) in the cohort: 4 in group A (4%) and 5 in group B (5%). There were no significant associations between SSIs and the use of prophylactic antibiotics in either group. Additionally, the high-risk group did not show a significantly increased rate of SSIs. CONCLUSION: Based on our study, prophylactic antibiotics are not necessary in elective LC, regardless of patient risk.

Intraoperative radiofrequency ablation for hepatocellular carcinoma in 112 patients with cirrhosis: a surgeon's view

PURPOSE: This retrospective study was an investigation of overall survival (OS), disease-free survival (DFS) and prognostic factors affecting OS and DFS in cirrhotic patients who received intraoperative radiofrequency ablation (IORFA). METHODS: Between April 2009 and November 2013, 112 patients (94 men, 84%; 18 women, 16%) underwent IORFA for 185 cases of hepatocellular carcinomas (HCC). Repeat IORFA was done in 9 patients during the same period (total of 121 treatments). RESULTS: All patients were followed-up for at least 12 months (mean follow-up, 32 months). Surgical resection combined with IORFA was performed in 20 patients. The technical effectiveness at 1 week was 91.78% (111 of 121). Readmission was 9.1% (11 of 121) and the most common cause was ventral hernia. Procedure-related mortality was 2.7% (3 of 112) and continued fatal biliary leakage was 1.8% (2 of 112). Local recurrence developed in 10 patients (8.9%). Most recurrence was intrahepatic. Cumulative survival was assessed in 33 patients who received IORFA as primary treatment (naive patients) and 79 non-naive patients. The cumulative DFS and OS rate at l and 3 years was 54% and 24%, and 87% and 66%, respectively. Moderate ascites (P = 0.001), tumor located segment I (P = 0.001), portal vein thrombosis (P = 0.001) had poor survival were significant factors by multivariate analysis. CONCLUSION: IORFA alone or in combination with surgical resection extends the spectrum of liver surgery. A fundamental understanding of RFA, additional comorbidities, and postablation complication are necessary to maximize the safety and efficacy of IORFA for treating HCC with cirrhosis.

Extramedullary Plasmacytoma of the Pancreas Diagnosed Using Endoscopic Ultrasonography-Guided Fine Needle Aspiration

Extramedullary plasmacytoma involves organs outside the bone marrow; however, involvement of the pancreas is rare. We recently experienced a case of extramedullary plasmacytoma of the pancreas that was diagnosed by endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). EUS-FNA, which has a high diagnostic accuracy and an excellent safety profile, is the modality of choice for establishing tissue diagnosis. We report a case of extramedullary plasmacytoma of the pancreas diagnosed using EUS-FNA.

Analysis of the Short-term Result of Laparoscopic Liver Resection vs Open Liver Resection for Hepatocellular Carcinoma

PURPOSE: Laparoscopic surgery has recently shown rapid development, and has been applied in most abdominal surgeries. It has also been adopted in hepatobiliary surgery, especially in the resection of liver tumors. Significant advantages of laparosopic surgery over the conventional open method have been reported, however, the safety of the surgical resection margin and radicality of the tumor resection remain to be clarified. This study was conducted in order to assess the feasibility and potential superiority of laparoscopic liver resection of hepatocellular tumors to open surgery. METHODS: This study included 76 patients who underwent liver resection for hepatocellular carcinoma at Dong-A University Hospital from January 2008 through June 2010. Of these 63 cases, 31 patients underwent laparoscopic resections and 33 underwent open liver resections. Both groups were confirmed as hepatocellular carcinoma by postoperative pathology and analyzed retrospectively. RESULTS: There were no statistically significant differences in preoperative parameters, such as age, height, body weight, Child Pugh score, ASA, and tumor size in both groups. There were no significant differences in operating time, duration of hospital stay, safety margins of surgical resection, postoperative complications, and rate of recurrence and occurrence of new lesions in both groups, however, better disease free survival was observed in the laparoscopic group (p=0.024). CONCLUSION: Findings of this study showed that the laparoscopic group had better results in free survival period than the open group. Conduct of larger scale prospective studies wound confirm the superiority of the laparoscopic liver resection to the conventional open procedure in patients with hepatocellular carcinoma. Findings of this study also suggest that assessment of the factors associated with the quality of life, such as degree of postoperative pain, and size of the incisional scar, and long term postoperative complications may play an additional role in favoring the laparoscopic liver resection. To elucidate the superiority of the laparoscopic liver resection to the conventional open method, conduct of study involving a larger study group and a longer prospective research period will be needed.

Management of giant hepatic cysts in the laparoscopic era / 대한외과학회지

PURPOSE: We sought to evaluate the feasibility and outcomes of laparoscopic resection of giant hepatic cysts and surgical success, focusing on cyst recurrence. METHODS: From February 2004 to August 2011, 37 consecutive patients with symptomatic hepatic cysts were evaluated and treated at Dong-A University Hospital. Indications were simple cysts (n = 20), multiple cysts (n = 6), polycystic disease (n = 2), and cystadenoma (n = 9). RESULTS: The median patient age was 64 years, with a mean lesion diameter of 11.4 cm. The coincidence between preoperative imaging and final pathologic diagnosis was 54% and half (n = 19) of the cysts were located in segments VII and VIII. Twenty-two patients had American Society of Anesthesiologists (ASA) classification I and II, and nine had ASA classification III. Surgical treatment of hepatic cysts were open liver resection (n = 3), laparoscopic deroofing (n = 24), laparoscopic cyst excision (n = 4), laparoscopic left lateral sectionectomy (n = 2), hand assisted laparoscopic procedure (n = 2), and single port laparoscopic deroofing (n = 2). The mean fellow-up was 21 months, and six patients (16%) experienced radiographic-apparent recurrence. Reoperation due to recurrence was performed in two patients. Among the factors predicting recurrence, multivariate analysis revealed that interventional radiological procedures and pathologic diagnosis were statistically significant. CONCLUSION: Laparoscopic resection of giant hepatic cysts is a simple and effective method to relieve symptoms with minimal surgical trauma. Moreover, the recurrence is dependent on the type of pathology involved, and the sclerotherapy undertaken.

Prognostic factors for gallbladder cancer in the laparoscopy era / 대한외과학회지

PURPOSE: Hepatobiliary surgery has changed dramatically in recent decades with the advent of laparoscopic techniques. The aim of this retrospective study was to compare survival rates according to stages, adjusting for important prognostic factors. METHODS: A retrospective study of a 17-year period from January 1994 to April 2011 was carried out. The cases studied were divided into two time period cohorts, those treated in the first 9-years (n = 109) and those treated in the last 7-years (n = 109). RESULTS: An operation with curative intent was performed on 218 patients. The 5-year survival rates according to the depth of invasion were 86% (T1), 56% (T2), 45% (T3), and 5% (T4). The number of cases of incidental gallbladder cancer found during 3,919 laparoscopic cholecystectomies was 96 (2.4%). Incidental gallbladder cancer revealed a better survival rate (P = 0.003). Iatrogenic bile spillage was found in 20 perforations of the gallbladder during laparoscopic cholecystectomies, 16 preoperative percutaneous transhepatic gallbladder drainages and 16 percutaneous transhepatic biliary drainages; only percutaneous transhepatic biliary drainage patients showed a significantly lower survival rate than patients without iatrogenic bile spillage (P < 0.034). Chemoradiation appeared to improve overall survival (P < 0.001). Multivariate analysis also revealed that time period, type of surgery, surgical margin, lymphovascular invasion, lymph node involvement, and chemoradiation therapy had significant effects. CONCLUSION: This study found that the prognosis of gallbladder cancer is still determined by the stage at presentation due to the aggressive biology of this tumor. Early diagnosis, radical resection and appropriate adjuvant therapy can increase overall survival.

Review of 100 cases of single port laparoscopic cholecystectomy / 대한외과학회지

PURPOSE: Single port laparoscopic cholecystectomy (SPLC) is a new advanced technique in laparoscopic surgery. Many laparoscopic surgeons seek to gain skill in this new technique. However, little data has been accumulated and published formally yet. This article reports the achievement of 100 cases of SPLC with the hopes it will encourage laparoscopic surgery centers in the early adoption of SPLC. METHODS: A retrospective review of 100 prospectively selected cases of SPLC was carried out. All patients had received elective SPLC by a single surgeon in our center from May 2009 to December 2010. Our review suggests patients' character, perioperative data and postoperative outcomes. RESULTS: Forty-two men and 58 women with an average age of 45.8 years had received SPLC. Their mean body mass index (BMI) was 23.85 kg/m2. The mean operating time took 76.75 minutes. However, operating time was decreased according to the increase of experience of SPLC cases. Twenty-one cases were converted to multi-port surgery. BMI, age, previous low abdominal surgical history did not seem to affect conversion to multi-port surgery. No cases were converted to open surgery. Mean duration of hospital stay was 2.18 days. Six patients had experienced complications from which they had recovered after conservative treatment. CONCLUSION: SPLC is a safe and practicable technique. The operating time is moderate and can be reduced with the surgeon's experience. At first, strict criteria was indicated for SPLC, however, with surgical experience, the criteria and area of SPLC can be broadened. SPLC is occupying a greater domain of conventional laparoscopic cholecystectomy.

Sodium Iodide Symporter and Phosphatase and Tensin Homolog Deleted on Chromosome Ten Expression in Cholangiocarcinoma Analysis with Clinicopathological Parameters

BACKGROUND/AIMS: This study was performed to investigate the correlation of sodium iodide symporter (NIS) expression with the functionality and loss of phosphatase and tensin homolog deleted on chromosome ten (PTEN) expression in human cholangiocarcinoma (CCA). METHODS: Immunohistochemistry for the expression of NIS and PTEN was performed in 60 biopsy specimens of CCA. The clinicopathological parameters were retrospectively identified from medical records. The expression pattern of NIS and loss of PTEN expression were analyzed in association with the clinicopathological characteristics, including survival. RESULTS: Normal biliary trees displayed NIS expression, but hepatocytes did not. NIS expression was divided into two patterns: cytoplasmic and membranous. Fifty-nine cases, all except for one case, displayed NIS expression in tumor cells. Twenty-two cases (33.3%) were mixed pattern, and 39 cases (65.05%) were cytoplasmic pattern; the pure membranous pattern was not noted. There was no association between the NIS expression pattern and clinicopathological parameters, including age, sex, differentiation grade, T stage and tumor, node, metastasis stage (p>0.05). The survival rates were similar among various NIS expression patterns. Normal hepatocytes and biliary trees exhibited PTEN expression in the nucleus and cytoplasm. CCA cells displayed nuclear staining. Thirty-six (60.0%) of 60 cases displayed a loss of PTEN expression. The loss of PTEN expression was observed in the advanced T-stage group (p=0.0036), but there was no association between the loss of PTEN expression and other clinicopathological parameters (p>0.05). No association between the loss of PTEN expression and survival was noted. CONCLUSIONS: NIS is expressed in most types of human CCA. The expression pattern suggests a role in cancer development. PTEN loss expression is common in the context of human CCA, especially in the advanced T stage.

The Learning Curve for Single-Port Laparoscopic Cholecystectomy by Experienced Laparoscopic Surgeon

PURPOSE: Single-port laparoscopic surgery is a rapidly advancing technique in laparoscopic surgery. However, there is currently limited evidence on the learning curve for this procedure. The aim of this study was to estimate the number of single port laparoscopic cholecystectomies required until improvement in the performance of the technique ceases. METHODS: This is a descriptive, single-center study using routinely collected clinical data from 70 patients who underwent single port laparoscopic cholecystectomy between May 2009 and June 2010 at Dong-A University Medical Center in Busan, Korea. The review includes the mean operating time, conversion cases, intra-operative GB perforation, post-operative wound infection and mean hospital stay. RESULTS: The mean operating time of the first 30 cases (the learning period) was 91.83 minutes. After 30 operations (the experience period), it plateaued to an average of 75.25 minutes, which remained steady in the next 40 operations - a reduction of more than 16%. Reduction in the operating time was significant (P<0.001) between the learning period and the experience period. Other factors including additional ports, intraoperative gall bladder perforation, mean hospital stay, post-operative wound infection were not significantly different between the two periods. CONCLUSION: We suggest that the learning curve for single port laparoscopic cholecystectomy should be around thirty cases for a surgeon with prior conventional laparoscopic cholecystectomy experience and for self-taught single port technique.

Lessons learned from 100 initial cases of laparoscopic liver surgery / 대한외과학회지

PURPOSE: Laparoscopic liver resection (LLR) is now widely accepted and is being increasingly performed. The present study describes our experience with LLR at a single center over an eight-year period. METHODS: This retrospective study enrolled 100 patients between October 2002 and February 2010. Forty-six benign lesions and 54 malignant lesions were included. The LLR performed included 58 pure laparoscopy procedures, 18 hand-assisted laparoscopy procedures and 24 hybrid technique procedures. RESULTS: The mean age of the patients was 57 years; among these patients, 31 were over 65 years of age. The mean operation time was 220 minutes. The overall morbidity was 11% and the mortality was zero. Among the 20 patients with simple hepatic cysts, 50% unexpectedly recurred. Among the 41 patients with hepatocellular carcinoma, 21 patients (51%) underwent preoperative radiofrequency ablation therapy or transarterial chemoembolization. During parenchymal-transection, 11 received blood transfusion. The width of the resection margins was under 0.5 cm in 11 cases (27%); 0.5 to 1 cm in 22 cases (54%) and over 1 cm in eight cases (12%). There was no port site seeding, but argon beam coagulation-induced tumor dissemination was observed in two cases. The overall two-year survival rate was 75%. CONCLUSION: This study suggests that the applications for LLR can be gradually expanded when assuring that the safety and curability of LLR are equivalent to that of open liver resection.

Isolated primary schwannoma arising on the colon: report of two cases and review of the literature / 대한외과학회지

Primary schwannoma of the large intestine is an extremely rare neoplasm. Here, we report two cases of colonic schwannoma confirmed pathologically after laparoscopic resection. A 52-year-old female and a 59-year-old female were referred by their general practitioners to our coloproctologic clinic for further evaluation and management of colonic submucosal masses. Colonoscopies performed in our institution revealed round submucosal tumors with a smooth and intact mucosa in the mid-ascending and descending colon, respectively. Computed tomography (CT) scans showed an enhancing soft tissue mass measuring 2 x 2 cm in the right colon and well-defined soft tissue nodule measuring 1.5 x 1.7 cm in the proximal descending colon, respectively. We performed laparoscopic right hemicolectomy and segmental left colectomy under the preoperative impression of gastrointestinal stromal tumors. Two cases were both diagnosed to be benign schwannoma of the colon after immunohistochemical stains (S-100 (+), smooth muscle actin (-), CD117 (-), and CD34 (-)).

Prognostic implication of metastatic lymph node ratio in node-positive rectal cancer / 대한외과학회지

PURPOSE: The aim of this study was to evaluate the prognostic significance of the ratio between metastatic and examined lymph nodes (LNs) in patients with stage III rectal cancer. METHODS: A review was made of 175 (male, 98) patients with stage III rectal cancer of R0 resection. LN disease was stratified both by the American Joint Committee on Cancer/International Union Against Cancer nodal classification (pN) and by quartiles of the lymph node ratio (LNR). Disease-free survivals (DFS) were made using Kaplan-Meier curves and assessed by the log rank test and multivariate analysis was performed using the Cox proportional hazards model. RESULTS: Patients ranged in age from 29 to 83 (median, 60) years with median follow-up of 47 months (range, 13 to 181 months). months. There was a significant correlation between the number of metastatic LNs and the LNR (r = 0.8681, P < 0.0001). Cut-off points of LNR quartiles best to separate patients with regard to 5-year DFS were between quartile 2 and 3, and between 3 and 4 (LNR1, 2, and 3); the 5-year DFS according to such stratification was 89.6%, 55.8%, and 18.2% in LNR1, 2, and 3, respectively (P < 0.0001). Cox model identified the LNR as the most significant independent prognostic covariate; LNR2 showed 3.6 times (95% confidence interval [CI], 1.682 to 7.584; P = 0.0009) and LNR3, 18.7 times (95% CI, 6.872 to 50.664; P < 0.0001) more risky than LNR1. CONCLUSION: This study suggests that ratio-based LN staging, which reflects the number of LNs examined and the quality of LN dissection, is a simple and reliable system for prognostic LN stratification in patients with stage III rectal cancer.

Primary Extrapulmonary Small Cell Carcinoma of the Appendix: A Case Report

Primary extrapulmonary small cell carcinoma (EPSCC) of the appendix is an extremely rare entity, and there has been only one previous report on this in the English medical literature. We report here on the first Korean case of EPSCC of the appendix in a 55-year-old woman. The patient had no history of an identified pulmonary tumor, and she presented with constipation and lower abdominal pain. The patient underwent right hemicolectomy with regional lymph node dissection and bilateral salphigo-oophorectomy. The histology of the entire appendiceal tumor revealed pure EPSCC with diffuse immunoreactivity for pancytokeratin, cytokeratin 7, cytokeratin 20, CD56, thyroid transcription factor 1, c-kit and carcinoembryonic antigen, and there was focal weak immunoreactivity for chromogranin A and synaptophysin. After the second cycle of chemotherapy, the condition of the patient gradually deteriorated due to cancer peritonei and the patient died 7 months later. EPSCC of the appendix is a distinctive clinicopathological entity that displays highly aggressive behavior and an unfavorable outcome.

The Effect of an Anti-adhesion Agent in Continuous Ambulatory Peritoneal Dialysis (CAPD) Catheter Insertion Operation

PURPOSE: Continuous ambulatory peritoneal dialysis (CAPD) is an important method of performing renal replacement therapy in patients with chronic renal failure. A significant complication of CAPD is malfunction of the catheter because of catheter adhesion that leads to catheter malposition. So we evaluated the effect of an anti-adhesive agent called Guardix-Sol(R). METHODS: We prospectively evaluated the clinical results of 78 patients who had received CAPD catheter insertion from Sep. 2007 to May 2009. A test group of 34 patients used the anti-adhesion agent and a control group of 44 patients did not use it. All the procedures were standardized and performed by a single surgeon. RESULTS: The patients consisted of 49 males and 29 females. The common reasons for CAPD insertion were diabetic nephropathy (47 patients) and hypertension (20 patients). Fifteen patients needed reposition operations during their postoperative course, which were done under spinal anesthesia. Out of 15 patients, 3 were from the test group (Guardix-Sol(R) group) and 12 from the control group (P=0.0526). All the repositioned patients had a malpositioned catheter because the greater omentum had adhered to the catheter, except for one patient in each group (P=0.0315). CONCLUSION: Using an anti-adhesive agent for CAPD insertion is an effective method to reduce the incidence of greater omental adhesion. So the rate of reoperation cases for catheter repositioning is decreased.

Comparing the Results of Method of Jejunal Anastmosis at Pylous-preserving Pancreaticoduodenectomy

PURPOSE: After performing pylous-preserving pancreaticoduodenectomy, there are several methods of performing pancreaticojejunostomy for preventing pancreatic leakage. The purpose of this study was to compare the results of two methods of jejunal anastomosis after pancreaticojejunostomy. METHODS: We retrospectively evaluated the clinical results of 49 patients who had received pancreaticojejunostomy for pylous-preserving pancreaticoduodenectomy. One method is the Billroth-I type, that is, choledochojejunostomy and pancreaticojejunostomy after anastomosis of one jejunum loop to the duodenum. The other method is the Roux-En-Y (R-Y) type. Choledochojejunostomy and pancreaticojejunostomy are done with an isolated jejunum loop. Then gastrojejunostomy is fashioned between the stomach and the distal jejunal segment. Finally, the end-to-side jejunojejunostomy is created. RESULTS: The Billroth-I type was used in 17 patients and the R-Y type was used in 32 patients. The median operation time was 397 min and 431 min, respectively. The median postoperative hospital day was 27.6 days and 22.1 days, respectively. The postoperative complications were 10 cases in 17 patients (58.8%) and 11 cases in 32 patients (34.4%), respectively. Leakage of the pancreaticojejunostomy was the most common complication in each group (23.5% and 15.6%, respectively). Most complications required no need surgical intervention. But two cases of Billroth-I type complications needed total pancreatectomy because of leakage of the pancreaticojejunostomy. CONCLUSION: Not only were there fewer complications for the R-Y type than for the Billroth-I type, but there was no need for operation to treat the complications of the R-Y type because of the isolated jejunal loop.

Hand Assisted Laparoscopic Transduodenal Ampullary Mass Excision / 대한내시경복강경외과학회지

Transduodenal ampullectomy may be an alternative procedure, and at times a more appropriate procedure, for the management of benign neoplasms of the ampulla. We describe here our technique for performing the lesser invasive transduodenal ampullectomy. First, the duodenum is mobilized with the left hand, which is inserted via a hand port, and a right Harmonic scarpel(R) (Ethicon. Endo-surgery, Cincinnati, OH, USA) is used for duodenal incision and mass removal via a right subcostal incision. After checking the continuity and that there is no leakage of the pancreatic duct and common bile duct, the operation is finished. For transduodenal mass excision, the hand assisted laparoscopic transduodenal procedure is as good for the duct continuity and anastomosis leakage as that for the open procedure. Furthermore, this procedure is less invasive than the open procedure.