Double Strand Break of DNA in Gastric Adenoma and Adenocarcinoma / 대한소화기학회지

BACKGROUND/AIMS: DNA double strand break (DSB) is one of the critical types of DNA damage. When unrepaired DSB is accumulated in the nucleus of the cells having mutations in such genes as p53, it will lead to chromosomal instability and further more to mutation of tumor-activating genes resulting in tumorogenesis. Some of malignant cancers and its premalignant lesions were proven to have DSB in their nuclei. The aim of this study was to define the differences in expression of 53BP1 and gamma-H2AX, the markers of DSB, among normal, gastric adenoma, and gastric adenocarcinoma tissues. METHODS: Tissue microarray was made with the tissues taken from 121 patients who underwent gastrectomy for gastric adenocarcinoma, and 51 patients who underwent endoscopic mucosal resection for gastric adenoma. Immunochemical stain was performed for the marker of DSB, 53BP1 and gamma-H2AX in the tissue microarray. The normal tissues were collected from histologically confirmed tissues with no cellular atypia obtained from the patients with gastric adenocarcinoma. RESULTS: In gastric carcinoma cells, 53BP1 and gamma-H2AX were highly expressed as compared to normal epithelial cells and gastric adenoma (p<0.01). There were no differences in the expression of 53BP1 and gamma-H2AX between normal epithelium and gastric adenoma. The expression of 53BP1 in the adenoma with grade II and III atypism was more elevated than in those with grade I atypism. The expression of 53BP1 and gamma-H2AX were not significantly different according to the clinicopathologic parameters in the patients with gastric adenocarcinoma. CONCLUSIONS: The DSB in DNA seems to be associated with the development of gastric adenocarcinoma, but does not affect the premalignant adenoma cells.

A case of a fractured and impacted central venous chemoport in a patient with stomach cancer / 대한내과학회지

A central venous port catheter is widely used to administer fluids, chemotherapeutic agents, and parenteral nutrition; however, similar to other invasive procedures, it has numerous potential complications. Among them, distal migration of a fractured central venous port catheter is a rare complication. A 66-year-old man had a central venous port catheter implanted into the right subclavian vein for adjuvant stomach cancer chemotherapy and presented with an ulceration at the chemoport insertion site. While removing the port catheter, it fractured and the distal tip and migrated and impacted the annulus of the right atrium. The impacted port catheter was successfully removed through a femoral vein approach using a radiofrequency ablation catheter and a multi snare.

Laparoscopic Totally Extraperitoneal Hernia Repair versus Open Lichtenstein Hernia Repair: Comparison of the Early Postoperative Outcomes and Complications / 대한내시경복강경외과학회지

PURPOSE: This study compared the postoperative outcomes and complications between laparoscopic totally extraperitoneal (TEP) hernia repair and open Lichtenstein hernia repair. METHODS: A total of 64 cases (30 cases by the TEP method and 34 cases by Lichtenstein repair) were enrolled in this study. The operative time, the hospital stay, the VAS score, the amount of analgesic used, the postoperative complications and recurrence were compared between the 2 methods. RESULTS: The mean operative time was 71 min for the TEP group, which was not significantly longer than that for the Lichtenstein group (66 min). The mean postoperative hospital stay was 3.7 days for the TEP group, which was significantly shorter than that for the Lichtenstein group (4.2) (p=0.035). The mean postoperative analgesic dose was 0.9+/-0.7 and 1.1+/-1.0 within 24 hours and 0.2+/-0.5 and 0.7+/-0.8 after 24 hours, respectively. The dose of analgesic after 24 hours was significantly lower for the TEP group (p=0.011), but the dose within 24 hours and the total dose was not significantly different. The VAS score was 2.3+/-1.0 and 2.6+/-0.9 at 12 hrs and 1.2+/-0.8 and 1.7+/-0.8 at 48 hrs, respectively. The VAS score was significantly lower for TEP group than that for the Lichtenstein group at 48 hrs (p=0.011), but there was no significant difference between the groups at 12 hrs. There was one recurrence in the TEP group. CONCLUSION: For the TEP group, the hospital stay was significantly shorter than that for the Lichtenstein group and this is maybe because the postoperative pain after 24 hours from the operation was less for the TEP group. Laparoscopic TEP repair may be performed efficiently with an acceptable operating time and a shorter hospital stay, as compared to open Lichtenstein hernia repair.

Is a Fast-track Critical Pathway Possible in Gastric Cancer Surgery?

PURPOSE: The postoperative hospital stay after gastric cancer surgery is usually 8 to 14 days. The main reason for a prolonged hospital stay may be the 3 to 4 day period of postoperative starvation. The aim of this study is to investigate the feasibility of a critical pathway for early recovery after gastric cancer surgery, and this pathway included early postoperative feeding. MATERIALS AND METHODS: One hundred three consecutive patients who underwent gastric resection and reconstruction for gastric cancer from October 2007 to June 2008 at St. Mary's Hospital were prospectively enrolled in a fast-track critical pathway. The pathway included minimal preoperative procedures, optimal pain relief, proper fluid administration, early mobilization and early enteral nutrition at postoperative 1 day. The exclusion criteria were determined preoperatively, intraoperatively and postoperatively. RESULTS: Of the 103 patients, 19 patients were excluded for preoperative (5), intraoperative (7) and postoperative (7) reasons. Eighty-four patients (81.6%) were included in the fast-track critical pathway. Sixty-eight (88.6%) of 84 patients were discharged at the planned 8 day after surgery during the initial period of the study, and the postoperative hospital stay was shortened up to 6 days during the more recent period. Postoperative complications occurred in 22 patients (26.2%), and these were gastrointestinal track-related complications in 6 cases (3 cases of ileus, 1 case of stasis and 2 cases of leakage) and infection-related complications in 8 cases. There was no statistical difference in the incidence of morbidity according to the clinic-operative features that included age, gender, stomach resection and lymphadenectomy. CONCLUSION: The fast-track critical pathway with using the available exclusion criteria was a valid option for patients who underwent gastric cancer surgery.

Primary Retroperitoneal Mucinous Cystadenoma

Primary retroperitoneal mucinous cystadenomas are rare tumors that are almost always found in women. They are similar to ovarian originated mucinous cystadenoma, but there is no any other evidence of an ovarian origin for primary retroperitoneal mucinous cystadenomas. A 33-year-old woman with complaints of RLQ pain was found to have a cystic mass in the right retroperitoneal space on her abdominal CT scan. The histological diagnosis was confirmed as primary mucinous cystadenoma. We report here on a case of retroperitoneal mucinous cystadenoma, and we also talk about this tumor, including its histogenesis, through a review of the available literature.

The Risk Factors for Pulmonary Embolism in Patients with Lower Extremity Deep Vein Thrombosis

PURPOSE: Pulmonary embolism (PE) represents the most important and fatal complication of deep vein thrombosis (DVT), of which a dislodged thrombus is most commonly derived from the deep venous system of the lower extremity. The aim of this study is to define the incidence and risk factors of PE in DVT patients. METHOD: We retrospectively reviewed 248 patients with DVT in a lower extremity at Uijeongbu St. Mary's Hospital between January 2000 and August 2008 and they had received additional examinations for making the diagnosis of PE regardless of its symptoms. RESULT: There were 117 men and 131 women, and their mean age was 59 years old (range: 13~91) at the time of diagnosis. There were 190 DVT-only patients and 58 patients with PE (the incidence rate of PE in the DVT patients: 23.8%). The gender ratio of the DVT only group was 1:1.3 (males: 83, female: 107) and the gender ratio of the DVT with PE group was 1:0.7 (males: 34, females: 24) (P<0.05). The risk factors of PE in the DVT patients were hypercoagulability (34%), cancer (23%), immobilization (17%), trauma/operation (10%), obesity (10%) and a past DVT history (7%). The idiopathic DVT patients had a relatively high cancer diagnosis rate (18.5%) and the majority of the newly detected cancer were from the chest or abdominal cavity. CONCLUSION: The incidence of DVT and PE is increasing and 23.8% of the DVT patients showed PE on their chest CT scan. The most significant risk factor for PE in the DVT patients was the male gender, yet an evaluation for cancer should be carefully done for idiopathic DVT patients because of their high rate of having cancer diagnosed.

Popliteal Artery Aneurysm Presenting as Acute Deep Vein Thrombosis

Popliteal artery aneurysms are rare, but they are the second commonest aneurysm in frequency after aorto-iliac aneurysms. The most commonly reported complications of popliteal artery aneurysm are arterial origin such as occlusion or distal embolization that may result in limb loss, so popliteal artery aneurysm is recognized as 'the silent killer of the leg circulation'. It rarely manifests the clinical symptoms of acute deep vein thrombosis. Thrombosis and compression of the popliteal vein may cause the symptoms of lower extremity venous insufficiency, which accounts for nearly 5% of all popliteal artery aneurysms. We report here a 40 year-old man with acute deep vein thrombosis in the lower extremity, and this was secondary to popliteal artery aneurysm. Preoperative Duplex ultrasound and CT angiography revealed a 6 cm-sized popliteal artery aneurysm and thrombosis of the popliteal vein. The aneurysm was treated with partial resection of the aneurysm with an end to end PTFE bypass graft. We feel it is important to exclude a popliteal artery aneurysm in a patient suffering with deep vein thrombosis.

Hydrocele of the Canal of Nuck

In females, a small evagination of parietal peritoneum accompanies the round ligament through the inguinal ring into the inguinal canal and is called the canal of Nuck; it is homologous to the process vaginalis in males. If it fails to undergo complete obliteration, an indirect inguinal hernia or a hydrocele of the canal of Nuck can occur. We report three cases of this rare developmental disorder, discuss the CT findings and its use in the diagnosis of a hydrocele of the canal of Nuck.

Primary Gastric Choriocarcinoma

The majority of choriocarcinomas occur in the uterus as gestational malignant tumors. Rarely, a choriocarcinoma appears in the gastrointestinal tract, and the tumor is assumed to arise from a different histogenetic origin as compared to tumors of other sites. A primary gastric choriocarcinoma is a rare aggressive, widely metastatic malignant tumor, and has a poor prognosis. Reported here is a case of a 69-year-old woman with a primary gastric choriocarcinoma who presented with melena, epigastric pain, and was diagnosed with a poorly differentiated adenocarcinoma based on a preoperative endoscopic biopsy. Gastrectomy with lymph node dissection, followed by postoperative chemotherapy, is the treatment of choice. Therefore, in the case of a poorly differentiated adenocarcinoma with a bleeding tendency, a meticulous examination with the suspicion of a choriocarcinoma should be undertaken.

Correlation between the Serum Leptin Level and the Expression of Leptin in Stomach Cancer Patients

PURPOSE: The adipocyte-derived cytokine leptin plays a major role in the control of stable body weight by suppressing food intake and increasing energy metabolism. Leptin regulates the cell proliferation of various epithelial cells and it may be involved in the promotion of cancer. Leptin and its receptor are highly expressed in gastric adenocarcinoma, but the association between the serum leptin level and the tissue expression of leptin is uncertain. We evaluated the serum leptin level and the expressions of leptin and leptin receptor in gastric cancer, and we explore the possible mechanism and role of leptin in the carcinogenesis of gastric cancer. MATERIALS AND METHODS: 72 carcinomas that were curatively resected at our hospital from October 2005 to March 2007 were included in this study. By immunoassay and immunohistochemical staining, we evaluated the serum leptin level and the expressions of leptin and its receptor, and we analyzed their relationship together with the clinicopathological variables. RESULTS: The serum leptin level was increased as the patient's BMI increased and it was decreased in H. pylori infected patients. The expression of leptin was increased as the TNM stage increased (P=0.014), and the expression of leptin receptor in the intestinal type gastric adenocarcinoma was higher than that in the diffuse type gastric adenocarcinoma (71.4% vs 28.6%, respectively, P=0.033). CONCLUSION: There was no significant correlation between the serum leptin level and expression of leptin in gastric cancer patients. The expression of leptin was associated with the TNM stage, but its role in the pathogenesis of gastric cancer has to be elucidated.

A Rare Cause of Duodenal Obstruction: Spontaneous Intramural Duodenal Hematoma Caused by a Hemangioma

Small bowel hemangioma is a rare benign lesion, and it usually presents with bleeding or as a leading point of an intussusception. However, obstruction due to intramural hematoma by this lesion is unusual. Intramural hematoma of the duodenum is also an uncommon lesion, and it is usually a complication of blunt abdominal trauma in children and young adults. We present here a case of an intramural hematoma that was caused by spontaneous bleeding of a hemangioma, and this caused duodenal obstruction.

Splenic Infarction Caused by Vivax Malaria

Splenic infarction caused by malaria is a rare complication and this is mostly caused by plasmodium falciparum. We report here on a 38 year-old female patient who developed symptomatic splenic infarction that was caused by vivax malaria. She presented with fever and left upper quadrant pain. Computed tomography showed multiple low density areas in the spleen, and the peripheral blood smear revealed plasmodium vivax infestation. We examined for other causes of splenic infarction, but all were negative. This is just the second report of symptomatic splenic infarction that was caused by vivax malaria only. Unlike the previous case, the levels of D-dimer and fibrinogen degradation factor were elevated. This may be related with the hypercoagulable state caused by malaria. Treatment was conservative and the further course was uneventful.

Clinical Findings of Appendiceal Mucocele

PURPOSE: A mucocele of the appendix is an uncommon pathology, representing 0.2% to 0.3% of all appendix specimens. It is often diagnosed clinically as a result of its ability to cause signs and symptoms similar to those of acute appendicitis. If it is asymptomatic, it is often detected as an incidental finding during ultrasonography, computed tomography, radiographic examination of the gastrointestinal tract, or laparotomy. The purpose of this study was to identify the clinical features of mucocele of the appendix. METHODS: We describe 35 cases of mucocele of the appendix diagnosed at Uijeongbu St. Mary's hospital between January 1993 and December 2006. We analyzed demographic, clinical, and pathologic data of all the cases. RESULTS: A total of 12 males and 13 females with mean age of 54.7+/-14.9 years are described. The peak incidence occurred in the seventh decade (34.3%). Sixteen patients presented with symptoms and signs similar to those found in acute appendicitis. Ten patients complained of a palpable mass, 2 patients complained of non-specific abdominal pain, and 7 patients were asymptomatic. Fourteen cases were diagnosed preoperatively, and 3 cases were discovered incidentally. Pathologic examination revealed mucosal hyperplasia in 20% of the cases, cystadenoma in 71%, and cystadenocarcinoma in 9%. The mean age of cystadenocarcinoma patients was older than the mean age of mucosal hyperplasia patients, and the diameter of the appendix was larger in cystadenoma patients than in mucosal hyperplasia patients. CONCLUSION: The preoperative diagnosis of appendiceal mucocele is very important to make in order to facilitate treatment planning and avoid inadvertent rupture of the mucocele during operation. We recommend more diagnostic studies in cases of suspected mucocele. Mucocele of the appendix must be included in the differential diagnosis of patients with pain in the right iliac fossa, patients older than 40 years of age, patients suffering from long-term symptoms, and patient with a palpable mass in the right iliac fossa.

The Use of Short-term Antimicrobial Prophylaxis in Elective Surgery for Gastric Cancer

PURPOSE: Although most surgeons generally administer prophylactic antibiotics for more than three days, the optimal duration of antimicrobial prophylaxis in elective gastric surgery is still open to debate. The aim of this study was to determine if the duration of prophylactic antibiotic use can affect the recovery of patients after elective gastric surgery. MATERIALS AND METHODS: A total of 93 patients with gastric cancer were enrolled in this study, between January 2007 and December 2007. Patients were excluded if they had an infection at the time of surgery or they underwent an emergency operation. The first antibiotics were commonly given from just prior to the operation. The patients were divided into three groups according to the operation periods: those who received antibiotics only on the day of operation (arm A), those who received antibiotics for up to 3 days (arm B), and those who received antibiotics for more than 5 days postoperatively (arm C). The antibiotic that was used was second generation cephalosporin. RESULTS: The rate of surgical site infection was 12.9% (n=4) in arm A, 16.1% (n=5) in arm B and 19.4% (n=6) in arm C, respectively (P=0.788). No relationship was observed between the duration of prophylaxis and the rate of fever or the neutrophil counts during postoperative 7 days (P=0.119, P=0.855). CONCLUSION: The prophylactic effect of antibiotics on recovery, with the antibiotics being received only on the day of the operation, is as effective as receiving antibiotics for a longer duration after gastric cancer surgery.

The Role of Abdomen-pelvis CT for the Diagnosis of Appendicitis

PURPOSE: We wanted to evaluate the value of intravenous contrast enhanced abdomen-pelvis computed tomography (CT) for diagnosing acute appendicitis and we wanted to determine which patients groups will benefit from preoperative CT. METHODS: Between January and June 2006, the medical records of 354 patients who had clinically suspected acute appendicitis were retrospectively reviewed. Appendectomy was performed in 260 patients and CT was conducted in 108 patients of the 260 patients. The 5mm slice CT scans were evaluated for the presence of appendicitis. The sensitivity, specificity and accuracy of CT were calculated. The negative appendectomy rate (NAR) was compared between the patients with CT scans and those without CT scans. Furthermore, the patients were classified into the children and adults groups and the male and female groups and the differences of the NARs were analyzed for each group. RESULTS: The sensitivity, specificity and accuracy were 95%, 93% and 94%, respectively. The NAR was lower for the patients with a CT scan (12%) compared to 27% for those patients without CT scans (P=0.002). The difference of the NAR between the preoperative CT group and the without CT group was statistically significant for the female (P=0.004) and adult groups (P=0.012) (14% vs 36%, 11% vs 26%, respectively). CONCLUSION: Preoperative intravenous contrast enhanced abdomen-pelvis CT was effective in reducing the negative appendectomy rate in patients who were suspected of having acute appendicitis. Especially, the adults and women benefit more from CT scanning and they had a significantly lower negative appendectomy rate than the children and men, respectively.

Primary Retroperitoneal Mucinous Cystadenocarcioma Involving the Splenic Hilum

Primary retroperitoneal mucinous cystadenocarcinoma is a rare tumor, and it is similar to its ovarian counterpart, but it is without any evidence of ovarian, pancreatic or any other extra-retroperitoneal origin. The histogenesis of this neoplasm remains uncertain. Mucinous or colemic metaplasia of the retroperitoneal mesothelium has recently been proposed as its origin. A 39-year-old woman was diagnosed with a 13-cm cystic lesion in the left retroperitoneum; this was mucinous cystadenocarcinoma and no primary tumor was identified. We report here on a primary retroperitoneal mucinous cystadenocarcinoma that involved the splenic hilum, and we include a review of literature.

Methylation Patterns of Cancer-Associated Genes in Breast Cancer / 한국유방암학회지

PURPOSE: To investigate the methylation status of cancerassociated genes in breast cancer to assess its use in the diagnosis of breast cancer and the relationship with distinctive clinical and pathological features. METHODS: A total of 29 benign tumors and their adjacent normal tissues as well as 67 malignant tumors and adjacent normal samples, from women undergoing surgery for primary invasive breast carcinoma at Uijongbu St. Mary's Hospital, between March 2003 and March 2005, were used. Eleven candidate genes were chosen; P14, P16, DAPK, MGMT, h-MLH, E-cadherin, RASSF1 , Twist, RAR , HIN-1, and Cyclin D. DNA was extracted from fresh tissues, and methylation specific PCR performed. RESULT: The number of methylated genes was increased in the malignant tissues compared to the benign tumors and adjacent normal tissues. 7 genes; P14, P16, MGMT, RASSF1, Twist, RAR beta and Cyclin D, were more frequently methylated in malignant than benign tumors, with the differences in the p14, p16, and RAR beta genes were statistically significant (p<0.05). In benign tumors, the p16 and HIN-1 genes were the most infrequently (6.9%) and frequently methylated (82.8 %), respectively. In malignant tumors, the h-MLH and RASSF1 genes were most infrequently and frequently methylated genes, respectively. The ubgroup showing methylation of the DAPK gene had a higher nuclear grade and greater progesterone receptor negativity. The group in which the RASSF1 gene was methylated, had greater estrogen receptor (ER) and progesterone receptor (PgR) positivities. The Twist gene was frequently methylated in the subgroup showing higher nuclear and histologic grades. The group with HIN- 1 and cyclin D methylation had a tendency to show greater ER positivity. CONCLUSION: The subgroups showing methylated DAPK and Twist should be more intensely treated and followed up more carefully than those with RASSF1 , HIN-1 and Cyclin D methylation. Gene methylation may be linked to various pathological features of breast cancer; however, this will require confirmation from larger studies.

Clinical Usefulness of a Totally Laparoscopic Gastrectomy

PURPOSE: In Korea, the number of laparoscopy-assisted distal gastrectomies for early gastric cancer patients has been on the increase. Although minimally invasive surgery is more beneficial, no reported case of a total laparoscopic gastrectomy has been reported because of difficulty with intracorporeal anastomosis. This study attempts, through our experience, to determine the safety and feasibility of a total laparoscopic gastrectomy with various types of intracorporeal anastomosis using laparoscopic linears stapler in treating early gastric carcinomas. MATERIALS AND METHODS: We investigated the surgical results and clinicopatholgical characteristics of 81 patients that underwent a totally laparoscopic distal gastrectomy at our department between June 2004 and May 2007. The intracorporeal anastomoses were performed by using laparoscopic linear staplers. RESULTS: The mean operative time was 287 minutes, the mean anastomotic time was 40 minutes, and the mean number of laparoscopic linear staplers used for an operation was 7.5. The mean time to the first flatus, the first food intake, and discharge from hospital was 2.9, 3.6, and 10.3 days respectively. There were 11 cases of postoperative complications, but no case of postoperative mortality or conversion to an open procedure. In 75 patients with an adenocarcinoma, the mean number of lymph nodes harvested was 38.1 and the stage distribution was as follows: stage I, 72 patients; stage II, 2 patients; stage IV, 1 patient. During the mean follow-up period of 14 months, 5 patients died of other causes and there were no cases of cancer recurrence. CONCLUSION: A total laparoscopic gastrectomy with intracorporeal anastomosis by using a laparoscopic linear stapler was found to be safe and feasible. We were able to obtain acceptable surgical outcomes in terms of minimal invasiveness.

Comparison of an Uncut Roux-en-Y Gastrojejunostomy with a Billroth I Gastroduodenostomy after Totally Laproscopic Distal Gastrectomy

PURPOSE: An uncut Roux-en-Y gastrojejunostomy has been known to be effective in preventing bile reflux gastritis in the remnant stomach and the Roux stasis syndrome. MATERIALS AND METHODS: To evaluate the usefulness of a totally laparoscopic uncut Roux-en-Y gastrojejunostomy (TLuRYGJ) after a distal gastrectomy, we reviewed the medical records of 19 consecutive patients that underwent a TLuRYGJ at our institution, and 11 consecutive patients who underwent a totally laparoscopic Billroth I gastrectomy (TLB-I) during the same period. RESULTS: Postoperative gastrointestinal symptoms related to the postgastrectomy syndrome and the Visick classification at six months after surgery were not different in the two groups; however, there was no case of symptomatic bile reflux gastritis and only one case of delayed gastric empting, for which medication was required, in the TLuRYGJ group. The endoscopic findings of the remnant stomach for bile reflux gastritis at six months after surgery were better in the TLuRYGJ group than in the TLB-I group. CONCLUSION: A TLuRYGJ was found to be effective in preventing bile reflux gastritis and the Roux stasis syndrome.

Pledget as a Useful Substitute for a Knot in Intracorporeal Continuous Gastrointestinal Suturing

PURPOSE: Pledget is a PTFE felt that is usually used for suture reinforcement in cardiovascular surgery. In order to minimize the difficulty in intracorporeal continuous gastrointestinal suturing by reducing the number of tied knots, we have used pledget as substitute for a knot (pledget suturing). MATERIALS AND METHODS: Thirty-two consecutive patients who underwent totally laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy in our institution were enrolled in this study, and the patients were divided into three groups according to the method of intracorporeal anastomosis. Basically, intracorporeal anastomosis was performed by several firings of linear staplers; however, the entry holes for the stapler at the jejunojejunostomy and the gastrojejunostomy were closed by pledget suturing in group A (8 patients), the entry hole for the stapler at jejunojejunostomy was closed by conventional suturing in group B (8 patients), and all of the entry holes for the stapler were closed by stapling in group C (16 patients). The surgical outcomes of each group were compared to each other. RESULTS: The anastomotic time in group A was not longer than in group B, although there were more sutures used in group A, but it was longer than in group C. The number of stapler cartridges used in group A was the smallest among the three groups. In group B, there were two cases of a break of suture material during anastomosis, there were no such cases in group A. There was no complication related to anastomosis in all of the groups. CONCLUSION: Pledget was found to be useful for minimizing the difficulty in intracoproreal continuous gastrointestinal suturing and reducing the number of stapler cartilages used in intracorporeal anastomosis.