Is Laparoscopy-assisted Radical Gastrectomy Safe in Patients with Child-Pugh Class A Cirrhosis?

PURPOSE: We investigated early postoperative morbidity and mortality in patients with liver cirrhosis who had undergone radical gastrectomy for gastric cancer. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 41 patients who underwent radical gastrectomy at the Chonnam National University Hwasun Hospital (Hwasun-gun, Korea) between August 2004 and June 2009. There were few patients with Child-Pugh class B or C; therefore, we restricted patient selection to those with Child-Pugh class A. RESULTS: Postoperative complications were observed in 22 (53.7%) patients. The most common complications were ascites (46.3%), postoperative hemorrhage (22.0%) and wound infection (12.2%). Intra-abdominal abscess developed in one (2.4%) patient who had undergone open gastrectomy. Massive ascites occurred in 4 (9.8%) patients. Of the patients who underwent open gastrectomy, nine (21.9%) patients required blood transfusions as a result of postoperative hemorrhage. However, most of these patients had advanced gastric cancer. In contrast, most patients who underwent laparoscopic gastrectomy had early stage gastric cancer, and when the confounding effect from the different stages between the two groups was corrected statistically, no statistically significant difference was found. There was also no significant difference between open and laparoscopic gastrectomy in the occurrence rate of other postoperative complications such as ascites, wound infection, and intra-abdominal abscess. No postoperative mortality occurred. CONCLUSIONS: Laparoscopic gastrectomy is a feasible surgical procedure for patients with moderate hepatic dysfunction.

Intraperitoneal Bronchogenic Cyst Misidentified as Gastric Submucosal Tumor

Most bronchogenic cysts originate in the mediastinum, while 15% to 20% occur in the lung parenchyma. According to the literature, most intrapulmonary cysts occur in the lower lobes. But, they are rarely located in an extrathoracic site, such as subdiaphragmatic retroperitoneal area. We describe a paraesophageal intra-abdominal bronchogenic cyst, first considered as gastric submucosal tumor. Resection was successfully realized by laparoscopy. A 20-year-old female was admitted to our hospital with incidentally detected gastric submucosal tumor. At operation, there was a 2.5x2 cm sized cystic tumor that was isolated from the gastric wall. We performed tumor resection laparoscopically. The postoperative course was uneventful and the patient was discharged on the second postoperative day. Histological examination reported a bronchogenic cyst. We, herein, report this case.

Discrepant Bowel Perforation from a Primary Lesion after Chemotherapy of Diffuse Large B Cell Lymphoma

Diffuse large B cell lymphoma is the most common type of non-Hodgkin's lymphoma, representing approximately one-third of all cases and involving the gastrointestinal tract in about 18%. With the development of modern chemotherapeutic regimens and advances in medical care, the prognosis for malignant lymphoma can be excellent. However, because of the aggressive adjuvant therapy required, complications such as bowel perforation may be fatal. In cases of chemotherapy for malignant lymphoma, we should keep in mind the possibility of perforation of the bowel after chemotherapy. Early detection is important to save patients.

The Impact of Obesity on Operative Results and Postoperative Courses in Laparoscopic-assisted Distal Gastrectomy (LADG)

PURPOSE: Despite known advantages of laparoscopy-assisted distal gastrectomy (LADG) over open surgery, including less blood loss, less pain, faster recovery, and shorter hospital stays, many surgeons still hesitate to perform LADG in overweight patients due to concerns about increased perioperative morbidity. We investigated whether surgical outcomes in LADG differ in overweight patients and normal patients, as well as the influence of surgical experience. METHODS: Between April 2004 and December 2006, 331 consecutive patients underwent LADG for preoperatively diagnosed early gastric cancer. Using the definition of overweight by western criteria, patients were classified into a low (n = 187, BMI 25 kg/m(2)) group. We retrospectively analyzed surgical outcomes, including operation time, retrieved lymph nodes, hospital courses, and postoperative complications. RESULTS: The only differences in overweight and normal patients were longer operation time, incision length, and fewer retrieved lymph nodes. As our surgical team accumulated experience (after 250 cases in our study), there were no differences at all between the two groups. CONCLUSION: Technical difficulty in overweight patients could hamper some surgical outcomes but didn't worsen the post- operative courses or complications. Moreover, those difficulties can be overcome as the surgical team accumulates experience.

Evaluation of the Safety and Feasibility of D2 Lymphadenectomy in Elderly Patients with Gastric Cancer

PURPOSE: The aim of this study was to evaluate the safety and feasibility of D2 lymphadenectomy in elderly patients with gastric cancerby comparing the surgical outcomes and postoperative courses between an elderly group and a control group undergoing the same procedure. MATERIALS AND METHODS: Clinical information was reviewed for 1251 patients with gastric cancer who underwent gastrectomy between May 2004 and May 2007. Patients were classified into the following two groups: an elderly group (older than the average life span in Korea) and a control group (younger than the elderly group). Clinicopathologic features and postoperative courses after D2 lymphadenectomy were reviewed and compared between the two groups. RESULTS: There were a total of 120 (9%) elderly group patients among all those reviewed, and 86 (72.2%) of them underwent D2 lymphadenectomy. There was 27.5% postoperative morbidity in the elderly group, which was significantly different from thecontrol group (12.8%, p=0.003). However, on multivariate analysis, ASA score and combined resection were independent predictive factors of postoperative complications, while age was not predictive. CONCLUSION: Older age is not a predictive factor of postoperative complications in itself, and D2 lymphadenectomy can be safely performed in elderly patients with gastric cancer, provided they have good ASA scores and do not undergo accompanying combined resection.

Short-term Surgical Outcomes after Laparoscopic D2 Lymphadenectomy in Patients with Distal Gastric Cancer

PURPOSE: With advancements in laparoscopic surgery, there have been efforts to expand the indication for laparoscopic surgery up to advanced gastric cancer. However, scant data are available regarding the feasibility and advantages of laparoscopy-assisted distal gastrectomy (LADG) with standard radical D2 lymph node dissection. MATERIALS AND METHODS: Twenty-two patients who were preoperatively diagnosed with cT1N0M0 gastric cancer underwent LADG with standard D2 lymphadenectomy between February and August 2007. They were compared with patients who underwent conventional open D2 lymphadenectomy with respect to clinicopathologic features, surgical outcomes, and postoperative course. RESULTS: The mean operative time was significantly longer in the LADG group than in the open group (160+/-25 min vs. 135+/-21 min, P<0.001). However, surgical outcomes, such as surgical margin and number of retrieved lymph nodes (25.7+/-11.1 vs. 26.9+/-9.2, P=ns) were comparable between the groups. The LADG group exhibited quicker postoperative recovery, and both groups exhibited similar postoperative morbidity and mortality. CONCLUSION: LADG with D2 lymphadenectomy is feasible and safe, with short-term surgical outcomes comparable to those seen in open D2 lymphadenectomy. Further prospective clinical investigation will be needed to better evaluate the advantages of LADG with D2 lymphadenectomy.

Laparoscopic Assisted Total Gastrectomy (LATG) with Extracorporeal Anastomosis and using Circular Stapler for Middle or Upper Early Gastric Carcinoma: Reviews of Single Surgeon's Experience of 48 Consecutive Patients

PURPOSE: Many recent studies have reported on the feasibility and usefulness of laparoscopy assisted distal gastrectomy (LADG) for treating early gastric cancer. On the other hand, there has been few reports about laparoscopy assisted total gastrectomy (LATG) because upper located gastric cancer is relatively rare and the surgical technique is more difficult than that for LADG, We now present our procedure and results of performingLATG for the gastric cancer located in the upper or middle portion of the stomach. MATERIALS AND METHODS: From Jan 2005 to Sep 2007, 96 patients underwent LATG by four surgeons at the Asan Medical Center, Seoul, Korea. Among them, 48 consecutive patients who were operated on by asingle surgeon were analyzed with respect to the clinicopathological features, the surgical results and the postoperative courses with using the prospectively collected laparoscopy surgery data. RESULTS: There was no conversion to open surgery during LATG. For all the reconstructions, Roux-en Y esophago- jejunostomy and D1+beta lymphadenectomy were the standard procedures. The mean operation time was 212+/-67 minutes. The mean total number of retrieved lymph nodes was 28.9+/-10.54 (range: 12~64) and all the patients had a clear proximal resection margin in their final pathologic reports. The mean time to passing gas, first oral feeding and discharge from the hospital was 2.98, 3.67 and 7.08 days, respectively. There were 5 surgical complications and 2 non-surgical complications for 5 (10.4%) patients, and there was no mortality. None of the patients needed operation because of complications and they recovered with conservative treatments. The mean operation time remained constant after 20 cases and so a learning curve was present. The morbidity rate was not different between the two periods, but the postoperative course was significantly better after the learning curve. Analysis of the factors contributing to the postoperative morbidity, with using logistic regression analysis, showed that the BMI is the only contributing factor forpostoperative complications (P=0.029, HR=2.513, 95% CI=1.097-5.755). Conclusions: LATG with regional lymph node dissection for upper and middle early gastric cancer is considered to be a safe, feasible method that showed an excellent postoperative course and acceptable morbidity. BMI should be considered in the patient selection at the beginning period because of the impact of the BMI on the postoperative morbidity.

The Usefulness of Serum Tumor Markers as a Predictor of Peritoneal Metastasis in Patients with Gastric Carcinoma: CA 19-9 and CEA

PURPOSE: The usefulness of serum tumor markers for assessing gastric carcinoma is very limited compared to that for neoplasms in other digestive organs. Many reports have shown that serum tumor markers are closely associated with the prognosis and tumor recurrence in gastric cancer patients. However, little is known about the usefulness of serum tumor markers as a predictor of distant metastasis for gastric carcinoma. MATERIALS AND METHODS: With excluding the non-specific causes of elevated tumor markers, a total of 788 patients with gastric carcinoma and who were seen at our hospitals between 2004 and 2006 were included in this study. The correlation between the preoperative level of tumor makers and the clinicopathological features was analyzed. RESULTS: CEA was significantly correlated with age, gender and nodal metastasis, but not with the depth of tumor. The CEA level was not correlated with distant metastasis, such as peritoneal or hematogenous metastasis. In contrast, the CA 19-9 level was significantly correlated not only with the depth of tumor and nodal metastasis, but also with peritoneal metastasis. Especially, the patients with over 500% elevation of the CA 19-9 level had a significant risk of peritoneal metastasis. CONCLUSION: CA 19-9 is useful for predicting peritoneal metastasis in gastric cancer patients. It can be used efficiently in making the diagnostic and the treatment plan, in combination with other diagnostic tools, for gastric cancer patients.

The Learning Curve of Laparoscopy-assisted Distal Gastrectomy (LADG) for Cancer

PURPOSE: Laparoscopic surgery for gastric cancer was introduced in the past decade because it was considered less invasive than open surgery, and this results in less postoperative pain, faster recovery and an improved quality of life. Several studies have demonstrated the safety and feasibility of this procedure. We examined the outcome of performing laparoscopic surgery for gastric cancer over the last two year. MATERIALS AND METHODS: From April 2004 to December 2006, 329 patients with gastric adenocarcinoma underwent a laparoscopy-assisted distal gastrectomy with lymph node dissection. The data was retrospectively reviewed in terms of the clinicopathologic findings, the perioperative outcomes and the complications. RESULTS: The total patient group was comprised 196 men (59.6%) and 133 women (40.4%). The mean BMI was 23.6 and the mean tumor size was 2.7 cm. The mean number of harvested lymph node was 22.7, and this was 18.6 before 30 cases and 23.1 after 30 cases, and the difference was significant (P=0.02). The mean operation time was 180.9 min, and this was than 287.9 min before 30 cases and 170.2 min after 30 cases. After 30 cases, there was a significant improvement of the operation time (P<0.01). The mean incision length after 30 cases was shorter than that before 30 cases (P<0.01). Postoperative complications occurred in 24 (7.3%) of 329 patients and there was no conversion to open surgery. CONCLUSION: Even though the LADG was accompanied by a difficult learning curve, we successfully performed 329 LADG procedures over the past 2 years and we believe that LADG is a safe, feasible operation for treating most early gastric cancers (EGC).

Analysis on the Clinical Significance of Biliary Exploration through the Left Hepatic Duct Opening during Left Hepatectomy for the Patients with Hepatolithiasis

PURPOSE: Left-sided hepatolithiasis has been often treated by left hepatectomy and bile duct exploration. Choledochotomy has been the preferred route for conducting exploration of the biliary system, and a T-tube has been routinely inserted. As the left hepatic duct opening can be an alternative route for bile duct exploration instead of choledochotomy, we analyzed the clinical usefulness of this alternative access route by performing a prospective study. METHODS: 42 consecutive cases of left hepatectomy for left- sided or bilateral hepatolithiasis were performed by one surgeon between January 2000 and June 2002. The left hepatic duct opening was the preferred access route for bile duct exploration. Choledochotomy was done only for large stone removal, variant biliary anatomy and intentional T-tube insertion for residual intrahepatic duct stone. RESULTS: Consecutive 42 left hepatectomies did not result in any serious surgical complications except for infection. Choledochotomy could be omitted for 35 of 42 patients and a T-tube was inserted in 7 patients. Residual right lobe stone was removed by choledochoscopy through the T-tube tract in 2 patients. On the 5 year follow-up, only one patient had to undergo percutaneous transhepatic stone removal due to the recurrence of hepatolithiasis. CONCLUSION: We think that bile duct exploration through the left hepatic duct opening is a reasonable and useful method to avoid choledochotomy and T-tube insertion for the patients with left-sided hepatolithiasis.

Pancreatic Carcinoma Presenting as Chronic Pancreatitis with Pseudocyst

A pseudocyst, one of the most prominent and definitive signs of pancreatitis, can also be cause by pancreatic carcinoma. However, a pancreas carcinoma and pancreatitis are sometimes indistinguishable. Reports of a pancreatic carcinoma coexisting with pancreatitis and a pseudocyst are rare. We have experienced a case of a pancreatic carcinoma, which was misdiagnosed as chronic pancreatitis with a pseudocyst. A 31-year-old man complaining of an epigastric pain visited our hospital. Ultrasonography (US) and computed tomography (CT) revealed two cystic lesions, about 8 and 2 cm in diameter, splenic vein thrombosis and diffuse inflammatory changes in the pancreatic body and tail. The value of the tumor marker, CA19-9, was 132 U/ml. Chronic pancreatitis with pseudocyst was suspected, and a cystogastostomy and splenectomy performed. A histological examination revealed a pancreatic pseudocyst. The patient was readmitted 7 months later due to abdominal pain. The serum CA19-9 level was 544 U/ml. The CT revealed severe diffuse inflammatory changes in the pancreatic body and tail. Percutaneous CT- guided fine-needle aspiration revealed a pancreatic adenocarcinoma. The differentiation between the pseudocyst of pancreatitis and the secondary cyst caused by a pancreatic carcinoma is important but is difficult or impossible in some cases. The CT features of pseudocysts secondary to a pancreatic carcinoma are identical to those of pseudocysts in pancreatitis. Even in retrospect, our case was difficult to differentiate from pancreatitis with pseudocysts. Our results indicate that whenever pancreatic cysts are encountered in patients with unusual presentation, further examinations, including percutaneous aspiration biopsies, should be performed to exclude malignancy.

Clinical Application of Sution-type Cigarette Drain for Hepatopancreatoabiliary Surgery

Commercially available intra-abdominal drains such as Penrose drain or closed suction drain have some demerits in either functional reliability of prolonged duration or easiness of bedside management. To cope with these demerits, we devised a Suction-type Cigarette Drain (SCD) and evaluated its usefulness. We made multiple side-holes at a silastic Penrose drain and a silastic tube. These two tubes were integrated as like a conventional cigarette drain. The outside portion of SCD was tightly tied to prevent air leak and the inner drainage tube was connected to a suction bag. SCD was applied to 26 cases of various hepatopancreatobiliary operations including pancreatoduodenectomy (n=10), distal pancreatectomy (n=4), hepatic posterior segmentectomy (n=3), partial cholecystectomy (n=7), and emergent laparotomy after liver transplantation (n=2). There was no significant fluid collection around the SCD in follow-up computed tomogram of all patients. All SCD remained functioning well at the time of removal (mean 13 days). There was no skin irritation, with the exception of 1 patient. Our experience supports that SCD is highly reliable and acceptably convenient for clinical use. We think that this type of intra-abdominal drainage deserves applying to various hepatopancreatobiliary operations.