An Investigation of Patients who have Undergone Curative Gastrectomy after Incomplete Endoscopic Mucosal Resection with a Diagnosis of Early Gastric Cancer

PURPOSE: Increasingly, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has been performed. However, yet, there is no standard therapy after incomplete EMR or ESD. The aim of this study was to evaluate the necessity of further resection after an incomplete EMR or ESD. METHODS: We analyzed 24 patients who underwent curative gastrectomy due to an incomplete EMR or ESD between January 2000 and February 2007. A retrospective review was performed evaluating the clinicopathological characteristics, operating methods and presence of residual tumor. RESULTS: After the gastrectomy, the total positive residual tumor rate was 66.7% (16/24), with a rate of 73.5% (11/15) for mucosal cancer a rate of 50.0% (4/8) for submucosal cancer, and a rate of 100% (1/1) for cancer that invaded the muscularis propria. There were no positive lymph nodes. There was no recurrence in a mean 35.5 months (range, 4~90 months) of follow-up. CONCLUSION: Further resection is recommended for patients with a positive resection margin, because of the possibility of the presence of a residual tumor. Laparoscopic resection may be one of the most effective therapeutic options for these patients as a minimally invasive procedure by which curative resection can be expected.

Is CO2 Gas Insufflation in Endoscopic Thyroidectomy Safe or Not?: A Prospective Study through the Continuous Measurement of the End-tidal CO2 Pressure

PURPOSE: Endoscopic thyroidectomy has recently been widely used in clinical practice. The operative method can be classified into CO2gas insufflation and the gasless technique. This study assessed the safety of low pressure CO2gas insufflation (up to 6 mmHg) by performing continuous measurement of the end-tidal CO2 (ETCO2) pressure. METHODS: From March 2003 to October 2006, 95 patients (90 hemithyroidectomies and 5 total thyroidectomies) underwent endoscopic thyroidectomy. The low pressure CO2gas insufflation technique was applied in all cases. The ETCO2 pressure of the patients was measured by capnometry at the time of a pre-gas insufflation status (0 minutes) and at the time of post-CO2gas insufflation (30 minutes) and then it was measured every 30 minutes with also performing capnograms. We analyzed the ETCO2 pressure at the time of the pre-CO2gas insufflation status (0 min) and we compared this with that of each status by using paired T-test. RESULTS: For all 95 cases, the mean patient age was 36.2+/-9.1 (range: 21~57 years), the mean tumor size was 1.7+/-1.1 (range: 0.1~4.5 cm) and the mean operative time was 135.0+/-46.1 (range: 50~340 min). The mean ETCO2 pressure (mmHg) was 33.0+/-3.9 at the time of pre-CO2gas insufflation status (0 min); the mean ETCO2 pressure was 31.1+/-3.7 at 30 min (n=95), 33.5+/-3.7 at 60 min (n=95), 35.2+/-3.6 at 90 min (n=95), 34.9+/-3.7 at 120 min (n=90), 34.6+/-3.8 at 150 min (n=70), 34.1+/-3.4 at 180 min (n=40), 34.3+/-5.2 at 210 min (n=15) and 34.0+/-4.2 at 240 min (n=9). There was a significant difference the early post-CO2gas insufflation status (P0.05; at 60 min, 150 min, 180 min, 210 min, 240 min). At each time point, the ETCO2 pressures were all within the normal range. CONCLUSION: We successfully performed endoscopic thyroidectomy with using the low pressure CO2gas insufflation technique and there were no significant complications. We think that performing endoscopic thyroidectomy with using the low pressure CO2gas insufflation technique is a safe procedure.

The effect of preoperative transarterial chemoembolization on the patient's outcome in resectable hepatocellular carcinoma / 대한내과학회지

BACKGROUND: Although hepatic resection (HR) is the mainstay for the treatment of hepatocellular carcinoma (HCC), high recurrence rate (>60%) is major serious problem. Thus preoperative transarterial chemoembolization (TACE) has been proposed as a neoadjuvant treatment before HR. However, the effect of preoperative TACE in preventing recurrence for initially resectable HCC remains controversial. This study aims at assessing the role of preoperative TACE on the early and long-term outcome following resection of HCC. METHODS: Retrospective randomized analysis was performed. A total of 366 patients who had HR for HCC between January 1995 and December 2000, were included, 132 patients underwent preoperative TACE (TACE plus HR) and 234 patients did not (HR). Statistically no baseline characteristic difference in two groups. RESULTS: HR group was significantly higher than TACE plus HR group in disease-free survival rate and overall survival rate (p<0.001, p<0.01). In subgroup analysis, the disease-free survival rate of HR group was higher than TACE plus HR group in UICC T1-2 and UICC T3 (p<0.01 for both), whereas the difference in overall survival rate was significant only in UICC T3 (p<0.01). Those who achieved tumor necrosis of more than 95% by preoperative TACE showed comparable overall survival rate with HR group, while it was significantly lower in patients who demonstrated tumor necrosis of less than 95% (p<0.001). CONCLUSIONS: Preoperative TACE for initially resectable HCC may promote early and late tumor recurrence and reduces overall survival rate after surgery particularly in patients with advanced- stage tumors.

Usefulness of Reagent Strips for the Diagnosis of Spontaneous Bacterial Peritonitis / 대한간학회지

BACKGROUND/AIMS: Spontaneous bacterial peritonitis (SBP) is one of the potentially life-threatening complications for patients with liver cirrhosis, and it has a mortality rate of over 20%. Early diagnosis of SBP and immediate use of an adequate antibiotic therapy are very important for achieving a better prognosis. The aim of our study was to assess the usefulness of reagent strips for making the rapid diagnosis of SBP. METHODS: A diagnostic paracentesis procedure was performed upon hospital admission in 257 cirrhotic patients (187 males, 70 females; mean age: 54 years) with ascites. Each fresh sample of ascitic fluid was tested using a reagent strip, and the result was scored as 0, 1+, 2+ or 3+. The leukocyte count, polymorphonuclear cell count, blood bottle culture, and chemistry of ascites were also done. RESULTS: We diagnosed 79 cases of SBP and 2 cases of secondary bacterial peritonitis by means of the polymorphonuclear cell count and the classical criteria. When a reagent strip result of 3+ was considered positive, the test's sensitivity was 86% (70 of 81), the specificity was 100% (176 of 176), and the positive predictive value was 94%. Furthermore, when a reagent strip result of 2+ or more was considered positive, the test sensitivity was 100% (81 of 81), the specificity was 99% (174 of 176), and negative predictive value was 99%. CONCLUSIONS: The use of reagent strips is a very sensitive and specific tool for the rapid diagnosis of SBP in cirrhotic patients. A positive result should be an indication for empirical antibiotic therapy, and a negative result may be useful as a screening test to exclude SBP.

Adefovir Dipivoxil Alone or in Combination with Ongoing Lamivudine in Patients with Decompensated Liver Disease and Lamivudine-resistant Hepatitis B Virus

The purpose of this prospective study was to evaluate the efficacy and safety of adefovir dipivoxil with or without ongoing lamivudine in decompensated lamivudine-resistant chronic hepatitis B patients. Forty-six hepatitis B e antigen (HBeAg)-positive patients with decompensated liver function and lamivudine-resistant hepatitis B virus (HBV) were assigned to adefovir dipivoxil monotherapy (n=18) or combination therapy with ongoing lamivudine (n=28) according to their own preference. After 24 weeks of treatment, 83% of monotherapy and 86% of combination therapy showed serum HBV DNA below detection limit (<0.5 pg/mL). Alanine aminotransferase (ALT) normalized in 78% and 82% respectively. Median Child-Pugh-Turcotte (CPT) score or Model for End-Stage Liver Disease (MELD) score reduced significantly by 3 or 5 point in monotherapy and 2 or 2 point in combination therapy respectively. There were no significant differences in rate of undetectable serum HBV DNA, median change of ALT and median reduction of CPT or MELD scores between the two groups. In conclusion, both adefovir dipivoxil monotherapy and combination therapy with ongoing lamivudine result in comparable virologic, biochemical, and clinical improvements in HBeAg-positive patients with decompensated liver function and lamivudine-resistant HBV. Combination with lamivudine showed no additional benefit over monotherapy during 24 weeks of treatment in these patients.

Autoimmune Chronic Pancreatitis Relapsing Despite the Maintenance Dose of Steroid

Autoimmune chronic pancreatitis is a disease characterized by diffuse swelling of the pancreas, irregular narrowing of the main pancreatic duct and elevated levels of serum IgG, and lymphoplasmacytic infiltration is observed on histologic examination. Steroid therapy can dramatically reverse the clinical symptoms and the histologic and radiologic findings. It is known that recurrence is very rare after successful steroid treatment. Furthermore, there have not yet been any reports about a case that relapsed during maintenance therapy with low dose steroid. We experienced a rare case of autoimmune chronic pancreatitis that relapsed despite maintenance therapy with low-dose steroid, and the patient again responded to high-dose steroid.

A New Strategy to Predict the Neoplastic Polyps of the Gallbladder Based on a Scoring System Using Endoscopic Ultrasonography / 대한소화기내시경학회지

No abstract available.

Sphincterotomy - Induced Hemorrhage: Prevalence, Risk Factors and Endoscopic Hemostasis / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic biliary sphincterotomy (EST)-induced hemorrhage occurs in approximately 0.5-12% of procedures. We prospectively investigated the risk factors of EST-induced hemorrhage and evaluated its safety as well as the effectiveness of endoscopic hemostasis. METHODS: One thousand three hundred and four patients, who underwent EST between July 1996 and June 1998, were enrolled. As a hemostatic treatment, epinephrine spray was initially used. If bleeding persisted, epinephrine injection was performed consecutively. In patients with exposed vessels, epinephrine injection followed by alcohol injection was given. RESULTS: EST-induced hemorrhage occurred in 136 (10.4%) patients. Types of sphincterotome (needle-knife sphincterotome, p=0.0079) and cutting speed (so-called, zipper cut, p=0.03) were revealed as significant variables for the occurrence of bleeding. Once bleeding occurred, patients with an associated ampullary lesion (impacted stone or cancer) or with coagulopathy were more likely to bleed profusely. Initial hemostasis was achieved in all patients. However, rebleeding occurred in eight patients who were initially classified in the moderate or severe bleeding group. Finally, EST-induced hemorrhage was successfully controlled in all patients after 1-3 treatment sessions (mean: 1.1 sessions). The difference in the incidence of complications between the groups with and without endoscopic hemostasis was not statistically significant. CONCLUSIONS: The use of needle-knife sphincterotome and cutting speed were independent risk factors for bleeding occurrence. Once bleeding occurred, its severity was affected by the associated ampullary lesion (impacted stone or cancer) or coagulopathy. Endoscopic hemostasis with epinephrine and/or alcohol was effective and safe in EST-induced hemorrhage.

Clinicopathological Features of Gastric Carcinoma in the Korean Elderly

BACKGROUND: Gastric carcinoma is the leading cause of cancer death in Korea. Although the incidence of gastric carcinoma has the tendency to increase in recent years with the increase in the elderly in Korea, clinicopathological characteristics of gastric carcinoma in the elderly has not been studied in detail yet. This study was undertaken to investigate the clinicopathological features of gastric carcinoma in the Korean elderly. METHODS: The clinicopathological data, such as age, gender, cancer location, macroscopic appearance, histopathology, depth of invasion, lymph node metastasis, distant metastasis, stage, and type of operation, were retropectively reviewed from the hospital records of 682 patients with gastric adenocarcinoma admitted to the Asan Medical Center from Jan. 1996 to Dec. 1996. In 581 patients treated with gastrectomy, the postoperative findings were used in analysis, while in 101 patients receiving no operation due to mestastasis, clinical and laboratory findings were used. All patients were divided into three groups: the young; 39 years of age or younger, the middle-aged; between 40 and 64 years old, and the elderly; 65 years old or over. RESULTS: A total of 183(26.8%) of 682 patients were in the elderly, while 91(13.3%) and 408(59.8%) were in the young and middle-aged, respectively. The gender ratio for male to female was 2.3: 1 in the elderly, which was not different from that the young or middle-aged. In the elderly patients, as compared with the young or middle-aged, the antral involvement, well and moderately differentiated adenocarcinoma, Borrmann type I and II, and stage IV were more frequent, and the rate of early gastric cancer was less common. There was no significant difference in the depth of invasion, lymph node metastasis, distant metastasis and type of operation between three groups. CONCLUSION: Some of the clinicopathological features of gastric adenocarcinoma in the elderly are different from those of the young or middle-aged, and in consequence these differences should be considered in the management and study of the elderly patients with gastric carcinoma.