Gastric Neuroendocrine Tumors According to the 2019World Health Organization Grading System: A Single-Center, Retrospective Study

Background/Aims@#Although gastric neuroendocrine tumors (NETs) are uncommon neoplasms, their prevalence is increasing. The clinical importance of the World Health Organization (WHO) classification of gastric NETs, compared with NETs in other organs, has been underestimated.This study aimed to systematically evaluate the clinical and pathologic characteristics of gastric NETs based on the 2019 WHO classification and to assess the survival outcomes of patients from a single-center with a long-term follow-up. @*Methods@#The medical records of 427 patients with gastric NETs who underwent endoscopic or surgical resection between January 2000 and March 2020 were retrospectively reviewed. All specimens were reclassified according to the 2019 WHO classification. The clinicopathologic characteristics, treatment, and oncologic outcomes of 139 gastric NETs were analyzed. @*Results@#The patients’ median age was 53.0 years (interquartile range [IQR], 46.0 to 63.0 years). The median follow-up period was 36.0 months (IQR, 15.0 to 63.0 months). Of the patients, 92, 44, and 3 had grades 1, 2, and 3 NETs, respectively. The mean tumor size significantly increased as the tumor grade increased (p=0.025). Patients with grades 2 and 3 gastric NETs more frequently had lymphovascular invasion (29.8% vs 10.9%, p=0.005) and deeper tissue invasion (8.5% vs 0%, p=0.012) than those with grade 1 tumors. The overall disease-specific survival rate was 100%. Two patients with grades 2-3 gastric NETs experienced extragastric recurrence. @*Conclusions@#Although gastric NETs have an excellent prognosis, grade 2 or grade 3 gastric NETs are associated with a larger size, deeper invasion, and extragastric recurrence, which require active treatment.

Comparison of Laparoscopic and Open Gastrectomy for Patients With Gastric Cancer Treated With Neoadjuvant Chemotherapy: A Multicenter Retrospective Study Based on the Korean Gastric Cancer Association Nationwide Survey

Purpose@#Despite scientific evidence regarding laparoscopic gastrectomy (LG) for advanced gastric cancer treatment, its application in patients receiving neoadjuvant chemotherapy remains uncertain. @*Materials and Methods@#We used the 2019 Korean Gastric Cancer Association nationwide survey database to extract data from 489 patients with primary gastric cancer who received neoadjuvant chemotherapy. After propensity score matching analysis, we compared the surgical outcomes of 97 patients who underwent LG and 97 patients who underwent open gastrectomy (OG). We investigated the risk factors for postoperative complications using multivariate analysis. @*Results@#The operative time was significantly shorter in the OG group. Patients in the LG group had significantly less blood loss than those in the OG group. Hospital stay and overall postoperative complications were similar between the two groups. The incidence of Clavien– Dindo grade ≥3 complications in the LG group was comparable with that in the OG group (1.03% vs. 4.12%, P=0.215). No statistically significant difference was observed in the number of harvested lymph nodes between the two groups (38.60 vs. 35.79, P=0.182). Multivariate analysis identified body mass index (odds ratio [OR], 1.824; 95% confidence interval [CI], 1.029–3.234; P=0.040) and extent of resection (OR, 3.154; 95% CI, 1.084–9.174; P=0.035) as independent risk factors for overall postoperative complications. @*Conclusions@#Using a large nationwide multicenter survey database, we demonstrated that LG and OG had comparable short-term outcomes in patients with gastric cancer who received neoadjuvant chemotherapy.

Early Clinical Outcomes of the Morbidly Obese Patients Who Underwent Laparoscopic Sleeve Gastrectomy by Gastric Cancer Surgeons: the Analysis of Fifty Consecutive Cases

Purpose@#The number of bariatric surgeries performed at our tertiary hospital has gradually increased since the national health insurance began to cover their expenses in January of 2019. This study examined the early surgical outcomes of laparoscopic sleeve gastrectomy (LSG) performed by experienced gastric cancer surgeons. @*Materials and Methods@#We retrospectively reviewed and analyzed data from 50 patients who underwent LSG between November of 2018 and April of 2020 at the Asan Medical Center by 1 of 5 experienced surgeons each of whom performed approximately 100–300 cases of gastrectomy annually. The age, body mass index (BMI), weight, presence of comorbidities, operation time, hospital stay after surgery, postoperative complications, postoperative excess weight loss (EWL), and resolution of comorbidities were examined. @*Results@#The mean age, BMI, and weight were 37.29±9.77 years, 37.12 kg/m2, and 102.00 kg, respectively. The mean operation time and postoperative length of hospital stay were 109.59±35.88 and 5.06±1.20 days, respectively. Two patients (4.00%) had early postoperative complications and postoperative leakage; bleeding and stenosis were not reported. The EWL after 1 and 6 months of operation was 26.55% and 60.34%, respectively. The resolution of diabetes, hypertension, and dyslipidemia after 6 months of operation was 88.89%, 54.54%, and 50.00%, respectively. @*Conclusion@#LSG is safe and effective when performed by an experienced gastric cancer surgeon; however, a long-term follow-up of patients is required.

Impact of Esophagojejunal Reconstruction without Division of the Mesentery for Total Laparoscopic Total Gastrectomy

Purpose@#This study aimed to compare the surgical outcomes of total laparoscopic total gastrectomy without mesentery division (LTG without MD) and conventional total laparoscopic total gastrectomy (CLTG), as well as evaluate the appropriate method for esophagojejunostomy (EJ) reconstruction after total laparoscopic total gastrectomy (TLTG). @*Materials and Methods@#We retrospectively analyzed data from 301 consecutive patients who underwent TLTG for upper or middle third gastric cancer between January 2016 and May 2019. After propensity score matching, 95 patients who underwent LTG without MD and 95 who underwent CLTG were assessed. Data on clinical characteristics and surgical outcomes, including operation time, length of postoperative hospital stay, pathological findings, and postoperative complications were analyzed. @*Results@#The LTG without MD group showed a shorter time to first flatus (3.26±0.80 vs.3.62±0.81 days, P=0.003) and a shorter time to soft diet (2.80±2.09 vs. 3.52±2.20 days, P=0.002). The total EJ-related complications in the LTG without MD group were comparable to those in the CLTG group (9.47% vs. 3.16%, P=0.083). EJ-related leakage (6.32% vs. 3.16%, P=0.317) and EJ-related stricture (3.16% vs. 1.05%, P=0.317) rates were not significantly different between the LTG without MD and CLTG groups. No significant differences were found between the two groups in terms of other early surgical outcomes such as early complications, late complications, hospital stay, and readmission rate. @*Conclusions@#LTG without MD is a safe surgical treatment for upper or middle third gastric cancer. LTG without MD may be an alternative procedure for EJ anastomosis during TLTG.

Advantages of ypTNM Staging in Post-surgical Prognosis for Initially Unresectable or Stage IV Gastric Cancers

Purpose@#For unresectable or initially metastatic gastric cancer, conversion surgery (CVS), after systemic chemotherapy, has received attention as a treatment strategy. This study evaluated the prognostic value of ypTNM stage and the oncologic outcomes in patients receiving CVS. @*Materials and Methods@#A retrospective review of clinicopathologic findings and oncologic outcomes of 116 patients who underwent CVS with curative intent, after combination chemotherapy, between January 2000 and December 2015, has been reported here. @*Results@#Twenty-six patients (22.4%) underwent combined resection of another organ and 12 patients received para-aortic lymphadenectomy (10.3%). Pathologic complete remission (CR) was confirmed in 11 cases (9.5%). The median overall survival (OS) and disease-free survival (DFS) times were 35.0 and 21.3 months, respectively. In multivariate analysis, ypTNM stage was the sole independent prognostic factor for DFS (P=0.042). Tumors invading an adjacent organ or involving distant lymph nodes showed better survival than those with peritoneal seeding or solid organ metastasis (P=0.084). Kaplan-Meier curves showed that the 3-year OS rate of patients with pathologic CR and those with CR of the primary tumor but residual node metastasis was 81.8% and 80.0%, respectively. OS was 65.8% for stage 1 patients, 49.8% for those at stage 2, and 36.3% for those at stage 3. @*Conclusions@#The ypTNM staging is a significant prognostic factor in patients who underwent CVS for localized unresectable or stage IV gastric cancers. Patients with locally advanced but unresectable lesions or with tumors with distant nodal metastasis may be good candidates for CVS.

Association between the MUC1 rs4072037 Polymorphism and Risk of Gastric Cancer and Clinical Outcomes

Purpose@#Mucin 1 (MUC1) was identified as a gastric cancer (GC) susceptibility gene by genome-wide association studies in Asians and candidate gene studies in Europeans. This study aimed to investigate the association between the MUC1 rs4072037 polymorphism and GC in terms of the Lauren classification and long-term clinical outcomes. @*Materials and Methods@#A total of 803 patients with GC and 816 unrelated healthy controls were enrolled in the study. The association between the MUC1 rs4072037 variant and GC histological types and clinical outcomes, including tumor recurrence and prognosis was investigated. @*Results@#The major A allele of rs4072037 was associated with increased GC risk (P0.05). Cox proportional hazards analysis revealed the heterozygote AG rs4072037 allele as an independent risk factor influencing tumor recurrence and disease-related death in diffuse-type GC (P0.05). @*Conclusions@#The exonic single nucleotide polymorphism rs4072037 in MUC1 was associated with diffuse-type GC and was an independent risk factor influencing tumor recurrence and disease-related death in diffuse-type GC.

Phase II Study of Induction Chemotherapy with Docetaxel, Capecitabine, and Cisplatin Plus Bevacizumab for Initially Unresectable Gastric Cancer with Invasion of Adjacent Organs or Paraaortic Lymph Node Metastasis / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study was to evaluate the efficacy and safety of induction chemotherapy with docetaxel, capecitabine, and cisplatin (DXP) plus bevacizumab (BEV) on initially unresectable locally advanced gastric cancer (LAGC) or paraaortic lymph node (PAN) metastatic gastric cancer (GC). MATERIALS AND METHODS: Patients with LAGC or unresectable PAN metastatic GC received six induction chemotherapy cycles (60 mg/m2 docetaxel intravenously on day 1, 937.5 mg/m2 capecitabine orally twice daily on days 1-14, 60 mg/m2 cisplatin intravenously on day 1, and 7.5 mg/kg BEV intravenously on day 1 every 3 weeks), followed by conversion surgery. The primary endpoint was R0 resection rate. RESULTS: Thirty-one patients with invasion to adjacent organs but without PAN metastasis (n=14, LAGC group) or with PAN metastasis regardless of invasion (n=17, PAN group) were enrolled between July 2010 and December 2014. Twenty-seven patients (87.1%) completed six chemotherapy cycles. The most common grade ≥ 3 toxicities were neutropenia (71%), neutropenia with fever/infection (22.6%/3.2%), and stomatitis (16.1%). The clinical response and R0 resection rates were 64.3% (95% confidence interval [CI], 46.6 to 82.0) and 64.5% (LAGC group, 71.4%; PAN group, 58.8%), respectively. The pathological complete regression rate was 12.9%. After a median follow-up of 44.5 months (range, 39.4 to 49.7 months), the median progression-free survival and overall survival were 13.1 months (95% CI, 8.9 to 17.3) and 38.6 months (95% CI, 22.0 to 55.1), respectively. CONCLUSION: Induction chemotherapy with DXP+BEV displayed antitumor activities with encouraging R0 resection rate and manageable toxicity profiles on patients with LAGC or PAN metastatic GC.

Performance of Half-dose Chest Computed Tomography in Lung Malignancy Using an Iterative Reconstruction Technique / 고신대학교의과대학학술지

OBJECTIVES: The purpose of this study was to evaluate the performance of half-dose chest CT using an iterative reconstruction technique in patients with lung malignancies. METHODS: The Dual-source CT scans were obtained and half-dose datasets were reconstructed with 5 different strengths in 38 adults with lung malignancies. Two radiologists graded subjective image quality; noise, contrast and sharpness at the central/peripheral lung, mediastinum and chest wall of the reconstructed half-dose images, compared with those of standard-dose images, using a three-point scale. A lesion assessment; lesion conspicuity and diagnostic confidence, was also performed. The quantitative image noises; contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured and compared with those of standard-dose images. RESULTS: The subjective image noise in the half-dose images was less than that of the standard-dose images. The contrast in strengths 2 to 5 was superior, the sharpness of the lung parenchyma in strengths 3 to 5 was inferior, and the CNR/SNR in all strengths were higher than those of standard-dose images (P < 0.05). The improvement of subjective image noise and contrast, the decrease in sharpness, were correlated with strength level (P < 0.05). The lesion conspicuity in half-dose images of strengths 4 and 5 was decreased. The diagnostic confidence of the half-dose images of all strengths was comparable to that of the standard-dose images (P < 0.05). CONCLUSIONS: Half-dose chest CT images using an iterative reconstruction technique show decreased image noise, increased contrast, and diagnostic confidence comparable to standard-dose images. Images reconstructed with strength 2 and 3 appear to be the optimal choice in clinical practice.

Erratum: Diagnostic Value of Elastography Using Acoustic Radiation Force Impulse Imaging and Strain Ratio for Breast Tumors / 한국유방암학회지

This article was initially published on the Journal of Breast Cancer with a misspelled name of the first author. His name should be corrected as "Yoonseok Kim".

A Case of Clear-Cell Sarcoma in the Stomach / 대한내과학회지

Clear-cell sarcoma (CCS) is a rare soft tissue sarcoma that usually develops in the lower extremities of young adults. CCS of the gastrointestinal tract is extremely rare. We report here the first case of CCS of the stomach in Korea. A 28-year-old female developed a large tumor of the stomach that was initially considered Ewing sarcoma, based on the results of a needle biopsy. She had paraneoplastic syndrome; fever, anemia, and hyperglycemia. Follow-up abdominal computed tomography after four-cycles of chemotherapy with vincristine-doxorubicin-cyclophosphamide or ifosfamide-etoposide showed no tumor shrinkage and revealed a fistula between the tumor and the gastric lumen. The infected tumor prompted debulking surgery, which resulted in improvement of her symptoms. The pathologic findings were consistent with CCS, and fluorescence in situ hybridization for EWS gene rearrangement was positive, confirming the diagnosis. This case highlights the importance of clinical suspicion for CCS in chemotherapy-refractory Ewing sarcoma.

Fucoidan promotes osteoblast differentiation via JNK- and ERK-dependent BMP2-Smad 1/5/8 signaling in human mesenchymal stem cells

Fucoidan has attracted attention as a potential drug because of its biological activities, which include osteogenesis. However, the molecular mechanisms involved in the osteogenic activity of fucoidan in human alveolar bone marrow-derived mesenchymal stem cells (hABM-MSCs) remain largely unknown. We investigated the action of fucoidan on osteoblast differentiation in hABM-MSCs and its impact on signaling pathways. Its effect on proliferation was determined using the crystal violet staining assay. Osteoblast differentiation was evaluated based on alkaline phosphatase (ALP) activity and the mRNA expression of multiple osteoblast markers. Calcium accumulation was determined by Alizarin red S staining. We found that fucoidan induced hABM-MSC proliferation. It also significantly increased ALP activity, calcium accumulation and the expression of osteoblast-specific genes, such as ALP, runt-related transcription factor 2, type I collagen-alpha 1 and osteocalcin. Moreover, fucoidan induced the expression of bone morphogenetic protein 2 (BMP2) and stimulated the activation of extracellular signal-related kinase (ERK), c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase by increasing phosphorylation. However, the effect of fucoidan on osteogenic differentiation was inhibited by specific inhibitors of ERK (PD98059) and JNK (SP600125) but not p38 (SB203580). Fucoidan enhanced BMP2 expression and Smad 1/5/8, ERK and JNK phosphorylation. Moreover, the effect of fucoidan on osteoblast differentiation was diminished by BMP2 knockdown. These results indicate that fucoidan induces osteoblast differentiation through BMP2-Smad 1/5/8 signaling by activating ERK and JNK, elucidating the molecular basis of the osteogenic effects of fucoidan in hABM-MSCs.

Diagnostic Value of Elastography Using Acoustic Radiation Force Impulse Imaging and Strain Ratio for Breast Tumors / 한국유방암학회지

PURPOSE: The aim of this study was to determine whether the combination of B-mode ultrasonography (BUS), acoustic radiation force impulse (ARFI) elastography, and strain ratio (SR) provides better diagnostic performance of breast lesion differentiation than BUS alone. METHODS: ARFI elastography and SR evaluations were performed on patients with 157 breast lesions diagnosed by BUS from June to September 2013. BUS images were classified according to the Breast Imaging-Reporting and Data System. ARFI elastography was performed using Virtual Touch(TM) tissue imaging (VTI) and Virtual Touch(TM) tissue quantification (VTQ). In VTI mode, we evaluated the color-mapped patterns of the breast lesion and surrounding tissue. The lesions were classified into five categories by elasticity score. In VTQ mode, each lesion was assessed using shear wave velocity (SWV) measurements. SR was calculated from the lesion and comparable lateral fatty tissue. We compared the diagnostic performance of BUS alone and the combination of BUS, ARFI elastography, and SR evaluations. RESULTS: Among the 157 lesions, 40 were malignant and 117 were benign. The mean elasticity score (3.7+/-1.0 vs. 1.6+/-0.8, p<0.01), SWV (4.23+/-1.09 m/sec vs. 2.22+/-0.88 m/sec, p<0.01), and SR (5.69+/-1.63 vs. 2.69+/-1.40, p<0.01) were significantly higher for malignant lesions than benign lesions. The results for BUS combined with ARFI elastography and SR values were 97.5% sensitivity, 92.3% specificity, 93.6% accuracy, a 79.6% positive predictive value (PPV), and a 99.1% negative predictive value. The combination of the 3 radiologic examinations yielded superior specificity, accuracy, and PPV compared to BUS alone (p<0.01 for each). CONCLUSION: ARFI elastography and SR evaluations showed significantly different mean values for benign and malignant lesions. Moreover, these two modalities complemented BUS and improved the diagnostic performance of breast lesion detection. Therefore, ARFI elastography and SR evaluations can be used as complementary modalities to make more accurate breast lesion diagnoses.

Early experiences of minimally invasive surgery to treat gastroesophageal reflux disease / 대한외과학회지

PURPOSE: There are fewer patients with gastroesophageal reflux disease (GERD) in Korea compared with Western countries. The incidence of GERD has increased in recent years however, concerning many physicians. Here, we report our early experiences of using a recently introduced method of laparoscopic antireflux surgery for the treatment of GERD in Korean patients. METHODS: Fifteen patients with GERD were treated using antireflux surgery between May 2009 and February 2012 at the University of Ulsan College of Medicine and Asan Medical Center. Laparoscopic Nissen fundoplication with 360degrees wrapping was performed on all patients. RESULTS: Eleven male and four female patients were evaluated and treated with an average age of 58.1 +/- 14.1 years. The average surgical time was 118.9 +/- 45.1 minutes, and no complications presented during surgery. After surgery, the reflux symptoms of each patient were resolved; only two patients developed transient dysphagia, which resolved within one month. One patient developed a 6-cm hiatal hernia that had to be repaired and reinforced using mesh. CONCLUSION: The use of laparoscopic surgery for the treatment of GERD is safe and feasible. It is also an efficacious method for controlling the symptoms of GERD in Korean patients. However, the use of this surgery still needs to be standardized (e.g., type of surgery, bougienage size, wrap length) and the long-term outcomes need to be evaluated.

The effects of laparoscopic assisted total gastrectomy on surgical outcomes in the treatment of gastric cancer / 대한외과학회지

PURPOSE: To evaluate the effectiveness of laparoscopic assisted total gastrectomy (LATG), we compared its early surgical outcomes with those of conventional open total gastrectomy (OTG) in patients who were diagnosed as having early gastric cancer preoperatively. METHODS: We retrospectively analyzed early surgical outcomes in 190 consecutive patients who underwent total gastrectomy for early gastric cancer between January 2009 to April 2010. The patients were divided into those who underwent LATG and those who underwent OTG. Their early surgical outcomes were analyzed to evaluate the effectiveness of LATG. RESULTS: There was no significant difference in postoperative complication rates (P = 0.291). But in the analysis of other early surgical outcomes, we found that LATG could improve time to first flatus (P < 0.001), time to commencement of soft diet (P = 0.034), administration of analgesics (P = 0.024), pain score (Numeric Rating Scale), and hospital discharge (P = 0.045). CONCLUSION: Although LATG didn't show better results for postoperative complications than those of OTG, LATG contributes to the improvement of early surgical outcomes, including bowel movement, pain score and hospital discharge. Therefore, we suggest that LATG could be a method to improve early surgical outcomes in patients who need total gastrectomy.

Surgical Treatment for Patients Who Underwent Endoscopic Mucosal Resection (EMR)/Endoscopic Submucosal Dissection (ESD) of Early Gastric Cancer (EGC)

PURPOSE: To evaluate the necessity for additional surgical treatment after Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD), we analyzed the pathologic results of patients who underwent surgical treatment. METHODS: 140 consecutive patients underwent additional surgical treatment after EMR/ESD with en bloc resection between April 2005 and November 2009 at ASAN Medical Center. Additional surgical treatments were undergone for following conditions such as incomplete dissection (involvement of margin), undifferentiated-type histology (> or =2 cm) and submucosal cancer. RESULTS: One patient with deep margin involvement displayed advanced gastric cancer after gastrectomy. Three of 74 patients with clear resection margin were confirmed to have residual cancer at ESD site and 2 of 3 patients displayed advanced gastric cancer after surgery. In univariate analysis for metastasis of lymph node, deep submucosal invasion (over sm2 or 500microm) and the presence of lymphovascular invasion showed significant differences for lymph node metastasis. Especially, lymphovascular invasion was an important predictive factor for lymph node metastasis in multivariate analysis. In analysis for residual cancer, lateral margin involvement and large tumor (>3 cm) were risk factors. And, only lateral margin involvement showed significant risk in multivariate analysis. CONCLUSION: Although EMR/ESD were fully accomplished for resection margin, gastrectomy and lymph node dissection were positively necessary for patients with deepsubmucosal invasion (over sm2 or 500microm) and the presence of lymphovascular invasion to eliminate the possibility of residual cancer or more advanced gastric cancer or metastatic lymph nodes.

Totally Laparoscopic Distal Gastrectomy with ROUX-EN-Y Reconstruction for Treatment of Duodenal Ulcer Obstruction

Because of advancement of medical treatment, surgical management of gastric or duodenal ulcer was indicated for treatment of perforation, massive hemorrhage and obstruction. The distal gastrectomy including ulcer was known as principle method of duodenal ulcer obstruction, but actually many surgeons have performed only bypass surgery for the difficulty of formation of duodenal stump. In our case, 61-year-old male with repetitive duodenal ulcer obstruction transferred with obstruction due to deformities and inflammations of duodenal ulcer. We had performed totally laparoscopic distal gastrectomy with ROUX-EN-Y reconstruction using the clear visibility of laparoscopy and fine dissections of harmonic scalpel. The patient started soft diet on postoperative day 5 and discharged on postoperative day 8. He returned to work after discharging immediately.

Utility of Surgical Resection in the Management of Metachronous Krukenberg's Tumors of Gastric Origin

PURPOSE: The aim of this study was to determine the prognostic factors and the significance of metastatectomy for Krukenberg's tumors of gastric origin. MATERIALS AND METHODS: Among the patient who underwent gastric surgery from 1992 through 2005, 90 female patients with Krukenberg's tumors of gastric origin were identified. We retrospectively reviewed the clinicopathologic characteristics, prognostic factors, and treatments for primary gastric cancer. We also investigated the prognostic risk factors for the onset of metachronous Krukenberg's tumors and the survival time of patients who underwent an operation for metachronous Krukenberg's tumors. RESULTS: The presence of a synchronous Krukenberg's tumor (mean survival time=17.6 months, P<0.01), peritoneal seeding (14.5 months, P<0.01), and non-curative resection (15.1 months, P<0.01), were statistically significant prognostic factors for survival time in female patients with gastric cancer. The stage of primary gastric cancer (P=0.049) and lymph node metastasis (P=0.011) were statistically significant risk factors for recurrence time of a metachronous Krukenberg's tumor. In the metachronous Krukenberg's tumor group (n=53), the mean survival time of the metastatectomy group (n=46, 43.2 months, P=0.012) was longer than that in the chemotherapy or conservative treatment groups (n=7 and 24 months, respectively). Metastatectomy, presense or abscence of residual tumor and extent of residual tumor were significant prognostic factors for survival time in female patients with metachronous Krukenberg's tumor of gastric origin. CONCLUSIONS: A close observation and evaluation with ultrasound or computed tomography is necessary in female patients with advanced gastric cancer to detect a metachronous Krukenberg's tumor as soon as possible. The surgeon must operate more aggressively in patients with metachronous Krukenberg's tumors.

Comparison of Laparoscopic Transperitoneal Versus Retroperitoneal Adrenalectomy / 대한내시경복강경외과학회지

PURPOSE: This study was designed to evaluate outcomes of transperitoneal and retroperitoneal approaches in laparoscopic adrenalectomy for resectable adrenal mass. METHODS: Laparoscopic adrenalectomy was performed on 134 patients with resectable adrenal mass between February 2004 and February 2009. We retrospectively reviewed the results of transperitoneal approach (TPA) and that of retroperitoneal approach (RPA) in terms of clinicopathologics and surgical outcomes. RESULTS: 80 patients (39 men and 41 women) underwent TPA, of them, 68 were located in left and 12 were located in right. 54 patients (25 men and 29 women) underwent RPA. In RPA group, 9 were located in left and 45 were located in right. There were no difference in clinicopathologics (including age, gender and BMI), in postoperative complication and in mortality. Operative time was shorter, blood loss was smaller and less pain killers was administered in RPA group (p<0.05). CONCLUSION: Our study shows that both approach (TPA and RPA) have a good peri-operative outcomes, but RPA is less painful and has a shorter operative time than TPA. It is needed to choose operative approach based on certain patient selection criteria for high patient and surgeon satisfaction.

The Comparison of Laparoscopic and Open Incisional and Ventral Hernia Repairs / 대한내시경복강경외과학회지

PURPOSE: We performed a prospective study for the purpose of analyzing and comparing outcomes after laparoscopic and open incisional hernia repairs. METHODS: Open incisional hernia repair with Rives-Stoppa method was performed on 35 patients between April 2003 and March 2008. Laparoscopic incisional hernia repair with intraperitoneal onlay mesh (IPOM) was performed on 35 patients during the same periods. Clinical features and surgical outcomes were compared in both groups. RESULTS: There were no significant differences in patients' clinical characteristics. There were no significant differences in defect size, location and surgical complication. While, the operation time and hospital stay were shorter, and postoperative pain was less in laparoscopic repair group (p<0.05). There was one recurrence in laparoscopic group and there were three recurrences in open group. CONCLUSION: Laparoscopic incisional hernia repair is safe and feasible procedure comparing to open method. We suggest that laparoscopic repair is initially recommended for incisional hernia if there is no contraindication or excessive adhesion.

Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma

PURPOSE: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis after hepatic resection have yet to be clarified. The purpose of this study was to analyze the outcome of sarcomatous HCC patients who underwent surgical resection. METHODS: From January 1997 to May 2005, 11 patients (1.1%) were diagnosed with sarcomatous HCC among 1,005 cases of HCC undergoing resection after pathology and immunohistochemical studies. RESULTS: All of the cases were male and their mean age was 55.8+/-8.1 years. R0 resection was achieved in nine of the 11 patients. The HCC lesions were classified as stage II in three, stage III in four, stage IVa2 in three, and IVb in one, according to the modified pTNM staging system. Extrahepatic metastases as the initial recurrence occurred in eight patients. Among the 11 patients, 10 died of a disease recurrence and only one is still alive. The overall 3-year survival rate was only 18%. CONCLUSIONS: The prognosis of sarcomatous HCC was very poor, showing widespread extrahepatic metastases and frequent early recurrence regardless of the tumor extent. Since some patients showed prolonged survival after a local recurrence, vigorous postoperative systemic surveillance appears to be beneficial for early detection and timely treatment of localized metastases.