Comparative Analysis of Laparoscopic Versus Open Appendectomy for Perforated Appendicitis in Children Under 12 Years Old at a Single Institute

PURPOSE: The purpose of this study is to evaluate the outcome of laparoscopic (LA) vs. open appendectomy (OA) in children under 12 years old with perforated appendicitis. METHODS: We reviewed the medical files of 156 children who underwent LA (n=96), OA (n=59), and conversion (CO) (n=1), and compared duration of operation, length of hospital stay, incidence of wound infection, mechanical ileus, intra-abdominal abscess (IAA), and re-admission. RESULTS: Compared to OA, LA resulted in longer duration of operation (58.32+/-17.105 min vs. 44.27+/-18.735 min; p=0.001), but fewer wound infections (2.1% vs. 10.2%; p=0.054), and fewer cases of mechanical ileus (0% vs. 5.1%; p=0.053). No differences in the length of hospital stay (5.85+/-1.824 days vs. 6.10+/-3.027 days; p=0.526), IAA (2.1% vs. 1.7%; p=1.000), or re-admissions (2.1% vs. 5.1%; p=0.369) were observed. CONCLUSION: We report that although LA showed an association with longer duration of operation compared to OA, it is superior to OA with regard to incidence of wound infection and mechanical ileus.

Single-center Comparative Study of Laparoscopic Versus Open Colon Surgery

PURPOSE: To examine the change in practice from open to laparoscopic practice in our local trust and compare the benefits with those of an open surgery group. METHODS: This retrospective comprehensive review analyzed 225 patients who underwent resection of colon cancers at the Dae Jin Medical Center, including 182 who underwent laparoscopic surgery (LAC) and 43 who underwent conventional open surgery (OC), conducted by a single surgeon from August 2002 to August 2010. The LAC group was divided into two groups, 50 patients during the early period and 132 patients during the late period, and short-term and oncologic outcomes were recorded. Patients identified through clinical coding and data were analyzed using the Statistical Package for Social Sciences, version 18.0 (2009. SPSS Inc. USA). RESULTS: Comparisons of 43 open versus 50 early and 132 late laparoscopic colon surgeries for various indications and outcomes were made. The operative time was longer in the LAC group (early and late LAC group) than in the OC group. However, post operative recovery time (hospital stay, days to sips of water and days to soft diet) was significantly shorter in the early and late LAC group than in the OC group. There was no significant difference between the LAC groups and open group with respect to age, sex, American Society of Anesthesiologists, tumor-node stage, morbidity, mortality, overall survival rates, disease free survival rates and recurrence rates. CONCLUSION: In our experience, laparoscopic surgery resulted in acceptable short term outcomes and our results support those of other studies with respect to clinical outcomes of laparoscopic surgery.

Comparative Analysis Between Totally Extraperitoneal Repair and Prolene Hernia System at a Single Institute

PURPOSE: Laparoscopic hernioplasty is a standard procedure used for the repair of inguinal hernia. However, due to the technical and anatomical complexities associated with this treatment and the requirement for long surgery time as compared to other methods, the use of laparoscopic hernioplasty remains questionable. This study compared the results of two surgical repair methods: totally extraperitoneal (TEP) hernia repair and the Prolene hernia system (PHS). METHODS: A retrospective review was conducted of all patients who underwent TEP (154 cases) and PHS (126 cases) from January 2008 to December 2010 as performed by a surgeon at our hospital. Operating time, length of hospital stay, recurrence rate, surgical site infection rate, wound hematoma rate and scrotum swelling rate were all compared. RESULTS: For the TEP treatment cases the mean operating time was 59.5 min, mean hospital stay was 4.9 days, there were 2 cases (1.3%) of recurrence, one case (0.6%) of surgical site infection, 20 cases (12.9%) of wound hematoma and 8 cases (5.2%) of scrotum swelling. In the case including treatment by PHS the mean operating time was 39.6 min, mean hospital stay was 5.4 days, there were no cases of recurrence, there were 2 cases (1.7%) of surgical site infection, 11 cases (9.5%) of wound hematoma and 12 cases (10.3%) of scrotum swelling. There were no cases involving neurogenic pain or chronic pain. CONCLUSION: Both PHS and TEP are safe and effective procedures for repairing inguinal hernia. Thus, with consideration of variable patient conditions and other factors, either PHS or TEP are recommended as viable procedures for treating inguinal hernia.

The Variation of Hepatic Duct Confluence and Asymptomatic Common Bile Duct Stone with Routine Intraoperative Cholangiogram during Laparoscopic Cholecystectomy / 대한소화기학회지

BACKGROUND/AIMS: Intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) has been used to evaluate bile duct stone. But, the routine use of IOC remains controversial. With routine IOC during LC, we reviewed the variation of hepatic duct confluence and try to suggest the diagnostic criteria of asymptomatic common bile duct (CBD) stone. METHODS: We reviewed the medical record of 970 consecutive patients who underwent LC with IOC from January 1999 to December 2009, retrospectively. RESULTS: Nine hundered seventy patients were enrolled. IOC were successful in 957 (98.7%) and unsuccessful in 13 (1.3%). Eighty two of 957 patients (8.2%) were excluded because of no or poor radiologic image. According to Couinaud's classification, 492 patients (56.2%) had type A hepatic duct confluence, 227 patients (26.1%) type B, 15 patients (17%) type C1, 43 patients (4.9%) type C2, 72 patients (8.2%) type D1, 21 patients (2.4%) type D2, 1 patient (0.1%) type E1, 1 patient (0.1%) type E2, 2 patients (0.2%) type F, and 1 patient (0.1%) no classified type. The CBD stone was found in 116 of 970 (12.2%) patients. In 281 patients, preoperative serologic and radiologic tests did not show abnormality. When preoperative findings were not remarkable, there was no difference of clinical features between patients with or without CBD stones. CONCLUSIONS: Although IOC during LC has some demerits, it is a safe and accurate method for the detection of CBD stone and the anatomic variation of intrahepatic duct.

Comparsion of Laparoscopic Appendectomy vs Open Appendectomy in Non-Complicated Appendicitis and Complicated Appendicitis / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic appendectomy has many benefits compared to the open technique, such as easy localization of the appendix, less scarring for cosmetic reasons and less reported wound infection. However, for patients with complicated appendicitis, controversy exists as to whether laparoscopic appendectomy is a safe procedure. Some recent studies have reported no significant difference of the complication rate compared to that of the open procedure, suggesting that laparoscopic appendectomy could be used as an alternative procedure. This study was performed to evaluate the safety and benefits of laparoscopic appendectomy as compared to that of the open technique for treating complicated and uncomplicated appendicitis. METHODS: We studied the patients who underwent appendectomy by either the laparoscopic or open technique at Bundang Jaesaeang General Hospital between January 2005 and September 2008. Of the total 2,226 patients, there were 168 patients in the laparoscopic appendectomy (LA) group and 2,058 patients in the open appendectomy (OA) group. We compared the patient demographic data and perioperative outcomes of the two groups. RESULTS: Both patient groups were comparable in terms of age. The mean operative time was 91.8 minutes in the LA group and 47.2 minutes in the OA group (p<0.00). There were no significant differences between the two groups in terms of the mean hospital stay. The noncomplicated appendicitis LA group showed a quicker time to start an oral diet (p=0.03) & wound infection (p=0.032). For complicated appendicitis, there were no differences of wound infection & intestinal obstruction between the two groups. CONCLUSION: Although laparoscopic appendectomies requires a longer operation time, it did not lengthen the hospital stay nor delay the start of a soft oral diet. Appendiceal abscess in complicated appendicitis did not occur in the laparoscopic or open appendectomy groups. Therefore, laparoscopic appendectomy is a safe procedure for both complicated and uncomplicated appendicitis. To reach a final consensus on the scope of this study, a prospective randomized controlled study is needed in the near future.

The Learning Curve for Totally Extraperitoneal (TEP) Repair in Inguinal Hernia / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic totally extraperitoneal (TEP) repair has been increasingly used for the treatment of inguinal hernias. This procedure is a very difficult technically and it requires a great deal of experience. However, there are only few studies on the learning curve (LC) of this procedure in the Korea literature. The aim of this study is to determine the number of case that are needed to overcome the learning curve of TEP hernia repairs and to document the surgical and clinical differences before and after overcoming the LC. METHODS: This study retrospectively reviewed 96 TEP hernia repairs that were performed by a single surgeon. The time required to overcome the LC was determined by examining the operation time. The preoperative and postoperative clinical data, such as incidental intraoperative findings, the rate of operative morbidity, the rate of conversion to an open procedure and the length of the postoperative hospital stay, were compared between the before and after groups with overcoming the LC. RESULTS: The 40th case was determined to be the transition point of overcoming the LC according to the operation time. The time before overcoming the LC averaged 73.0 minutes compared to 55.6 minutes after overcoming the LC. The postoperative hospital stay and the conversion rate were all significant (p<0.05). However, the other postoperative outcomes did not show significant differences. CONCLUSION: Based on the plateau of the operative time, this study shows that the downward slope of LC for TEP repair is at the 40th operation.

Arm Sentinel Lymph Node Detection for Preserving the Arm Lymphatic System / 한국유방암학회지

PURPOSE: The objective of arm sentinel lymph node (SLN) detection were to identify the presence of different drainage tracts of the breast and arm lymphatics and eventually to prevent lymphedema after an axillary procedure. METHODS: Twenty one patients underwent surgery for breast cancer, with arm SLN detection, from March to July 2008 at Samsung Medical Center. We used the (99)Tc-tin colloid isotope in two patients, blue dye in 18 and green dye in one for the arm SLN detection. RESULTS: Stained and/or hot nodes from the arm lymphatics were identified in 15 of the 21 patients (71.4 %). Among the 15 patients who had the arm SLN identified, one patient had a metastasis at the arm SLN, and another patient had common breast and arm lymphatic drainage. CONCLUSION: Identification of the arm lymphatic drainage was possible. Since there were cases of common pathway of the arm and breast lymphatics and metastasis of the arm SLN, we cannot conclude that the arm SLN detection was safe and effective. A subsequent study for identifying the presence of two different drainage systems of the breast and arm lymphatics and confirmation of no metastasis at the arm SLN is needed.

Experience with Intracystic Papillary Carcinoma of the Breast at a Single Institute in Korea / 한국유방암학회지

Intracystic papillary carcinoma (IPC) of the breast is a rare entity, which can be associated with ductal carcinoma in situ (DCIS) or an invasive carcinoma. There have been only limited reports describing IPC in Korea and the incidence among breast cancer cases in Korea has not yet been reported. From a database of 7,109 breast cancer cases treated surgically at Samsung Medical Center, we could only identify four IPC cases (0.056%). We also found that there are some differences between the clinicopathological characteristics of our cases and the alleged characteristics of IPC as reported from Western countries, such as a relatively young age of onset, small tumor size and various expression levels of hormonal receptors. We suspect this very low incidence may be caused by a true rarity of IPC in women in Korea or may be due to a lack of clinical interest for IPC. Upon presentation of our experience with IPC, we suggest the diagnosis for this rare disease entity needs to be reappraised.

Expression of p53 and bcl-2 in Gastric Adenocarcinoma Affects the Prognosis and Survival Rate

PURPOSE: p53 and bcl-2 are important markers of apoptosis. The expression of p53 and bcl-2 in gastric adenocarcinoma was examined in relation to prognosis and survival rate. MATERIALS AND METHODS: The clinicopathologic data from 238 patients who underwent gastrectomies for gastric adenocarcinoma between December 1999 and July 2007 were reviewed. Immunohistochemical staining of gastric adenocarcinoma tissues embedded in paraffin blocks was performed using an Envision kit (DAKO, Glostrup, Denmark). Statistical comparisons were made between age, gender, tumor invasion, lymph node metastasis, TNM stage, Lauren's classification, cell differentiation, and the relationship with p53 and bcl-2. RESULTS: The expression of p53 was related to cell differentiation (P=0.028) and UICC TNM stage (P<0.001). The expression of bcl-2 was related to UICC TNM stage (P=0.005). The co-expression of p53 and bcl-2 was related to UICC TNM stage (P=0.002). The co-expression group exhibited a greater reduction in the survival rate (P=0.001). CONCLUSION: The expression of p53 and bcl-2 nuclear proteins has significant relationships with other conventional prognostic factors and the survival rate. Bcl-2 will be characterized through analysis of a greater number of patients and comparison with survival data over a longer period of time.

Thyroidectomy Using Ultrasonically Activated Shears; Prospective Randomized Study / 대한내분비외과학회지

PURPOSE: Adequate hemostasis in thyroidectomy is important to reduce postoperative complications including bleeding and hematoma. The object of this study was to evaluate the utility of thyroidectomy using ultrasonically activated shears. METHODS: This was a prospective randomized controlled study. It was conducted on 95 patients who underwent total thyroidectomy between January and March 2009. Patients were divided into two groups according to operation method used: group A (n=49) underwent total thyroidectomy using ultrasonically activated shears, group B (n=46) involved the conventional clamp and tie maneuver. Comparisons included operation time, drain amount, hospitalization, postoperative complications and off-thyroglobulin. RESULTS: The two groups had no significant differences regarding drain amount, hospitalization, postoperative complications and off-thyroglobulin. Operation time was statistically shorter in group A than group B (96.6±22.7 min vs 114.6±24.3 min) (P=.00). CONCLUSION: Thyroidectomy using ultrasonically activated shears reduces operation time significantly, and enables a complete and safe operation without postoperative complications. We recommend the use of ultrasonically activated shears in thyroidectomy.

Implications of Isolated Tumor Cells in Sentinel Lymph Nodes of Breast Cancer Patients

PURPOSE: Sentinel lymph node (SLN) biopsy has replaced unnecessary axillary dissection in breast cancer surgery except when the nodes are positive for macrometastasis. But guidelines for isolated tumor cells (ITCs) found in SLNs has not yet been established and further study is ongoing. The goal of this study was to consider the implication of the isolated tumor cells found in the SLNs of Korean breast cancer patients. METHODS: Between September 2003 and March 2008, 985 primary breast cancer patients underwent SLN biopsy. On reviewing the medical records, 81 patients were found to have ITCs in SLNs without macrometastasis or micrometastasis. ITCs were detected by serial sectioning and immunohistochemistry. RESULTS: The mean number of detected SLNs was 3.5+/-1.7. Thirty three patients had multifocally distributed ITCs and 9 had ITCs in multiple SLNs whose N stage was N0 (i+). Completion axillary dissection has been performed in 9 patients and 3 of them (33.3%) finally were found to be N1 or N1mi. CONCLUSION: The characteristics of ITCs are not clear yet and their prognostic value is still under investigation. Until the significance of ITCs found in SLNs become definite, axillary dissection should be more aggressively considered.

The Impact of the Ratio of Positive Nodes to Removed Nodes on Recurrence and Overall Survival in Node Positive Breast Cancer Patients / 한국유방암학회지

PURPOSE: The status of axillary lymph node (LN) metastasis is the most important prognostic factor in breast cancer. Postoperative regional nodal radiotherapy is recommended usually based on the number of metastatic LNs, which is associated with the total number of removed LNs during the axillary dissection. We evaluated the prognostic impact of the ratio of metastatic LNs to removed LNs on disease free survival and overall survival in breast cancer patients. METHODS: The medical records of 743 breast cancer patients with metastatic axillary LNs and treated at Samsung Medical Center between 1994 and 2003 were retrospectively analyzed. The ratio of metastatic/removed LNs as well as the other prognostic factors were analyzed. RESULTS: Both disease-free survival and overall survival rates were significantly worse in patients with a ratio of metastatic/removed LNs greater than 20% compared to those patients with a ratio of less than 20% (p=0.028, p<0.001, respectively). In patients with T1-2 and N1 breast cancer, the ratio of metastatic/removed LNs greater than 20% was significantly associated with poorer disease-free survival (p=0.027). CONCLUSION: A ratio of metastatic/removed LNs greater than 20% in the axilla can be an adverse prognostic factor in breast cancer patients with axillary node metastasis. In T1-2 N1 breast cancer patients, adjuvant radiotherapy as well as more aggressive chemotherapy therapy may be indicated.

Comparison between Laparoscopic Adrenalectomy and Conventional Open Adrenalectomy in the Treatment of Pheochromocytoma / 대한내분비외과학회지

PURPOSE: This study comparedthe effectiveness and safety of laparoscopic adrenalectomy with conventional open adrenalectomy for the treatment of pheochromocytoma. METHODS: Medical records of 100 patients who underwent surgical removal of pheochromocytoma (open adrenalectomy, n=59; laparoscopic adrenalectomy, n=39) at Samsung Medical Center from June 1995 to August 2007 were retrospectively reviewed. RESULTS: To draw an appropriate comparison, patients with a tumor less than 7 cm in size were evaluated (open adrenalectomy, n=23; laparoscopic adrenalectomy n=31). No statistically significant differences were evident according to age, gender and tumor size. The mean operating time was 158 min for the open surgery group and 114 minfor the laparoscopic group (P<0.01). The mean postoperative hospital stay was 10.4 days following open surgery and 5.6 days following laparoscopic surgery (P<0.01). The mean volume of the estimated blood loss for the laparoscopic surgery group (482 ml) was less than for the open surgery group (mean 229 ml) (P=0.06), and the time to first oral intake was 1.7 days after laparoscopic adrenalectomy and 3.5 days after open surgery (P<0.01). The frequency of using analgesics for postoperative pain after laparoscopic adrenalectomy was markedly lower than following conventional open adrenalectomy. There was no recurrence or complications during the follow-up periods (mean: 30 months). CONCLUSION: Laparoscopic adrenalectomy offers advantages of less postoperative pain, shorter operative time and a shorter hospital stay as compared with conventional open adrenalectomy. Laparoscopic adrenalectomy for treating pheochromocytoma is a minimally invasive alternative to conventional open adrenalectomy.

Successful Surgical Treatment of Aortoenteric Fistula

In order to establish optimal management for aortoenteric fistula (AEF) the records of five patients treated for AEF (four aortoduodenal and one aortogastric fistula) were retrospectively reviewed. The arterial reconstruction procedures were selected according to the surgical findings, underlying cause, and patient status. In situ aortic reconstructions with prosthetic grafts were performed on three patients who had no gross findings of periaortic infection, whereas axillo-bifemoral bypass was carried out in the other two patients with periaortic purulence. In all patients, after retroperitoneal irrigation a pedicled omentum was used to cover the aortic graft or aortic stump. In the preoperative abdominal computed tomography (CT) scan there was a periaortic air shadow in four out of five patients. There was no surgical mortality or graft infection observed during a mean follow-up period of 40 months (range, 24-68 months). Therefore, the treatment results of an AEF can be improved using intravenous contrast-enhanced abdominal CT for rapid diagnosis and selection of an appropriate surgical procedure based on the surgical findings and underlying cause.

Surgical Approach of Concomitant Coronary and Carotid Artery Disease

PURPOSE: A definite guideline for the surgical approach to patients suffering with combined coronary and carotid artery disease remains controversial. The aim of this study was to compare the cardiovascular and neurologic complications between the staged approach and the synchronous approach. METHODS: This study reviewed the outcomes following each procedure in 17 cases from 1995 to 2004; 8 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group I), 6 patients underwent CEA followed by CABG (group II) and the remaining 3 patients underwent CABG followed by CEA (group III). RESULTS: In group I, the mean percentage of internal carotid artery stenosis was 77.9%. Preoperatively, 3 patients had neurologic symptoms, and all the cases had triple vessel disease. Off-pump CABG (OPCABG) was performed for 4 cases. In group II, the mean percentage of internal carotid artery stenosis at the time of CEA was 78.7%; all cases had triple vessel disease and/or left mainstem coronary artery disease and 4 cases had neurologic symptoms. OPCABG was performed for 1 case. In group III, the mean percentage of internal carotid artery stenosis at the time of CABG was 76.7%. One patient had neurologic symptoms;all cases had triple vessel disease. OPCABG was performed for 2 cases. Neurologic complication occurred in 1 patient of group III. CONCLUSION: Because the data was reviewed retrospectively, there were limitations for understanding the reasons for the staged or synchronous approach. However, we obtained the result that the synchronous approach resulted in fewer perioperative neurologic complications and this might be a good operative strategy, while OPCABG allowed the use of the synchronous approach.