HER2-Positive Gastric Hepatoid Adenocarcinoma / 대한내과학회지

Gastric hepatoid adenocarcinoma is a rare adenocarcinoma that develops in the stomach. The prognosis of gastric hepatoid adenocarcinoma is poorer than that of ordinary gastric adenocarcinoma. Here, we report the first case of human epidermal growth factor receptor 2 (HER2)-positive gastric hepatoid adenocarcinoma in Korea. A 57-year-old male presented with abdominal distension and underwent endoscopic gastric biopsy and percutaneous core needle liver biopsy. The pathological findings were consistent with HER2-positive gastric hepatoid adenocarcinoma. He received six cycles of chemotherapy with cisplatin-capecitabine plus trastuzumab, which is a HER2 targeted agent. After chemotherapy, a follow-up abdominal computed tomography scan showed a partial tumor response. This case emphasizes the importance of using trastuzumab in a patient with HER2-positive gastric hepatoid adenocarcinoma.

Analysis of Minerals before and after Gastrectomy Using Hair Tissues in Stomach Cancer Patients

PURPOSE: Gastric cancer is the most common cancer in Korea. The principal therapy for this type of cancer is surgical operation along with neoadjuvant or adjuvant therapy. Gastric cancer patients develop disorders such as poor oral intake and indigestion after receiving a gastrectomy. Such patients gradually fall into nutritional disorders. The selection of gastrectomy procedures and anastomosis methods applied differentiate the presence of post-operative complications; and furthermore, whether the application adjuvant chemotherapy causes a difference in the grade of the nutritional disorder. In the past, the survival length was too short after the gastric cancer operation for interest to arise in the post-operative nutritional failure problems. However, current early screening tests have increased the detection rate of early gastric cancers, and the advancements in surgical techniques and immunochemical therapy have lengthened the expected life span long enough to raise the nutritional problems. This aim of this research was to study the changes in the mineral contents before and after a gastrectomy using hair tissues. METHODS: Twenty gastric cancer patients who received operation in Severance Hospital Yonsei University between January and March, 2002, were selected. Hair tissues with a length of 3 cm were collected from the posterior cephalic region before and 3 months after the operation. The collected hair tissues were sent to Tei KOREA CO., LTD. for the levels of 23 different minerals before and after the operation to be examined and measured. RESULTS: The average age was 53.55+/-11.74 years old, and the male and female ratio was 14: 6. Five cases received a total gastrectomy, while the other 15 received a subtotal gastrectomy. Six out of the 20 received post-operative adjuvant chemotherapy. The levels of almost all the minerals were marginally decreased, with the exception of two. The level of sodium had meaningfully decreased while that of molybdenum had increased. CONCLUSION: The mineral contents gradually decreased three month after the gastrectomy has been carried out. The level of sodium significantly decreased, while that of molybdenum increased. Further study and prolonged follow-up observations are essential to detect minerals changes in the evaluation of nutritional changes in those patients having received a gastrectomy.

OK-432 (picibanil) Chemical Pleurodesis for the Treatment of Persistent Chylothorax after Esophagectomy

Chylothorax is an uncommon but well recognized complication of esophagectomy. We present a case 65-year-old man with midthoracic esophageal carcinoma who underwent three stage radical esophagectomy by right thoracotomy. The postoperative course was uneventful until the 12th postoperative day, when the right chest tube was removed. On the 19th postoperative day the patient complained of dyspnea, and a chest roentgenogram showed massive pleural effusion in the right lower chest. A chest tube was reinserted into the right lower pleural cavity. The pleural fluid showed milky appearance and its amount was about 800 ml/day. The characteristics and composition of the pleural fluid was similar to those of chyle. Though conservative management was applied for 20 days, pleural effusion was remained. and then explo-laparotomy for thoracic duct ligation was performed near right crus, but chyle leakage persisted. We treated by intrapleural infusion of OK-432 (picibanil), without major side effects. This procedure should be considered one of the treatment of option for patient with persistent chylothorax not responding to conservative and surgical management.

A Case of Complete Remission to Advanced Esophageal Cancer by a Concurrent Chemoradiation Therapy

Esophageal cancer is still a virulent disease that leads to death. Surgery has been regarded as the treatment of choice in patients suffering this type of cancer and recent improvements in surgical techniques and perioperative management have significantly increased the resection rate and reduced the operative mortality. Nevertheless, long-term survival rates remain poor. The poor prognosis reflects the fact that the disease is usually advanced at the time of diagnosis. Therefore, a combination of chemotherapy and radiotherapy has recently been developed as a treatment for advanced esophageal cancer patients. Chemoradiation therapy is based on the concept of the biochemical modulation effects and radiosensitizing effects of the chemotherapeutic agents. How ever, the optimal choice of chemotherapeutic agents and their doses, as well as the chemotherapy and radiotherapy regimens have not been precisely established. We report a case of concurrent chemoradiation protocol by which a complete response was achieved. 5-FU (1,800 mg/body/day) was continuously infused over 24 hours and cisplatin (45 mg/ body/day) was administered 1 hour before radiotherapy for 3 days. This chemotherapy course was repeated once more after 4 weeks. The radiotherapy (180 cGy/day) was scheduled for 5 consecutive days, followed by a 2-day withdrawal, and a total dose of 5,940 cGy within 7 weeks. Our concurrent chemoradiation therapy is deemed rational, effective and safe because an endoscopically and pathologically complete response was achieved 1 year after chemoradiation therapy without any severe side effects. Therefore, we believe that our concurrent chemoradiation therapy can be recommended as a treatment for advanced esophageal cancer patients.

Opinions for Surgical Residency Education

PURPOSE: Since the induction of the residency program in the surgical departments, more than 200 residents now enter postgraduate year-1 (PGY-1) every year. This number has been declining in recent years while the dropout has been on the rise. To suggest a solution to this problem, we evaluated the current status of residency education and proposed an improved method for postgraduate surgical education. METHODS: We analyzed the responses from mailed questionnaires sent to the 789 residents in 123 different training hospitals in April 2001. Twenty-five questions were analyzed according to PGY, working conditions, and other variables. RESULTS: The response rate was 40.8% (322/789). The mean age of the residents was 30 years, and there were 28 (9%) female residents. The number of married residents were 137 (42.5%), and there were 91 1st year PGYs, 77 2nd year, 82 3rd year and 70 4th year. Most of them were being trained in university based hospitals (89.8%). The residents felt that their number was insufficient (70.8%), and that their work load was greater than that of other residents (92.9%). Their greatest stress was physical exhaustion (64.3%). Most residents discussed their problems with the senior residents (78%). They needed standardized training programs (62.1%). A majority (77.7%) responded that they did not have enough opportunities to perform surgical procedures. The single most important problem in PGY education was perceived to be the excessive work load (75.8%), which could be improved by specialized educational programs (64.6%). CONCLUSION: The absences of both educational programs and supporting manpower are the major problems facing surgical residents. Adequate stipend would be also beneficial, and increased attention and demonstrations of experience should be offered by the staff physicians.

Reconstruction Using Stomach after Resection of Hypopharynx and Esophagus

PURPOSE: This study sought to evaluate the treatment modality, morbidity and mortality after surgery, the method of nutritional support and the survival rate for patients with cancer of the hypopharynx, larynx and cervical esophagus. METHODS: A retrospective review was undertaken of 17 hypopharyngeal, laryngeal and cervical esophageal carcinoma patients who had undergone surgical treatment in the Department of Surgery and Otorhinolaryngology, Yonsei University, College of Medicine, from January 1995 to April 2000. All patients underwent transhiatal esophagectomy in order to avoid pulmonary complications. Outcome measures were calculated using the Kaplan-Meier estimator. RESULTS: The 17 consecutive patients included 11 cases of hypopharyngeal cancer, 3 glottic cancers, 2 cervical esophageal cancers and one thyroid cancer with invasion of the trachea and esophagus. Fifteen patients (88%) presented with an advanced tumor stage. As for nutritional support following surgery, 12 underwent feeding jejunostomy, 4 a nasoenteric tube feeding and the other recieved total parenteral nutrition. Nine patients (53%) developed complications following surgery. One of the patients who had surgery died postoperatively. The mean survival time was 26 months and the 2-year and 4-year overall survival rates were 69.5% and 53.0%, respectively. CONCLUSION: Reconstruction of the hypopharynx and esophagus using stomach was low mortality and low severe morbidity. A total pharyngolaryngoesophagectomy with gastric transposition and primary hypopharyngogastric anastomosis offers the best chance for cure or palliation with acceptable morbidity and degree of function for selected patients with advanced hypopharyngeal, laryngeal and cervical esophageal carcinomas.

Treatment of Primary Esophageal Malignant Lymphoma in Complete Remission and Associated with Stricture

Gastrointestinal involvement has been reported to occur in about 10 to 20% of patients with malignant lymphoma. The most common gastrointestinal site for the lymphoma is the stomach, followed by the small intestine, the ileocecal region and the colon. Esophageal involvement by a malignant lymphoma is unusual, and that by a primary lymphoma is extremely rare. When a lymphoma is found in the esophagus, generally it is a case with contiguous involvement of the gastric fundus or the cervical node, with secondary to mediastinal lymph node compression, or with late manifestation of advanced disease. Such cases cannot be labeled as primary esophageal lymphoma. We describe a case of primary esophageal malignant lymphoma diagnosed by endoscopy and CT scan. It was treated with concurrent chemoradiation, resulting in complete remission; nowever an esophageal stricture developed, so esophageal bougienation was performed several times. An Operation was performed because the esophageal stricture was not improved by endoscopic dilatation.

Surgical Treatment of Crohn's Disease

PURPOSE: This study was undertaken to investigate the preoperative diagnosis, indication for operation, postoperative complication, postoperative medical treatment and recurrence rate in patients with Crohn's disease who were treated with operation. METHODS: Forty patients with Crohn's diseases had been operated on at the Department of Surgery, Yonsei University College of Medicine during the period from Jan 1986 to May 1999 and they were reviewed retrospectively. We studies symptoms, surgical indications, preoperative and postoperative treatments, involvement sites, types of operation and recurrence rate in Crohn's disease. RESULTS: The male to female ratio was 1.5: 1, and age distribution was from 8 to 69 years old with mean age of 33 years old. The duration of symptoms varies from within 1 day to above 10 years and most of them had within 1 month as 17 cases (42.5%). Symptoms are abdominal pain, hematochezia, anorexia, abdominal mass and diarrhea. The most frequent symptom was the abdominal pain as 85%. Crohn's disease was diagnosed only 45% before operation, less than what we expected. In another hand it surprised us find out that tuberculosis enteritis was diagnosed as much as 20%. The most common indication of operation was medical treatment failure as 13 cases, and fistula was 7 cases, intestinal obstruction with stenosis and tumor were 6 cases each other. The involvement of small bowel was most common as 40%, and the most common operative findings were ulceration and fistula for 17 cases and 12 cases respectively. Small bowel cases were treated with segmental resection and anastomosis in all 16 cases. Large bowel cases were performed right hemicolectomy in 10 cases and total colectomy in 1 case. Both small and large bowel involvement cases, right hemicolectomy was done in 4 cases, right hemicolectomy and segmental resection of small bowel was done in 6 cases. The recurrence rate of postoperative medical treatment was 16% and 28% for 5 years and 10 years respectively. The recurrence rate with no postoperative medical treatment was 13% and 26% for each 5 years and 10 years. There was no significantly difference in both groups. CONCLUSION: The major surgical indications for Crohn's disease were medical treatment failure, fistula and intestinal obstruction. Specially in Korea, differential diagnosis with tuberculosis enteritis was very important. Postoperative complication and recurrence rate has relatively low incidence. Our study suggest that postoperative medical treatment was controversial.

Management of Penetrating Neck Injuries

BACKGROUND: The management of penetrating neck injuries presents a difficult problem. Although many authors have stated that surgical exploration should be mandatory for all neck injuries that penetrate platysma, recent reports from many centers now claim selective exploration. The aim of this study was to review a policy of selective neck exploration based on clinical presentation, anatomic location, and the result of diagnostic studies. METHOD: We reviewed retrospectively medical records of 66 patients who were admitted and managed at Yongdong Severance hospital, Yonsei university college of medicine due to penetrating neck injuries from Jan. 1990 to Dec. 1996. RESULTS: Forty-one patients(62%) were underwent immediate neck exploration, while the remaining 25 patients(38%) were admitted and observed. Three had esophagoscopy, four had esophagogram, and three had direct laryngoscopy, all of which revealed normal result except one patient had blood tinged larynx on laryngoscopy. Results of 12 neck explorations(29%) were negative. There was no delayed diagnosis during conservative treatment. There was no mortality. CONCLUSION: We concluded that selective exploration of penetrating neck injuries is both safe and resonable.

Strategy of Early Diagnosis in Blunt Diaphragm Rupture

Diaphragm rupture often challenges the surgeon by it's subtle presentation in the face of more obvious injuries, equivocal chest roentgenography, and no obvious indication of celiotomy or thoracotomy. Delayed diagnosis is one variable implicated in increased morbidity and mortality. This retrospective study was performed to determine the diagnostic value of diaphragm rupture on initial evaluation and to present an algorithm for initial evaluation. We reviewed the hospital records and the radiographs of 37 patients with a blunt diaphragmatic rupture who were treated at Yongdong Severance Hospital during a period of 5 years. The blunt diaphragmatic ruptures in 14 (38.9%) of the thirty-seven patients were missed on initial admission. At admission, initial physical findings were diagnostic in 3 cases (8.1%), suspicious in 24 cases (64.9%) and normal in 10 cases (27%). On chest roentgenogram, findings were diagnostic in 6 cases (16.2%), suspicious in 28 cases (75.7%) and normal in 3 cases (8.1%). Chest CT scans were performed on 20 patients. Findings were diagnostic in 6 (30%) of these, suspicious in 11 (55%) and normal in 3 (15%). On the chest roentgenograms of the 15 cases with suspicious physical findings, which were diagnosed early, the findings were diagnostic in 4 cases (26.7%) and suspicious in 11 cases (73.3%). Chest CT scans were performed in 10 out of 15 cases with suspicious physical findings which were diagnosed early, and the findings were diagnostic in 3 cases (30%), suspicious in 6 cases (60%), normal in 1 case (10%). In 23 patients (61.1%), diagnosis was established within 48 hours. In 4 (17.4%) of these patients, the diaphragm rupture was detected at the time of the celiotomy performed for other injuries. In conclusion, a blunt diaphragm rupture can easily be missed in the absence of obvious indications for a celiotomy or a thoracotomy, because radiologic abnormalities are often interpreted as other injuries. In such cases, a high index of suspicion coupled with selective use of a CT scan, fluoroscopy, thoracoscopy, or laparoscopy may be necessary for early detection of the diaphragm rupture.

Diagnostic value of fine needle aspiration of thyroid nodules / 대한내분비학회지

No abstract available.

A Case of Cystic Duct Stone and Cholecystitis Misdiagnosed as Gall Bladdr Carcinoma: A case report / 대한소화기내시경학회지

A 56 year old female was admitted because of the right upper quadrant mass for 4 days. She complained of intermittent colicky RUQ pain, fever and chills. So diagnostic procedures was performed: Blood chemistry testings. Ultrasonography. Barium enema, Liver scan, Hepatobiliary scan, ERCP and Abdomen CT, which diagnosed as gall bladder carcinoma. So explolaparotomy was performed and gross operative finding was gall bladder carcinoma with metastatic lymph node and cystic duct stone. So cholecystectomy, hemigastrectomy and anterior segmentectomy of right liver was done. But the biopsy result was cystic duct stone, cholecystitis and gall bladder empyema.