Perioperative Nutritional Support

Malnutrition in surgical patients is a prevalent problem. As the geriatric population gradually increases, surgeons need to be more careful in preventing the risk of iatrogenic malnutrition. Delayed wound healing, exposure to infection, pressure sores, gastrointestinal bacterial overgrowth, and immunosuppression in malnourished patients can be prevented or diminished with active nutritional support. Preoperative nutritional assessment and support, as well as adequate postoperative nutrition, will improve surgical outcomes, which in turn will lead to fewer postoperative complications, shorter hospital stays, and lower medical costs. The success of surgery depends not only on technical surgical skills but also on metabolic interventions that take into account the patient’s ability to deliver the metabolic load and provide adequate nutritional support.

Perioperative Nutritional Support

Malnutrition in surgical patients is a prevalent problem. As the geriatric population gradually increases, surgeons need to be more careful in preventing the risk of iatrogenic malnutrition. Delayed wound healing, exposure to infection, pressure sores, gastrointestinal bacterial overgrowth, and immunosuppression in malnourished patients can be prevented or diminished with active nutritional support. Preoperative nutritional assessment and support, as well as adequate postoperative nutrition, will improve surgical outcomes, which in turn will lead to fewer postoperative complications, shorter hospital stays, and lower medical costs. The success of surgery depends not only on technical surgical skills but also on metabolic interventions that take into account the patient’s ability to deliver the metabolic load and provide adequate nutritional support.

Prospects for the Korean model of the surgical hospitalist system

To meet the increasing social demand for improved patient safety and quality medical care in Korea, a pilot project of the hospitalist system in the field of internal medicine and surgery was initiated in 2016. Since the hospitalist system in the field of surgery in Korea should be based on the specific Korean medical environment, it is difficult to adopt a precedent model from other countries, and therefore a uniquely Korean operational model is necessary. Surgical hospitalists (surgeons working only within wards) in Korea are in charge of advanced primary care, perioperative care, and medical system care. Surgical hospitalists are able to care for older adult patients who have undergone a major operation to treat a highly severe condition. For inpatient care, the axis will need to shift from a trainee-centered structure to a surgical hospitalist-centered structure. This change will make possible the improvement of patient safety and quality medical care. The role of surgical hospitalists will extend not only to medical care, but also to education, academic activities, research, and related administrative aspects. To build a more stable and sustainable system, it is necessary to create a systemic operational foundation for proceeding with this new surgical hospitalist system.

Development of the role of teaching hospitalists in the education of residents

Resident law was enacted to improve the training environment and working conditions. However, the law caused confusion in the field and resulted in a medical vacuum in inpatient care. It also resulted in a lack of training time. A hospitalist system was introduced to improve the quality of patient care and to cover the shortage of residents. This study aimed to outline a development strategy for hospitalists participation in resident education in Korea. The result of pilot study of the hospitalists in Korea showed that patients, nurses, and residents were satisfied with hospitalists. Eighty-five percent of surgical residents were helped in postoperative patient care and 70.7% of residents were willing to work with a hospitalist. The competency of surgical hospitalists includes understanding surgery and the appropriate management of postoperative complications. In order to shift the paradigm of resident education, the Korean government must pay the expenses for resident training. Through hospitalists' participation in the resident training, it may be possible to provide residents with more comprehensive and continuous education for inpatient care.

Development of the role of teaching hospitalists in the education of residents

Resident law was enacted to improve the training environment and working conditions. However, the law caused confusion in the field and resulted in a medical vacuum in inpatient care. It also resulted in a lack of training time. A hospitalist system was introduced to improve the quality of patient care and to cover the shortage of residents. This study aimed to outline a development strategy for hospitalists participation in resident education in Korea. The result of pilot study of the hospitalists in Korea showed that patients, nurses, and residents were satisfied with hospitalists. Eighty-five percent of surgical residents were helped in postoperative patient care and 70.7% of residents were willing to work with a hospitalist. The competency of surgical hospitalists includes understanding surgery and the appropriate management of postoperative complications. In order to shift the paradigm of resident education, the Korean government must pay the expenses for resident training. Through hospitalists' participation in the resident training, it may be possible to provide residents with more comprehensive and continuous education for inpatient care.

Gastric gastrointestinal stromal tumor: Does the newly proposed UICC TNM staging system provide better prognostic ability than the National Institutes of Health consensus criteria?

PURPOSE: The main limitation of the National Institutes of Health (NIH) consensus criteria is the biological and prognostic heterogeneity of tumors while the utility of the newly proposed UICC TNM staging system has not yet been validated. Our object is to compare the overall and disease-free survival (DFS) of patients with gastric gastrointestinal stromal tumors (GIST) using the UICC TNM staging system and the NIH consensus criteria and to determine the optimal risk stratification system for GIST.METHODS: Retrospective analysis of 164 patients who underwent operative management for primary gastric GIST between 1994 and 2004.RESULTS: The overall five-year survival rate was 89.6%. In the 149 patients who underwent an R0 resection, the five-year DFS rate was 86.3%. According to the NIH consensus criteria, the five-year survival rate after resection was 100% for patients in the very low-, low-, and intermediate-risk groups and 71.9% for patients in the high-risk group. The UICC TNM stages IA, IB, and II had the same survival rates (100%) and stage IIIA (75.0%) and stage IIIB (69.5%) showed no significant difference in survival compared to the NIH criteria, which precluded better risk stratification. The patients who were included in the high-risk group by NIH consensus criteria (>10 cm, ≤5/50 high power field) and were stage II by the UICC TNM staging system had a 100% five-year survival rate.CONCLUSION: Using the current schemes, one system does not demonstrate superior prognostic ability over the other. However, the high-risk group (T4/low mitotic rate) and stage II patients appear to be appropriately classified.

Clinical Characteristics and Incidence of Thyroid Nodule in the Male Population for Health Check-up / 대한내분비외과학회지

PURPOSE: Thyroid nodules are a common disease in clinical practice. The prevalence of thyroid nodules has recently increased according to the development of thyroid ultrasonography. Thyroid nodules are more commonly found in women, but the potential for malignant nodules is much higher in men. The purpose of this study was to assess clinical characteristics and the incidence of thyroid nodules and malignancy in the adult male population. METHODS: Clinical characteristics and incidence of thyroid nodules was examined by screening ultrasonography targeting 6,968 male patients over the age of 40 who visited the National Police Hospital from January 2012 and April 2015. RESULTS: Among 6,968 male patients, 2,481 (35.6%) showed abnormal findings on ultrasonography. Of the 2,481 patients, 2,370 patients (34.01%) had a thyroid nodule and 111 patients (4.47%) had thyroiditis without a thyroid nodule, previous thyroidectomy, lymphadenopathy, esophageal diverticulum, parathyroid cyst, and benign calcification. Of the 2,481 patients, 958 patients (38.6%) had abnormal TFT and 204 patients (8.22%) had thyroiditis with or without a thyroid nodule. Thyroid nodules were benign in 1993 (80.33%) cases, indeterminate in 313 (12.61%) cases, and suspicious in 64 (2.56%) cases. Among the 2,481 subjects, thyroid cancer was detected in 37 subjects (1.49%). CONCLUSION: The incidence of thyroid nodules has recently increased according to the development of thyroid ultrasonography.

Effect of triclosan-coated sutures on surgical site infection after gastric cancer surgery via midline laparotomy

PURPOSE: Surgical site infection (SSI) after open abdominal surgery is still a frequently reported nosocomial infection. To reduce the incidence of SSI, triclosan-coated sutures with antiseptic activity (Vicryl Plus) were developed. The aim of this study was to analyze the effect of Vicryl Plus on SSI after gastric cancer surgery via midline laparotomy. METHODS: A total of 916 patients who underwent gastric cancer surgery at Samsung Medical Center between December 2009 and September 2011 were prospectively collected. We examined the occurrence of SSI (primary endpoint), assessments of wound healing (secondary endpoint). They were evaluated postoperatively on days 3, 7, and 30. RESULTS: Of the 916 patients, 122 were excluded postoperatively by screening (out of the study protocol, adverse events, etc.). The remaining 794 patients were enrolled and monitored postoperatively. The cumulative SSI incidence was 11 cases (1.39%; 95% confidence interval [CI], 0.77-2.50) on day 30. Seromas were most frequently detected in wound healing assessments, with a cumulative incidence of 147 cases (18.51%; 95% CI, 15.98-21.39) on day 30. CONCLUSION: The use of triclosan-coated sutures (Vicryl Plus) for abdominal wall closure can reduce the number of SSIs in gastric cancer surgery.

The Predictors and Clinical Impact of Positive Resection Margins on Frozen Section in Gastric Cancer Surgery

PURPOSE: The aim of this study is to compare the characteristics of tumor and prognosis, depending on the status of resection margin involvement, on the frozen section diagnosis in gastric cancer. MATERIALS AND METHODS: This study was conducted retrospectively, in 83 margin-positive patients on the frozen section diagnosis, who underwent gastrectomy from July 1995 to September 2006. The control group was selected by matching the age, gender, TNM stage and status of adjuvant chemoradiotherapy, among those who had shown clear resection margins. The characteristics of tumor and patient survival are investigated, and they were analyzed between the two groups. RESULTS: The tumor size was significantly larger in the study group than that of the control group (P=0.037). There was significant difference between the two groups in location of the tumors (P=0.003). Multivariate analysis indicated that only the location and Lauren's classification are independent factors, which affected the resection margin involvement. Median survival was 41.0+/-11.5 months in the study group and 93.0+/-30.3 months in the control group (P=0.049). In the survival analysis, it was investigated that TNM stage and the resection margin involvement of the frozen section diagnosis were the critical variables. CONCLUSIONS: When the tumor is located at the middle or the upper third, or the Lauren's indeterminate type, they are highly likely to show the resection margin involvement on the frozen section diagnosis, and it can, therefore, have negative effects on the prognosis. It is considered as good to perform more extensive resection as possible, during the initial resection.

Early gastric cancer arising from heterotopic gastric mucosa in the gastric submucosa / 대한외과학회지

The incidence of heterotopic gastric mucosa located in the submucosa in resected stomach specimens has been reported to be 3.0 to 20.1%. Heterotopic gastric mucosa is thought to be a benign disease, which rarely becomes malignant. Heterotopic gastric mucosa exists in the gastric submucosa, and gastric cancer rarely occurs in heterotopic gastric mucosa. Since tumors are located in the normal submucosa, they appear as submucosal tumors during endoscopy, and are diagnosed through endoscopic biopsies with some difficulty. For such reasons, heterotopic gastric mucosa is mistaken as gastric submucosal tumor. Recently, two cases of early gastric cancer arising from heterotopic gastric mucosa in the gastric submucosa were treated. Both cases were diagnosed as submucosal tumors based on upper gastrointestinal endoscopy, endoscopic ultrasound, and computed tomography findings, and in both cases, laparoscopic wedge resections were performed, the surgical findings of which also suggested submucosal tumors. However, pathologic assessment of the surgical specimens led to the diagnosis of well-differentiated intramucosal adenocarcinoma arising from heterotopic gastric mucosa in the gastric submucosa.

Adenocarcinoma derived from gastric hamartomatous polyps / 대한외과학회지

Most hamartomatous polyps in the stomach occur in patients with adenomatous polyposis coli and dysplasia. The authors report a case of a 57-year-old man without prior history of polyposis coli who presented with adenocarcinomas derived from hamartomatous polyps in the stomach. The patient underwent a radical subtotal gastrectomy with Billroth I anastomosis. Pathology revealed adenocarcinomas with moderate differentiation without evidence of lymph node metastasis in 60 nodes. We report a case of gastric cancers arising from de novo gastric hamartomatous polyps.

Mesenteric Fibromatosis Mimicking Recurrence after Distal Gastrectomy for Gastric Cancer

Mesenteric fibromatosis is a monoclonal, fibroblastic proliferation arising from musculoaponeurotic structure, and it is distinctive lesions defined as a group of non-metastasizing fibroblastic tumors which has local invasion and has a high recurrence rate after the surgical excision. The main treatment modality is the surgical excision. Radiation therapy, chemotherapy, and hormone therapy are also known as useful treatments. We report our experience of a recent case of Mesenteric fibromatosis. A 62-year old female patient had undergone gastrectomy due to gastric cancer. 18 months after gastrectomy, we detected an abdominal mass. The preoperative radiologic findings were suggestive of recurrence. Exploratory laparotomy was performed and post-operative pathologic diagnosis was confirmed as fibromatosis. We report a patient with mesenteric fibromatosis that mimic recurrence after gastrectomy for gastric cancer.

Frequency and Predictive Factors of Lymph Node Metastasis in Mucosal Cancer

PURPOSE: The incidence of lymph node metastasis has been reported to range from 2.6 to 4.8% in early stage gastric cancer with mucosal invasion (T1a cancer). Lymph node metastasis in early stage gastric cancer is known as an important predictive factor. We analyzed the prediction factors of lymph node metastasis in T1a cancer. MATERIALS AND METHODS: A total of 9,912 patients underwent radical gastrectomy due to gastric cancer from October 1994 to July 2006 in the Department Of Surgery at Samsung Medical Center. We did a retrospective analysis of 2,524 patients of these patients, ones for whom the cancer was confined within the mucosa. RESULTS: Among the 2,524 patients, 57 (2.2%) were diagnosed with lymph node metastasis, and of these, cancer staging was as follows: 41 were N1, 8 were N2, and 8 were N3a. Univariate analysis of clinicopathological factors showed that the following factors were significant predictors of metastasis: tumor size larger than 4 cm, the presence of middle and lower stomach cancer, poorly differentiated adenocarcinoma and signet-ring cell carcinoma, diffuse type cancer (by the Lauren classification), and lymphatic invasion. Multivariate analysis showed that lymphatic invasion and tumor larger than 4 cm were significant factors with P<0.001 and P=0.024, respectively. CONCLUSIONS: The frequency of lymph node metastasis is extremely low in early gastric cancer with mucosal invasion. However, when lymphatic invasion is present or the tumor is larger than 4 cm, there is a greater likelihood of lymph node metastasis. In such cases, surgical treatments should be done to prevent disease recurrence.

Frequency and Predictive Factors of Lymph Node Metastasis in Mucosal Cancer

PURPOSE: The incidence of lymph node metastasis has been reported to range from 2.6 to 4.8% in early stage gastric cancer with mucosal invasion (T1a cancer). Lymph node metastasis in early stage gastric cancer is known as an important predictive factor. We analyzed the prediction factors of lymph node metastasis in T1a cancer. MATERIALS AND METHODS: A total of 9,912 patients underwent radical gastrectomy due to gastric cancer from October 1994 to July 2006 in the Department Of Surgery at Samsung Medical Center. We did a retrospective analysis of 2,524 patients of these patients, ones for whom the cancer was confined within the mucosa. RESULTS: Among the 2,524 patients, 57 (2.2%) were diagnosed with lymph node metastasis, and of these, cancer staging was as follows: 41 were N1, 8 were N2, and 8 were N3a. Univariate analysis of clinicopathological factors showed that the following factors were significant predictors of metastasis: tumor size larger than 4 cm, the presence of middle and lower stomach cancer, poorly differentiated adenocarcinoma and signet-ring cell carcinoma, diffuse type cancer (by the Lauren classification), and lymphatic invasion. Multivariate analysis showed that lymphatic invasion and tumor larger than 4 cm were significant factors with P<0.001 and P=0.024, respectively. CONCLUSIONS: The frequency of lymph node metastasis is extremely low in early gastric cancer with mucosal invasion. However, when lymphatic invasion is present or the tumor is larger than 4 cm, there is a greater likelihood of lymph node metastasis. In such cases, surgical treatments should be done to prevent disease recurrence.

Changes of the Preoperative and Postoperative Nutritional Statuses in Patients with Gastric Cancer and Assessment of the Nutritional Factors That Are Correlated with Short-Term Postoperative Complications

PURPOSE: The aim of this study was to evaluate the preoperative and postoperative nutritional statuses of patients with gastric cancer and to investigate the nutritional factors that are correlated with perioperative complications. MATERIALS AND METHODS: From January 2008 to Jun 2008, 669 patients who underwent curative gastrectomy were enrolled in a retrospective study. To evaluate the changes of their nutritional status preoperatively and postoperatively, we measured the total lymphocyte count, the serum albumin, the body weight change and the BMI. The nutritional factors correlated with short-term postoperative complications were analyzed. RESULTS: The total lymphocyte count and serum albumin decreased from the first preoperative day to the 5th day after operation, but they tended to increase and approach the normal range 6 months after operation. The only factor correlated with the short-term postoperative complications (defined as the ones that occurred for 30 days) was the serum albumin checked on the 5th day after operation. CONCLUSION: Low serum albumin on the 5th day after operation was correlated with postoperative short-term complications. Serum albumin can be the preoperative statistical parameter that can predict the occurrence of postoperative complications.

The Analysis of the Trend of Research on Gastric Cancer Reported in Professional Journals in the Field of Surgery in Korea

PURPOSE: The aim of this study was to analyze the trend of the literature reported in the Journal of Korean Gastric Cancer Association (JKGCA) and the Journal of Korean Surgical Society (JKSS) in order to suggest new directions for the future studies on gastric cancer. MATERIALS AND METHODS: The papers published in the Journal of Korean Gastric Cancer Association (JKGCA) and the Journal of Korean Surgical Society (JKSS) between 2001 and 2008 were compared and summarized in terms of the following categories, retrospective study, prospective study, case report, biomolecular study, genetic study, tumor marker study, review article, and report. RESULTS: For recent 8 years, while the number of review articles in JKSS had initially increased, gradually fallen down and recently increased again, only a few (only 6 publications) in JKGCA have been published. The number of case reports in JKSS has gradually increased and fallen down. On the other hand, a few of case reports (1~3 publications) has been annually published in JKSS. Uniquely, reports were published only in JKGCA with the noticeable increase during the period from 2004 to 2005. For retrospective studies, in JKGCA the number started off very high and decreased, and finally increased again (U-shaped), whereas it had a bell-shaped trend in JKSS. The number of prospective studies in JKGCA had a bell-shaped trend, but the one in JKSS continued to decrease. Few papers of molecular biologic study, tumor marker study and genetic study had been published in both journals. CONCLUSION: We concluded that the transition from retrospective studies to prospective studies as well as a comprehensive multi-disciplinary team management of a clinical research would represent a desirable strategy in gastric cancer research.

Benign Stricture of Esophagojejunostomy after Radical Total Gastrectomy

PURPOSE: Benign anastomotic stricture after an esophagojejunostomy using EEA stapler following a radical total gastrectomy is one of the most serious complications. The purpose of this study is to evaluate the incidence, risk factors, and treatment associated with benign stricture. MATERIALS AND METHODS: From March 1998 to February 2001, 436 patients underwent an esophagojejunostomy with Roux-en-Y anastomosis using an EEA stapler followed by an endoscopy. Thirty three of the 436 patients (5.5%) developed an anastomotic stricture; included 24 of the 33 patients had a benign stricture. Nine patients with a malignant stricture were excluded. RESULTS: The median age of the 436 patients was 57 years (23~85 years). Two hundred ninety two patients were male, and 144 patients were female. The median time to diagnosing the stricture was 1.5 months (0.5~6 months). There was no statistical significance in any of the risk factors, including the diameter of the stapling device, the status of adjuvant treatment, the status of reflux esophagitis, and a clinical history of diabetes and hypertension. The strictured patients were treated with balloon dilatation, one to three times, with symptom relief. CONCLUSION: There were no statistically significant risk factors. However, further study of the vascularity of anastomoses and benign strictures needs to be considered. In the anastomotic strictured patients, endoscopic balloon dilatation appeared to be the first line of treatment.

Ultrastructure of Rabbit Pyloric Mucosa Following Ligation of Common Bile Duct / 체질인류학회지

The purpose of this study was to examine the ultrastructural characteristic of the normal pylorus mucosa, and their structural changes induced by the ligation of common bile duct of the male rabbits weighing about 1.5 kg each. Experiment animals were divided into normal, sham operation, and experimental groups. Common bile duct ligation was performed under ether anesthesia and anjmals were sacrificed on the 1st, 3rd, 5th, 7th and 14th day after operation. The mucosal specimen of the pylorus, were fixed and embedded with common method. The sections were cut on a LKB-V ultratome, and observed under a JEM 100CX II electron microscope. The results were as follow : 1. In the early stages (1st, 3rd, 5th day groups) following the ligation, surface mucous cells have the various electron densities and shape of the mucous granules. In the late stages (7th, 14th day groups) following the ligation, many surface mucose cells containing numerous electron dense mucous granules are seen. 2. In the early stage of the ligation of bile duct, secretory function of EC cells was depressed, but in the later stage, the cells showed recovered secretory activity. 3. Secretory function of D cells was depressed on the early groups after the ligation of common bile duct, but they showed recovered secretory activity from the late groups after the ligation of the common bile duct. 4. Secretory function of G cells was activated on the early groups after the ligation of common bile duct, but they showed depressed secretory activity from the late groups after the ligation of the common bile duct. Considering the above findings, common bile duct ligation probably causes the dysfunction of the pyloric surface mucous cells that results in delayed mucous formation and secretion, and recovered mucous secretory function on the late stages. EC cells and G cells, depressed the secretory activities on the early stages and recovered on the late stages of the ligation of common bile duct. But D cells in the pyloric mucosa was activated on the early groups after the ligation of common bile duct ligation, but they was depressed secretory activities on the late groups.

Development of Independent Target Approximation by Auto-computation of 3-D Distribution Units for Stereotactic Radiosurgery / 의학물리

The stereotactic radiosurgery (SRS) describes a method of delivering a high dose of radiation to a small target volume in the brain, generally in a single fraction, while the dose delivered to the surrounding normal tissue should be minimized. To perform automatic plan of the SRS, a new method of multi-isocenter/shot linear accelerator (linac) and gamma knife (GK) radiosurgery treatment plan was developed, based on a physical lattice structure in target. The optimal radiosurgical plan had been constructed by many beam parameters in a linear accelerator or gamma knife-based radiation therapy. In this work, an isocenter/shot was modeled as a sphere, which is equal to the circular collimator/helmet hole size because the dimension of the 50% isodose level in the dose profile is similar to its size. In a computer-aided system, it accomplished first an automatic arrangement of multi-isocenter/shot considering two parameters such as positions and collimator/helmet sizes for each isocenter/shot. Simultaneously, an irregularly shaped target was approximated by cubic structures through computation of voxel units. The treatment planning method by the technique was evaluated as a dose distribution by dose volume histograms, dose conformity, and dose homogeneity to targets. For irregularly shaped targets, the new method performed optimal multi-isocenter packing, and it only took a few seconds in a computer-aided system. The targets were included in a more than 50% isodose curve. The dose conformity was ordinarily acceptable levels and the dose homogeneity was always less than 2.0, satisfying for various targets referred to Radiation Therapy Oncology Group (RTOG) SRS criteria. In conclusion, this approach by physical lattice structure could be a useful radiosurgical plan without restrictions in the various tumor shapes and the different modality techniques such as linac and GK for SRS.