The Relationship between Perioperative Blood Transfusion and Prognosis in Stomach Cancer

PURPOSE: Perioperative blood transfusion and its influence on the immune system in cancer surgery is a subject of controversy. We made a retrospective study to comprehend the prognostic effects of perioperative blood transfusion in gastric cancer surgery. METHODS: A total 284 patients who underwent gastrectomy for gastric cancer from 1991 to 1998 were retrospectively reviewed. Uni- and multi-variated analyses of the incidence and amount of perioperative blood transfusion were performed, along with a comparison of the clinicopathologic features. RESULTS: Of the 284, 119 (42%) required no blood transfusion and 165 (58%) required blood transfusion within the perioperative period. The transfused group included patients with larger tumors (more than 4 cm, 67.1% vs 47.5%, P=0.001), with longer operation time (260.8 vs 229.2 min, P=0.001), with total gastrectomy (29.7% vs 14.4%, P=0.001), with advanced T-stages (P=0.001), and with more advanced nodal metastasis (P=0.005) than the nontransfused group. Overall comparison of transfused patients versus nontransfused patients by log rank analysis revealed a statistically significant adverse influence of blood transfusion on survival rate (58.7% vs 80.3%, P=0.001). However, after stratifying patients into stages and applying Cox-regression analyses, blood transfusion did not appear to have any effect on prognosis except stage III. CONCLUSION: We could not find any direct causal relationship between perioperative transfusion and long term prognosis in patients receiving gastric cancer surgery. However, in cases with advanced gastric cancer, it is better to refrain from unnecessary blood transfusion in the perioperative periods.

Porto-Mesenteric Venous Thrombosis

Porto-mesenteric venous thrombosis is a rare disorder, which can occur as a complication of many diseases. Porto-mesenteric venous thrombosis leads to venous hypertension, outpouring of blood into the bowel lumen and mesentery, distension and rupture of venules, and hemorrhgae and edema of the bowel wall. In cases of mild porto-mesenteric venous thrombosis, nonoperative management-consisting of fluid resuscitation, anticoagulation, and thrombolysis-may be acceptable in clinically stable patients with early diagnosis. If patients show clinical signs of peritonitis or deteriorates on medical management, prompt surgical intervention is warranted. At laparotomy, segmental resection of the involved bowel with primary anastomosis is easily accomplished, because the hemorrhagic infarction associated with porto-mesenteric venous thrombosis is limited. The optimal duration of anticoagulation therapy has not been defined. However, recommendation is that anticoagulation should be continued indefinitely, as it reduces the incidence of porto-mesenteric venous thrombosis recurrence. The patient in our study presented with a severely edematous duodenum and proximal jejunum in CT scan with signs of peritonitis due to perforation of the upper-jejunum. We had performed a percutaneous drainage for intraabdominal abscess which occurred the jejunal infarction. About 1 month later, a resection of a well-controlled fistula tract was done.

Hemoperitoneum Due to Spontaneous Rupture of an Aneurysm of the Right Gastric Artery

We report a case of a 46-year-old male patient who presented with sudden abdominal pain and hypovolemic shock. The initial hemoglobin level was 11.9 g/dl, which fell to 6.9 g/dl after hydration. The emergent CT showed a large amount of hemoperitoneum and dye leakage. Emergent angiography and gell foam embolization were performed under the diagnosis of right gastric artery aneurysm rupture.

The Prognostic Significance of Immunohistochemically Detected Isolated Tumor Cells in Lymph Node in Colorectal Cancer

PURPOSE: Metastasis of a colorectal carcinoma to regional lymph nodes indicates poor prognosis. The detection of lymph node metastasis is routinely performed by his topathological analysis of hematoxylin-eosin (H&E) stained sections. However the routine histological technique may fail to detect isolated tumor cells in lymph nodes. The aims of this study are to elucidate the prognostic significance of the presence of isolated tumor cells in the regional lymph nodes in colorectal cancer, and to elucidate the correlation between the presence of isolated tumor cells and p53 protein expression in the primary colorectal cancer tissue. METHODS: We used immunohistochemical staining with anti-cytokeratin antibody to examine 452 lymph nodes in 24 patients (11 recurrent and 13 nonrecurrent) who were histologically determined Astler-Coller B. And we used immunohistochemical staining with p53 protein to examine primary colorectal cancer tissues of the patients. RESULTS: Immunohistochemical staining of cytokeratin revealed the presence of isolated tumor cells in 5/13 patients (38.5%), 5/214 lymph nodes (2.34%) in the nonrecurrent group and 6/11 patients (54.6%), 11/244 lymph nodes (4.51%) in the recurrent group, respectively. The detection rate of isolated tumor cells in the recurrent group was slightly higher than nonrecurrent group, but the difference was not significant statistically. The expression rate of p53 protein was 23.1% (3/13) in the nonrecurrent group and 36.4% (4/11) in the recurrent group, respectively. The expression rate of the p53 protein was not significantly correlated with the presence of isolated tumor cells in regional lymph nodes and the rate of tumor recurrence. CONCLUSIONS: The presence of isolated tumor cells in regional lymph nodes was not a prognostic indicator in predicting recurrence in histologically determined Astler- Collar B colorectal cancer patients.

PCNA Expression as a Prognostic Factor in Papillary Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: Assessment of the proliferative ability of cancer cells is necessary not only for the biologic characterization of tumors, but also for the selection of treatment and evaluation of prognosis. Recently, there have been several studies examining the proliferative activity of various malignant tumors using immunohistochemical methods. PCNA is a nuclear protein related to the cell cycle and found with high expression in proliferative tissues, including cancers. METHODS: In our study, to evaluate whether PCNA expression was useful as a prognostic factor in patients with papillary thyroid carcinoma, we quantitated the immunohistochemical expression of PCNA in the formalin-fixed paraffin embedded tissue from 55 patients with papillary thyroid carcinoma and correlated the results with established clinicopathologic parameters. RESULTS: The results were as follows. 1) PCNA expression in papillary thyroid carcinoma did not correlate with the age, sex or metastatic L/N activity of the patient, nor with the size, invasion, or recurrence of the tumor. 2) There was a close relationship between the expression rate of PCNA in thyroid tumor cells and that in metastatic L/N cells (p=0.056, in p<0.1). 3) The expression of PCNA in the metastatic L/N (+) group was higher than in the metastatic L/N (+) group (p=0.045). CONCLUSION: It is suggested that PCNA expression is not an appropriate prognostic factor in papillary thyroid carcinoma.

Chronic Thyroiditis in Association with Thyroid Cancer / 대한내분비외과학회지

No abstract available in English.

Migrating pancreatic duct stone: a case report / 한국간담췌외과학회지

Most reports describe acute gallstone pancreatitis as a result of common bile duct and pancreatic duct obstruction at the Ampulla of Vater. The pathophysiology leading to the development of pancreatitis includes the common channel theory of obstruction leading to bile reflux, ductal hypertension secondary to pancreatic duct obstruction, and sphincter incompetence with duodenal content reflux.Rarely stones which from common bile duct have been demonstrated by ERCP to lie within the pancreatic duct. We experienced the patient who complained epigastric and RUQ pain. She was 51-year-old and had both intrahepatic duct, common bile duct stones and pancreatic duct stone. Initial amylase and lipase was 112 IU/L, 1925 U/L. We performed Lt. lateral segmentectomy, Roux-en-Y choledochojejunostomy, distal pancreatectomy. So We report this case.

Eosinophilic Enteritis Diagnosed by Laparoscopic Biopsy / 대한소화기내시경학회지

Eosinophilic gastroenteritis is a rare disease characterized by the eosinophilic infiltration of the gastro-intestinal tract without involvement of organs outside the gastrointestinal tract and may be misdiagnosed in clinical practice. The pathophysiology of eosinophilic gastroenteritis is not known well. We report a case of serosal eosinophilic enteritis presenting sterile eosinophilic ascites, peripheral eosinophilia and abdominal pain. Diagnosis was confirmed by laparoscopic biopsy of small bowel. The patient was improved dramatically with prednisolone therapy.

A Study on the Tolerability of Early Postoperative Feeding in Patients with Colorectal Cancer

BACKGROUND: Resolution of postoperative ileus has traditionally been the moment at which bowel function returns. The re-start of postoperative oral feeding usually occurs after that. Recently, many reports have been published on early postoperative feeding in patients operated on laparoscopically and even in patients receiving a laparotomy. The aim of this study was to scrutinize the validity of early postoperative feeding. METHODS: Fiftyfour colorectal cancer patients who had undergone radical resective surgery for cure were included in this study and were divided into two group. Group 1 included 32 patients who were fed in a traditional manner. Group 2 consisted of 22 patients who received a regular diet on the first postoperative day. The mean age was 62, the male-to-female ratio was 1.2:1. Thirteen tumor were located on the right side colon, 4 on the left side colon, 10 on the rectosigmoid, 27 on the rectum. Operative methods were 13 right hemicolectomies, 4 left hemicolectomies, 19 low anterior resections, and 18 abdominoperineal resections. The possible problems associated with early oral feeding were well understood by the patients and consents were obtained. Immediately after the operation, the nasogastric tube was removed in the operation room, and The time of complete recovery from anesthesia was 3 to 5 hours later. At that time, liquid drink was given; then, liquid food or blended food was allowed. RESULT: Early oral intake was tolerable in 14 patients out of 21 (67%); in 8 patients a nasogastric tube was reinserted due to severe nausea, vomiting, and/or abdominal distension. All those minor problems were resolved after reinsertion of the nasogastric tube and returning to the traditional method. In one patient, who had a received a low anterior resection, a serious complication, anastomatic leakage, developed. Early oral intake was not thought to be the exact cause of the leakage, but it made the problem more complicated. A huge amount of feces soiled the peritoneal cavity and the already dissected retroperitoneum. CONCLUSIONS: The tolerability of early postoperative oral intake was 67%. In the remainder of patients, all the minor problems except one, were relieved by simply returning to the traditional method. However, early postoperative oral intake should be used with caution for patients who experience difficulty with anastomosis or have an intraoperative technical breakdown and in whom the possibility of leakage exists.

Tumor Angiogenesis and the Relationship to the Prognosis in Breast Cancer

BACKGROUND: The status of axillary lymph nodes has been the most important prognostic factor in operable breast carcinomas, but it does not fully account for the varied disease outcome. More accurate prognostic indicators would help in the selection of patients at high risk for disease recurrence and death and in the selection of candidates for systemic adjuvant therapy. Many studies have suggested that tumor growth is angiogenesis-dependent and that implies an increase in the delivery of nutrients to the tumor cells. This neovascularization also increases the opportunity for tumor cells to enter the circulation, which indicates the importance of tumor angiogenesis to the metastastic potential of tumors. The aim of this study was designed to further define the relationship of microvessel density (MVD) to overall and relapse- free survival and to other reported prognostic indicators in breast carcinomas. METHODS: To investigate the status of angiogenesis in breast carcinomas, we highlighted the microvessels within primary invasive breast carcinomas by using a immunohistochemical study with a monoclonal antibody against the factor-VIII-related antigen. Using light microscopy, we counted the microvessels per 200x field in the most active areas of neovascularization, and we graded the microvessel density. RESULTS: In this study 86 patients with a breast carcinoma were classified into two groups. There were 47 patients with low MVD ( or =42/200xPF). The MVD was in the range between 8 and 173. A significant correlations between microvessel density and the overall survival rates (p=0.0003) and relapse-free survival rates (p=0.0003) were found in all patients. Also, there was a significant association of tumor size and lymph node metastasis states with the overall survival rates and the relapse-free survival rates in all patients. A significant correlation was found between MVD and tumor size (p=0.010). The relapse-free 5-years survival rate of low-MVD patients was 85.5+/-5.52%, and that of high-MVD patients was 44.36+/-9.73% (p=0.0003). The overall 5-yearssurvival rate of low-MVD patients was 84.12+/-6.01%, and that of high-MVD patients was 37.75+/-10.07% (p=0.0003). CONCLUSIONS: In conclusion the present study found a significant correlation between MVD and both tumor size, lymph-node metastasis. The present study shows that the MVD in the area of the most intense neovascularization in an invasive breast carcinoma is an independent and significant prognostic indicator for the overall survival rate and the relapse-free survival rate in patients. Thus, determination of the MVD in an invasive breast carcinoma would be valuable.

Prognostic Value of Tumor Angiogenesis in Advanced Gastric Carcinomas

BACKGROUND: Tumor angiogenesis is considered to be essential for tumor growth and progression. Recently, new technology for counting microvessels using antifactor-VIII-related antigen antibody, which recognizes endothelial cells, has been developed. In order to evaluate whether tumor angiogenesis can be used as an independent prognostic factor in advanced gastric carcinomas. We counted tumor microvessels, and we investigated the relationship between microvessel count and progression of a gastric carcinoma, by using a multivariate analyses. METHODS: Seventy (70) patients with advanced gastric carcinomas who had undergone a gastrectomy at Gyeongsang National University Hospital from January 1990 to December 1994 were evaluated by staining with a monoclonal antibody against F-VIII RAg. Microvessel counts were determined by immunohistochemical staining of a monoclonal antibody against F-VIII RAg, which was localized to the vascular endothelium. The correlation between the microvessel count (the mean number of microvessels in the three areas of highest vascular density at 200 times magnification) and the prognosis was studied. RESULTS: The microvessel counts ranged from 2 to 99.8, and the mean was 26. The microvessel counts were significantly higher in patients with recurrence than in those without recurrence. In patients who had undergone a curative operation, the survival time in the hypervascular group was significantly shorter than that in the hypovascular group. Multivariate analysis indicated that the microvessel count was an independent prognostic factor in patients with a gastric carcinoma. CONCLUSIONS: Microvessel count may be a good prognostic indicator and may be useful as a predictor for recurrence in patients with a gastric carcinoma.

Surgical Experience with Intrahepatic Duct Stones

BACKGROUND: Stones in the biliary tree situated proximal to the origin of the common hepatic duct are considered intrahepatic duct stones. This condition causes serious problems, including cholangitis, obstructive jaundice and liver abscess. METHODS: This study was a clinical review of the results from 178 patients with intrahepatic stones who were surgically treated at the Department of Surgery, Gyeongsang National University Hospital from January 1991 to December 1997. RESULTS: The sex ratio of males to females was 1:2.1, and the most prevalent age group was the 6th decade. Common symptoms and signs were RUQ pain (83.2%) and tenderness (64.7%). Common laboratory findings were elevated alkaline phosphatase (56.6%), elevated serum GOT (47.4%), leukocytosis (44.5%) and hyperbilirubinemia (36.4%). C. sinensis was identified in 22 (12.4%) of the operation cases. Intrahepatic stones were located in the left hepatic duct in 87 cases (48.9%), the right duct in 27 cases (15.2%), and both intrahepatic ducts in 64 cases (35.9%). A partial hepatectomy was performed in 94 cases (52.8%); other procedures without a hepatectomy were performed in 84 cases (47.2%). The remaining stones were noted in 57 (32%) of the operation cases. Among them, 39 cases (68%) were in the non-hepatic resection group, and 18 cases (32%) were in the hepatic resection group. The postoperative complication rate in hepatic resection group (29.8%) was higher than that in the non-hepatic resection group (15.5%). The most common complication was wound infection. The operative mortality was 2.1% in the hepatic resection group and 2.4% in the non-hepatic resection group. The follow-up study showed that 146 cases (82%) were graded as a good result, 7 cases (3.9%) as fair, and 25 cases (14%) as poor and that the relative incidence of good results in the hepatic resection group(88.3%) was higher than that in the non-hepatic resection group (75%). CONCLUSIONS: We conclude that a hepatic resection, rather than a biliary bypass procedure alone, is satisfactory as an initial treatment for hepatolithiasis.

Surgical Experience for Intrahepatic duct Stones / 한국간담췌외과학회지

BACKGROUND: The stones in the biliary tree situated proximal to the origin of the common hepatic duct are considered intrahepatic duct stone. This conditon causes the serious problems including cholangitis, obstructive jaundice and liver abscess. AIM AND METHOD: This study is a clinical review for the results of surgical treatment in 178 cases of patients with intrahepatic stones in the Department of Surgery, Gyeongsang National University Hospital from January 1991 to December 1997. RESULTS: Sex ratio of male to female was 1 : 2.1 and most prevalent age group was 6th decade. Common symptom and sign was RUQ pain(83.2%) and tenderness(64.7%). Common laboratory finding were elevated alkaline phosphatase(56.6%), elevated serum GOT(47.4%), leukocytosis (44.5%) and hyperbilirubinemia(36.4%). C. Sinensis was identified in 22 cases(12.4%) of operation cases. Intrahepatic stones were located in the left hepatic duct in 87 cases(48.9%), the right duct in 27 cases(15.2%) and both intrahepatic duct in 64 cases (35.9%). Partial hepatectomy was performed in 94 cases(52.8%), non-hepatectomy was performed in 84 cases(47.2%). The remained stone was noted in 57 cases(32%) of operation cases. Among them, 39 cases(68%) were non-hepatic group, 18 cases(32%) were hepatic group. Postoperative complication rate in hepatic resection group(29.8%) was higher than that in non-resection group(15.5%). Most common complication was wound infection and operative mortality was 2.2%. The follow-up study showed that 146 cases(82%) were graded as good, 7 cases(3.9%) as fair and 25 cases(14%) as poor result and relative incidence of good result in hepatic resection group(88.3%) was higher than that in non-hepatic group(75%). CONCLUSIONS: We conclude that hepatic resection rather than biliary bypass procedure alone as an initial treatment for hepatolithiasis is satisfactory treatment.

Autosomal Dominant Polycystic Kidney Disease Complicated by Aldosterone-producing Adrenal Adenoma / 대한신장학회잡지

We report the case of a 34-year-old woman with autosomal dominant polycystic kidney disease associated with primary aldosteronism due to left adrenal adenoma. Although autosomal dominant polycystic kidney disease could mask hypokalemia and hypertension, refractory hypertension and hypokalemia were the clues that led to this diagnosis. The diagnosis of primary hyperaldosteronism was based on the presence of hypokalemia with excessive urinary potassium excretion and characteristic hormonal changes. Under laparoscopy, left adrenalectomy was performed. After surgery, plasma renin activity, plasma aldosterone titer, and serum potassium level normalized with only partial correction of the blood pressure. This could be explained by the persisting underlying polycystic kidney disease. We conclude that extrarenal causes in a hypertensive and hypokalemic patient with polycystic kidney disease may be ruled out.

Laparoscopic Primary Endorectal Pull-through Procedure (Boley's) for Hirschsprung's Disease

Advances in instrumentation and technique now make laparoscopic correction of some congenital anomalies possible. Author reports a 6-day-old boy with Hirschsprung's disease successfully treated by a laparoscopic endorectal pull-through procedure. The technique and its potential role in the treatment of Hirschsprung's disease are described. One camera port and three working ports were used for access to the peritoneal cavity. The descending and sigmoid colons were mobilized laparoscopically. A submucosal sleeve was developed transanally to meet the dissection from above. The colon was then pulled down in continuity, divided above the transition zone, and secured to the anal mucosa about 10 mm above the pectinate line. Author concludes that the laparoscopic endorectal pull-through procedure could be performed in safe.