Comparison of Clinical Outcomes between Pylorus Preserving Pancreaticoduodenectomy and Pancreaticoduodenectomy / 한국간담췌외과학회지

PURPOSE: A pancreaticoduodenectomy (PD) and pylorus-preserving pancreaticoduodenectomy (PPPD) are the two methods commonly used to treat periampullary neoplasms. This study was designed to compare these two methods in terms of the post-operative complications, the recurrence rate, and the post-operative weight change. METHODS: The medical records of 110 patients who underwent PD or PPPD from February 1986 through to June 2002 were retrospectively reviewed. The PD was performed on 54 patients and PPPD was performed on 56 patients, respectively. The mean follow-up periods were 25.33 months in the PD group and 25.39 months in the PPPD group, respectively. RESULTS: Diabetes mellitus occurred in 9 patients (16.7%) in the PD group and 8 patients (14.3%) in the PPPD group, and gastric emptying was delayed in 14 (25.9%) and 15 (26.8%) patients of each group after surgery. Procedure related deaths occurred in 2 (3.7%) and 4 (7.1%) patients from each group. There were no statistically significant differences in the post-operative complications between the two groups. The disease recurrence rate was significantly lower in the PPPD group than in the PD group (60.5% vs. 22.9%, p=0.001). Post-operative weight loss just after surgery at 3 months and 6 months after surgery was 3.56 kg, 3.68 kg, and 3.97 kg in the PD group and 2.78 kg, 1.77 kg, and 1.8 kg in the PPPD group, respectively, without showing a statistically significant difference. CONCLUSION: The clinical outcomes of the PPPD was not different from those of the PD in terms of the post-operative complications and weight loss. The disease recurrence rate was lower in the PPPD group. These results suggest that PPPD could be the treatment choice periampullary neoplasms.

Role of Surgery in the Management of Primary Lymphoma of the Gastrointestinal Tract

BACKGROUND: Primary lymphoma of the gastrointestinal tract is an unusual disease for which the optimal management strategy has not been clearly defined. The role of surgery in the management of primary gastrointestinal lymphoma remains controversial. METHODS: We retrospectively reviewed the management and the outcome of 55 patients a diagnosis of gastrointestinal lymphoma who were treated at Kyung-Hee University Medical Center during the period 1986-1997. Thirty-seven of them underwent a resection for cure, and 23 patients of them underwent chemotherapy. 18 patients underwent chemotherapy only. Radiation therapy was excluded due to the small number of patients. Surgery consisted of wide local resection of the primary tumor (curative for stages I and II, and palliative for stages III and IV), and regional lymph nodes, with re-establishment of bowel continuity. Chemotherapy involved 6-10 courses of CHOP-B (cyclophosphamide, adriamicin, vincristine, prednisone, and bleomycin). Survival curves were calculated by using the Kaplan and Meier method. RESULTS: The mean age was 51 years (range: 3-82), the peak incidence of age was the fifth decades (34%), and the male-to-female ratio was 1.3:1. Common signs and symptoms at presentation were abdo minal pain (n=46), palpable mass (n=28), nausea/vomiting (n=26), and weight loss (n=18). The diagnostic sensitivities of ultrasound, contrast radiography, endoscopic biopsy, and computed tomography were 52%, 57%, 76%, and 78%, respectively. The primary tumor sites were the stomach (n=18), the terminal ileum & cecum (n=15), the small bowel (n=13), and the large bowel (n=9). The respective cumulative overall 5-year survival rates for stage I, II, III tumors were 89%, 74%, and 43% (p<0.05). The respective overall 5-year survival rate for resection only, resection with chemotherapy, and chemotherapy only were 100%, 78%, and 40% (p<0.05). By the Kaplan-Meier method, the prognostic factors of survival were stage and curative resection (p<0.05). CONCLUSION: A curative resection in a stage I, II lymphoma confined to the gastrointestinal tract and to regional involvement may improve patient survival.

Breast Reconstruction Using the Pedicled Transverse Rectus Abdominis Myocutaneous (Tram) Flap

In many cases the breast reconstruction surpasses the goal of a normal breast mound appearance in clothing and achieves a result that, in time, may look almost normal in the unclothe state. Breast reconstructions with autologous transverse rectus abdominis myocutaneous (TRAM) flaps are well known to produce the most aesthetically excellent results. the pedicled to TRAM flap cannot be used in high risk patient such as obese or smoking patients due to partial flap necrosis. But, the free TRAM flap have more robust blood supply and less donor site morbidity than the pedicled TRAM flap and is therefore the currently preferred technique in western. However, the free TRAM flaps has a problem related to the anastomotic failure which has been reported as high as 6% to 10%. Moreover many Korean women have smaller sized breast than western women and have no risk factors compromising flap circulation. So the single pedicled TRAM flap can be safely used for breast reconstruction without any flap necrosis. 60% of the elevated flap area has a sufficient volume to mold a new breast that matches with the contralateral breast and the unneccessary distal portion of the flap that has the marginal circulation can be resected. In this study we review our 20 consecutive cases of breast reconstruction using the pedicled TRAM flap and have a conclusion that the pedicled TRAM flap produce an aesthetically acceptable new breast in Korean mastecotmy patients without any flap necrosis or donor site morbidity.

Clinical Experience and Imitation of the Immediate Breast Reconstruction Using the Permanent Expander Prosthesis

Tissue expansion in breast reconstruction is a invaluable alternative surgical procedure. the advent of permanent expander prosthesis eliminated a second operative procedure for removal of the expander and replacement with another permanent implant. When we consider the choice of method for breast reconstruction, we have to take account of the extent of mastectomy, past-medical history of the patient, timing of operation, and patient's motivation. It is still accepted that autogenous Breast reconstruction is the best choice of the mothed. As autogenous breast reconstruction increase in popularity, however, it requires longer operation time, more complicated technique, and careful attention to donor site. Autogenous breast reconstruction is also not good candidate for the patients who have diabetes, vascular disease, smoking, obesity, previous history of cesarean section, or further pregnancy planning. We have performed 10 immediate breast reconstructions after modified radical mastectomy using the permanent expander prosthesis, manufactured by Mentor corporation. Among these cases, 8 patients underwent cesarean section and 2 patients pregnancy. Although this method has advantages of simple technique, minimal morbidity, and low cost, it has some limitations for orientals. First, it is inevitable in superior fullness of the reconstructed breast because of round shape of the expander. Second, it is difficult to get ptotic breast because of thick and inelastic characteristics of oriental skin. Third, the ratio of expander base to projection is not appropriate for orientals because of their smaller chest size. We experienced 2 cases of spontaneous deflation for its manufactural defect itself. In our experience, we would like to suggest that new type of permanent expander prosthesis should be innovated.