A multicenter, prospective, randomized clinical trial of marine mussel-inspired adhesive hemostatic materials, InnoSEAL Plus

Purpose@#InnoSEAL Plus is an adhesive, coagulant-free hemostatic material that mimics the adhesion mechanism of marine mussels. This study reports on the safety and efficacy of InnoSEAL Plus for patients with hemorrhage after hepatectomy despite first-line hemostasis treatments. @*Methods@#This is a multicenter, prospective, single-blinded, randomized clinical trial involving 96 hepatectomy patients. TachoSil was used as a comparator group. Three-minute and 10-minute hemostatic success rates were monitored. Rebleeding rates were also observed. Safety was assessed by recording all novel undesirable symptoms. @*Results@#InnoSEAL Plus showed a 3-minute hemostasis rate of 100%, while TachoSil had a rate of 98.0% (48 of 49 patients), demonstrating that the 2 had similar hemostatic efficacies. The difference in efficacy between the test and comparator group was 2.04%, and the lower limit of the one-sided 97.5% confidence interval was –1.92%; as this is greater than the noninferiority limit of –23.9%, the 2 treatments were equivalent. Meanwhile, the 10-minute hemostatic success rate was the same in both groups (100%). No rebleeding occurred in either group. In the safety evaluation, 89 patients experienced adverse events (45 in the test group and 44 in the comparator group). The difference between the 2 groups was not significant. No death occurred after application of the test or comparator group product. @*Conclusion@#Given that InnoSEAL Plus is a coagulation factor-free product, the hemostasis results are encouraging, especially considering that TachoSil contains a coagulation factor. InnoSEAL Plus was found to be a safe and effective hemostatic material for control of bleeding in hepatectomy patients.

Diffuse large B-cell lymphoma presenting with cholecystitis-like symptoms

Diffuse large B-cell lymphoma that arises from the gallbladder is extremely rare, and the associated studies are not well described in the literature. We report our experience that diffuse large B-cell lymphoma of the gallbladder was diagnosed by histological findings after laparoscopic cholecystectomy in a 75-year-old man. The patient was diagnosed with stage IV lymphoma, and chemotherapy was performed following surgery. The abdominal, chest, neck computed tomography (CT) and positron emission tomography (PET)-CT were performed after chemotherapy, and the results showed that there were no multiple lymphadenopathies. The patient was considered to have achieved complete remission. Diffuse large B-cell lymphoma of the gallbladder is extremely rare and never been diagnosis preoperatively. Pathological examination of the cholecystectomy specimen is important. This will be very helpful for identifying patients who need additional treatment.

Hepatic resection for isolated breast cancer liver metastasis: A single-center experience

PURPOSE: The objective of this study was to investigate the outcomes of selected patients with breast cancer liver metastases (BCLM) without extrahepatic metastases after hepatic resection.METHODS: Patients whose imaging findings did not show extrahepatic disease were selected for hepatic resection. If R0 resection was available and the operative risk was low in preoperative tests, the patients underwent surgery.RESULTS: Between 2011 and 2014, six patients underwent hepatic resection for BCLM. All patients received hepatic resection to achieve an R0 resection. The time interval between initial detection of breast cancer and that of liver metastases in the patients, excluding one patient with synchronous metastases, was 55.2 months. Major liver resection was performed in four patients. Differences were observed in the hormone receptor status between the primary breast tumor and liver metastases; however, no difference was observed in the human epidermal growth factor receptor 2 status. The 1-year and 3-year overall survival rates after hepatic resection were 100% and 83.3%, respectively. The 1-year and 3-year disease free survival rates after hepatic resection were 66.7% and 50.0%, respectively.CONCLUSION: Curative resection may be considered as one of the multimodality treatments for BCLM. It shows benefit in selected patients; its selection criteria needs to be investigated.

Laparoscopic Splenectomy for a Patient with Splenomegaly and Hypersplenism due to Idiopathic Portal Hypertension

Idiopathic portal hypertension (IPH) is a rare disorder which is clinically characterized by portal hypertension, splenomegaly, hypersplenism and the absence of liver cirrhosis. Patients with IPH have massive splenomegaly leading to increased portal venous flow and subsequent portal hypertension. In selected IPH patients with splenomegaly and hypersplenism, splenectomy can be regarded as an effective treatment protocol for decreasing portal hypertension. We report a case of a 44-year-old woman who was diagnosed with IPH accompanied by splenomegaly and hypersplenism. She underwent laparoscopic splenectomy and clinical symptoms and hypersplenism resolved. Our study shows that laparoscopic splenectomy can be considered as a procedure for treating patients with splenomegaly and hypersplenism due to IPH.

Necrotizing soft tissue infection: analysis of the factors related to mortality in 30 cases of a single institution for 5 years

PURPOSE: Necrotizing soft tissue infection is the infection of the soft tissue with necrotic changes. It is rare, but results in high mortality. We analyzed the characteristics of patients, prognosis, and mortality factors after reviewing 30 cases of a single hospital for 5 years. METHODS: From January 2009 to December 2013, 30 patients diagnosed with necrotizing fasciitis or Fournier's gangrene in Pusan National University Hospital were enrolled for this study. The following parameters were analyzed retrospectively: demographics, infection site, initial laboratory finding, initial antibiotics, isolated microorganisms, number of surgeries, time to first operation, length of intensive care unit, and total hospital stays. RESULTS: The overall mortality rate was 23.3%. Mean body mass index (BMI) of the survival group (24.7 ± 5.0 kg/m2) was significantly higher than the nonsurvival group (22.0 ± 1.4 kg/m2, P = 0.029). When BMI was less than 23 kg/m2, the mortality rate was significantly higher (P = 0.025). Two patients (6.7%) with chronic kidney disease requiring hemodialysis died (P = 0.048). Initial WBC count (>13×103/µL), CRP (>26.5 mg/dL), and platelet (PLT) count (27.6 mg/dL), serum creatinine (>1.2 mg/dL) that reflected kidney function were significant mortality factors. CONCLUSION: Patients with low BMI or abnormal values of WBC count, CRP, and PLT count reflecting the degree of infection or abnormal renal function will need more intensive care.

Necrotizing soft tissue infection: analysis of the factors related to mortality in 30 cases of a single institution for 5 years

PURPOSE: Necrotizing soft tissue infection is the infection of the soft tissue with necrotic changes. It is rare, but results in high mortality. We analyzed the characteristics of patients, prognosis, and mortality factors after reviewing 30 cases of a single hospital for 5 years. METHODS: From January 2009 to December 2013, 30 patients diagnosed with necrotizing fasciitis or Fournier's gangrene in Pusan National University Hospital were enrolled for this study. The following parameters were analyzed retrospectively: demographics, infection site, initial laboratory finding, initial antibiotics, isolated microorganisms, number of surgeries, time to first operation, length of intensive care unit, and total hospital stays. RESULTS: The overall mortality rate was 23.3%. Mean body mass index (BMI) of the survival group (24.7 ± 5.0 kg/m2) was significantly higher than the nonsurvival group (22.0 ± 1.4 kg/m2, P = 0.029). When BMI was less than 23 kg/m2, the mortality rate was significantly higher (P = 0.025). Two patients (6.7%) with chronic kidney disease requiring hemodialysis died (P = 0.048). Initial WBC count (>13×103/µL), CRP (>26.5 mg/dL), and platelet (PLT) count (27.6 mg/dL), serum creatinine (>1.2 mg/dL) that reflected kidney function were significant mortality factors. CONCLUSION: Patients with low BMI or abnormal values of WBC count, CRP, and PLT count reflecting the degree of infection or abnormal renal function will need more intensive care.

Does Laparoscopic Splenectomy have the Advantage on Postoperative Pain?

PURPOSE: The aim of this study is to elucidate the fundamental characteristics of the laparoscopic splenectomy and to compare the clinical outcomes and postoperative pain between the laparoscopic splenectomy and the conventional open splenectomy. METHODS: From January 2005 to January 2013, 28 patients underwent a splenectomy at Pusan National University Hospital, South Korea (PNUH). This study was a comparison of the demographic features and clinical results between the laparoscopic splenectomy (n=15) and open splenectomy (n=13). RESULTS: For the two groups of patients, the following were similar: estimated blood loss, transfusion, operative time, duration of patient-controlled analgesia, and the additional administration of painkillers. In the laparoscopic splenectomy group, the postoperative hospital stay (7.9+/-1.6 days versus 5.9+/-1.4 days, p=0.002) and the diet start time (2.7+/-0.3 days versus 1.8+/-0.8 days, p=0.003) were significantly shorter. No significant difference in postoperative pain was observed between the two groups. CONCLUSION: In this study, there was no benefit for postoperative pain in the LS group. However, the laparoscopic splenectomy has several benefits, including a shorter postoperative hospital stay and an earlier diet start time; in addition, it is feasible and safe.

Heterotopic pancreas of the gallbladder associated with segmental adenomyomatosis of the gallbladder / 대한외과학회지

Heterotopic pancreas in the gallbladder is extremely rare and usually incidentally discovered at the pathologic examination followed by cholecystectomy for symptomatic gallbladder disease. Up to the presents, only about 30 cases have been reported. We report the case of a 36-year-old female who presented with symptoms of cholecystitis. The histological analysis followed by cholecystectomy revealed heterotopic pancreas of the cystic duct.

Long-term follow-up may be needed for pancreaticobiliary reflux in healthy adults / 대한외과학회지

PURPOSE: The reflux of pancreatic enzymes into the biliary tract is associated with chronic inflammation and increases cellular proliferation of the biliary epithelium, leading to biliary carcinoma. The aim of this study is to detect the incidence of occult pancreaticobiliary reflux (OPBR) in patients who underwent elective cholecystectomy. METHODS: Forty-seven patients with symptomatic gallstones who underwent cholecystectomy were recruited for this study. The gallbladder bile samples were obtained from the specimen of gallbladder and the amylase level was measured. The immunohistochemistry of p53, SMAD4 and Ki-67 were performed for the detection of metaplasia and dysplasia. RESULTS: Biliary amylase was higher than the serum amylase in 10 patients (group A, 15,402.66 +/- 33,592.43 IU/L; group B, 13.06 +/- 18.12 IU/L). The mean age was 67.2 years in group A and 51.2 in group B (P < 0.01). The ratio of male to female was 1:2.3 and 1:1.8 in group A and B, respectively (P = 0.297). Eight patients in group A and thirteen patients in group B had inflammation (P = 0.014). The positive results of the Ki-67 test were exhibited in five cases in each group (P = 0.024). CONCLUSION: Results from the study indicate that the age was older, degree of inflammation and positive rate of Ki-67 were higher when OPBR was suspected. In conclusion, the patients with OPBR would need long-term follow-up, because the OPBR can cause dysplasia and the reflux of pancreatic juice may be considered as a risk factor for extrahepatic bile duct carcinoma.

Primary leiomyosarcoma of gallbladder / 대한외과학회지

Malignant mesenchymalneoplasms of the gallbladder are extremely rare with only 105 cases of primary gallbladder sarcoma having been described. It has a very aggressive behavior and is usually diagnosed at advanced stages. Therefore, curative surgical management may not be possible. We performed a radical cholecystectomy (S4b + S5 segmentectomy), omentectomy and small bowel resection in a 54-year-old patient with locally invasive leiomyosarcoma of the gallbladder. Further studies are needed to confirm the benefit of aggressive treatment for patients with leiomyosarcoma of the gallbladder.

Complication analysis of distal pancreatectomy based on early personal experience

BACKGROUNDS/AIMS: The objective of this study was to evaluate the relationship between initial personal experiences with distal pancreatectomy and perioperative risk factors, outcomes, and management of pancreatic fistulas. METHODS: Between May, 2007 and May, 2010, a total of 28 patients who had undergone elective distal pancreatectomy were evaluated for this study. Perioperative factors and the occurrence of pancreatic fistula were analyzed on the basis of International Study Group of Pancreatic Fistula (ISGPF) criteria. RESULTS: There were sixteen cases of benign neoplasms and twelve cases of malignant tumors. The remnant pancreas was manually sutured with ligation of the pancreatic duct (n=14), auto-suture stapling along with manual sutures (n=12), or stapling alone (n=2). According to the ISGPF classification, morbidity and mortality associated with pancreatic fistulas was 42.9% (n=12) and 0%, respectively. These pancreatic fistulae were classified as grade A in 8 cases (28.6%), grade B in 3 cases (10.7%), and grade C in one case (3.6%). All patients with pancreatic fistula were treated conservatively. CONCLUSIONS: Perioperative factors do not affect the risk of pancreatic fistula. Adequate drainage is the most effective method for management of a pancreatic fistula after distal pancreatectomy.

Clinical Analysis of Endovenous Laser Treatment Combined with High Ligation for Treatment of Varicose Vein

PURPOSE: Endovenous laser treatment (EVLT) for varicose vein has been shown to be an effective method of treatment. But, after EVLT, recurrence due to recanalization of the great saphenous vein has been identified as a complication. This study was performed to evaluate the effectiveness of EVLT combined with high ligation and to assess the recurrence rate. METHODS: Between April 2004 and April 2009, medical records of 163 patients treated with EVLT combined with high ligation and stab phlebectomy were reviewed retrospectively. Duplex ultrasonography was performed before surgery. All patients were followed up with clinical evaluation at 1 week and 1, 3, and 6 months after operation. The mean follow up period was 5.9 months. RESULTS: In total, 178 limbs of 163 patients were reviewed. In our study, almost all (98.8%) patients had symptomatic and cosmetic improvement. We observed complications such as ecchymosis (22.1%), edema (12.9%), pain (5.5%), and in one case, hematoma. Ecchymosis, edema, and pain were controlled by conservative treatment. The patient with hematoma was hospitalized and improved with conservative therapy. There were no cases of recanalization during the follow up period. CONCLUSION: Compared to previous studies, EVLT combined with high ligation showed satisfactory results, with no recurrence. However, the longer operation time and higher cost were issues and further studies are necessary for objective comparison.

Clinical Analysis of Jejunal Pouch Reconstruction after Total Gastrectomy for Gastric Cancer

PURPOSE: The use of a total gastrectomy for gastric cancer has increased with the increasing incidence of gastric cancer involving the proximal stomach. Various types of reconstruction have been introduced to reduce the associated complications, such as reflux esophagitis and malnutrition, following a total gastrectomy. METHODS: Between January 2002 and September 2003, the incidence of reflux esophagitis and the nutritional status, according to three types of reconstructive, were analyzed in 67 patients who underwent a total gastrectomy for gastric cancer involving the proximal stomach. The three types of reconstruction were a Lygidakis pouch (LY-26 cases), a Hunt-Laurence pouch (HR-25 cases) and an Aboral pouch (AB-16 cases). RESULTS: Twenty three (88%), 21 (84%) and 10 (62%) patients complained of reflux esophagitis symptoms following the Lygidakis pouch, Hunt-Laurence pouch and Aboral pouch procedures, respectively. Less reflux esophagitis complications were observed following the Aboral pouch than with the other two procedures (P=0.03). No significant differences were found in the levels of serum hemoglobin, cholesterol, total protein and albumin for nutritional status between the three types. CONCLUSIONS: The Aboral pouch procedure was superior to the other two reconstructive procedures with respect to reflux esophagitis.