Surgical Outcomes and Survival Prognostic Factors for Palliative Gastrectomies in Stage IV Resectable Gastric Cancer Outlet Obstruction Patients

Purpose@#Currently, there is no clear evidence to support any specific treatment as a principal therapy for stage IV gastric cancer outlet obstruction (GCOO) patients. This study evaluated the outcomes of palliative gastrectomies and survival prognostic factors in patients with stage IV resectable GCOO. @*Materials and Methods@#We retrospectively reviewed the medical records of 48 stage IV GCOO patients who underwent palliative gastrectomies between June 2010 and December 2019.Palliative gastrectomies were performed only in patients with resectable disease. Early surgical outcomes and prognostic factors were analyzed using univariate and multivariate analyses. @*Results@#There were no specific risk factors for postoperative complications, except for being underweight. Severe postoperative complications developed in five patients, and most of the patients underwent interventional procedures and received broad-spectrum antibiotics for intra-abdominal abscesses. The multivariate survival analysis showed that palliative chemotherapy is a positive prognostic factor, while the specific type of hematogenous and lymphatic metastasis is a negative prognostic factor. @*Conclusions@#We recommend that the treatment method for stage IV GCOO should be selected according to each patient's physical condition and tumor characteristics. In addition, we suggest that palliative gastrectomies can be performed in stage IV resectable GCOO patients without unfavorable prognostic factors (types of hematogenous and lymphatic metastases).

Surgical Outcomes and Survival Prognostic Factors for Palliative Gastrectomies in Stage IV Resectable Gastric Cancer Outlet Obstruction Patients

Purpose@#Currently, there is no clear evidence to support any specific treatment as a principal therapy for stage IV gastric cancer outlet obstruction (GCOO) patients. This study evaluated the outcomes of palliative gastrectomies and survival prognostic factors in patients with stage IV resectable GCOO. @*Materials and Methods@#We retrospectively reviewed the medical records of 48 stage IV GCOO patients who underwent palliative gastrectomies between June 2010 and December 2019.Palliative gastrectomies were performed only in patients with resectable disease. Early surgical outcomes and prognostic factors were analyzed using univariate and multivariate analyses. @*Results@#There were no specific risk factors for postoperative complications, except for being underweight. Severe postoperative complications developed in five patients, and most of the patients underwent interventional procedures and received broad-spectrum antibiotics for intra-abdominal abscesses. The multivariate survival analysis showed that palliative chemotherapy is a positive prognostic factor, while the specific type of hematogenous and lymphatic metastasis is a negative prognostic factor. @*Conclusions@#We recommend that the treatment method for stage IV GCOO should be selected according to each patient's physical condition and tumor characteristics. In addition, we suggest that palliative gastrectomies can be performed in stage IV resectable GCOO patients without unfavorable prognostic factors (types of hematogenous and lymphatic metastases).

Laparoscopic High Ligation of Hernia Sac of Inguinal Hernia in Pediatric Patients

PURPOSE: Although laparoscopic surgery in children has expanded in recent years. laparoscopic hernia repair in children is still debatable. We aimed to summarize and describe our results of laparoscopic inguinal hernia repair and techniques among children. METHODS: Between March 2011 and August 2013, 117 children (81 male, 36 female) underwent laparoscopic inguinal hernia repair at the department of surgery. The clinical outcomes were collected retrospectively. RESULTS: The mean follow-up period was 26.2 months. Thirteen patients were ex-premature infants and a contralateral patent processus vaginalis (PPV) was present in 44 of the 110 unilateral inguinal hernia patients. There were two postoperative complications (transient hydrocele, umbilical port site infection). The mean operative time was 47 minutes. Recurrence, metachronous hernia, and testicular atrophy were not observed during the follow-up period. CONCLUSION: Our preliminary experiences suggest that the laparoscopic purse-string suture of internal inguinal opening of the hernia sac could be an effective and reliable alternative for management of pediatric inguinal hernia.

What Are the Risk Factors for Complication in Transumbilical Single-Port Appendectomy?

PURPOSE: Along with the development of minimally invasive surgery, laparoscopic surgery has recently been adopted worldwide. In cases of laparoscopic appendectomy, single port appendectomy is increasingly being adopted due to its cosmetic advantages and reduced pain. This study was conducted to evaluate the risk factors associated with post-operative complications in single port appendectomy. METHODS: Forty-nine consecutive patients who underwent transumbilical single port appendectomy (TUSPLA) were enrolled in this study. We reviewed the initial WBC count, hsCRP, position of the appendix, and intra operative findings and then analyzed the data by univariate and multivariate analysis. RESULTS: Complications were observed in five of the 49 patients (10.2%). Specifically, wound complications were observed in three patients (6.1%), and periappendiceal fluid collection occurred in two patients (4.1%). Univariate analysis revealed a retrocecal type appendix (p=0.046) and overweight (BMI> or =23, p=0.034) as risk factors significantly correlated with the occurrence of complications. Conversely, retrocecal type appendix (p=0.121) and overweight (BMI> or =23, p=0.329) were not significantly correlated with complications upon multivariate analysis. CONCLUSION: For patients with a high risk of postoperative complications, including those with retrocecal appendix undergoing TUSPLA and obese patients, sufficient informed consent is necessary, and intensive monitoring for the incidence of complications must be considered postoperatively. However, further studies enrolling larger groups of patients should be conducted to confirm these findings.

What are Risk Factors Associated with Conversion to Open Appendectomy in Laparoscopic Appendectomy? / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic appendectomy has recently been performed more frequently than open appendectomy because of its advantages. Yet laparoscopic appendectomy has the risk of converting to open appendectomy. We evaluated the preoperative evaluation factors that can influence the rate of conversion to open appendectomy. METHODS: For the 255 patients admitted to our hospital, we reviewed their medical history, their clinical and laboratory examination etc. and the final diagnosis was made by CT scan. The preoperative characteristics of the patients who underwent laparoscopic appendectomy and the patients who were converted to open appendectomy were compared using univariate and multivariate analysis. RESULTS: Out of 255 patients who underwent laparoscopic appendectomy, 15 patients (5.8%) were converted to open appendectomy. The main reasons were adhesion and periappendiceal abscess formation. Periappendiceal fat infiltration (p=0.030) seen in the CT scan and perforation (p=0.019) were significant risk factors associated with converting to open appendectomy. CONCLUSION: Periappendiceal fat infiltration and perforation seen on preoperative CT scanning are important when considering performing laparoscopic appendectomy. Identifying the potential preoperative factors for conversion may assist surgeons when making decisions concerning the management of patients with appendicitis and for the judicious use of LA.

Bilaterality of Papillary Thyroid Carcinoma: Analysis of Clinicopathologic Factors and the Value of Preoperative Ultrasonography / 대한내분비외과학회지

PURPOSE: Papillary thyroid carcinoma (PTC) is the most common endocrine malignancy. The extent of the initial surgical treatment for PTC is still controversial and the bilaterality of PTC is an important factor for determining the extent of surgical resection. The aim of this study was to analyze clinicopathologic factors and the value of preoperative ultrasonography (PU) for bilateral tumor. METHODS: We retrospectively reviewed clinicopathologic factors and PU findings of 91 patients who underwent total thyroidectomy for PTC at the Dongguk University Ilsan Hospital from January 2006 to April 2009. RESULTS: Of the 91 patients, 28 (30.7%) had bilateral PTC in postoperative pathology. Of these 28 patients, only 18 patients (64.3%) were checked for bilateral PTC by PU findings and fine needle aspiration cytology. Sensitivity and specificity for bilaterality of PTC were 64.3% and 85.7%, respectively. The presence of benign nodules or malignant nodules in the same lobe in PU (P=0.008) and post-operative pathology (P=0.014) were statistically correlated with bilaterality. CONCLUSION: For the surgical care of PTC, bilaterality must always be considered, even though the tumor is diagnosed unilateral small PTC. PU in PTC patients has limited diagnostic value for bilateral PTC.

Analysis of the CT and Clinical Findings of Perforated Blunt Small Bowel Injury according to the Elapsed Time since Accident

PURPOSE: The high mortality and morbidity rates associated with traumatic rupture of the small bowel have been attributed to the clinical difficulty of establishing an early diagnosis. CT scan is the most widely used tool for the diagnosis of blunt abdominal trauma, but its accuracy in diagnosing small bowel perforation is still controversial. This study was conducted to determine the overall and time-dependent diagnostic value of abdominal CT and the clinical findings of small bowel perforation. METHODS: The clinical data and CT images of 21 patients with small bowel perforation after blunt trauma were retrospectively analyzed. The patients were divided into the early and late elapsed time groups based on the elapsed time of 8 hours from the initial trauma to the time of evaluation. RESULTS: Any changes of the vital signs, including hypotension, tachycardia or fever, were observed in only half of the patients. Signs of peritonitis were evident in 7/11 of the early lapse group and in 10/10 of the late lapse group. The most common CT finding of small bowel perforation was free peritoneal air (17 of 21 patients), followed by segmental bowel wall thickening (15/21), high density ascites (14/21), an intermesentric fluid collection (13/21) and mesentic fat obliteration (11/21). Extraluminal air and segmental bowel wall thickening were detected more frequently in the late lapse group (P=0.03 and 0.01, respectively). In the one patient, bowel perforation was not evident at the initial evaluation according to the clinical findings and CT, but the follow-up CT exam showed specific findings for bowel perforation. CONCLUSION: CT scanning is a sensitive and effective modality for the evaluation of small bowel perforation, but this is less sensitive during the earlier post traumatic period. Therefore, careful clinical and radiological follow up is necessary for suspected cases, and even when an initial evaluation shows negative findings for bowel injury.

Treatment Strategy of Gastric Cancer in Patients Older than 80 Years of Age

PURPOSE: The geriatric population will continue to increase in the coming decades, and the number of gastric cancer patients who are over 80 years of age is increasing. The aim of this study was to suggest optimal treatment in these patients on the basis of the cause of death. METHODS: Forty-four patients who underwent curative resection in the course of gastric cancer treatment and were over 80 years of age at Asan Medical Center between January 1990 and February 2002 were included in this study. The cause of death of those patients was retrospectively analyzed by checking medical record or calling to relatives. RESULTS: Average age of 41 patients was 81.41 years old and follow up duration was 49 months. Until February 2004, overall mortality was 23 patients (56%). The mortality from gastric cancer-related and from other disease was 12 patients (52%) & 11 patients (48%), respectively. The most common cause of death from other disease was senility. Median survival time of 11 patients from cancer none-related death was 57 months. Median survival time of 32 patients corresponding stage l & ll was 52.5 months. CONCLUSION: We, therefore, conclude that a standard gastrectomy is basically appropriate for patients older than 80 years of age, as long as they demonstrate a good risk.

Effect of Imatinib Mesylate in Recurrent Gastric GIST

PURPOSE: Gastrointestinal stromal tumor (GIST) is the designation for c-kit signal driven mesenchymal tumor. A great majority of these tumors occur in the stomach and small intestine, and rarely in the colon, rectum and esophagus. Metastatic or recurrent GIST must be resected surgically because it is resistant to conventional cytotoxic chemotherapy. Following recent evidence for the dramatic effect of Imatinib mesylate (Glivec), Glivec has become available in our country since June 2001 without insurance coverage. Although some doubt remained, we applied Glivec to recurrent GIST patients with great expectation. METHODS: A retrospective analysis was made for 16 GIST patients who were resected during 2001. Follow up duration was 19 to 29 months. All pathologic slides were reexamined immunohistochemically by an experienced pathologist. Clinicopathologic comparison between the recurred and non-recurred groups was summarized into the tables. The therapeutic and side effects of Glivec were surveyed. CT scan files were reviewed to decided tumor regression or progression. RESULTS: Fifteen GISTs were resected in 2001. Seven cases recurred during 19 to 29 months of follow up. The recurred group was characterized by huge tumor size (mean 14 cm), serosal invasion and more than 10 mitosis in 50 HPF. A daily dose of 400 mg of Glivec was prescribed to every recurred GIST patients and CT scan was followed serially. The therapeutic effect of Glivec effect was drastic but variable; complete tumor remission (n=3), rebounded tumor growth at the same location after remission (n=1), and recurrence at another location after complete remission (n=2). CONCLUSION: Glivec drastically reduced the size of recurrent gastric GIST initially. However, it is not clear how long Glivec should be taken at a great expense in fear of rebounded growth after abstaining. It appears that reoperation is necessary without delay when tumor remission slows down.

Expression of E-cadherin and CD44H in Borrmann Type IV Gastric Cancer

PURPOSE: E-cadherin and CD44H have been shown to play a role in the progression and the metastasis of tumors. This study evaluated the clinical correlations between expression of E-cadherin and CD44H and various clinicopathologic factors and the value of expressions of E-cadherin and CD44H as prognostic factors in Borrmann type IV gastric cancer. MATERIALS AND METHODS: In 122 patients with Borrmann type IV gastric cancer, we performed the immunohistochemical stainings for E-cadherin and CD44H. We analyzed the correlation between the expressions of E-cadherin and CD44H and lymphatic invasion, venous invasion, perineural invasion, histologic type, lymph node metastasis, depth of invasion, stage, and peritoneal dissemination, and survival. RESULTS: There were no correlations between reduced expression of E-cadherin and CD44H and lymphatic invasion, venous invasion, perineural invasion, histologic type, lymph node metastasis, depth of invasion, and stage. However, there was a significant correlation between lymph node metastasis and the lymphatic invasion (P=0.022). There was also a significant correlation between the peritoneal dissemination and CD44H expression (P=0.005). The 5-year survival rate was correlated with CD44H expression (P=0.026), peritoneal dissemination (P<0.01), depth of invasion (P<0.01), lymph node metastasis (P<0.01), stage of tumor (P<0.01), and lymphatic invasion (P<0.01). There was no correlation between expression of E-cadherin and survival rate. CONCLUSION: The expression of CD44H and peritoneal dissemination was correlated. The expression of CD44H was an independent prognostic factor in Borrmann type IV gastric cancer. Further prospective studies with a large number of cases are required.

Clinical Analysis of 61 Krukenberg Tumors

PURPOSE: A Krukenberg tumor is an ovarian tumor of a signet-ring cell type. This tumor arises more commonly in young women, and the prognosis is poor. The primary focus of this tumor is often found at gastrointestinal malignancy, especially gastric cancer. We tried to identify the clinical characteristics of this tumor, and in that regard, this report might be helpful. MATERIALS AND METHODS: We reviewed the 61 patients with Krukenberg tumors, who had been diagnosed at our hospital from 1994 to 2002, and retrospectively analyzed the clinical features. RESULTS: The age distribution ranged from 15 to 59 years, and the mean age was 41 years. The most common symptom was a lower abdominal mass (46%). Fourty-two cases (77%) showed bilateral ovarian involvement, and the size of this tumor was variable, but in 24 cases (44%) the size was 5~0 cm for the largest diameter. Among 54 cases, 40 cases had ascites, and the volume of ascites was variable. The median survival of the 61 patients was 10 months, and Krukenberg tumor developed 19.7 months after the primary operation. The median survival durations of recurrence patterns were 20 months for the Krukenberg tumor alone, and 7 months for the Krukenberg tumor with peritoneal seeding. CONCLUSION: In young women treated with a gastrectomy, especially one for an advanced tumor, closed observation with abdominal ultrasonography or computed tomography to detect a Krukenberg tumor is recommended. The patient with a Krukenberg tumor alone has a better prognosis than one with a Krukenberg tumor combined peritoneal seeding. We will have to consider more progressive treatment for the patient with a Krukenberg tumor alone.

Prognostic Significance of Group 2 Lymph Node Metastasis in pT3pN1 Gastric Cancer Patients

PURPOSE: The most important prognostic factors in gastric cancer is the depth of invasion of the primary tumor and lymph node metastasis. The nodal staging of the 5th edition of the Union Internationale Contrala Cancrums (UICC) TNM classification in 1997 was changed based on the number of metastatic lymph node. We attempted to evaluate the prognostic significance of N2 group metastasis in pT3pN1 gastric cancer patients by comparing two different nodal staging systems. MATERIALS AND METHODS: A retrospective analysis was made for 352 gastric cancer patients who underwent curative resection, including D2 dissection, from 1991 to 1997 at Asan Medical Center. A clinicopathologic comparison between two groups by using a nodal staging systems was summarized into a table. Cumulative survival rates were calculated by using the Kaplan-Meier method. The difference between the two groups was evaluated by using the log rank test with SPSS 11.5 for Windows RESULTS: There were no statistical differences in clinicopathologic factors. However, there was a significant difference in survival rate between the two groups (P=0.0009). This suggests that N2 group metastasis in pT3pN1 gastric cancer patients has a clinical significance for predicting prognosis. CONCLUSION: Our results suggest a possibility of prognostic significance of N2 group metastasis. Therefore, anatomical location of the lymph node should be described.

Characteristics of Recurred Early Gastric Cancer after Gastric Resection

PURPOSE: The proportion of early gastric cancer has recently increased. Although early gastric cancer has a very good prognosis following a curative resection, and recurrences rarely occur, if there is a distant recurrence the prognosis is grave. To predict to the potential of a recurrence after a gastrectomy, early gastric cancer patients were retrospectively analyzed. METHODS: 1, 131 early gastric cancers were curatively resected at the Asan Medical Center between Jan, 1990 and Sep, 1997. Recurrences were observed in 46 patients during the follow up period. The clinical characteristics of the recurred and cured groups were compared. Any statistical significance was calculated using Chi-Squared and Log rank tests, using SPSS version 10.0. RESULTS: The recurrence and 5-year survival rates of the recurred patients were and 9%, respectively. Hematogenous recurrences were the most common mode of recurrence, followed by lymph node recurrences. The mean tumor size, numbers of lesions, location of tumor, status of lymph node dissection and operation type, did not affect tumor recurrences. The grossly elevated type of tumor, submucosal layer invasion and differentiated cancer, most frequently recurred. The rate of recurrence linearly increased with increase of the nodal stage. All patients with a lymph node recurrence had lymph node metastasis at the initial surgery. CONCLUSION: In early gastric cancer patients, the elevated type, or a differentiated adenocarcinoma, may recur at a distant organ. A more careful follow-up will be required if the surgical removal of a metastatic tumor is intended, as chemotherapy is ineffective. The sentinel lymph node should be examined by a frozen biopsy at the beginning of the initial surgery, in order to determine the range of a lymph node dissection to avoid a nodal recurrence.

Neuroendocrine Carcinoma of the Stomach: A Clinicopathologic Study of 18 Cases

PURPOSE: Neuroendocrine carcinomas of the stomach account for only about 0.3% of all gastric tumors. The prognosis of this disease is very poor compared with the common type of gastric adenocarcinoma. The purpose of this retrospective study was to review the clinicopathologic features of 18 cases of this unusual gastric tumor and to establish a treatment strategy for this tumor. MATENRIALS AND METHODS: Excluding 2 cases of non-curative resection and 1 case of operative mortality, 18 cases of typical neuroendocrine carcinoma who had curative resection from January 1991 to December 2000 at Asan Medical Center were analyzed; 6841 gastric cancer patient were treated surgically during the same period. RESULTS: The mean age at the time of diagnosis was 58.6 years (range: 35~75 yr). Sixteen patients were male, and two were female. Eleven tumors (61.1%) developed in the lower part of the stomach, three (16.7%) in the middle part, and three (16.7%) in the upper part. One tumor involved the entire stomach. Eight cases (44.4%) were Borrmann type 2, and six case (33.3%) were Borrmann type 3. The mean tumor size was 6.94 cm (range: 0.6~15 cm). Nine cases (50%) showed recurrence of the disease, and eight of them died within 20 months. Of the nine recurred cases, 7 cases (77.8%) showed liver metastasis. The mean disease-free interval was 6.8 months (range: 2.5~11 months) after surgical resection, and the mean survival was 17.9 months (range: 8~40 months) for recurrence cases. One patient with liver metastasis was treated with a liver-wedge resection just after diagnosis and was still alive for 37.5 months postoperatively. There were 9 deaths after the median follow-up period of 40 months (range: 8~72 months). CONCLUSION: Gastric neuroendocrine carcinomas frequently recur at the liver, even in early stage cancer, and have a poor prognosis. We experienced a case of successful control of hepatic metastasis by surgical resection and a case of a small cell carcinoma which was successfully controlled with systemic chemotherapy.

Postoperative Mechanical Ileus Requiring Surgery in Patients with Colorectal Cancer

BACKGROUND: Postoperative ileus is not an infrequent problem in clinical practice and is the major cause of morbidity with occasional mortality. The purposes of this study were to analyze clinical features and to assess associated risk factors in postoperative mechanical ileus. METHODS: We reviewed the cases of 43 patients with mechanical ileus who had undergone exploration from among the 1631 colorectal cancer patients treated between June 1989 and December 1997. RESULTS: The causes of postoperative ileus were postoperative adhesion, recurrence of cancer, and hernia, and these causes were closely associated with postoperative periods (period I, 12 months). Adhesion was the most common cause of obstruction in the early postoperative period (period I, 86%), while cancer recurrence increased with time (period I: 7%, period II: 36%, period III: 53%). The clinical features of simple and strangulated obstructions were not significantly different. We could find no significant correlation between clinicopathological findings of the tumor and postoperative ileus requiring surgery. Among 874 rectal cancer patients, 122 patients (15.1%) received adjuvant radiation therapy (RT) postoperatively. The cases receiving RT presented a significant increase in the incidence of postoperative ileus and surgical treatment (28% vs 7.5%, 15% vs 1%, respectively, p<0.001). CONCLUSIONS: major cause of postoperative mechanical ileus requiring surgery in colorectal cancer patients was adhesion until one year postoperatively and cancer recurrence thenafter. Postoperative RT seems to be a risk factor of postoperative mechanical ileus.

Adult-to-Adult Living Donor Liver Transplantation

BACKGROUNDS: Living-donor liver transplantation (LDLT) has been established as an efficacious option to resolve the shortage of cadaveric donor organs for pediatric recipients. This surgical innovation has significantly reduced the pretransplantation mortality for children, but the crisis of increasing scarcity of donor organs in our hospital has led us to extend LDLT to adult recipients. However, the extension of LDLT from pediatric recipients to adult recipients has been made only with limited success largely because of the inability of a relatively small-size left-lobe graft to meet the metabolic demands of an adult recipient. It has been postulated that a left-lobe graft smaller than 40% of the recipient's standard liver volume will not result in a successful adult-to-adult LDLT in chronic parenchymal liver disease. METHODS: From February 1997 to October 1997, 10 LDLTs, using 9 extended left-lobe grafts and 1 right-lobe graft, were performed on patients with end-stage parenchymal liver diseases (9 cases of B-hepatitis-induced cirrhosis with or without an associated hepatocellular carcinoma and 1 case of alcoholic cirrhosis) at the Department of Surgery, Asan Medical Center. The ratios of the graft to the standard liver volume of the recipients were in the range of 30% to 55%. RESULTS: All grafts showed immediate function, but delayed normalization of the serum total bilirubin was demonstrated in all recipients receiving left-lobe grafts. There were no mortalities and serious complications in donors. Two recipients died of sepsis 21 days and 40 days after transplantation, and 8 recipients (80%) are alive with good liver function at a median follow-up of 5.1 months (range 2~10 months). CONCLUSIONS: The aim of this article is to report our experience with adult-to-adult LDLT shows that a graft size greater than 30% of the recipient's standard liver volume is able to meet the metabolic demands of adult recipients with chronic parenchymal liver disease and that LDLT might open a new donor pool for adult recipients when the supply of cadaveric organs is severely restricted.

Rhabditis elongata Schneider, 1866 from students in Korea

As the result of a fecal examination performed in October 1978 on 320 middle and high school students of Hapcheon, Korea, we found 2 cases of Rhabditis nematodes in 16-year old high school girls. Rhabditis nematodes isolated from their feces were cultured at 30 C by a filter paper culture method. After careful observation of male and female adults, we confirmed them as Rhabditis elongata Schneider, 1866 on the morphological basis of the male genitalia, and the papillae and measurements of various parts of the worm bodies.