Who Can Perform Adjuvant Chemotherapy Treatment for Gastric Cancer? A Multicenter Retrospective Overview of the Current Status in Korea

PURPOSE: To investigate the current status of adjuvant chemotherapy (AC) regimens in Korea and the difference in efficacy of AC administered by surgical and medical oncologists in patients with stage II or III gastric cancers. MATERIALS AND METHODS: We performed a retrospective observational study among 1,049 patients who underwent curative resection and received AC for stage II and III gastric cancers between February 2012 and December 2013 at 29 tertiary referral university hospitals in Korea. To minimize the influence of potential confounders on selection bias, propensity score matching (PSM) was used based on binary logistic regression analysis. The 3-year disease-free survival (DFS) rates were compared between patients who received AC administered by medical oncologists or surgical oncologists. RESULTS: Between February 2012 and December 2013 in Korea, the most commonly prescribed AC by medical oncologists was tegafur/gimeracil/oteracil (S-1, 47.72%), followed by capecitabine with oxaliplatin (XELOX, 16.33%). After performing PSM, surgical oncologists (82.74%) completed AC as planned more often than medical oncologists (75.9%), with statistical significance (P=0.036). No difference in the 3-year DFS rates of stage II (P=0.567) or stage III (P=0.545) gastric cancer was found between the medical and surgical oncologist groups. CONCLUSIONS: S-1 monotherapy and XELOX are a main stay of AC, regardless of whether the prescribing physician is a medical or surgical oncologist. The better compliance with AC by surgical oncologists is a valid reason to advocate that surgical oncologists perform the treatment of AC for stage II or III gastric cancers.

The Learning Curve for Laparoscopic Totally Extraperitoneal Herniorrhaphy by Logarithmic Function

PURPOSE: Totally extraperitoneal (TEP) hernia repair has gained in popularity in the past two decades. Despite the advantages TEP hernia repair, the approach is hindered by the relatively long learning curve of the surgery. We tried to estimate the necessary number of repetitions of TEP hernia repair in the learning curve using logarithmic and exponential function models. METHODS: We performed a retrospective review of all patients who underwent TEP hernia repair by a single surgeon consecutively at a single center. We calculated how many operations were needed to achieve a reduction in the expected operating time to mean operating time using logarithmic and exponential function models. RESULTS: In the 91 patients, the logarithmic function model predicted that 37 cases were needed to overcome the learning curve for TEP hernia repair while the exponential model predicted that 39 cases were needed. CONCLUSION: According to this study, at least 37 to 39 cases are needed in the overcome learning curve of TEP hernia repair. Further studies are needed to optimize surgical education and maximize quality.

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.

Can serum interleukin-2 receptor alpha predict lymph node metastasis in early gastric cancer? / 대한외과학회지

PURPOSE: Although local resection like endoscopic mucosal resection for early gastric cancer is accepted as a treatment option, one of the most important drawbacks of such an approach is the inability to predictlymph node metastasis. The aim of this study was to evaluate the serum soluble receptor alpha for interleukin-2 (IL-2Ralpha) level as a predictor of lymph node metastasis in the patients with early gastric cancer. METHODS: Assessment of pre-operative serum IL-2Ralpha levels was performed on 86 patients with early gastric cancer treated by gastrectomies combined with D2 lymph node resections and 20 healthy controls at Samsung Medical Center. Data on patient age and gender, tumor size, depth of invasion, histologic differentiation, and endoscopic findings were reviewed post-operatively. The submucosal lesions were divided into three layers (sm1, sm2, and sm3) in accordance with the depth of invasion. RESULTS: Lymph node metastasis was observed in 16 patients (18.6%). Statistically, the serum IL-2Ralpha level was an important predictive factor of lymph node metastasis in undifferentiated gastric cancer, and the cut-off point for the predictive value of serum IL-2Ralpha level was 200 U/mL. CONCLUSION: The serum IL-2Ralpha level might be a good predictor of lymph node metastasis in undifferentiated early gastric cancer.

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.

Inflammatory Pseudotumor of the Inguinal Lymph Node: A Case Report

Inflammatory pseudotumor of a lymph node is a rare cause of benign inguinal lymphadenopathy, and this mimics the malignant causes of inguinal lymphadenopathy. The imaging features of inflammatory pseudotumor affecting the inguinal lymph nodes have not previously been described. We report here on a case in which the lesion was depicted on the contrast-enhanced CT scan as a well-defined mass with strong enhancement. Inflammatory pseudotumor of a lymph node may be included as one of the rare causes of inguinal lymphadenopathy.

Impact of Adjuvant Chemoradiation Therapy on the Postoperative 5-year Survival Rates for Stage-II Gastric Cancer

PURPOSE: This study was conducted to evaluate the effectiveness and the role of post-operative adjuvant chemoradiation therapy in a stage-II (UICC,1997) primary gastric cancer. MATERIALS AND METHODS: From September 1994 to December 2004, 954 stage-II gastric-cancer patients were seen, and all of them underwent a curative resection with extensive (D2) lymph-node dissection. The chemotherapy consisted of fluorouracil (400 mg/m2) plus leucovorin (20 mg/m2) for 5 days, followed by 4,500 cGy of radiotherapy for 5 weeks with fluorouracil and leucovorin on the first 4 days and the last 3 days of radiotherapy. Two five-day cycles of chemotherapy were given four weeks after the completion of radiotherapy. The Kaplan-Meier method was used to estimate the survival rates. To assess the importance of potential prognostic factors, we performed univariate and multivariate analyses using a log-rank test and Cox's proportional hazards regression model. A P value <0.05 was considered significant. RESULTS: Univariate analysis revealed that age, tumor size, gross type, surgical method, and postoperative adjuvant therapy had statistical significance. Among these factors, age, surgical method, tumor size, surgical method, and postoperative adjuvant therapy were found to be independent prognostic factors by using a multivariate analysis. The postoperative adjuvant chemotherapy group and the chemoradiation therapy group had survival benefit compared to the surgery-only group. However, the chemoradiation therapy group had no significant survival benefit compared to the chemotherapy group. CONCLUSION: The postoperative adjuvant therapy in stage-II gastric-cancer patients had significant benefit. Therefore, postoperative adjuvant chemoradiation therapy has an acceptable effect. A large-scale, randomized study is needed to evaluate the effectiveness and the role of postoperative radiation therapy.

Impact of Adjuvant Chemoradiation Therapy on the Postoperative 5-year Survival Rates for Stage-II Gastric Cancer

PURPOSE: This study was conducted to evaluate the effectiveness and the role of post-operative adjuvant chemoradiation therapy in a stage-II (UICC,1997) primary gastric cancer. MATERIALS AND METHODS: From September 1994 to December 2004, 954 stage-II gastric-cancer patients were seen, and all of them underwent a curative resection with extensive (D2) lymph-node dissection. The chemotherapy consisted of fluorouracil (400 mg/m2) plus leucovorin (20 mg/m2) for 5 days, followed by 4,500 cGy of radiotherapy for 5 weeks with fluorouracil and leucovorin on the first 4 days and the last 3 days of radiotherapy. Two five-day cycles of chemotherapy were given four weeks after the completion of radiotherapy. The Kaplan-Meier method was used to estimate the survival rates. To assess the importance of potential prognostic factors, we performed univariate and multivariate analyses using a log-rank test and Cox's proportional hazards regression model. A P value <0.05 was considered significant. RESULTS: Univariate analysis revealed that age, tumor size, gross type, surgical method, and postoperative adjuvant therapy had statistical significance. Among these factors, age, surgical method, tumor size, surgical method, and postoperative adjuvant therapy were found to be independent prognostic factors by using a multivariate analysis. The postoperative adjuvant chemotherapy group and the chemoradiation therapy group had survival benefit compared to the surgery-only group. However, the chemoradiation therapy group had no significant survival benefit compared to the chemotherapy group. CONCLUSION: The postoperative adjuvant therapy in stage-II gastric-cancer patients had significant benefit. Therefore, postoperative adjuvant chemoradiation therapy has an acceptable effect. A large-scale, randomized study is needed to evaluate the effectiveness and the role of postoperative radiation therapy.

Clinical Significance of the Ghrelin Concentrations in Plasma and Tumor Tissue from Patients with Gastric Cancer

PURPOSE: Ghrelin, produced primarily in the gastrointestinal tract, including the stomach, has been reported to reflect nutritional status and to control homeostasis by influencing food intake and adiposity. The purpose of this study is to evaluate nutritional status, as well as plasma and gastric tissue ghrelin levels, in patients with gastric cancer who underwent a gastrectomy. MATERIALS AND METHODS: Eighty patients were analyzed by the degree of weight loss (weight loss > or =5% or < 5%) and the extent of gastrectomy (subtotal or total gastrectomy). Blood samples were collected from all patients preoperatively and postoperatively especially at seven days. Gastric tissues, including tumor and normal tissues, were obtained from the resected stomach. Levels of plasma and tissue ghrelin were measured with a commercial ELISA kit. RESULTS: There were no significant differences in the clinical characteristics and ghrelin levels of plasma, gastric tumor tissue and normal tissue by the degree of weight loss. The ghrelin levels in plasma and tumor tissue showed no correlations with each other while the ghrelin level in tumor tissue was significantly lower than that in normal tissue. The degree of cellular differentiation also had an association with ghrelin production. A gastrectomy proved to decrease significantly plasma ghrelin levels, body mass index, and biochemical markers, regardless of the extent of gastric resection. CONCLUSION: These results show that gastric cancer affects the production of ghrelin in the gastric mucosa and that ghrelin is mainly produced in stomach even though it could be partially covered by endogenous ghrelin from other organs following a gastrectomy. However, we should further investigate which other factors have an impact on energy consumption, ghrelin secretion, and changes in ghrelin levels after a gastrectomy.

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.

Development of International Medical Teleconference System Using Advanced Research Network and Digital Video Transport System(DVTS) / 대한의료정보학회지

OBJECTIVE: The purpose of this study is to develop telesurgical conference system by establishing a gigabit broad-banded network between hospitals in Korea and Japan using Digital Video Transport System(DVTS) on internet protocol, and to audit performance of this system through questionnaire study. METHODS: The Korea Advanced Research Network(Korean side), the Fukuoka Gigabit Highway(Japanese side), and the Korea-Japan Cable Network(international line)were used for assuring a high speed network connectivity. DVTS streaming was propagated with 30 M bps bandwidth for two channels on IPv4 network. Network security was built with virtual private network solution to guarantee protecting patient's privacy. Technological performance and satisfaction of users were evaluated following the events. RESULTS: The teleconference sessions and live surgery transmission with DVTS on internet protocol using advanced research network were performed successfully. Bandwidth of 60 Mbps for two-line transmission was maintained throughout the conference. The quality of the transmitted pictures had no frame loss with the rate of 30 frames per second. The sound was also clear and the time delay was less than 0.3 sec. Effectiveness of telesurgical conference using advanced network was felt beneficial for 94% of the attendants in questionnaire study. CONCLUSION: Establishing an international telesurgical conference system with high quality digital video transmission over internet protocol using international gigabit network was performed successfully. With the improvement of network engineering, this system is expected to contribute penetration of medical skills and knowledge through network infrastructure.

Primary Small Cell Carcinoma of the Stomach

Small cell carcinomas most often arise in the lung, and metastatic involvement of the stomach is uncommonly reported. Primary small cell carcinomas of the stomach have similar biological features to those of pulmonary small cell carcinomas, an aggressive behavior, with a very poor prognosis. Herein, two cases of primary gastric small cell carcinoma, diagnosed after gastrectomy from their clinicopathological features, are reported. A 78-year-old female and a 68-year-old male with dyspepsia and weight loss, respectively, were admitted to our hospital. Their upper gastrointestinal endoscopy and abdomen-pelvis CT were checked. A preoperative histological examination of the endoscopic biopsy specimens revealed poorly differentiated adenocarcinomas. A radical subtotal gastrectomy was performed for both patients. The histological finding and immunohistochemical staining of the resected stomach indicated small cell carcinomas. After the operations, the patients were discharged without any postoperative complications. Postoperative adjuvant chemotherapy, with cisplatin and etoposide, was performed for the latter patient. The patients have been followed up for 10 and 8 months, respectively, without recurrence or metastasis.

Usefullness of CT Gastrography and Vurtual Gastroscopy using Computed Tomography in Detection of Gastric Cancer

PURPOSE: Advancement of computed tomography (CT) hardware and software has allowed thin section scanning and reconstruction of fascinating 2-dimentional (2D) and 3- dimentional (3D) images. Especially, the reconstruction of 3D images of gastrointestinal tract has been used in the detection and diagnosis of pre-malignant and malignant diseases. To compare the efficacy of CT gastrography with conventional upper gastrointenstinal series (UGIs) in gastric cancer patients. MATENRIALS AND METHODS: During Nov. 2002 and Mar. 2003, twenty-seven patients who had gastric cancer received both double contrast upper GI series and CT gastrography prior to radical surgery. Among these patients, nineteen had early gastric cancer (EGC) and 8 had advanced gastric cancer (AGC). Fifteen patients were male and 12 were female. The mean age was 54 yrs (range, 27~75 yrs). The patients were placed on NPO and Stomach was distended with gas in fasting state prior to CT scanning. Double contrast upper GI series were performed as routine manual. CT scan was conducted in all patients using 8 or 16-channel multidetector CT in this study. The collimation and reconstruction for CT scanning were set at 2.5 mm and 1.25 mm, respectively. CT scanning was performed in the supine position. For image processing, CT gastrography, in which raysum and surface rendering images were constructed, virtual and 2D image in coronal and sagittal images were performed. The detectability of gastric cancer was assessed between UGIs and CT gastrography. RESULTS: In AGCs, the detection rate of cancer using CT gastrography and virtual gastroscopy was higher than EGC cases. However, CT gastrography and virtual gastroscopy showed less favorable results than UGIs. Even though only a small number of cases had been studied, we might conclude that CT gastrography and virtual gastroscopy could replace UGIs in the detection of AGC cases. CONCLUSION: The detection rate used with CT gastrography and Virtual gastroscopy is not better than that of UGIs in early gastric cancer, however, in advanced gastric cancer cases, it is nearly equal to that of UGIs.