Safety and Tolerability of Weekly Genexol-PM, a Cremophor-Free Polymeric Micelle Formulation of Paclitaxel, with Carboplatin in Gynecologic Cancer: A Phase I Study / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#This phase I study was conducted to determine the maximum tolerated dose and the recommended phase II dose of weekly administered Genexol-PM combined with carboplatin in patients with gynecologic cancer. @*Materials and Methods@#This open-label, phase I, dose-escalation study of weekly Genexol-PM included 18 patients with gynecologic cancer, who were equally divided into three cohorts of dose levels. Cohort 1 received 100 mg/m2 Genexol-PM and 5 area under the curve (AUC) carboplatin, cohort 2 received 120 mg/m2 Genexol-PM and 5 AUC carboplatin, and cohort 3 received 120 mg/m2 Genexol-PM and 6 AUC carboplatin. The safety and efficacy of each dose were analyzed for each cohort. @*Results@#Of the 18 patients, 11 patients were newly diagnosed and seven patients were recurrent cases. No dose-limiting toxicity was observed. The maximum tolerated dose was not defined, but a dose up to 120 mg/m2 of Genexol-PM in combination with AUC 5-6 of carboplatin could be recommended for a phase II study. In this intention-to-treat population, five patients dropped out of the study (carboplatin-related hypersensitivity, n=1; refusal of consent, n=4). Most patients (88.9%) with adverse events recovered without sequelae, and no treatment-related death occurred. The overall response rate of weekly Genexol-PM in combination with carboplatin was 72.2%. @*Conclusion@#Weekly administered Genexol-PM with carboplatin demonstrated an acceptable safety profile in gynecologic cancer pati-ents. The recommended phase II dose of weekly Genexol-PM is up to 120 mg/m2 when combined with carboplatin.

Optimal timing for inguinal hernia repair in premature infants: surgical issues for inguinal hernia in premature infants

Purpose@#We analyzed the timing of inguinal hernia repair in premature infants in the neonatal intensive care unit (NICU) considering recurrence, incarceration, and other complications. @*Methods@#In this multicenter retrospective review, premature infants (<37 weeks) in the NICU diagnosed with inguinal hernia between 2017 and 2021 were segregated into 2 groups based on the timing of inguinal hernia repair. @*Results@#Of 149 patients, 109 (73.2%) underwent inguinal hernia repair in the NICU and 40 (26.8%) after discharge. Preoperative incarceration did not differ, but complications with recurrence and postoperative respiratory insufficiency were higher in the NICU group (11.0% vs. 0%, P = 0.029; 22.0% vs. 5.0%, P = 0.01). Multivariate analysis showed that the significant factors affecting recurrence were preoperative ventilator dependence and body weight of <3,000 g at the time of surgery (odds ratio [OR], 16.89; 95% confidence interval [CI], 3.45–82.69; P < 0.01 and OR, 9.97; 95% CI, 1.03–95.92; P = 0.04). @*Conclusion@#Our results suggest that when premature infants are diagnosed with inguinal hernia in the NICU, inguinal hernia repair after discharge may decrease the odds of recurrence and postoperative respiratory insufficiency. In patients who have difficulty delaying surgery, it is thought that surgery should be performed carefully in a ventilator preoperatively or weighed <3,000 g at the time of surgery.

Intestinal obstruction caused by acute perforated appendicitis misdiagnosed as Hirschsprung’s disease in a 31-month-old boy

Symptomatic abdominal distension in young children requires a differential diagnosis, such as overeating, constipation or surgical emergency. If the distension is associated with intestinal obstruction, clinicians should determine the cause, such as adhesion, hernia, tumor or inflammatory lesions. Herein, the author reports a case of intestinal obstruction caused by acute perforated appendicitis. A 31-month-old boy was referred with a 10-day history of abdominal distension and a presumptive diagnosis of Hirschsprung’s disease. He had undergone an unsuccessful enema. Initial plain radiography and computed tomography showed severely dilated bowel loops with the colon collapsed. During laparotomy, the perforated appendix was found attached to the retroperitoneum and mesentery, which resulted in ileal stenosis with ischemia. The author resected 10 cm of the ileum, and performed ileocecectomy. Postoperatively, the boy recovered uneventfully, except wound seroma. Due to the low incidence and vague symptoms, it is difficult to diagnose intestinal obstruction caused by appendicitis, particularly in young children. This case may serve as a reminder that acute perforated appendicitis can cause sudden onset of intestinal obstruction in young children without a history of surgery.

Intussusception and Jejunal Atresia Caused by an Ectopic Pancreas in a Newborn

Ectopic pancreas is defined as an abnormally located pancreatic tissue not sufficiently connected with the normal pancreas, which rarely occurs in neonates. To our knowledge, only a few cases of ectopic pancreas have been reported in newborns in South Korea. We report a case of ectopic pancreas as the cause of intussusception and jejunal atresia in a newborn. This clinical association is extremely rare, and this is the first report in South Korea.

Intussusception and Jejunal Atresia Caused by an Ectopic Pancreas in a Newborn

Ectopic pancreas is defined as an abnormally located pancreatic tissue not sufficiently connected with the normal pancreas, which rarely occurs in neonates. To our knowledge, only a few cases of ectopic pancreas have been reported in newborns in South Korea. We report a case of ectopic pancreas as the cause of intussusception and jejunal atresia in a newborn. This clinical association is extremely rare, and this is the first report in South Korea.

The Treatment Experience of Lymphatic Malformations in Pediatric Patients / 소아외과

PURPOSE@#The management of lymphatic malformation (LM) in pediatric patients is challenging. Complete excision of LM is difficult to achieve in some cases. We reviewed our experience how to manage LM.@*METHODS@#We retrospectively reviewed the patients who were treated for LM between 2010 and 2017. Medical records were reviewed about age of diagnosis, age of treatment age, gender, symptom, location of tumor, treatment modality, response and complication.@*RESULTS@#Sixty-three patients (39 boys and 24 girls) were included. Mean age at diagnosis was 14.5±28.0 months (range, neonate-10 years). The involved lesion were head and neck in 27 patients (42.9%), abdominal cavity in 7 patients (11.1%), chest wall and abdominal wall in 11 patients (17.5%), buttock in 7 patients (11.1%), and extremities in 11 patients (17.5%). The treatment options were including surgical resection in 32 patients, sclerotherapy in 7 patients, surgical resection combined sclerotherapy in 19 patients, and close observation in 5 patients. We achieved complete remission in 39 patients. Fourteen patients showed partial remission and 6 showed recurrences.@*CONCLUSION@#Despite surgical difficulty, meticulous excision with supportive treatment, and adjuvant sclerotherapy could get a favorable outcome without fatal complication. Decision should be based on surgeon's experience, location of LM, related symptoms, and consultation with patient's parents.

Risk Factors for the Development of Incisional Hernia in Mini-laparotomy Wounds Following Laparoscopic Distal Gastrectomy in Patients with Gastric Cancer

PURPOSE: To determine the incidence of incisional hernia (IH) in mini-laparotomy wounds and analyze the risk factors of IH following laparoscopic distal gastrectomy in patients with gastric cancer. MATERIALS AND METHODS: A total of 565 patients who underwent laparoscopic distal gastrectomy for gastric cancer at Dong-A University Hospital, Busan, South Korea, between June 2010 and December 2015, were enrolled. IH was diagnosed through physical examination or computed tomography imaging. Incidence rate and risk factors of IH were evaluated through a long-term follow-up. RESULTS: Of those enrolled, 16 patients (2.8%) developed IH. The median duration of follow-up was 58 months (range, 25–90 months). Of the 16 patients with IH, 15 (93.7%) were diagnosed within 12 months postoperatively. Multivariate analysis showed that female sex (odds ratio [OR], 3.869; 95% confidence interval [CI], 1.325–11.296), higher body mass index (BMI; OR, 1.229; 95% CI, 1.048–1.422), and presence of comorbidity (OR, 3.806; 95% CI, 1.212–11.948) were significant risk factors of IH. The vast majority of IH cases (15/16 patients, 93.7%) developed in the totally laparoscopic distal gastrectomy (TLDG) group. However, the type of surgery (i.e., TLDG or laparoscopy-assisted distal gastrectomy) did not significantly affect the development of IH (P=0.060). CONCLUSIONS: A median follow-up of 58 months showed that the overall incidence of IH in mini-laparotomy wounds was 2.8%. Multivariate analysis showed that female sex, higher BMI, and presence of comorbidity were significant risk factors of IH. Thus, surgeons should monitor the closure of mini-laparotomy wounds in patients with risk factors of IH undergoing laparoscopic distal gastrectomy.

Feasibility of Laparoscopic Surgery for Intussusception in Pediatric Patients and Risk of Bowel Resection

PURPOSE: Intussusception is a common cause of intestinal obstruction in children. While most patients can be treated by enema reduction, about 20% require surgery. We investigated the usefulness and feasibility of laparoscopic surgery and the intraoperative risk of bowel resection. METHODS: We retrospectively reviewed pediatric patients who underwent surgery for intussusception from 2010 to 2017. We collected data for age, gender, body weight, associated symptoms, duration of symptoms, white blood cell count, operating time, and postoperative complications. RESULTS: Of 155 patients, 37 (23.8%) underwent surgery due to enema reduction failure in 29 (78.3%), recurrence in 6 (16.3%), a suspicious lead point in 1, and suspicious ischemic change observed on ultrasonography in 1. The mean age was 26.8±18.9 months (range, 3.5~76.7 months), and the mean body weight was 12.9±3.9 kg (range, 5.4~22.2 kg). Laparoscopic surgery was successful in 29 patients (78.4%), and 7 (18.9%) needed bowel resection and anastomosis. The mean operating time was 56.7±32.8 min. A lead point was found in 3 patients in the bowel resection group (p=0.005); in addition, the operating time and hospital stay were longer in this group. There were no intra- or postoperative complications. CONCLUSION: Laparoscopic surgery was successful in 78.4% of the patients with a short hospital stay and early oral intake. The only predictive factor for bowel resection was the presence of a lead point. Laparoscopic surgery may be an optimal treatment intervention for children with intussusception, except for those who show initial peritonitis.

The Treatment Experience of Lymphatic Malformations in Pediatric Patients

PURPOSE: The management of lymphatic malformation (LM) in pediatric patients is challenging. Complete excision of LM is difficult to achieve in some cases. We reviewed our experience how to manage LM. METHODS: We retrospectively reviewed the patients who were treated for LM between 2010 and 2017. Medical records were reviewed about age of diagnosis, age of treatment age, gender, symptom, location of tumor, treatment modality, response and complication. RESULTS: Sixty-three patients (39 boys and 24 girls) were included. Mean age at diagnosis was 14.5±28.0 months (range, neonate-10 years). The involved lesion were head and neck in 27 patients (42.9%), abdominal cavity in 7 patients (11.1%), chest wall and abdominal wall in 11 patients (17.5%), buttock in 7 patients (11.1%), and extremities in 11 patients (17.5%). The treatment options were including surgical resection in 32 patients, sclerotherapy in 7 patients, surgical resection combined sclerotherapy in 19 patients, and close observation in 5 patients. We achieved complete remission in 39 patients. Fourteen patients showed partial remission and 6 showed recurrences. CONCLUSION: Despite surgical difficulty, meticulous excision with supportive treatment, and adjuvant sclerotherapy could get a favorable outcome without fatal complication. Decision should be based on surgeon's experience, location of LM, related symptoms, and consultation with patient's parents.

A novel and simple method using a transanal intestinal long tube for protecting intestinal anastomosis and decompressing the small bowel

PURPOSE: I introduce the use of transanal intestinal long tube (TILT) using nasogastric tube. TILT passes from anus to the anastomosis, helping to decompress a dilated bowel loop. METHODS: TILT procedure was limited to those patients predicting a severe luminal size discrepancy after intestinal anastomosis, and who had postoperative prolonged ileus. We retrospectively reviewed the medical records of 10 infants (7 male an 3 female patients) who were treated using the TILT procedure between 2012 and 2016. RESULTS: Median gestational age was 27⁺⁵ weeks and birth weight was 940 g. The first operation was done at a median of 4.5 days after birth due to necrotizing enterocolitis perforation (4 cases), isolated intestinal perforation (3 cases), meconium related ileus (1 case), congenital ileal volvulus (1 case), and ileal atresia (1 case). Nine cases of ileostomy closure were planned at a median of 130.5 days with a body weight of 3,060 g. For the ileal atresia case, TILT procedure without additional small bowel resection was performed to treat postoperative prolonged ileus. Nine out of ten were well functioned and defecation via anus was observed in a median of 4.5 days. Milk feeding began at a median of 6 days and the long intestinal tube was removed in a median of 14.5 days. CONCLUSION: I suggested that TILT procedure could be a noninvasive operative option, predicting of size mismatched anastomosis causing prolonged ileus. Passive drainage of proximal intestinal contents might be helpful for decompress endoluminal pressure during the time of anastomosis healing with bowel movement recovery.

Laparoscopic reinforcement suture on staple-line of duodenal stump using barbed suture during laparoscopic gastrectomy for gastric cancer

PURPOSE: Duodenal stump fistula (DSF) is a serious complication after gastrectomy for gastric cancer. Although risk evaluation and management of DSF were presented by some investigators, there was no technical attempt has been made to prevent DSF during laparoscopic gastrectomy until now. METHODS: Consecutive 99 patients were enrolled from April 2014 to February 2016 in 2 institutes. All patients were performed laparoscopic gastrectomy for gastric cancer. After cutting of duodenal stump, laparoscopic reinforcement suture (LARS) commenced with continuous invagination method or interrupted method by barbed suture. Clinicopathologic features and postoperative outcomes were analyzed. RESULTS: Fifty-six patients had comorbidity including 5 patients with duodenal ulcer. Most patients were performed distal gastrectomy with B-II, and 10 patients total gastrectomy with Roux en Y esophagojejunostomy. Although there were 2 esophagojejunostomy leakage and 1 artificial lesser curvature leakage, DSF did not occurred at all in this study. Mean operation time was 3 hours and mean LARS procedure time was 8 minutes. CONCLUSION: LARS of duodenal stump can be considered as one of prevention methods of DSF during laparoscopic gastrectomy for gastric cancer. So this new technique will be necessary to appropriately evaluate by prospective randomized controlled trial in the future.

Laparoscopic reinforcement suture on staple-line of duodenal stump using barbed suture during laparoscopic gastrectomy for gastric cancer

PURPOSE: Duodenal stump fistula (DSF) is a serious complication after gastrectomy for gastric cancer. Although risk evaluation and management of DSF were presented by some investigators, there was no technical attempt has been made to prevent DSF during laparoscopic gastrectomy until now. METHODS: Consecutive 99 patients were enrolled from April 2014 to February 2016 in 2 institutes. All patients were performed laparoscopic gastrectomy for gastric cancer. After cutting of duodenal stump, laparoscopic reinforcement suture (LARS) commenced with continuous invagination method or interrupted method by barbed suture. Clinicopathologic features and postoperative outcomes were analyzed. RESULTS: Fifty-six patients had comorbidity including 5 patients with duodenal ulcer. Most patients were performed distal gastrectomy with B-II, and 10 patients total gastrectomy with Roux en Y esophagojejunostomy. Although there were 2 esophagojejunostomy leakage and 1 artificial lesser curvature leakage, DSF did not occurred at all in this study. Mean operation time was 3 hours and mean LARS procedure time was 8 minutes. CONCLUSION: LARS of duodenal stump can be considered as one of prevention methods of DSF during laparoscopic gastrectomy for gastric cancer. So this new technique will be necessary to appropriately evaluate by prospective randomized controlled trial in the future.

RNA-Seq for Gene Expression Profiling of Human Necrotizing Enterocolitis: a Pilot Study

Necrotizing enterocolitis (NEC) characterized by inflammatory intestinal necrosis is a major cause of mortality and morbidity in newborns. Deep RNA sequencing (RNA-Seq) has recently emerged as a powerful technology enabling better quantification of gene expression than microarrays with a lower background signal. A total of 10 transcriptomes from 5 pairs of NEC lesions and adjacent normal tissues obtained from preterm infants with NEC were analyzed. As a result, a total of 65 genes (57 down-regulated and 8 up-regulated) revealed significantly different expression levels in the NEC lesion compared to the adjacent normal region, based on a significance at fold change ≥ 1.5 and P ≤ 0.05. The most significant gene, DPF3 (P < 0.001), has recently been reported to have differential expressions in colon segments. Our gene ontology analysis between NEC lesion and adjacent normal tissues showed that down-regulated genes were included in nervous system development with the most significance (P = 9.3 × 10⁻⁷; P(corr) = 0.0003). In further pathway analysis using Pathway Express based on the Kyoto Encyclopedia of Genes and Genomes (KEGG) database, genes involved in thyroid cancer and axon guidance were predicted to be associated with different expression (P(corr) = 0.008 and 0.020, respectively). Although further replications using a larger sample size and functional evaluations are needed, our results suggest that altered gene expression and the genes' involved functional pathways and categories may provide insight into NEC development and aid in future research.

Underestimated risks of rare-earth magnet ingestion in children: when does it need surgery?

This review discusses an underestimated risk of rare-earthmagnet (henceforth, magnet) ingestion in children and its surgical indication. Due to the ubiquity of magnets, the incidence of magnet ingestion has rapidly increased. While most foreign body ingestions show spontaneous passage, multiple magnet ingestion requires surgery in 30%-70% of the cases. Multiple magnets can attract each other across the bowel wall, leading to pressure necrosis, and subsequently, fistula, perforation, obstruction or volvulus. After recognizing magnet ingestion, the number of magnets should be checked using radiographs. In case of multiple magnet ingestion, surgery should be promptly considered.

Minimally invasive surgery for congenital cystic adenomatoid malformations - early experience

PURPOSE: The aim of this study is to present our experience with minimally invasive surgery (MIS) for congenital cystic adenomatoid malformations (CCAMs). METHODS: The medical records of infants under 2 years of age who underwent operation for a CCAM from 2009 to 2014 were retrospectively reviewed. RESULTS: MIS (9 of thoracoscopy and 1 of laparoscopy) was performed for 10 infants (male:female = 7:3) with CCAM. CCAM were discovered prenatally around gestational age of 24.7 weeks. The median gestational age was 38.6 weeks, and the median body weight was 2,817.5 g. None had respiratory distress after birth. The median age at the time of operation was 0.94 years (range: 8 days-1.66 years). Two underwent the operation during the neonatal period; one because of a coexisting large esophageal duplication cyst and the other due to diagnostic uncertainty. While awaiting operation, 5 of CCAM had grown without respiratory symptoms, and 2 infants had experienced pneumonia. The mean operative time was 98 minutes (range: 70-227 minutes), and there were no conversions or perioperative complications. The infants resumed enteral feeding within 2 days and were discharged within 7 days, except for 1 infant who underwent esophageal duplication cyst excision. During the follow-up period, there were no cases of either remnant lesions or respiratory symptoms. CONCLUSION: MIS for CCAMs is safe and feasible, with excellent cosmesis and short hospital stays. Increasing experience with various MIS procedures will widen the indications for MIS in lung pathology.

Associated Factors with Parenteral Nutrition Associated Cholestasis in Neonates / 소아외과

PURPOSE: Long time total parenteral nutrition (TPN) can induce irreversible liver damage. In this study, we investigated the associated factors of parenteral nutrition associated cholestasis (PNAC) in neonates. METHODS: We retrospectively reviewed 227 neonates (male:female=110:117) those who had received TPN over 2 weeks from March 2010 to February 2014. PNAC was defined as direct bilirubin was higher than 2.0 mg/dL without any cause except TPN. RESULTS: Overall incidence was 28.6%. PNAC was frequently developed in younger gestational age with lower birth weight. Episodes of sepsis, underlying bronchopulmonary dysplasia, history of necrotizing enterocolitis, and experience of gastrointestinal surgery increase the incidence of PNAC. PNAC was directly associated the duration of TPN and long period to full enteral feeding, reaching 60 and 150 mL/kg/day. Overall mortality rate was 9.7%. It was higher in PNAC group despite PNAC was not the primary cause of death. All survivors were recovered from cholestasis with encourage of enteral nutrition. CONCLUSION: PNAC in neonate was associated with younger gestational ages and lower birth weights, duration of TPN, or who experienced sepsis, necrotizing enterocolitis, gastrointestinal surgery or bronchopulmonary dysplasia.

Heterotopic Pancreas Presented as Duodenal Tumor with Obstruction / 대한소아소화기영양학회지

Heterotopic pancreas (HP) is defined as pancreatic tissue lacking anatomic and vascular continuity with the main body of the pancreas. Most are asymptomatic, but can cause ulcer, bleeding, intussusception, and mechanical obstruction. Herein, we presented one case of HP presented as duodenal tumor causing duodenal obstruction. A 7-year-old girl visited the emergency room for abdominal pain with vomiting for 24 hours. Computed tomography and upper gastrointestinal series revealed a polypoid mass with short stalk in the 2nd portion of duodenum. We attempted an endoscopic removal. However, the lumen was nearly obstructed by the mass and the stalk was too broad and hard to excise. The mass was surgically removed via duodenotomy. It was confirmed as a HP with ductal and acini components (type 2 by Heinrich classification). Postoperatively, the patient has been well without any complication and recurrence.

Erratum: Impact of Meconium Obstruction-Related Risk Factors on Surgical Intervention in Very Low Birth Weight Infants

We found an error in this article.

Impact of Meconium Obstruction-Related Risk Factors on Surgical Intervention in Very Low Birth Weight Infants

PURPOSE: This study investigated the risks of development and surgical complications of meconium obstruction (MO) in very low birth weight (VLBW) infants. METHODS: We performed a retrospective medical record review of VLBW infants admitted to the neonatal intensive care unit of Haeundae Paik hospital and diagnosed with MO of prematurity (MOP) between March 2010 and August 2013. RESULTS: Of 267 VLBW infants admitted to the neonatal intensive care unit, 28 were diagnosed with MOP. Perinatal factors including maternal pregnancy-induced hypertension and small for gestational age were associated with MOP development (P<0.05). Over two-thirds of VLBW infants with MOP were successfully treated with a gastrografin enema. The remaining eight VLBW infants required surgery. Although small for gestational age was more frequent in the medical treatment group, specific risk factors associated with MOP development did not affect the need for surgical intervention. CONCLUSION: MOP is common in VLBW infants, as most VLBW infants have risk factors for MOP. Identifying risk factors permits early diagnosis and initiation of appropriate medical treatment, reducing the necessity for surgery. However, the presence of specific risk factors does not increase risk of surgical complications.

Inguinal Lipoblastoma Mimicking Recurrent Inguinal Hernia / 소아외과

Palpable inguinal mass in children should be differentiated from inguinal hernia, hydrocele, lymph node, and tumor. Though using ultrasonography, fatty tumor would be misdiagnosed as incarcerated inguinal hernia containing fatty component. We experienced the huge inguinal lipoblastoma in 5-year-old girl mimicking recurrent incarcerated hernia. Laparoscopic exploration revealed it was not incarcerated hernia but well demarcated bulging mass from abdominal wall. Mass was about 10x4x3 cm and extended from internal inguinal ring to saphenous opening. It was near total excised because of right external iliac vein injury. Pathologically, it was proven as lipoblastoma containing mature adipocyte with lipoblast and fibrous septa. Postoperatively, we noticed a segmental thrombotic occlusion of external iliac vein. After 1 year, she has no symptom related to occluded vessel. The remained lipoblastoma showed no interval change. Even lipoblastoma has a good prognosis with low recurrence rate, we need careful follow-up.