Measurement and Control of Surgical Smoke to Enhance Surgical Team Safety.

Amid the coronavirus disease 2019 era, concern about the safety of surgical teams related to surgical smoke (SS) is rising. As simple ventilation improvement methods (SVIMs), we replaced 4 of the 8 supply diffusers with a direction-adjustable louver-type, closed 2 of the 4 exhaust grills, and strengthened the sealing of the doorway. Dynamic changes in the concentration of particulate matter (PM) with sizes of < 1.0 µm (PM1.0) were measured using low-cost PM meters (LCPMs) at eight locations in the operating room (OR). SS concentration up to 4 minutes at the location of the surgeon, first assistant, and scrub nurse before and after SVIMs application decreased from 65.4, 38.2, 35.7 µg/m3 to 9.5, 0.1 and 0.7 µg/m3 respectively. A similar decrease was observed in the other 5 locations. SVIMs could effectively control SS and the LCPM was also effective in measuring SS in the OR or other spaces of the hospital.

Accuracies of diagnostic methods for acute appendicitis.

The objectives were to evaluate the effectiveness of ultrasonography, computed tomography, and physical examination for diagnosing acute appendicitis with analyzing their accuracies and negative appendectomy rates in a clinical rather than research setting. A total of 2763 subjects were enrolled. Sensitivity, specificity, positive predictive value, and negative predictive value and negative appendectomy rate for ultrasonography, computed tomography, and physical examination were calculated. Confirmed positive acute appendicitis was defined based on pathologic findings, and confirmed negative acute appendicitis was defined by pathologic findings as well as on clinical follow-up. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography were 99.1, 91.7, 96.5, and 97.7 per cent, respectively; for computed tomography, 96.4, 95.4, 95.6, and 96.3 per cent, respectively; and for physical examination, 99.0, 76.1, 88.1, and 97.6 per cent, respectively. The negative appendectomy rate was 5.8 per cent (5.2% in the ultrasonography group, 4.3% in the computed tomography group, and 12.2% in the physical examination group). Ultrasonography/computed tomography should be performed routinely for diagnosis of acute appendicitis. However, in view of its advantages, ultrasonography should be performed first. Also, if the result of a physical examination is negative, imaging studies after physical examination can be unnecessary.

Significance of CD133 as a cancer stem cell markers focusing on the tumorigenicity of pancreatic cancer cell lines.

PURPOSE: The cancer stem cell hypothesis states that the capacity of a cancer to grow and propagate is dependent on a small subset of cells. To determine the significances of the cancer stem cell markers CD133, CD44, and CD24 using a comparative analysis with a focus on tumorigenicity. METHODS: Four pancreatic cancer cell lines, Capan-1, Mia-PACA-2, Panc-1, and SNU-410 were analyzed for the expressions of CD133, CD44, and CD24 by flow cytometry. The tumorigenicity was compared using tumor volumes and numbers of tumors formed/numbers of injection in nonobese diabetic severe combined deficiency mice. Fluorescence-activated cell sorting (FACS) analysis was used to confirm that xenograft explants originated from human pancreatic cancer cells. RESULTS: CD133 was positive in only Capan-1, CD44 positive in all, CD24 partially positive in Panc-1. After injecting 2 × 10(6) cells, all mice administered Capan-1 or Mia-Paca-2 developed tumors, 3 of 5 administered Panc-1 developed tumors, but no mouse administered SNU-410 developed any tumors. The volumes of Capan-1 tumors were seven times larger than those of Mia-Paca-2 tumors. When 2 × 10(5) or 2 × 10(4) of Capan-1 or Mia-Paca-2 was injected, tumors developed in all Capan-1 treated mice, but not in Mia-Paca-2 treated mice. Furthermore, xenograft explants of Capan-1 expressed CD133+CD44+ and Capan-1 injected mice developed lung metastasis. FACS analysis showed that xenograft explants originated from human pancreatic cancer cell lines. CONCLUSION: CD133 positive cells have higher tumorigenic and metastatic potential than CD44 and CD24 positive cells, which suggests that CD133 might be a meaningful cell surface marker of pancreatic cancer stem cells.

Conservative treatment for patients with acute right colonic diverticulitis.

Little is known about the natural history of right colonic diverticulitis treated with conservative management. The purpose of this study was to analyze the short-term outcome of a conservative approach to the treatment of patients with acute right colonic diverticulitis. A retrospective review of the clinical and radiological findings of 62 patients with acute right colonic diverticulitis was carried out. Conservative treatment was provided to 47 patients and surgical treatment to 15 patients with the diagnosis of acute right colonic diverticulitis. An initial ultrasound was performed in 45 of 62 patients (73%) and a CT was performed in 16 of 62 patients (26%). Diverticulitis was confirmed pretreatment diagnosis in 56 of 61 (91.8%) patients who had radiological evaluation. There were seven (11.3%) pericolic abscesses identified as a complication of the diverticulitis. All 47 patients who received conservative management were successfully treated and had improvement of symptoms with no sign of clinical deterioration. For the fifteen patients who had surgery: 5 had right hemicolectomies, 8 had appendectomies without diverticulectomy, 1 had an appendectomy with diverticulectomy, and 1 had diverticulectomy alone. During a median followup of 23.9 months, two of 55 (3.6%) patients who did not have surgical resection for inflamed diverticulum had recurrences one and ten months after the initial treatment; they were successfully treated again with bowel rest and antibiotics without complication. Conservative treatment should be considered as a safe and effective option for acute right colonic diverticulitis. In addition, a less aggressive approach may be more suitable for recurrent diverticulitis than extended surgical resection.

[Prognostic factors after major resection for distal extrahepatic cholangiocarcinoma].

BACKGROUND/AIMS: Although diagnosis and surgical treatment for distal common bile duct cancer have enormously advanced, survival is not satisfactory and its prognostic factors are still being debated. Thus, we evaluated the outcomes and prognostic factors after major resection for distal extrahepatic cholangiocarcinoma (dCC). METHODS: One hundred and fifty-four patients who underwent major resection such as pancreatic oduodenectomy for dCC were retrospectively analyzed. We investigated clinical features, postoperative complications, survival, and prognostic factors of dCC. RESULTS: One hundred and three (66.9%) male and 51 (33.1%) female patients were enrolled and their mean age was 59.6 (31-78) years. Among them, 97 patients (63.0%) underwent Whipple's procedure, 45(29.2%) pylorus-preserving pancreatic oduodenectomy, 7 (4.5%) total pancreatectomy, and 5 (3.3%) hepatopancreaticoduodenectomy, respectively. Mean follow-up duration was 26.6 (0.4-108.5) months. The postoperative morbidity and mortality were 42.2% and 1.3%, respectively. Five-year survival rate was 32.8% and mean survival duration was 47.2 (39.1-55.3) months. Type of biliary drainage (percutaneous transhepatic biliary drainage), lymph node status (positive), and cellular differentiation (moderate or poor) were significant indicators for death in multivariate analysis of resectable dCC. CONCLUSIONS: Moderate or poor cellular differentiation and lymph node metastasis maybe independent poor prognostic factors for resectable dCC.

Predicting survival after surgical resection for pancreatic ductal adenocarcinoma.

OBJECTIVES: We reviewed the pancreatectomies that were done for pancreatic ductal adenocarcinoma to evaluate patient survival and prognostic predictors. METHODS: A review was performed on 94 patients who underwent surgical resection for pancreatic ductal adenocarcinomas from 1995 to 2002. The perioperative factors were compared between the proximal and distal lesions by the chi2 test and t test. Possible predictors for survival were examined for by univariate and multivariate analysis. RESULTS: The 5-year survival was 16%. The proximal lesions had a smaller tumor size (3.0 +/- 0.11 vs. 3.9 +/- 0.33 cm, respectively; P = 0.03), a higher incidence of nodal involvement (60.6% vs. 34.8%, respectively; P = 0.031), and poorer histologic differentiation (25.4% vs. 13.0%, respectively; P = 0.01) compared with the distal lesions, and both types of lesions had similar rates of intraoperative transfusion, complete resection, and survival. The factors shown to have favorable independent prognostic significance were negative resection margins (hazard ratio [HR] = 0.23; 95% confidence interval [CI] = 0.12-0.42; P < 0.001), a tumor diameter less than 3 cm (HR = 0.46; 95% CI = 0.27-0.78; P = 0.004), well/moderate tumor differentiation (HR = 0.37; 95% CI = 0.19-0.72; P = 0.004), and adjuvant therapy (HR = 0.61; 95% CI = 0.37-0.99; P = 0.49). CONCLUSIONS: For the long-term survival of patients with pancreatic ductal adenocarcinoma, complete excision is the most important therapeutic option, and adjuvant therapy is a significant contributing factor.

The efficacy of the prophylactic use of octreotide after a pancreaticoduodenectomy.

This study was performed to analyze the efficacy of the prophylactic use of octreotide (Novartis, Stein, Switzerland) for pancreatic fistula following a pancreaticoduodenectomy. The medical records of 190 patients who underwent a pancreaticoduodenectomy at the Samsung Medical Center in Seoul, Korea between January 2000 and December 2002 were reviewed. Patients were divided into either the octreotide (n = 81) or control group (n = 109). The octreotide group received subcutaneous injections of 100 microg of octreotide every 12 hours for more than five days after surgery. The control group was not treated with octreotide. The criterion of pancreatic fistula was the drainage of the amylase rich fluid, over 500 U/mL in the three days after surgery. The morbidity and mortality rates were 32.1% and 1.2% in the octreotide group and 31.2% and 0% in the control group, respectively. Pancreatic fistula was the second most common complication (8.4%). In the univariate analysis, octreotide was ineffective in reducing pancreatic fistula (p = 0.26). However, in the multivariate regression analysis, combined gastrectomy (p = 0.018), cellular origin of the disease (p = 0.049), and use of octreotide (p = 0.044) were the risk factors that increased the frequency of pancreatic fistula. Therefore, the routine use of octreotide after a pancreaticoduodenectomy should be avoided until a worldwide consensus is established.

Delayed hemorrhage after pancreaticoduodenectomy.

BACKGROUND: Postoperative hemorrhage, particularly delayed hemorrhage after pancreaticoduodenectomy, is a serious complication and one of the most common causes of mortality after pancreaticoduodenectomy. STUDY DESIGN: The medical records of 500 patients who underwent pancreaticoduodenectomy between October 1994 and December 2002 were analyzed with regard to postoperative hemorrhagic complications. Delayed hemorrhage was defined as bleeding at the operation site after 5 or more postoperative days. RESULTS: Delayed hemorrhage occurred in 22 patients (4.4%), with a median time of 13 days (range 7 to 32 days) after pancreaticoduodenectomy, and developed more frequently (9/77 versus 13/423, p = 0.003) in patients with preceding intraabdominal complications such as pancreatic fistula, bile fistula, and intraabdominal abscess. In 17 of these 22 patients, angiography and laparotomy revealed bleeding foci at 14 arterial and 3 anastomotic sites. In nine patients, hemorrhage developed from pseudoaneurysms of the major arteries around the pancreaticojejunostomy. Hemostatis was attempted by transcatheter arterial embolization in 14 patients and with laparotomy in 4 patients. Four of 14 patients who received transcatheter arterial embolization eventually required laparotomy. Overall, 4 of the 22 delayed hemorrhage patients died (18.2%) of complications related to massive bleeding or transcatheter arterial embolization. CONCLUSIONS: Delayed hemorrhage after pancreaticoduodenectomy is associated with a high mortality. Intraabdominal complications after pancreaticoduodenectomy should be evaluated properly and guidelines for the diagnosis and treatment of delayed hemorrhage should be established in advance. Clinicians must be alert to the possibility of pseudoaneurysm hemorrhage.

[A result of surgical treatment for ductal adenocarcinoma of the head of the pancreas].

BACKGROUND/AIMS: Ductal adenocarcinoma of the head of the pancreas can only be cured with pancreaticoduodenectomy. However, the prognosis after resection has been poor. This study analyzed the possible prognostic factors of resected ductal adenocarcinoma through pancreaticoduodenectomy in a single institution. METHODS: Between Oct. 1994 and May. 2002, 81 patients underwent pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas. Perioperative and pathologic factors were analyzed with univariate and multivariate analysis. RESULTS: The overall 5-year survival rate of the 81 patients was 10.8% with median survival of 11.8 months. Ninety-six percent of the patients were in stage IIa, IIb or III. In univariate analysis, factors favoring survival were as follows: CA19-9 antigen