Management of recurrent ileocolic intussusception.

PURPOSE: The aims of this study were to evaluate the need for surgical intervention for patients with recurrent ileocolic intussusception (RICI), especially for multiple recurrences, and to investigate whether early and late recurrence patterns were associated with surgery. METHODS: Patients with ileocolic intussusception (ICI) during the years 2007-2019 were included. Demographic data, recurrences, and outcomes were analyzed. Early RICI was defined as recurrence within 48 h. RESULTS: Overall, 604 episodes of ICI were confirmed in 491 patients. The recurrence rate was 13.8%, with 113 episodes in 68 patients. There were no statistically significant differences in age, reduction success rate, operation, or pathological lead points (PLPs) between the recurrence and non-recurrence groups. There was no significant association between the number of recurrences and the presence of a PLP or between the number of recurrences and whether the recurrences were early or late. The presence of PLPs was not significantly associated with age or recurrence, but the reduction success rate was significantly lower (P < 0.001). CONCLUSIONS: Each recurrence should be managed as a first episode, regardless of early or late recurrence. Operative reduction should be considered when nonoperative reduction fails, a PLP is suspected, or there are signs of peritonitis. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

Totally Laparoscopic Distal Gastrectomy in Post Liver Transplant Patient.

The risk of malignancy after transplantation is higher than that of general population. Laparoscopic surgery has become a standard treatment of gastric cancer. However, there are no case reports evaluating totally laparoscopic gastrectomy in patients with previous liver transplantation. Herein we report our experience with a liver transplant recipient who underwent totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. A 63 year-old man underwent orthotopic liver transplantation (OLT) for cryptogenic liver cirrhosis. 8 years later, gastric cancer was diagnosed during the follow-up. Endoscopic submucosal dissection was performed and additional surgical resection was needed. TLDG and D1+ lymph node dissection was performed, and the patient was discharged on the 8th post-operative day without any complications. To the best of our knowledge, this is the first case of de novo gastric cancer treated with TLDG after OLT. This suggests that TLDG is a feasible for patients after OLT.

Beneficial effect of low caloric intake in the early period after orthotopic liver transplantation: a new concept using graft weight.

BACKGROUND/AIMS: Although various factors are correlated with early graft function after orthotopic liver transplantation (OLT), caloric supplementation is not considered in postoperative period. This retrospective study investigated the correlation between caloric intake and early graft function and compared calorie/ body weight ratio (CBWR) and calorie/graft weight ratio (CGWR) as standards for nutritional provision. METHODOLOGY: Patients were divided into the low caloric group (<18 kcal/kg/day) and eucaloric group (≥18 kcal/kg/day) according to caloric intake until 48 hours post-OLT. Graft function was assessed according to aminotransferase level, bilirubin level, and international normalised ratio (INR) on postoperative days (POD) 0, 2, and 7. The variables associated with caloric intake were compared to identify the superiority between CBWR and CGWR. RESULTS: There were 32 and 8 patients in the low caloric and eucaloric groups. INR on POD 2 was significantly lower in the low caloric group (p = 0.018). CGWR was more strongly correlated with INR than CBWR on POD 2 (r = 0.08, p = 0.63 vs. r = 0.36, p = 0.024). CONCLUSIONS: Low caloric intake has a beneficial effect on the restoration of early graft function. CGWR is superior to CBWR as a standard for nutritional supplementation.

Analysis of gallbladder polypoid lesion size as an indication of the risk of gallbladder cancer.

BACKGROUNDS/AIMS: Recent advances in ultrasonography have contributed to the early detection of gallbladder cancer. We attempted to predict the progression of the disease by comparing the sizes of polypoid lesions, and we suggest that the size of the lesion would be a useful guideline to determine an appropriate primary surgical approach for polypoid lesions of the gallbladder. METHODS: We have retrospectively analyzed 253 patients that, during the operation period from January 2009 to December 2011, had had ultrasonographically detected gallbladder polypoid lesions, and who underwent cholecystectomy at Ulsan university hospital. We have analyzed the demographic data of the patients, the preoperative size of polypoid lesions, and pathologic findings. RESULTS: Of a total of 253 patients, 235 patients had benign lesions, and 18 patients had malignant lesions. Among the malignant polyp patients, 11 had pT1 cancer, 6 had pT2 cancer, and 1 had pT3 cancer. The average size of polypoid lesions was 9.1±3.1 mm and that of malignant lesions was 28.2±16.4 mm. The receiver operating characteristic (ROC) curve of the benign and malignant groups shows that 14.5 mm is the optimal point of prediction of the malignancy. Of a total of 18 patients of GB cancer, 11 had pT1 and the average size of their polypoid lesions was 20.5±5.8 mm 7 had pT2 with a size of 39.1±20.7 mm. ROC curve analysis of the pT1 and pT2 groups shows that 27 mm would be the optimal point to predict T2 and above cancer. CONCLUSIONS: In the case of an early cancer, curative treatment can be achieved through a simple and minimally invasive laparoscopic cholecystectomy. We attempted to predict early cancer occurrence among polypoid lesions of the gallbladder using the simplest standard, size. Although there are some limitations, size can be a simple and easy way to evaluate polypoid lesions of the gallbladder.

A case of rapunzel syndrome.

Rapunzel syndrome refers to a very rare condition in which swallowed hair forms a gastric trichobezoar that has a long tail extending into the small bowel. We describe a case of Rapunzel syndrome in an 8-year-old girl who presented with abdominal mass, epigastric pain and vomiting. Abdominal computed tomography scan showed a markedly dilated stomach filled with coarse heterogeneous materials. Upper gastrointestinal endoscopy revealed a huge hairy ball with a tail extending through the pylorus. We performed a surgical laparotomy and successfully removed a huge trichobezoar with a long tail extending into the middle portion of jejunum. Psychiatric consultation with review showed her past history of trichotillomania and trichophagia 4 years ago. But her parents denied further psychiatric therapy and she was lost to the follow-up. Rapunzel syndrome should be included in the differential diagnosis in children with chronic abdominal pain and trichophagia.

Ladder-type SAW filters using thinned density of randomly distributed "hot" electrodes.

A new method for the design of relatively narrowband ladder-type SAW filters is proposed. It consists of the thinning procedure and consecutive randomization of positions of the remaining transductive periods inside the IDT to suppress undesirable additional passbands. A 0.9% fractional bandwidth filter on LiTaO(3) 42°-cut was designed and manufactured using the proposed approach.

Fragile histidine triad gene alterations are not essential for hepatocellular carcinoma development in South Korea.

AIM: To establish the role of FHIT in the pathogenesis hepatocellular carcinoma (HCC). METHODS: We examined genomic alterations, as well as, mRNA and protein expression patterns from the FHIT gene, in 48 surgically resected hepatocellular carcinoma (HCC) tissues. Additionally, p53 mutations were analyzed. RESULTS: Aberrant FHIT transcripts were detected in 11 of 48 surrounding non-tumor liver tissues and 27 of 48 HCC samples (22.9% vs 56.3%, P = 0.002). No point mutations were identified within the open reading frame region of FHIT. Loss of heterozygosity (LOH) of the FHIT locus was detected in 4 of 42 informative cases for D3S1300, and 3 of 29 informative cases for D3S1313. Reduced expression of FHIT protein (Fhit) was observed in 8 (16.7%) of 48 HCC samples, with complete loss of Fhit in only 1 case. There were no associations with abnormal transcripts, LOH, and Fhit expression. p53 mutations were identified in 9 of the 48 HCC cases. However, none of the cases displayed a G to T transversion at p53 codon 249. CONCLUSION: Aberrant FHIT transcripts were more common in HCC tissues as compared to non-cancerous liver tissues. However, Fhit expression was lost or reduced in a minor fraction of HCC tissues, while it was strongly expressed in non-cancerous liver tissues. Therefore, our study suggests that FHIT plays a role in relatively few HCC cases in South Korea.

Mitotic checkpoint gene MAD1 in hepatocellular carcinoma is associated with tumor recurrence after surgical resection.

OBJECTIVE: Underlying mechanism of mitotic checkpoint gene mitosis arrest deficiency 1 (MAD1) in human hepatocellular carcinoma (HCC) is rarely known. MATERIALS AND METHODS: We studied genetic change of the MAD1 gene as well as protein expression in 44 HCC and their associated non-cancerous surrounding liver tissues. RESULTS: Genotype AG of MAD1 G-1849 A promoter was highly significant in microscopic vascular invasion than other genotypes (P = 0.006). Moreover, the mean tumor size of HCC with genotype AG (7.71 cm) was significantly larger than those of other genotypes (AA, 4.41 cm; GG, 4.59 cm; P = 0.033). After a median follow-up of 22 months, 18 (41%) of the 44 patients relapsed. Eleven (32.4%) of 34 with MAD1 protein expression and 7 (70%) of 10 with no expression of MAD1 protein showed tumor recurrence. The incidence of tumor recurrence in patients with the lost MAD1 expression was significantly higher than in those with the expressed MAD1 protein (P = 0.011). CONCLUSION: These results suggest that MAD1 promoter genotype may be involved in tumor progression. Moreover, the loss of MAD1 protein expression may be related to the tumor recurrence after surgical resection of HCC.

Fixed dose rate infusion of gemcitabine with oral doxifluridine and leucovorin for advanced unresectable pancreatic cancer: a phase II study.

The standard beneficial chemotherapy proven for patients with advanced pancreatic cancer is a regimen containing gemcitabine. In the pregemcitabine era, 5-fluorouracil (5-FU) was the standard agent. Oral 5-FU can be added to gemcitabine to improve the efficacy of chemotherapy and to provide better patient convenience. The possibility to improve efficacy of gemcitabine by fixed dose rate infusion (FDRI) was proposed in addition to combining it with 5-FU. We tried a new chemotherapy combining FDRI of gemcitabine with doxifluridine and leucovorin. Eligibility criteria were pathologically proven, chemotherapy-naïve, and metastatic or nonoperable advanced pancreatic cancer. Gemcitabine 1,000 mg/m(2) was infused over 100 min (days 1, 8 and 15). Doxifluridine 200 mg/m(2) t.i.d. and leucovorin 15 mg b.i.d. were given orally (days 1-21). Chemotherapy was repeated every 28 days until a patient had received 6 cycles or progression was found. Twenty-nine patients were enrolled from October 2002 to December 2004. A total of 78 cycles were given at a mean of 2.7 cycles per patient. Response could be evaluated in 26 patients. Responses were partial remission in 4/26 patients (15.4%), stable disease in 8/26 (30.8%) and progression in 14/26 (53.8%). All patients progressed except for 2 in partial remission and 2 in stable disease. Toxicities could be assessed in 23 patients. Maximal hematological toxicities greater than grade 2 were leucopenia in 3 patients (11.5%), neutropenia in 2 (7.7%), anemia in 2 (7.7%), thrombocytopenia in 1 (3.8%) and febrile neutropenia in 3 (11.5%). Maximal nonhematological grade 3 or 4 toxicities were asthenia in 1 patient (3.8%), anorexia in 1 (3.8%), vomiting in 1 (3.8%), diarrhea in 2 (7.7%), allergic reaction in 1 (3.8%), hand-foot syndrome in 1 (3.8%) and hyperbilirubinemia in 1 (3.8%). All 29 patients were dead on last follow-up. Median progression-free survival was 3.91 months in 26 evaluable patients and median overall survival was 5.59 months in all patients. Combination chemotherapy including FDRI of gemcitabine seems minimally active for patients with advanced, nonoperable pancreatic cancer. Further research to improve effectiveness of chemotherapy for advanced pancreatic cancer is mandatory.

[Hemobilia from pancreatic arteriovenous malformation: successful treatment with transportal coil embolization of draining veins].

Pancreatic arteriovenous malformations (AVM) are extremely rare diseases frequently complicated by gastrointestinal hemorrhage. While surgical resection of affected lesion is preferred for the treatment of pancreatic AVM, angiographic intervention can be used as an alternative treatment, especially in surgically high-risk patients. We experienced a patient with pancreatic AVM manifested by hemobilia and biliary sepsis. Superior mesenteric and common hepatic arteriography showed pancreaticoduodenal AVM composed of nidus supplied by numerous fine feeding arteries and of draining veins encircling the common bile duct (CBD). Hemobilia was controlled by transportal coil embolization of draining veins of AVM around the CBD. Herein, we report this case with the review of literatures.

Benign retroperitoneal schwannoma: surgical consideration.

Schwannoma, which arises from the neural sheath of peripheral nerves, is the most common benign tumor in the retroperitoneum in adults. Complete excision is the treatment of choice for retroperitoneal schwannoma. During surgery, it seems to be unnecessary to identify the small peripheral nerve from which it develops. Keeping a dry field, however, through meticulous control of fine vasculature is of primary importance to avoid inadvertent injury to any of the adjacent organs, large vessels or important nerves. There are few vessels, if any, on the anterior and lateral surfaces of the tumor. Numerous small vessels to and from the tumors are located at its posterior and medial (aortic) aspects, without forming large trunks. Harmonic scalpel may be a good armamentarium in this area. In conclusion, considering such multiple small tumor vessels running adjacent to the aorta, the surgeon should pay close attention to the course of central dissection of these tumors in the retroperitoneum.

Duodenal duplicated cyst manifested by acute pancreatitis and obstructive jaundice in an elderly man.

A duodenal duplication cyst is an uncommon congenital anomaly that is usually encountered during infancy or in early childhood. Duodenal duplication cysts generally appear on the first or second portion of the duodenum and may cause duodenal obstruction, hemorrhage or pancreatitis. Here, we report a case of a duodenal duplication cyst on the second and third portion of the duodenum in an old aged man with obstructive jaundice and acute pancreatitis, which was treated successfully by a surgical excision.

A case of simultaneous xanthogranulomatous cholecystitis and carcinoma of the gallbladder.

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder. Not only does XGC occasionally present as a mass formation with adjacent organ invasion like a malignant neoplasm, it can also infrequently be associated with gallbladder cancer. In the situation, it is difficult to make a differential diagnosis between the diseases. Here, we describe a case of a simultaneous XGC and a carcinoma of the gallbladder in a 61-year-old woman. To the best of our knowledge, there are only a small number of reports on this combination of diseases.

Gemcitabine therapy in patients with advanced pancreatic cancer.

BACKGROUND: Advanced, unresectable pancreatic cancer is an extremely aggressive disease. The 5-year survival rate for pancreatic cancer is only less than 5%. Current therapeutic options for patients with locally advanced or metastatic disease are limited. This analysis is a retrospective evaluation of the efficacy and toxicity of gemcitabine regimen as first-line chemotherapy in patients with advanced pancreatic cancer. METHODS: Seventeen chemotherapy-naive patients with advanced or recurred pancreatic cancer were consecutively treated. Gemcitabine was diluted in normal saline and administered intravenously over 1 hour. Gemcitabine 1,000 mg/m2 was administered once weekly for 3 out of every 4 weeks. RESULTS: The median age of patients was 55 years (range 44-82 years). Based on RECIST criteria, there were 5 cases of stable disease (45%) and 6 cases of progressive disease (55%) among the 11 assessable patients. The median survival time was 189 days (range, 84 to 409 days), the 1 year survival rate was 18% in all 17 patients. Grade 3-4 toxic side effect was leucopenia only (29%) and was easily managed without infection. CONCLUSION: Gemcitabine is well tolerated, but has no objective response in advanced pancreatic cancer.