Impacts of sleeve gastrectomy on gastroesophageal reflux disease in severely obese Korean patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has established popularity as a bariatric and metabolic surgery. However, the incidence of gastroesophageal reflux disease (GERD) following LSG is controversial. This study aims to describe the prevalence of de novo GERD after LSG. METHODS: A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms. RESULTS: The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p = 0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B = 15 (11.5%), C = 4 (3.1%), and D = 6 (4.6%). CONCLUSION: In this study, 42.3% (n = 55) of total patients developed newly developed GERD, and 7.7% (n = 10) had LA grade C or D esophagitis.

Outcomes of primary sleeve gastrectomy versus conversion sleeve gastrectomy in morbidly obese patients.

PURPOSE: Our aim for this study was to evaluate early and late complications and outcomes of primary sleeve gastrectomy (PSG) versus conversion sleeve gastrectomy (CSG). METHODS: From February 2013 to December 2016, a total of 180 patients underwent sleeve gastrectomy (150 PSG and 30 CSG). All patients received a metal clipping at the end of the stapling line and a continuous seromuscular suture at the resection margin, for reinforcement. RESULTS: There were no differences in the percentages among males and females or age between the 2 groups, but the body mass index (BMI) of the PSG group was higher at 36.8 ± 4.7 than that of the CSG group (32.4 ± 5.7, P < 0.001). Three early postoperative complications were noted in the PSG group; 1 patient underwent repeat laparoscopic exploration due to pancreatic injury, and 2 other patients developed pulmonary atelectasis. On the contrary, 2 early minor complications were noted in the CSG group. Thirty-eight patients (25.3%) in the PSG group developed 43 late, minor complications, while 9 patients (30.0%) developed 11 late minor and 1 major complication in the CSG group. However, there was no difference in complication rate between PSG and CSG. Percentage excess BMI loss at 3, 6, and 12 months after surgery was comparable between the groups. CONCLUSION: PSG and CSG were comparable in terms of postoperative complications and loss of weight. Therefore, CSG could be used for failed primary restrictive bariatric surgery. However, the durability of these outcomes remains unknown.

Recurrence Rates and Characteristics of Phyllodes Tumors Diagnosed by Ultrasound-guided Vacuum-assisted Breast Biopsy (VABB).

BACKGROUND/AIM: Recently, the development of ultrasonography (US)-guided vacuum-assisted breast biopsy (VABB) has enabled the excision of benign breast tumors with normal surrounding breast tissues; thus, complete excision is possible without residual tumor tissue. We sought to identify the clinicopathological characteristics and recurrence rates of benign phyllodes tumors diagnosed by US-guided VABB. PATIENTS AND METHODS: Data from 11,221 US-guided VABBs performed at the Gangnam Cha Medical Center over 12 years were analyzed. Eighty-three lesions were diagnosed as benign phyllodes tumors; 67 with >24 months of follow-up data were investigated. All lesions were excised using an 8-gauge probe without residual tissue; patients underwent follow-up US every 3-6 months. RESULTS: Five patients (7.46%) experienced local recurrence during a mean follow-up period of 27.8 months; no distant metastases occurred. The mean tumor size was 3.0 cm in the recurrence group and 1.87 cm in the non-recurrence group (p=0.05). CONCLUSION: Benign phyllodes tumors excised and diagnosed using VABB showed a low recurrence rate during the follow-up period; thus, these tumors, particularly those <3 cm, can be safely monitored with ultrasonography instead of performing immediate re-excision.

Clinicopathological Analysis of Ultrasound-guided Vacuum-assisted Breast Biopsy for the Diagnosis and Treatment of Breast Disease.

BACKGROUND/AIM: To evaluate the usefulness and safety of vacuum-assisted breast biopsy (VABB) for breast lesion diagnosis and treatment. PATIENTS AND METHODS: Clinical and histopathological data of 8,748 patients, who underwent 11,221 VABB procedures were analyzed. RESULTS: Most patients (58.2%) were <40 years old. Most lesions (39.6%) were 0.6-1.0 cm in diameter while 3.2% were ≥3.0 cm; fibroadenomas were the most common (46.6%). Eight (14% of 57) cases of atypical ductal hyperplasia were underestimated. The positive predictive values (PPVs) of breast imaging reporting and data system (BI-RADS) ultrasound category were 0.6%, 3.4%, 34.8%, 66.2%, and 93.8% for category 3, 4a, 4b, 4c, and 5 lesions, respectively. The mean number of core specimens was 9.5±8.8; the mean procedure time was 3.4±2.7 min. No residual lesions were found in 94.4% of the 7,480 patients. CONCLUSION: VABB could replace ultrasound-guided core biopsy and surgical excisional biopsy for the diagnosis of breast disease and the treatment of benign breast lesions.

Clinically suspected T4 colorectal cancer may be resected using a laparoscopic approach.

BACKGROUND: The role of laparoscopic resection in patients with clinically suspicious T4 colorectal cancer remains controversial. The aim of this study was to compare the long-term and oncologic outcomes of laparoscopic resection and the open approach in clinical T4 colorectal cancer. METHODS: Two hundred ninety-three consecutive patients undergoing curative surgery for colorectal cancer suspected to be T4 by computed tomography and/or magnetic resonance imaging were reviewed. RESULTS: Despite clinical suspicion of T4 disease in all cases, concordance with pathologic determination of T4 was only 37.9 %. Of the 71 patients in the laparoscopic group, four (5.6 %) were converted to the open technique. Patients in the laparoscopic group had significantly lower estimated blood loss (p < 0.001), fewer days to first flatus (p = 0.001), shorter length of hospital stay (p < 0.001), and fewer adverse events (14.1 % versus 31.5 %, p = 0.004). After a median follow-up of 36 months, 5-year disease-free survival was not significantly different between the two groups (81.8 % in laparoscopic versus 73.9 % in open surgery, p = 0.433). The clinical factors that predicted T4 staging on pathologic examination were found to be male sex (p = 0.038), preoperative carcinoembryonic antigen status (p = 0.021), clinical N status (p = 0.046), and clinical cancer perforation (p = 0.004). CONCLUSIONS: Laparoscopic colorectal resection for T4 colorectal cancer has perioperative and long-term oncologic outcomes similar to those of the open approach when performed by an experienced surgeon.

Risk Factors of Anastomotic Leakage and Long-Term Survival After Colorectal Surgery.

Anastomotic leakage (AL) is one of the most serious complications of colorectal surgery. It can affect long-term oncologic outcomes, but the impact on long-term survival remains uncertain. The aim of this study is to evaluate the operative characteristics of leakage and no leakage groups and to analyze long-term oncologic outcomes.We prospectively enrolled 10,477 patients from 2000 to 2011 and retrospectively reviewed the data.Male sex (odds ratio [OR], 3.90; P < 0.001), intraoperative transfusion (OR, 2.31; P = 0.042), and operative time (OR, 1.73; P = 0.032) were independent risk factors of AL in the colon. In the rectum, male sex (OR, 2.37; P < 0.001), neoadjuvant chemoradiotherapy (OR, 2.26; P < 0.001), and regional lymph node metastasis (OR, 1.43; P = 0.012) were independent risk factors of AL, and diverting stoma (OR, 0.24; P < 0.001) was associated with a deceased risk of AL. AL in the rectum without a diverting stoma was associated with disease-free survival (DFS, OR, 1.47; P = 0.037). Colonic leakage was not associated with 5-year DFS (leakage group vs nonleakage group, 72.4% vs 80.9%, P = 0.084); however, in patients undergoing rectal resection, there was a significant difference in 5-year DFS (67.0% vs 76.6%, P = 0.005, respectively).AL in the rectum is associated with worse long-term DFS and overall survival. A diverting stoma was shown to protect against this effect and was associated with long-term survival in rectal surgery. Therefore, creating a diverting stoma should be considered in high-risk patients undergoing rectal surgery.

Prognostic comparison between mucinous and nonmucinous adenocarcinoma in colorectal cancer.

Mucinous adenocarcinoma (MAC) is a histological subtype of colorectal cancer. The oncologic behavior of MAC differs from nonmucinous adenocarcinoma (non-MAC). Our aim in this study was to characterize patients with colorectal MAC through evaluation of a large, institutional-based cohort with long-term follow-up. A total of 6475 patients with stages I to III colorectal cancer who underwent radical surgery were enrolled from January 2000 to December 2010. Prognostic comparison between MAC (n = 274, 4.2%) and non-MAC was performed. The median follow-up period was 48.0 months. Patients with MAC were younger than those without MAC (P = 0.012) and had larger tumor size (P < 0.001), higher preoperative carcinoembryonic antigen (P < 0.001), higher pathologic T stage (P < 0.001), more right-sided colon cancer (49.3%, P < 0.001), and more frequent high-frequency microsatellite instability (10.2%, P < 0.001). Five-year disease-free survival (DFS) was 76.5% in the MAC group and 83.2% in the non-MAC group (P = 0.008), and 5-year overall survival was 81.4% versus 87.4%, respectively (P = 0.005). Mucinous histology (MAC vs non-MAC) in the entire cohort was not an independent prognostic factor of DFS but had a statistical tendency (P = 0.071). In subgroup analysis of colon cancer without rectal cancer, mucinous histology was an independent prognostic factor (P = 0.026). MAC was found at more advanced stage, located mainly at the right side and was an independent factor of survival in colon cancer. Because of the unique biological behavior of MAC, patients with MAC require special consideration during follow-up.

Perioperative and oncologic outcomes of single-incision laparoscopy compared with conventional laparoscopy for colon cancer: an observational propensity score-matched study.

Single-incision laparoscopic (SIL) surgery is a recent advance in minimally invasive surgical techniques. From May 2011 to August 2012, 77 patients underwent primary SIL surgery for colon cancer by one colorectal surgeon. Among them, 61 patients were one-to-one-matched to control patients who had undergone conventional laparoscopic (CL) surgery with a propensity-matched score, and the outcomes were compared. Two hundred forty-seven patients with colon cancer underwent radical colectomy. Of these, 77 patients underwent SIL colectomy. After matching, there were no significant differences in the general characteristics between the patients undergoing the two types of surgery. Operation time was significantly longer in SIL surgery (139 vs 121 minutes, P = 0.001), but procedure time (107 vs 99 minutes, P = 0.069) was not significantly longer than CL surgery after eliminating closure time (31 vs 22 minutes, P < 0.001) from the operation time. There was no significant difference in postoperative complications between the two groups (3.3 vs 1.6%, P = 1.000). The mean number of harvested lymph nodes was 23 and 22 for SIL and CL surgery, respectively (P = 0.332). The mean follow-up period was 15.7 for the SIL group and 21.4 months for the CL group (P < 0.001) with two recurrences in the SIL group (3.3%) and three recurrences in the CL group (4.9%, P = 1.000). Disease-free survival at 20 months did not differ significantly between the two groups (93.3 vs 94.7%, P = 0.939). SIL for colonic malignancy can be safely applied for various types of operations and can provide equivalent oncologic resection and perioperative outcomes compared with CL surgery.

A circumferential resection margin of 1 mm is a negative prognostic factor in rectal cancer patients with and without neoadjuvant chemoradiotherapy.

BACKGROUND: There is ongoing debate about the appropriate criterion for defining a positive circumferential resection margin after radical surgery for rectal cancer. OBJECTIVE: The purpose of this work was to determine the importance of the extent of the circumferential resection margin with regard to outcomes in patients with rectal cancer who underwent total mesorectal excision with and without neoadjuvant chemoradiotherapy. DESIGN: This was a retrospective review of prospectively collected data. SETTINGS: The study was conducted in a tertiary care hospital. PATIENTS: We reviewed the medical charts of 780 patients with rectal cancer who underwent radical surgery from 2004 to 2009. There were 599 patients (76.8%) who did not receive neoadjuvant chemoradiotherapy and 181 patients (23.2%) who did. MAIN OUTCOME MEASURES: The relationship between the extent of the circumferential resection margin (0.5, 1.0, 2.0, and 3.0 mm) and recurrence and survival was assessed. RESULTS: Among circumferential resection margins ≤0.5, ≤1.0, ≤2.0, and ≤3.0 mm, the HR was highest and disease-free survival was longest for a circumferential resection margin ≤1 mm in both the chemoradiotherapy and nonchemoradiotherapy groups. A circumferential resection margin ≤1 mm, lymphatic invasion, histology, pathologic T category, pathologic N category, preoperative CEA, and adjuvant chemotherapy were independent predictors of disease-free survival in the nonchemoradiotherapy group. In the chemoradiotherapy group, a circumferential resection margin ≤1 mm and histology were independent predictors of disease-free survival. Multivariate analysis revealed that a circumferential resection margin ≤1 mm was an independent prognostic factor for overall survival in both of the 2 groups. LIMITATIONS: This was a single-institution, retrospective study. CONCLUSIONS: A circumferential resection margin of ≤1 mm had a strong association with disease-free survival compared with circumferential resection margins ≤0.5, ≤2.0, and ≤3 mm. A circumferential resection margin ≤1 mm was an independent predictor of a poor outcome in both the nonchemoradiotherapy and chemoradiotherapy groups.

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.