Age Over 80 is a Possible Risk Factor for Postoperative Morbidity After a Laparoscopic Resection of Colorectal Cancer.

PURPOSE: With extended life expectancy, the mean age of patients at the time of diagnosis of colorectal cancer and its treatment, including radical resection, is increasing gradually. We aimed to evaluate the impact of age on postoperative clinical outcomes after a laparoscopic resection of colorectal cancers. METHODS: This is a retrospective review of prospectively collected data. Patients with primary colorectal malignancies or premalignant lesions who underwent laparoscopic colectomies between January 2009 and April 2013 were identified. Patients were divided into 6 groups by age using 70, 75, and 80 years as cutoffs: younger than 70, 70 or older, younger than 75, 75 or older, younger than 80, and 80 or older. Demographics, pathological parameters, and postoperative clinical outcomes, including postoperative morbidity, were compared between the younger and the older age groups. RESULTS: All 578 patients underwent a laparoscopic colorectal resection. The overall postoperative complication rate was 21.1% (n = 122). There were 4 cases of operative mortality (0.7%). Postoperative complication rates were consistently higher in the older groups at all three cutoffs; however, only the comparison with a cutoff at 80 years showed a statistically significant difference between the younger and the older groups. CONCLUSION: Age over 80 is a possible risk factor for postoperative morbidity after a laparoscopic resection of colorectal cancer.

100 cases of endoscopic thyroidectomy: breast approach.

Neck surgery is one of the newest fields of endoscopic surgical application. One hundred patients underwent endoscopic thyroidectomy. We used 3 incisions: 1 on both upper circumareolar areas and 1 approximately 3 cm below the clavicle on the tumor side. Subplatysmal and subcutaneous operative space was created with CO2 insufflation at 6 mm Hg of pressure. The thyroidal vessels and the parenchyma of the gland were dissected and divided with ultrasonic scalpel and commonly used laparoscopic instruments. The mean (+/-SD) operation time was 136 +/- 10 minutes before the year 2000 and 67 +/- 9 in the year 2000 (P < 0.05). There were six cases of conversion to conventional thyroidectomy. Postoperative complications occurred in five cases. There was no subcutaneous emphysema. The patients were satisfied with the cosmetic result. On the basis of our experience with these 100 patients, we believe that endoscopic thyroidectomy is feasible and safe for resection of thyroid tumors. Thus, this procedure will provide another surgical technique for treatment of thyroid tumors, with maximized cosmetic effect.(2)

Thyroid hormone levels and incident chronic kidney disease in euthyroid individuals: the Kangbuk Samsung Health Study.

BACKGROUND: Overt and subclinical hypothyroidism are associated with higher levels of serum creatinine and with increased risk of chronic kidney disease (CKD). The prospective association between thyroid hormones and kidney function in euthyroid individuals,however, is largely unexplored. METHODS: We conducted a prospective cohort study in 104 633 South Korean men and women who were free of CKD and proteinuria at baseline and had normal thyroid hormone levels and no history of thyroid disease or cancer. At each annual or biennial follow-up visit, thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and free thyroxin (FT4) levels were measured by radioimmunoassay. The study outcome was incident CKD, defined as an estimated glomerular filtration rate (eGFR)<60 ml/min/1.73 m2 based on the Chronic Kidney Disease Epidemiology Collaboration creatinine equation. RESULTS: After a median follow-up of 3.5 years, 1032 participants developed incident CKD.There was a positive association between high-normal levels of TSH and increased risk of incident CKD. In fully-adjusted models including baseline eGFR, the hazard ratio comparing the highest vs the lowest quintiles of TSH was 1.26 [95% confidence interval (CI) 1.02 to 1.55; P for linear trend=0.03]. In spline models, FT3 levels below 3 pg/ml were also associated with increased risk of incident CKD. There was no association between FT4 levels and CKD. CONCLUSIONS: In a large cohort of euthyroid men and women, high levels of TSH and low levels of FT3, even within the normal range, were modestly associated with an increased risk of incident CKD.

Thyroid hormones and mortality risk in euthyroid individuals: the Kangbuk Samsung health study.

CONTEXT: Hyperthyroidism and hypothyroidism, both overt and subclinical, are associated with all-cause and cardiovascular mortality. The association between thyroid hormones and mortality in euthyroid individuals, however, is unclear. OBJECTIVE: To examine the prospective association between thyroid hormones levels within normal ranges and mortality endpoints. SETTING AND DESIGN: A prospective cohort study of 212 456 middle-aged South Korean men and women who had normal thyroid hormone levels and no history of thyroid disease at baseline from January 1, 2002 to December 31, 2009. Free T4 (FT4), free T3 (FT3), and TSH levels were measured by RIA. Vital status and cause of death ascertainment were based on linkage to the National Death Index death certificate records. RESULTS: After a median follow-up of 4.3 years, 730 participants died (335 deaths from cancer and 112 cardiovascular-related deaths). FT4 was inversely associated with all-cause mortality (HR = 0.77, 95% confidence interval 0.63-0.95, comparing the highest vs lowest quartile of FT4; P for linear trend = .01), and FT3 was inversely associated cancer mortality (HR = 0.62, 95% confidence interval 0.45-0.85; P for linear trend = .001). TSH was not associated with mortality endpoints. CONCLUSIONS: In a large cohort of euthyroid men and women, FT4 and FT3 levels within the normal range were inversely associated with the risk of all-cause mortality and cancer mortality, particularly liver cancer mortality.

Pain after laparoscopic appendectomy: a comparison of transumbilical single-port and conventional laparoscopic surgery.

PURPOSE: Conventional laparoscopic appendectomy is performed using three ports, and single-port appendectomy is an attractive alternative in order to improve cosmesis. The aim of this study was to compare pain after transumbilical single-port laparoscopic appendectomy (SA) with pain after conventional three-port laparoscopic appendectomy (TA). METHODS: From April to September 2011, 50 consecutive patients underwent laparoscopic appendectomy for simple appendicitis without gangrene or perforation. Patients who had undergone appendectomy with a drainage procedure were excluded. The type of surgery was chosen based on patient preference after written informed consent was obtained. The primary endpoint was postoperative pain evaluated by the visual analogue scale score and postoperative analgesic use. Operative time, recovery of bowel function, and length of hospital stay were secondary outcome measures. RESULTS: SA using a SILS port (Covidien) was performed in 17 patients. The other 33 patients underwent TA. Pain scores in the 24 hours after surgery were higher in patients who underwent SA (P = 0.009). The change in postoperative pain score over time was significantly different between the two groups (P = 0.021). SA patients received more total doses of analgesics (nonsteroidal anti-inflammatory drugs) in the 24 hours following surgery, but the difference was not statistically significant. The median operative time was longer for SA (P < 0.001). CONCLUSION: Laparoscopic surgeons should be concerned about longer operation times and higher immediate postoperative pain scores in patients who undergo SA.

Comparison of radiofrequency ablation and resection for hepatic metastasis from colorectal cancer.

BACKGROUND/AIMS: Radiofrequency ablation (RFA) has been mostly used as a therapeutic alternative to hepatic resection for treating liver metastasis of colorectal cancer. The purpose of the present study was to determine whether there were differences in outcome between RFA and surgical resection in the treatment of colorectal cancer with liver metastases. METHODS: We performed a retrospective analysis of 53 patients who underwent only hepatic resection or only RFA for colorectal liver metastases. Twenty-five patients who underwent hepatic resection were compared with 28 patients who underwent RFA for synchronous or metachronous liver metastases. RESULTS: The median CEA level at the time of diagnosis of liver metastases was significantly higher in the resection group (14.2 ng/mL vs. 2.8 ng/mL, p=0.002). The median size of main liver metastases was significantly larger in the resection group (4.0 cm vs. 2.05 cm, p=0.002). There was no difference in the percentage of patients experiencing major complication (one patient in each group). The marginal recurrence rate was significantly higher in the RFA group (p=0.004). Disease-free and overall survival were longer in the resection group (p=0.008 and 0.017, respectively). In multivariate analysis, only the type of treatment was a factor associated with disease-free and overall survival (p=0.004 and 0.007, respectively). CONCLUSIONS: Because of the high marginal recurrence rate, RFA shows an inferior outcome in comparison with surgical resection. Therefore, RFA should be considered for only selected patients with unresectable (by any means) disease or with high operative risk.

Laparoscopic totally extraperitoneal repair without suprapubic port: comparison with conventional totally extraperitoneal repair.

PURPOSE: We have treated 24 patients through laparoscopic totally extraperitoneal (TEP) repair without suprapubic port by using reliability and reducing the invasiveness of two surgery. This study is aimed to assess the safety and feasibility of the TEP repair without suprapubic port compared to conventional TEP repair. METHODS: From September 2007 to 11 May 2010, we compared two groups that suffer from inguinal hernias. One is comprised of 24 patients who were treated without suprapubic port laparoscopic totally extraperitoneal repair (Group A), and the other is comprised of 100 patients who were treated with conventional laparoscopic totally extraperitoneal repair (Group B). Data regarding patient demographics (sex, age, site of hernia, and the type of hernia), operating time, postoperative hospital stay, the use of analgesics, and complications were prospectively collected. RESULTS: There was no significant difference noted between two groups in relation to sex, age, site, and the type of hernia. The mean operating time and postoperative hospital stay was longer for the Group B (62.9 minutes, 3.55 days) than for the Group A (59.0 minutes, 2.54 days) (P = 0.389, P < 0.001). Postoperative urinary retention, seroma, wound infection were respectively 4.2%, 8.3%, 0% in Group A, and 12.0%, 8.0%, 7% in group B. There was difference between the two groups, but not statistical significance. Group B used more analgesics than Group A (0.33 vs. 0.48), but it wasn't significant statistically (P = 0.234). CONCLUSION: Although prospective randomized studies with long-term follow-up evaluation are needed to confirm our study between laparoscopic totally extraperitoneal repair without suprapubic-port and conventional laparoscopic totally extraperitoneal repair, our method have some advantages in postoperative pain, urinary retention, operating time, postoperative hospital stay, and cosmetic effect.

HER-2/neu overexpression is an independent prognostic factor in colorectal cancer.

BACKGROUND AND AIMS: The HER-2/neu protein is intimately involved with normal cell proliferation and tissue growth, as it is extensively homologous and is related to the epidermal growth factor receptor. This phenomenon has been most intensively studied in the context of breast carcinoma, in which its amplification and overexpression correlate with the overall course of disease and poor prognoses, and also constitute a predictive factor of poor response to chemotherapy and endocrine therapy. In this study, we investigated the relationships between the expression of HER-2/neu and the clinicopathological characteristics of colorectal cancer, including survival. This study was performed with a view toward the future introduction of Herceptin therapy for colorectal cancer patients. PATIENTS AND METHODS: HER-2/neu overexpression and gene amplification were examined via semiquantitative standardized immunohistochemical staining and fluorescence in situ hybridization (FISH) in 137 colorectal cancer patients who underwent curative surgery at the Kangbuk Samsung Hospital. RESULTS: Sixty-five (47.4%) out of 137 patients were determined by immunohistochemistry to have overexpressed HER-2/neu protein. HER-2/neu gene amplification was detected in two patients by FISH. Tumors with HER-2/neu overexpression showed higher postoperative recurrence rate (39.3% vs 14.6%, p=0.013). Tumors with HER-2/neu overexpression were associated with poor 3-year (70.8% vs 83.7%) and 5-year survival rates (55.1% vs 78.3%, p<0.05). Advanced TNM stage, postoperative recurrence, and overexpression of HER-2/neu were found to be independently related to survival by multivariate analysis. CONCLUSION: HER-2/neu overexpression may constitute an independent prognostic factor in colorectal cancer patients, and patients exhibiting HER-2/neu overexpression might constitute potential candidates for a new adjuvant therapy which involves the use of humanized monoclonal antibodies.

Proximal gastrectomy reconstructed by jejunal pouch interposition for upper third gastric cancer: prospective randomized study.

Proximal gastrectomy with jejunal pouch interposition (PGJP) has been advocated as an alternative operation for upper third gastric cancer. However, there has been no prospective randomized trial comparing PGJP with total gastrectomy with Roux-en-Y esophagojejunostomy (TGRY). The aim of this study was to compare the short- and medium-term results of PGJP and TGRY in a randomized clinical trial. Fifty-one patients with upper third gastric cancer were randomized to either PGJP (n = 25) or TGRY (n = 26). Outcome measures were postoperative complications, nutritional status assessed by serum nutritional parameters, and postgastrectomy symptoms. There were no significant differences in operating time, hospital stay, and postoperative complications. Blood loss was significantly less in the PGJP group (P = 0.036). Nineteen patients (73%) in the TGRY group had one or more postgastrectomy symptoms, which was significantly more frequent than in the PGJP group (32%; P = 0.012). There were also significant differences between the two groups with regard to food intake, weight recovery, hemoglobin, and serum vitamin B12 levels in favor of PGJP. In conclusion, proximal gastrectomy with jejunal pouch interposition for upper third gastric cancer is safe, and is associated with a greater reduction in postgastrectomy symptoms and better nutritional status compared with conventional total gastrectomy.

Long-term results of proximal and total gastrectomy for adenocarcinoma of the upper third of the stomach.

PURPOSE: The choice of surgical strategy for patients with adenocarcinoma of the upper one third of the stomach is controversial. This study was performed to analyze the surgical results of a 11-year experience with these lesions. MATERIALS AND METHODS: From January 1990 to December 2000, 259 patients with upper third gastric cancer underwent proximal gastrectomy (n=74) or total gastrectomy (n=185) through an abdominal approach. Morbidity, mortality, recurrence patterns, and survival were compared between these two groups retrospectively. RESULTS: There were no significant differences in general complication and mortality rates between the two groups. However, the incidences of reflux esophagitis (16.2%) and anastomotic stricture (35.1%) were more common in the proximal gastrectomy group compared with the total gastrectomy group (0.5 and 8.1%). Regarding the main patterns of recurrence, local recurrence was dominant in the proximal gastrectomy group, whereas distant recurrence was dominant in the total gastrectomy group. Five-year overall survival (54.8 versus 47.8%) and survival according to tumor stage were no different between the groups. Multivariate analysis showed that the extent of resection was not an independent prognostic factor. CONCLUSION: The extent of resection for upper third gastric cancer did not appear to affect long-term outcome. However, proximal gastrectomy is associated with an increased risk of reflux esophagitis, anastomotic stricture, and local recurrence.

Analysis of Local Recurrence Following Proximal Gastrectomy in Patients with Upper Third Gastric Cancer.

PURPOSE: Little is known about local recurrence following proximal gastrectomy in patients with upper third gastric cancer. We performed this study to evaluate the long-term results of a proximal gastrectomy, and to analyze the risk factors of local recurrence affecting survival in these patients. MATERIALS AND METHODS: We undertook a retrospective study of 63 patients who underwent potentially curative proximal gastrectomy between 1990 and 1999, with special reference to local recurrence. RESULTS: During a median follow-up period of 37 months, 25 of the 63 patients (39.7%) developed a recurrence of cancer, with local recurrence in 15 patients (23.8%), the majority of these occurring at the remnant stomach or anastomosis. The median time to local recurrence was 38 months (8~78 months). Univariate analysis of risk factors for local recurrence revealed an infiltrative or diffuse gross type, with a tumor sizes>5 cm, a distal resection margin

Nasogastric decompression is not necessary in operations for gastric cancer: prospective randomised trial.

OBJECTIVE: To assess the need for routine nasogastric decompression after extensive resections in patients with gastric cancer. DESIGN: Prospective randomised study. SETTING: University hospital, Korea. SUBJECTS: Over a 1-year period (July 1999-July 200), 136 patients with gastric cancer who underwent radical gastrectomy with D2 or more lymph node dissection. INTERVENTIONS: Randomised to have nasogastric decompression (n = 69) or not (n = 67). MAIN OUTCOME MEASURES: Postoperative course, morbidity, and mortality. RESULTS: Time to passage of first flatus, time to taking liquid diet, length of operation, and postoperative hospital stay were all significantly shorter in the no decompression group. Two patients in each group required subsequent nasogastric decompression. There were no significant differences between the two groups concerning the presence of postoperative fever, nausea, vomiting, anastomotic leaks, or pulmonary or wound complications. No patients died. CONCLUSIONS: Routine nasogastric decompression is not necessary in elective operations for gastric cancer.

Predictive value of preoperative serum CEA, CA19-9 and CA125 levels for peritoneal metastasis in patients with gastric carcinoma.

PURPOSE: Peritoneal metastasis is a crucial factor for the prognosis in gastric cancer, but its diagnosis is difficult before laparotomy. This study analyzed the usefulness of diagnostic imaging and various tumor markers in the detection of peritoneal metastasis in gastric cancer. MATERIALS AND METHODS: The sera from 768 patients with gastric cancer were measured for CEA, CA19-9 and CA125 levels using a commercial immunoradiometric assay. All the patients underwent diagnostic imaging with computed tomography (CT) and ultrasound (US) before laparotomy. RESULTS: Preoperative levels of CEA, CA19-9 and CA125 were above the cut-off levels in 15.4%, 8.7% and 5.7% of all cases, respectively. Eighty-eight patients were diagnosed with peritoneal metastasis by laparotomy. CT and US revealed peritoneal dissemination in 15 of 88 patients (17%). Among the three tumor markers, CA19-9 and CA125 showed similar detection rates of peritoneal metastasis (37.5% and 38.6%, respectively). In particular, the serum CA125 levels showed the best sensitivity (38.6%), specificity (98.4%), and diagnostic accuracy (91.5%), and the highest odd ratio (24.46, 95% CI: 11.17 approximately 53.57) for predicting peritoneal metastasis among the markers tested. CEA did not add significant predictive information (p=0.471). CONCLUSION: Preoperative serum CA19-9 and CA125 levels may provide a predictable value in determining peritoneal metastasis in patients with gastric cancer.