Effects of Abdominal Massage for Preventing Acute Postoperative Constipation in Hip Fractures: A Prospective Interventional Study

Background@#This prospective randomized controlled study aimed to determine the effects of abdominal massage on constipation management in elderly patients with hip fractures. @*Methods@#From August 2017 to December 2018, patients aged above 65 years with hip fractures (n = 88) were randomly assigned to a massage group that received a bowel massage (n = 48) or a control group that did not receive a bowel massage (n = 40). Patients in the bowel massage group received a bowel massage from a trained caregiver after breakfast at approximately 9:00 AM for an hour. On admission, 5 days after surgery, and on the day of discharge, the patient’s normal and actual defecation pattern, stool consistency, and any problems with defecation were assessed through a structured interview. The questionnaire comprising the Bristol Stool Scale, patient assessment of constipation, time to defecation, medication for defecations, failure to defecate, cause of admission, admission period, and date of surgery were recorded. Statistical analyses were performed 5 days after surgery and on the day of discharge. @*Results@#The mean age of the study cohort was 81.4 years (range, 65–99 years). The number of constipation remedies was significantly lower in the massage group than in the control group on postoperative day (POD) 5 and at discharge (9 vs. 15, p = 0.049 and 6 vs. 11, p = 0.039, respectively). The number of defecation failures was significantly lower in the massage group than in the control group (10 vs. 17, p = 0.028) on POD 5. However, the number of defecation failures at discharge was not significantly different between the two groups ( p = 0.131). The development of postoperative ileus ( p = 0.271) and length of hospital stay ( p = 0.576) were not different between the groups. @*Conclusions@#The number of constipation remedies was significantly lower in the massage group than in the control group on POD 5 and discharge, and the number of defecation failures was significantly lower in the massage group than in the control group on POD 5. Therefore, abdominal massage may be considered as an independent nursing initiative for constipation management.

Comparison of postoperative pain after needle grasperassisted single-incision laparoscopic appendectomy versus single-incision laparoscopic appendectomy: a prospective randomized controlled trial (PANASILA trial)

Purpose@#This study was performed to compare the efficacies of newly developed needle grasper-assisted (Endo Relief) single-incision laparoscopic appendectomy (NASILA) and single-incision laparoscopic appendectomy (SILA). @*Methods@#This study enrolled 110 patients with acute appendicitis without periappendiceal abscess, diagnosed using computed tomography, who were randomized to the SILA (n = 54) and NASILA groups (n = 56) between December 2017 and August 2018 (6 patients withdrawn). The NASILA technique entailed a small umbilical incision for the glove port (equivalent to that for a 12-mm trocar), and a 2.5-mm suprapubic incision for the needle grasper. @*Results@#The SILA and NASILA groups included 49 (male, 61.2%) and 55 (male, 54.5%) patients, respectively. Age, body mass index, abdominal surgical history, symptom duration, and use of patient-controlled analgesia did not differ significantly between the 2 groups. The main wound size was significantly smaller in the NASILA group than in the SILA group (1.8 ± 0.4 cm vs. 2.2 ± 0.4 cm, P < 0.001). The operative time and estimated blood loss did not differ significantly between both groups. The immediate postoperative pain score, i.e., the primary endpoint, was significantly lower in the NASILA group than in the SILA group (2.33 ± 0.98 vs. 2.82 ± 1.29, P = 0.031). The complaints for scar status 1 month postoperatively did not differ significantly between the groups. @*Conclusion@#NASILA could attenuate postoperative pain by minimizing the size of the surgical wound; further, NASILA may not be inferior to SILA in terms of cosmetic results.

Safe Completion of Laparoscopic Anterior Resection in a Patient With a Solitary Pelvic Kidney: A Case Report

Pelvic kidney, an ectopic renal mass caused by developmental failure, is a rare condition. Here, we report a case of laparoscopic anterior resection in a patient with a solitary pelvic kidney. A 76-year-old man was diagnosed as having rectosigmoid colon cancer. Preoperative computed tomography revealed a left ectopic kidney in his pelvis. Computed tomographic angiography and retrograde pyelography were performed preoperatively to identify the renal vessels and the ureter. To keep the surgical plane intact for complete mesocolic excision, a complete laparoscopic anterior resection was safely performed without open conversion, and there was no injury to the pelvic kidney. The patient was discharged on postoperative day eight without any complication. No deterioration of renal function was observed after surgery. This report describes a case of laparoscopic anterior resection that was safely performed without conversion to open surgery in a patient with a pelvic ectopic kidney.

Erratum to: Vitamin D Deficiency Is Highly Concomitant but Not Strong Risk Factor for Mortality in Patients Aged 50 Year and Older with Hip Fracture

In this article, The author's name and Table 1 should be corrected.

The effect of laparoscopic versus robotic low anterior resection of rectum on postoperative pain: A propensity score matching analysis

PURPOSE: The aim of this study was to compare postoperative outcomes regarding pain and pain management in patients who underwent robot-assisted low anterior resection (RA-LAR) with laparoscopy-assisted low anterior resection (LA-LAR).METHODS: Medical records of adult patients who underwent LA-LAR (group L) or RA-LAR (group R) using robotic system (da Vinci Surgical System, Intuitive Surgical Inc., Sunnyvale, CA, USA) were collected prospectively at Chung-Ang University Hospital between January 1, 2010 and December 31, 2015. Patients were matched at a 1 to 1 ratio from Group L and R using propensity score-matching method. Intravenous patient-controlled analgesia (IV-PCA) was applied to the patients postoperatively, and the severity of postoperative pain visual analogue scale (VAS) and nausea as the numerical rating scale (NRS) was evaluated. The incidence of vomiting, dizziness, headache, and PCA clamping was also recorded. Additional fentanyl was administered as a rescue analgesic if the VAS score was over 3, and until VAS was less than 3.RESULTS: In the overall series, there was no significant difference between group L and group R regarding pain VAS, nausea NRS, number of vomiting episodes at day 0 and day 1. However, after propensity score analysis, pain VAS and the use of rescue analgesic at day 0 was lower in group L compared to group R (P=0.038, P=0.040).CONCLUSION: In regards to postoperative pain, RA-LAR did not show clear benefit over LA-LAR.

Vitamin D Deficiency Is Highly Concomitant but Not Strong Risk Factor for Mortality in Patients Aged 50 Year and Older with Hip Fracture

BACKGROUND: The purpose of this study was to ascertain the prevalence of vitamin D deficiency and risk factors associated with mortality in patients > or =50-year-of-age with hip fractures. METHODS: A total of 489 patients > or =50-year-of-age who sustained a hip fracture from January 2010 to October 2014 were followed-up for a minimum of 1 year. Clinical and radiological outcomes were evaluated including prevalence of vitamin D deficiency. Crude mortality rates were calculated, and the effects of different risk factors on mortality were assessed. RESULTS: Vitamin D deficiency was present in 76.5% of cases (n=237). The prevalence of vitamin D insufficiency was 12.3%, and only 11.2% of patients had normal vitamin D levels. Accumulated mortality was 11% (54 patients) at 1 year. A univariate analysis showed that vitamin D deficiency (P=0.012), age (P<0.001), BMI (P<0.001), type of management (P<0.001), American Society of Anesthesiologists (ASA) score (P=0.009), pre-fracture ambulatory status (P<0.001), and osteoporosis (P<0.001) were associated with mortality. A multivariate analysis performed using a Cox proportional hazards model demonstrated that ASA score (P=0.001) and pre-fracture ambulatory status (P=0.011) were independently associated with mortality after hip fracture. CONCLUSIONS: We did not find a relationship between serum 25-hydroxy-vitamin D levels and mortality after hip fracture, although we observed a high prevalence of vitamin D deficiency and a significant association with mortality in the univariate analysis.

Clinicopathologic Significance of BRAF Mutation and Extracellular Signal Regulated Kinase 1/2 Expression in Patients With a Colorectal Adenocarcinoma

PURPOSE: BRAF mutation and expression of extracellular signal regulated kinase (ERK) are linked with colorectal carcinogenesis through the serrated pathway. BRAF and ERK1/2 play important roles in the activation of mitogen-activated protein (MAP) kinase signaling pathways. The present study investigated the clinicopathologic outcomes of BRAF mutation and ERK1/2 expression in patients with colorectal cancer (CRC) and the possibility of using them as prognostic indicators. METHODS: Dual-priming oligonucleotide-based multiplex polymerase chain reaction for BRAF(V600E) mutation and immunohistochemical analysis of ERK1/2 were performed using 65 formalin-fixed, paraffin-embedded samples from patients with CRC. We analyzed the dependences of the clinicopathologic features on BRAF mutation and ERK1/2 expression. RESULTS: Out of 65 samples from CRC patients, BRAF mutation was detected in 3 (4.6%). The 3 patients with BRAF mutation presented with T3 CRC with lymph node metastasis (stage III) showing moderately or poorly differentiated histology. ERK1 and ERK2 were positively detected in 73.8% and 15.4% of the patients with CRC, respectively. ERK1 expression was significantly correlated with lymph node metastasis (P = 0.049). ERK2 expression was significantly correlated with tumor emboli (P < 0.05), tumor invasion (P = 0.035), lymph node metastasis (P = 0.017), and stage (P = 0.02). CONCLUSION: BRAF mutation and ERK1/2 expression may be associated with advanced or more aggressive CRC. These molecular markers might play prognostic roles in CRC developed through the serrated pathway.

Undertreatment of Osteoporosis Following Hip Fractures in Jeju Cohort Study

BACKGROUND: Osteoporosis treatment following hip fracture is well known to not enough. We previously performed intervention study for orthopaedic surgeon's education and reported twofold increase in osteoporosis detection and treatment rate observed between 2005 and 2007. This follow-up observational study was conducted to find out the rate in which a diagnostic workup and treatment for osteoporosis were done in patients with hip fracture. METHODS: Medical records and radiographs in patients who were older than 50 years and diagnosed as having femoral neck or intertrochanteric fractures at 8 hospitals in Jeju island, South Korea from 2008 to 2011 were reviewed. The numbers of patients who were studied with bone densitometry and who were treated for osteoporosis after the diagnosis of hip fracture were analyzed. RESULTS: Nine hundred forty five hip fractures (201 in 2008, 257 in 2009, 265 in 2010, and 304 in 2011) occurred in 191 men and 754 women during the study periods. The mean age of the patients was 79.7 years. The mean rate of osteoporosis detection using dual energy X-ray absorptiometry was 36.4% (344/945 hips) (ranged from 24.2% in 2009 to 40.5% in 2011). The mean initiation rate of osteoporosis treatment was 23.1% (218/945 hips) (ranged from 20% in 2009 to 29% in 2008). CONCLUSIONS: Detection and treatment rate of osteoporosis following hip fracture during follow-up periods was still not enough. Additional intervention studies are required to further improvement of osteoporosis treatment rates after hip fracture.

Omental Actinomycosis Coexisting with Colon Cancer

Actinomycosis is a rare infection caused by Actinomyces species, normal commensal inhabitants of the human bronchial and gastrointestinal tract. Infection occurs after preceding mucosal break-down by variable causes. A preoperative diagnosis is difficult because of its nonspecific clinical features, mimicking malignancy, tuberculosis or other inflammatory diseases. We report a case of abdominal actinomycosis presenting as an omental mass, which coexists with ascending colon cancer. Actinomycosis was diagnosed by histopathologic demonstration of sulfur granules in a specimen resected by laparoscopic exploration. Following surgery, the patient was treated with IV penicillin (20 million IU/day) for 3 weeks, and follow-up colonoscopy showed adenocarcinoma in the ascending colon. The patient underwent right hemicolectomy, then treated with intravenous penicillin for 4 weeks postoperatively and oral penicillin for 6 months. The patient has been free of recurrence for 6 months.

Correlation of Decreased Expressions of Claudin 4 and E-cadherin Proteins and the Clinicopathologic Factors of Stomach Cancer

PURPOSE: We examined the expressions of claudin-4 and E-cadherin, which are known as cell adhesion-associated proteins, in stomach cancer. The relationship of their expression with the clinicopathologic factors was examined to investigate the roles of these proteins in the invasion or metastasis of stomach adenocarcinoma. METHODS: The expressions of claudin-4 and E-cadherin were examined in 73 cases of adenocarcinoma of the stomach by performing immunohistochemical staining. RESULTS: The expressions of claudin-4 and E-cadherin in the stomach adenocarcinoma were both correlated with the histologic grade, the T-stage and nodal metastasis, respectively (P<0.05). The expression of claudin-4 was significantly associated with the expression of E-cadherin. CONCLUSION: Our data suggests that claudin-4 and E-cadherin are involved in the processes of histologic differentiation, invasion and metastasis of stomach adenocarcinoma.

Immunohistochemical Expression of p53 Protein and CREB-binding Protein in Gastric Adenocarcinomas

PURPOSE: The wild-type p53 protein participates in suppressing cell transformations while its mutant forms has tumorigenic potential. Alterations in the structure of the p53 protein are one of the most common changes associated with human cancers. CREB-binding protein (CBP) and its homologue, p300, are transcriptional co-activators of various sequence-specific DNA-binding transcription factors and are involved in a wide range of cellular activities, such as DNA repair, cell growth, differentiation, and apoptosis. Several studies suggested that an association between p53 and p300 might account for the p53-responsible negative regulation. This study examined the relationship between p53 and CBP expression in terms of the clinicopathological factors and significance. METHODS: The level of p53 protein and CBP expression was measured in 150 gastric adenocarcinoma patients, who had undergone a gastrectomy, and the relationship between p53 and CBP was examined. Immunohistochemical stain was performed on formalin-fixed paraffin-embedded sections using monoclonal anti-p53 and anti-CBP antibody. RESULTS: 1. p53 protein was expressed in 46.3% (31/67) of early gastric cancers (EGC), 69.9% (58/83) of advanced gastric cancers (AGC)(P0.05), 47.8% (32/67) of EGC, 69.8% (58/83) of AGC (P0.05). 3. p53 protein and CBP expression was coincidentally observed in 66.7% of gastric adenocarcinomas, and there was a significant correlation between the expression of both (P<0.05). CONCLUSION: That the expression of the p53 protein and CBP indirectly indicate the malignant potential of a cell, and may play an indirect role in the CBP and p53-mediated tumorigenic potential.

Analysis and Consideration of the Complications of Laparoscopic Cholecystectomy

PURPOSE: Laparoscopic cholecystectomy has replaced open cholecystectomy as the standard treatment and it has widely gained rapid acceptance. However, laparoscopic cholecystectomy has many complications and it can require conversion to open cholecystectomy or further management. We reviewed our cases for determining the complications and clinical results in order to improve the efficacy and safety of laparoscopic cholecystectomy in our hospital. METHODS: The data from 3,224 laparoscopic cholecystectomies that were performed at our hospital from January 1995 to December 2004 were reviewed retrospectively. The pre-operative laboratory data, operative findings, post-operative pathologic findings, complications and proper treatment were evaluated. RESULTS: 52 of all the patients developed complications. The median patient age was 51.8+/-11.6 years, and the median admission time was 29.9+/-10.6 days. The most common complications were post operative bleeding (20 case), and bile duct injury (15 cases). A collection of bile was noted in 12 cases. The treatment of complications were operations (16 case) radiologic interventions (14 case), and observation with conservative management (22 case). CONCLUSION: There were various complications of laparoscopic cholecystectomy, and these patients needed a longer hospital stay and operative treatment. So, improvement of surgeons' skill with a carefully approach and better understanding of the anatomical variations of the biliary tree and vascular system, recognition of pre-operative patients' general condition and the severity of inflammation, and prompt and proper management for complications should be done to prevent serious problems.

Metachronous Tripple Primary Malignant Neoplasm

According to the development of new diagnostic techniques and the extension of aging population, the diagnosis of multiple primary malignant neoplasm has increased. We report a 76 years old man who had prostate cancer, colon cancer and stomach cancer metachronously and review literatures about the history, criteria, incidence and causes of the multiple primary malignant neoplasm.

Polypoid Lesions of Gallbladder: Clinicopathological Features and Indication of Operation

PURPOSE: Polypoid lesions of the gall bladder (PLG) have a variety of pathologies. Problems exist in the selection of patients for operation and in the operative approach used. We studied the accuracy of the preoperative radiologic diagnosis and suspected risk factors. METHODS: 121 polypoid lesions of gallbladder were sugically treated during 10 years. Preoperative radiologic diagnosis, age, gender, related symptoms, concurrent gallstone, size, shape, number and histologic diagnosis of the ployps were retrospectively reviewed. RESULTS: The average size of malignancy was 23.0 mm, and that of benign tumors was 7.1 mm (P=0.000). The mean age of patients with a malignancy was significant higher than that of those with benign tumor (P=0.000). The preoperative sensitivity of computed tomography for a malignancy was 67.7%. The patients with malignancy more frequently had related symptoms. CONCLUSION: A CT must be considered, for patients with risk factors, even if the ultrasonographic diagnosis was benign. An Age greater than 60 years, a tumor size greater than 10 mm, a solitary polyp, sessile shape, and related symptoms are predictive factors of a malignancy.

The Comparative Analysis between Laparoscopic and Open Appendectomy

PURPOSE: Nowadays laparoscopic appendectomy is widely practiced in developed countries. The purpose of this study was to evaluate laparoscopic appendectomy in comparison with open appendectomy. METHODS: On hundred cases each of laparoscopic appendectomy and open appendectomy, performed between February 2001 and June 2002, were reviewed for age, sex, operative time, hospital days, time for first meal, number of used parenteral analgesia, number of OPD visits, etc. RESULTS: Operative time was longer in the laparoscopic appendectomy group (P>0.05) and the number of used parenteral analgesia was slightly higher in the laparoscopic group (P>0.05). However, recovery time for diet was slightly shorter in the laparoscopic group (P>0.05). None of these trends were statistically significant. The times of OPD visit after discharge was less in the laparoscopic group (P<0.05). The hospital days of pathological simple appendicitis were shorter in the laparoscopic appendectomy group (P<0.05). In the laparoscopic group, intraabdominal abscess was developed in 2 cases, wound infection in 4, and intestinal obstruction in 2. The conversion rate to open appendectomy was 7% (7/100) in the laparoscopic group. CONCLUSION: Laparoscopic appendectomy can shorten overall OPD follow up days and in case of simple appendicitis, laparoscopic appendectomy can also shorten hospital days.

The Immunohistochemical Expression of E2F-1 Protein and DNA Topoisomerase II-alpha E2F-1 Protein in Colorectal Cancer and Their Relationship with Clinicopathologic Factors

PURPOSE: E2F-1 is a transcriptor that converts G1 to S in the cell cycle, and Topoisomerase II-alpha is a key enzyme in the metabolism of DNA, and an indicator of cell replication. The purpose of this study was to evaluate the clinical validity of E2F-1 and Topoisomerase II-alpha as prognostic factors in colorectal cancer. METHODS: The expressions of E2F-1 and Topoisomerase II-alpha were studied immunohistochemically using tumor specimen sections fixed with formalin and paraffin-embedded for 84 cases of colorectal cancer. The correlation between E2F-1 and Topoisomerase II-alpha expressions, and their relationship with the clinicopathological factors, such as tumor differentiation, tumor invasion, lymph node metastasis and tumor stage were investigated. RESULTS: Of the 84 specimens, 43 (51.2%) were immunohistochemically negative for E2F-1, and 41 (48.8%) were positive. The expression of E2F-1 correlated with poor tumor differentiation, increased lymph node metastasis and high tumor stage. The expression of Topoisomerase II-alpha also correlated with poor tumor differentiation, increased lymph node metastasis and high tumor stage. The E2F-1 and Topoisomerase II-alpha expressions indices were significantly correlated. CONCLUSION: These results suggest that the expressions of E2F-1 and DNA Topoisomerase II-alpha may play a role as a prognostic factor for colorectal cancer, but further studies will be required for its comfirmation.

Factors for Conversion from Laparoscopic Cholecystectomy to Open Cholecystectomy

PURPOSE: Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy (OC) for the majority of patients. However, a minority of patients still require conversion to open cholecystectomy during the perioperative period. This study was designed to determine the contributing factors related to conversion to open cholecystectomy. METHODS: The data from 3,510 laparoscopic cholecystectomies, performed at Chung-Ang university hospital from September 1990 to June 2001, were reviewed retrospectively. Pre-operative laboratory data, post-operative pathologic findings, complications, and the reasons for conversion to open cholecystectomy were evaluated. RESULTS: Sixty six (1.88%) of 3,510 patients were converted to open surgery, due to bleeding (39%), adhesion (26%), bile duct injury (23%) and inflammation (6%). These conversion cases were more prevalent in males and needed longer hospital stay. Thickening of the gallbladder wall and gangrenous cholecystitis were frequent pathologic findings among the conversion cases. CONCLUSION: Thickening of the gallbladder wall, inflammation and anatomical variation of the gallbladder were important factors for conversion to open surgery. Thus, these predictive findings allow the surgeons to preoperatively discuss the higher risk of conversion and allow for an earlier judgement and decision on conversion if intraoperative difficulty is encountered.

Expression of p27Kip1 Protein and Correlation with Clinicopathologic Factors in Colorectal Carcinoma

PURPOSE: The p27Kip1 gene has been recognized as a negative regulator of the cell cycle and a potential tumor suppressor gene. Reduced expression of the p27Kip1 protein has been reported in several human tumors and has been associated with a poor prognosis in breast, lung, colon, prostate, bladder, esophageal and gastric cancers. In the present study, we assessed p27 expression in patients with colorectal cancer in relation to their clinicohistological parameters. METHODS: We investigated p27 expression in 80 patients with colorectal cancers using immunohistochemical staining and the results were analyzed regarding the survival and clinicopathological parameters. RESULTS: Among 80 cases of clolorectal carcinomas, p27Kip1 expression was detected in the nuclei of tumor cells in 48 cases (60%). With the exception of differentiation (p<0.01), no significant correlation was found between p27Kip1 and TMN stage, lymph node metastasis, depth of tumor invasion or overall survival. CONCLUSION: The results suggest that reduced expression of p27Kip1 protein plays a role in the differentiation of colorectal carcinoma and may be a potential prognostic factor. But, more studies are reqired in order to determine whether p27Kip1 protein expression is a clinically valuable prognostic factor.

Clinical Analysis of Primary Gallbladder Carcinoma to Improve Early Diagnosis

PURPOSE: The prognosis for primary gallbladder cancer is very poor. Because of the lack of specific symptoms, late diagnosis, advanced stage, and ineffective treatment are typical. The purpose of the present study was to investigate the early diagnostic factors that improve the survival rate, by comparing a preoperatively diagnosed group with a postoperatively diagnosed group. METHODS: This study was a clinical analysis of our surgical experience with primary gallbladder carcinomas during the 6 years from 1992 to 1997 at Chung-Ang University in Korea. RESULTS: The incidence of gallbladder carcinomas was 0.6% of the 6132 biliary-tract operations performed during the 6 years (suspected group: unsuspected group=15:23). The sex ratio of males to females was 1 to 2.46 with female predominance. Primary GB cancer was seen most commonly in patients in their 50s and 60s, and this group accounted for 68.4% of the entire group and had a median age of 65 years. The most common clinical manifestation was right upper abdominal pain in 27 cases (71.1%). The duration of the illness in preoperatively suspected patients was much shorter than that for intraoperatively or only pathologically diagnosed patients (p=0.046) As for diagnostic methods, ultrasound and abdominal CT scans were performed, and the preoperative diagnostic accuracies were 31.6% and 69.3%, respectively. The patients were grouped according to the staging system of Nevin et al. The five stages were classified as follows: stage I (suspected group-0 cases; unsuspected group-2 cases), stage II (1 case; 5 cases), stage III (1 case; 2 cases), stage IV (7 cases; 9 cases), and stage V (6 cases; 5 cases). Adenocarcinoma was the most common type of gallbladder cancer (32 cases: suspected group-10 cases; unsuspected group-22 cases), followed by squamoadenocarcinoma (3 cases: 2 cases/1 case), neurogenic carcinoma (1 case: 1 case/0 cases), histiocytoma (1 case: 1 case/0 cases), and papillary carcinoma (1 case: 1 case/0 cases). The total cumulative 1-year, 2-year, and 3-year survival rates were 67.7%, 37.6%, and 12.1%, respectively (suspected: 46.2%, 15.4%, and 0%; unsuspected: 71.4%, 52.9%, and 23.2%). The cumulative survival rates for patients in the unsuspected group were higher than those for patients in the suspected group (p=0.008). CONCLUSION: The survival rate of the preoperatively unsuspected group was better than that of the suspected group. The survival improvement depended the invasion by the gallbladder carcinoma. We suggest that the survival rate should be improved by early detection of the gallbladder carcinoma and on extended operation. Conclusively, further evaluation of patients with etiologic factors should be done, more specific exams (CT or MRI) should be evaluated, and an acceptable operation should be done.

Clinical Analysis of Primary Gallbladder Carcinoma to Improve Early Diagnosis

PURPOSE: The prognosis for primary gallbladder cancer is very poor. Because of the lack of specific symptoms, late diagnosis, advanced stage, and ineffective treatment are typical. The purpose of the present study was to investigate the early diagnostic factors that improve the survival rate, by comparing a preoperatively diagnosed group with a postoperatively diagnosed group. METHODS: This study was a clinical analysis of our surgical experience with primary gallbladder carcinomas during the 6 years from 1992 to 1997 at Chung-Ang University in Korea. RESULTS: The incidence of gallbladder carcinomas was 0.6% of the 6132 biliary-tract operations performed during the 6 years (suspected group: unsuspected group=15:23). The sex ratio of males to females was 1 to 2.46 with female predominance. Primary GB cancer was seen most commonly in patients in their 50s and 60s, and this group accounted for 68.4% of the entire group and had a median age of 65 years. The most common clinical manifestation was right upper abdominal pain in 27 cases (71.1%). The duration of the illness in preoperatively suspected patients was much shorter than that for intraoperatively or only pathologically diagnosed patients (p=0.046) As for diagnostic methods, ultrasound and abdominal CT scans were performed, and the preoperative diagnostic accuracies were 31.6% and 69.3%, respectively. The patients were grouped according to the staging system of Nevin et al. The five stages were classified as follows: stage I (suspected group-0 cases; unsuspected group-2 cases), stage II (1 case; 5 cases), stage III (1 case; 2 cases), stage IV (7 cases; 9 cases), and stage V (6 cases; 5 cases). Adenocarcinoma was the most common type of gallbladder cancer (32 cases: suspected group-10 cases; unsuspected group-22 cases), followed by squamoadenocarcinoma (3 cases: 2 cases/1 case), neurogenic carcinoma (1 case: 1 case/0 cases), histiocytoma (1 case: 1 case/0 cases), and papillary carcinoma (1 case: 1 case/0 cases). The total cumulative 1-year, 2-year, and 3-year survival rates were 67.7%, 37.6%, and 12.1%, respectively (suspected: 46.2%, 15.4%, and 0%; unsuspected: 71.4%, 52.9%, and 23.2%). The cumulative survival rates for patients in the unsuspected group were higher than those for patients in the suspected group (p=0.008). CONCLUSION: The survival rate of the preoperatively unsuspected group was better than that of the suspected group. The survival improvement depended the invasion by the gallbladder carcinoma. We suggest that the survival rate should be improved by early detection of the gallbladder carcinoma and on extended operation. Conclusively, further evaluation of patients with etiologic factors should be done, more specific exams (CT or MRI) should be evaluated, and an acceptable operation should be done.