Supra-ampullary duodenectomy in a patient with positive distal resection margin after subtotal gastrectomy for gastric cancer: a case report

Resection margin involvement after curative intent resection for gastric cancer results in a poor prognosis and deprives the patient of the chance for a cure. Reoperation to achieve an R0 status should guarantee tolerable morbidity and achievement of negative margins. We performed laparoscopic distal gastrectomy with extracorporeal Billroth II reconstruction in a 56-year-old woman with gastric cancer following neoadjuvant chemotherapy. Scattered cancer cells were observed in the proximal and distal resection margins on immunohistochemical staining for cytokeratin. Two weeks postoperatively, remnant total gastrectomy and supra-ampullary duodenectomy were performed. Before reoperation, percutaneous transhepatic gallbladder drainage and angiocatheter placement outside the ampulla of Vater (AoV) via the cystic duct were performed to avoid pancreaticoduodenectomy and to obtain the maximal distal margin. Duodenal transection was performed 1 cm above the AoV. The resected duodenum was 4 cm in length. The patient had no postoperative complications and received adjuvant chemotherapy 1 month after the reoperation.

Trends and outcomes of emergency general surgery in elderly and highly elderly population in a single regional emergency center

Purpose@#The number of elderly patients, especially aged ≥80 years, undergoing emergency surgery is gradually increasing. The aim of this study was to find out the trends and results of emergency general surgery for elderly patients over 9 years in an emergency medical center in South Korea, where the population is aging most rapidly. @*Methods@#The clinical characteristics, outcomes, and medical expenses of emergency general surgery for the elderly (aged 65–79 years) and highly elderly (aged ≥80 years) patients who visited to a regional emergency medical center from 2012 to 2020 were analyzed. @*Results@#The number of highly elderly patients increased with each 3-year interval, whereas the proportion of patients aged 19–79 years was similar, and that of pediatric patients was decreasing. The higher the age group, the higher the mortality (young adult vs. elderly vs. highly elderly: odds ratio [OR], 1 vs. 3.689 vs. 11.293; P < 0.001) and complication rates (OR, 1 vs. 2.840 vs. 4.633; P < 0.001), and longer length of hospital stay (β = 0.949, P = 0.001) even after adjusting for the type of surgery and the American Society of Anesthesiologists physical status classification. Non-covered medical expenses were significantly related to the age groups (β = 151,608.802, P < 0.001). @*Conclusion@#The higher age group was associated with increased number of unfavorable outcomes after emergency general surgery, along with increased medical cost. Efforts to prevent emergency surgery for elderly patients and a specialized treatment system are needed.

Effect of bupivacaine on postoperative pain and analgesics use after single-incision laparoscopic appendectomy: double-blind randomized study

PURPOSE: Local anesthetics can decrease postoperative pain after appendectomy. This study sought to verify the efficacy of bupivacaine on postoperative pain and analgesics use after single-incision laparoscopic appendectomy (SILA).METHODS: Between March 2014 and October 2015, 68 patients with appendicitis agreed to participate in this study. After general anesthesia, patients were randomized to bupivacaine or control (normal saline) groups. The assigned drugs were infiltrated into subcutaneous tissue and deep into anterior rectus fascia. Postoperative analgesics use and pain scores were recorded using visual analogue scale (VAS) by investigators at 1, 8, and 24 hours and on day 7. All surgeons, investigators and patients were blinded to group allocation.RESULTS: Thirty patients were allocated into the control group and 37 patients into bupivacaine group (one patient withdrew consent before starting anesthesia). Seven from the control group and 4 from the bupivacaine group were excluded. Thus, 23 patients in the control group and 33 in the bupivacaine group completed the study. Preoperative demographics and operative findings were similar. Postoperative pain and analgesics use were not different between the 2 groups. Subgroup analysis determined that VAS pain score at 24 hours was significantly lower in the bupivacaine group (2.1) than in the control group (3.8, P = 0.007) when surgery exceeded 40 minutes. During immediate postoperative period, bupivacaine group needed less opioids (9.1 mg) than control (10.4 mg).CONCLUSION: Bupivacaine did not decrease pain and analgesics use. When surgery exceeded 40 minutes, bupivacaine use might be associated with less pain and less analgesics use.

Clinical Outcome of Modified Laparoscopy-Assisted Proximal Gastrectomy Compared to Conventional Proximal Gastrectomy or Total Gastrectomy for Upper-Third Early Gastric Cancer with Special References to Postoperative Reflux Esophagitis

PURPOSE: This study evaluated the functional and oncological outcomes of proximal gastrectomy (PG) in comparison with total gastrectomy (TG) for upper-third early gastric cancer (EGC). MATERIALS AND METHODS: The medical records of upper-third EGC patients who had undergone PG (n=192) or TG (n=157) were reviewed. The PG group was further subdivided into patients who had undergone conventional open PG (cPG; n=157) or modified laparoscopy-assisted PG (mLAPG; n=35). Patients who had undergone mLAPG had a longer portion of their intra-abdominal esophagus preserved than patients who had undergone cPG. Surgical morbidity, recurrence, long-term nutritional status, and the incidence of reflux esophagitis were compared between the groups. RESULTS: The rate of postoperative complications was significantly lower for PG than TG (16.7% vs. 31.2%), but the five-year overall survival rate was comparable between the two groups (99.3% vs. 96.3%). Postoperative levels of hemoglobin and albumin were significantly higher for patients who had undergone PG. However, the incidence of reflux esophagitis was higher for PG than for TG (37.4% vs. 3.7%; P<0.001). mLAPG was related to a lower incidence of reflux esophagitis after PG (P<0.001). CONCLUSIONS: Compared to TG, PG showed an advantage in terms of postoperative morbidity and nutrition, and there was a comparable prognosis between the two procedures. Preserving the intra-abdominal esophagus may lower the incidence of reflux esophagitis associated with PG.

A Prospective, Long-Term Follow-Up Study of 1,444 nm Nd:YAG Laser: A New Modality for Treating Axillary Bromhidrosis

BACKGROUND: Surgery for bromhidrosis has a high risk of complications such as hematoma and necrosis. New nonsurgical methods may reduce the burden on surgery and the risks for the patient. OBJECTIVE: This study was performed to evaluate the efficacy and side-effects of the 1,444 nm Nd:YAG interstitial laser for treating axillary bromhidrosis. METHODS: Eighteen bromhidrosis patients were treated with a 1,444 nm Nd:YAG laser at Korea University Ansan Hospital. The post-treatment follow-up was 6 months. After the procedure, we confirmed apocrine gland destruction through histopathological examination. At each follow-up, we measured the severity of the remaining odor, postoperative pain, degree of mobility restriction, and overall satisfaction. RESULTS: After 180 days of follow-up, malodor elimination was good in 20 axillae, fair in 12 axillae, and poor in four axillae. At the end point of the study, 14 patients were totally satisfied with the laser treatment, three patients were partially satisfied, and one patient was disatisfied. Pain and limitation of mobility were significantly reduced within 1 week post-operatively, and were almost resolved within 4 weeks post-operatively. A histopathological examination revealed decreased density and significant alterations to the apocrine glands. CONCLUSION: Subdermal coagulation treatment with a 1,444 nm Nd:YAG interstitial laser may be a less invasive and effective therapy for axillary bromhidrosis.

The Effect of Combined Enteral and Parenteral Nutrition for Anastomotic Leakage after Gastric Cancer Surgery

PURPOSE: The effectiveness of enteral nutrition for patients with anastomotic leakage after gastric cancer surgery is controversial. The purpose of this study is to compare effectiveness between combined enteral nutrition with parenteral nutrition (EPN) and total parenteral nutrition (TPN). METHODS: Patients who underwent gastric cancer surgery for primary gastric cancer from April 2010 to August 2012 were reviewed. Clinicopathologic characteristics, complication, laboratory tests, and body weight (Bwt) were compared between EPN and PN. RESULTS: Among patients with postoperative leakage within postoperative 1 month (n=43), 13 patients were supported by EPN and 23 patients by TPN. Clinicopathologic characteristics, including preoperative Bwt, body mass index, nutritional status, other complications, and TNM stage were similar. Preoperative serum albumin and Bwt were similar between EPN and TPN. However, after 1 week of nutritional support, albumin at EPN was significantly higher than that of PN (3.52+/-0.3 and 3.25+/-0.3; P=0.010). Adjusted by preoperative Bwt, preoperative nutritional status, and difference in Bwt between preoperative and pre-nutritional support period, decrease of Bwt between pre-nutritional support and discharge was significantly less at EPN than at TPN (-4.5+/-5.4% and -6.3+/-4.1%; P=0.001). CONCLUSION: In terms of the maintenance of serum albumin and Bwt during nutritional support, EPN may be a better supportive option than TPN for patients with anastomotic leakage after gastric cancer surgery.

Subdermal Coagulation Treatment of Axillary Bromhidrosis by 1,444 nm Nd:YAG Laser: A Comparison with Surgical Treatment

Bromhidrosis is a disease presenting as malodor caused by interaction between the discharge of apocrine glands and bacteria. The main therapeutic modalities are applying topical agents, liposuction surgery, and elective surgery. Among these, elective surgery is reported to be most effective. However, the efficiency largely depends on surgical technique. Additionally, other side effects, such as hematoma and scarring, are occasionally reported. Currently, CO2 laser and 1,064 nm Nd:YAG laser therapy are used, but as the wavelength is not specific to apocrine glands, these laser therapies have certain limitations. Recently, a 1,444 nm wavelength Accusculpt(TM) laser (LutronicCorp., Seoul, Korea) has been developed which is now commonly used for facial fat plasty and laser liposuction therapy. The use of this laser for bromhidrosis therapy targeting apocrine sweat glands is currently being discussed. Still, no studies on practical clinical use and side effects of this 1,444 nm wavelength laser have been published. In this report, we treated one bromhidrosis patient with 1,444 nm wavelength Accusculpt(TM) laser therapy on one side while conventional surgery was performed on the other side using a modified Inaba's method. We compared the efficacy of this laser therapy to the surgical modality by measuring malodor severity and overall satisfaction by questionnaire. We also checked for other complications and recurrence for 12 months after the treatment. This patient was largely satisfied as it has a much shorter down time with the same therapeutic outcome. As subdermal coagulation treatment by 1,444 nm Nd:YAG laser may be less invasive but effective therapy, we would like to recommend this modality as a possible treatment option.

The Value of Postoperative Serum Carcinoembryonic Antigen and Carbohydrate Antigen 19-9 Levels for the Early Detection of Gastric Cancer Recurrence after Curative Resection

PURPOSE: This study aimed to evaluate the value of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels to detect gastric cancer recurrence. MATERIALS AND METHODS: We retrospectively reviewed 154 patients who developed recurrence within 2 years after curative gastric cancer surgery and analyzed the relationship between postoperative CEA and CA19-9 levels and recurrence. We readjusted the cut-off values to improve the detection of recurrence. Subgroup analysis according to clinicopathologic variables was performed to further investigate the relationship between recurrence and CEA and CA19-9 levels. RESULTS: The sensitivity and specificity for elevated CEA levels to detect recurrence were 40.6% and 89.5%, respectively, and those for CA19-9 were 34.2% and 93.6%, respectively. The sensitivity and specificity for elevation of either tumor marker were 54.3% and 84.0%, respectively; those for elevation of both tumor markers were 19.2% and 98.4%, respectively. By readjusting the cut-off values from 5.0 ng/ml to 5.2 ng/ml for CEA and from 37.00 U/ml to 30.0 U/ml for CA19-9, the sensitivity was increased from 34.2% to 40.2% for CA19-9, while there was no increase in sensitivity for CEA. In subgroup analysis, the sensitivity of CEA was higher in patients with elevated preoperative CEA levels than in patients with normal preoperative CEA levels (86.7% versus 33.7%; P<0.001). Furthermore, the sensitivity of CA19-9 was higher in patients with elevated preoperative CA19-9 levels than in patients with normal preoperative CA19-9 levels (82.61% versus 26.83%; P<0.001). CONCLUSIONS: CEA and/or CA19-9 measurement with the readjusted cut-off values allows for more effective detection of gastric cancer recurrence.

Effects of Screening on Gastric Cancer Management: Comparative Analysis of the Results in 2006 and in 2011

PURPOSE: This study aimed to analyze the effect of screening by using endoscopy on the diagnosis and treatment of gastric cancer. MATERIALS AND METHODS: The clinicopathologic characteristics of gastric cancer were compared in individuals who underwent an endoscopy because of symptoms (non-screening group) or for screening purposes (screening group). The distributions of gastric cancer stages and treatment modalities in 2006 and 2011 were compared. RESULTS: The proportion of patients in the screening group increased from 45.1% in 2006 to 65.4% in 2011 (P<0.001). The proportion of stage I cancers in the entire patient sample also increased (from 60.5% in 2006 to 70.6% in 2011; P=0.029). In 2011, the percentages of patients with cancer stages I, II, III, and IV were 79.9%, 8.2%, 10.9%, and 1.1%, respectively, in the screening group, and 47.9%, 10.8%, 29.8%, and 11.5%, respectively, in the non-screening group. The proportion of laparoscopic and robotic surgeries increased from 9.6% in 2006 to 48.3% in 2011 (P<0.001), and endoscopic submucosal dissection increased from 9.8% in 2006 to 19.1% 2011 (P<0.001). CONCLUSIONS: The proportion of patients diagnosed with gastric cancer by using the screening program increased between 2006 and 2011. This increase was associated with a high proportion of early-stage cancer diagnoses and increased use of minimally invasive treatments.

Laparoscopic Distal Gastrectomy in a Patient with Situs Inversus Totalis: A Case Report

We report our experience with two cases of situs inversus totalis, both involving patients diagnosed with gastric cancer. These were a 52-year-old male with a preoperative staging of cT1bN0M0 and a 68-year-old male with a staging of cT2N0M0, both of whom underwent surgery. The former was found to have vascular anomalies in the preoperative computed tomography, so we performed a computed tomography angiography with three-dimensional reconstruction. Laparoscopy-assisted distal gastrectomy with Billroth I anastomosis was performed with D1+ lymph node dissection, and a small laparotomy was made for extracorporeal anastomosis. In contrast, the latter case showed no vascular anomalies in the preoperative computed tomography, and totally laparoscopic distal gastrectomy with delta anastomosis was performed with D1+ lymph node dissection. There were no intraoperative problems in either patient and they were discharged without postoperative complications. Histopathological examination revealed a poorly differentiated adenocarcinoma (pT2N0M0) and a well-differentiated adenocarcinoma (pT1aN0M0), respectively.

A Comparative Study on Recurrence of Earlobe Keloids after Postoperative Adjuvant Therapy / 대한피부과학회지

BACKGROUND: Earlobe keloids are a cosmetically and symptomatically bothersome clinical problem with frequent recurrence despite various treatments including surgical excision and intralesional injection of corticosteroids. OBJECTIVE: The aim of this study was to compare the results and recurrence of earlobe keloids after various postexcisional adjuvant therapies and to identify the most effective postoperation adjuvant therapy. METHODS: We retrospectively evaluated 36 patients with earlobe keloids (n=71) who underwent core excision and a suprakeloidal flap using photographs. One group did not have adjuvant therapy, one group was treated with adjuvant triamcinolone intralesional injection (TRA/ILI), and another group was treated with postoperative irradiation. RESULTS: Among treated 71 keloids, 18 lesions (25.4%) recurred; 42.9% (12/28) of the operation-only group and 19.4% (6/31) of TRA/ILI group showed recurrence. The adjuvant radiation therapy group had no recurrence. The difference in recurrence rate was statistically significant. CONCLUSION: Postexcisional adjuvant therapy was more effective than excision monotherapy for keloid treatment, and radiation therapy had more sustained effects than that of TRA/ILI.

Simultaneous Liver, Kidney Transplantation: A Single Center Experience / 대한이식학회지

BACKGROUND: Simultaneous liver and kidney transplants have proved to be a favorable treatment for combined renal and hepatic end-stage diseases. However, it is extremely difficult to find a simultaneous liver and kidney donor in Korea due to the narrow requirements. This study had three aims: to explore the therapeutic experience of simultaneous liver and kidney transplants in Seoul National University Hospital (SNUH), to compare the overall survival outcome between simultaneous liver and kidney transplants and liver transplants alone in patients with liver and renal failure, and to determine the indications for simultaneous liver and kidney transplants. METHODS: The clinical data of 8 simultaneous liver and kidney transplants at SNUH from November 2004 to October 2010 were retrospectively studied. Indications for simultaneous liver and kidney transplants, patient and graft survival, and the causes of death were analyzed and compared with 5 liver transplants alone performed on patients experiencing liver and renal failure. RESULTS: The clinical characteristics of the recipients for simultaneous liver and kidney transplants and liver transplants alone were similar with regards to age, renal function, and the Model for End-Stage Liver Disease (MELD) score (all P>0.05). One patient died at 15 months after simultaneous liver and kidney transplants due to HBV related HCC recurrence, and three patients died at 2, 3, and 21 months after liver transplants due to ARDS, bleeding, and hepatic failure, respectively. Only one liver graft loss in simultaneous liver and kidney transplant cases occurred on POD 3 due to primary non-function. The outcome analysis demonstrated a superior overall survival in simultaneous liver and kidney transplants recipients compared with recipients of only liver transplants (P=0.041). CONCLUSIONS: Simultaneous liver and kidney transplants showed a superior outcome in patients with end-stage liver disease and chronic renal failure compared with liver transplants alone. The allocation criteria of simultaneous liver and kidney transplants in Korea should be changed to expand its indications.

Simultaneous Liver, Kidney Transplantation: A Single Center Experience / 대한이식학회지

BACKGROUND: Simultaneous liver and kidney transplants have proved to be a favorable treatment for combined renal and hepatic end-stage diseases. However, it is extremely difficult to find a simultaneous liver and kidney donor in Korea due to the narrow requirements. This study had three aims: to explore the therapeutic experience of simultaneous liver and kidney transplants in Seoul National University Hospital (SNUH), to compare the overall survival outcome between simultaneous liver and kidney transplants and liver transplants alone in patients with liver and renal failure, and to determine the indications for simultaneous liver and kidney transplants. METHODS: The clinical data of 8 simultaneous liver and kidney transplants at SNUH from November 2004 to October 2010 were retrospectively studied. Indications for simultaneous liver and kidney transplants, patient and graft survival, and the causes of death were analyzed and compared with 5 liver transplants alone performed on patients experiencing liver and renal failure. RESULTS: The clinical characteristics of the recipients for simultaneous liver and kidney transplants and liver transplants alone were similar with regards to age, renal function, and the Model for End-Stage Liver Disease (MELD) score (all P>0.05). One patient died at 15 months after simultaneous liver and kidney transplants due to HBV related HCC recurrence, and three patients died at 2, 3, and 21 months after liver transplants due to ARDS, bleeding, and hepatic failure, respectively. Only one liver graft loss in simultaneous liver and kidney transplant cases occurred on POD 3 due to primary non-function. The outcome analysis demonstrated a superior overall survival in simultaneous liver and kidney transplants recipients compared with recipients of only liver transplants (P=0.041). CONCLUSIONS: Simultaneous liver and kidney transplants showed a superior outcome in patients with end-stage liver disease and chronic renal failure compared with liver transplants alone. The allocation criteria of simultaneous liver and kidney transplants in Korea should be changed to expand its indications.

Congenital Onychodysplasia of the Index Fingers with a Y-shaped Bifurcation of the Distal Phalanx / 대한피부과학회지

Congenital onychodysplasia of the index fingers (COIF, Iso and Kikuchi syndrome) is a congenital disorder characterized by various forms of nail dysplasias mainly-involving the index fingers. Its etiopathogenesis is still unknown, but ischemia of the palmar digital arteries has been suggested to play a role in this disorder. Although not specific to it, a Y-shaped bifurcation of the distal affected phalanx is a characteristic finding of this syndrome. In this review, we report a case of COIF who presented with bilateral micronychia with a Y-shaped bifurcation of the distal phalanx.