[Primary Tumor Resection in Incurable Stage IV Colorectal Cancer].

The influence of primary tumor resection on the prognosis of patients with incurable Stage IV colorectal cancer is unclear. We retrospectively analyzed 30 patients with incurable Stage IV colorectal cancer who underwent primary tumor resection. Postoperative complications occurred in 13 patients(43.3%)classified as grades greater than Clavien-Dindo classification II . There was no mortality. Median duration of hospital stay after surgery was 23 days. Fourteen patients(46.7%)underwent chemotherapy after surgery, of which 12 were administered molecular targeted therapy. The median number of chemotherapy regimens was 2(range, 1 to 3). The median time between start and end of chemotherapy was 11.8 months. The median survival time(MST)of all patients was 16.9 months. The MST of patients treated with chemotherapy combined with molecular targeted therapy(60.6 months)was significantly longer than those who did not undergo chemotherapy(10.9 months). Chemotherapy combined with molecular targeted therapy contributes to survival after primary tumor resection in patients with incurable Stage IV colorectal cancer.

[Report of a Successful Case of Combined Modality Therapy for a Patient with Local Recurrence of Rectal Cancer].

A 67-year-old man underwent abdominoperinealresection for rectalcancer (Rb, tub2>muc, A, N1, H0, P0, M0, Cy1, Stage III a). We administered mFOLFOX6 as adjuvant chemotherapy for 6 months. Twenty-seven months after surgery, his serum tumor marker level was increased, and local recurrence in the left rear of the prostate was detected by pelvic CT. The patient selected radiation(50 Gy/25 Fr), after rejecting resection for the local recurrence. After radiation, we performed chemotherapy combined with bevacizumab. Seventeen months from the start of chemotherapy, 47 months after surgery, chemotherapy was stopped because his tumor maker levels normalized and pelvic CT revealed a partial response. At present, his progression-free survival is 7 months after completion of chemotherapy. We conclude that combined modality therapy is an option for a patient with locally recurrent rectal cancer.

Omental packing with continuous suction drainage following abdominoperineal resection.

BACKGROUND/AIMS: Primary closure of the perineum along with drainage after abdominoperineal resection for lower rectal cancer is a widely accepted procedure but is associated with non-healing of the perineal wound a major complication. We evaluated the efficacy of omental packing and continuous suction drainage after abdominoperineal resection. METHODOLOGY: We retrospectively studied 45 patients with adenocarcinoma of the lower rectum who underwent abdominoperineal resection, either without omental packing (NOP group) or with omental packing and continuous suction drainage (OPCD group). A pedicled omentum supplied by the epiploic arcade was conducted and drawn down through the perineal wound, over the small intestine and into the pelvis. Drains were placed on both sides of the pelvis through the perineal wall and continuous suction was performed. RESULTS: Perineal wound infection was significantly more frequent in the NOP group (32%) than in the OPCD group (5%). Ileus was not observed in the OPCD group. The duration of hospitalization was shorter in the OPCD group (17.8±4.2 days) than in the NOP group (21.0±9.1 days). CONCLUSIONS: Omental packing with continuous suction is useful to prevent non-healing of the perineal wound after abdominoperineal resection for lower rectal cancer.

Administration of bisphosphonates for malignant hepatic tumor with hypercalcemia.

BACKGROUND/AIMS: Hypercalcemia is a paraneoplastic syndrome that is a serious condition requiring urgent treatment. We administered alendronate to hypercalcemia patients with advanced cancer with metastasized liver tumors or hepatocellular carcinoma (HCC) and then evaluated the mechanism and anticancer function of this compound. METHODOLOGY: We retrospectively studied 17 patients with hypercalcemia associated with metastatic liver tumor or HCC. Alendronate (10mg) was administered via the intravenous route for patients with metastatic liver tumor (n=12) and via the hepatic artery for patients with HCC (n=5). RESULTS: Intravenous administration of alendronate resulted in decrease in serum calcium levels in all patients. The serum levels of tumor markers also decreased in 66.7% (8/12) of these patients. After intra-arterial alendronate administration, the serum calcium and parathyroid hormone-related protein levels decreased in all the patients. The serum levels of tumor markers such as AFP and PIVKA-II were decreased in 80% (4/5) of these patients. Electron microscopic examination of the resected hepatic tumor revealed an increase in the vascularization and formation of apoptotic vesicles in the vascular endothelial cells. CONCLUSIONS: Alendronate is effective not only for controlling hypercalcemia but also for directly enhancing the apoptosis of HCC cells.

Duodenal switch operation for juxtapapillary duodenal diverticula.

BACKGROUND/AIMS: Since the first case of juxtapapillary diverticlum reported by Lemmel, several reports have demonstrated an association between periampullary diverticulum and gallstone disease. Thus, we compared the efficiency of the duodenal switch operation and choledchojejunostomy for patients who underwent surgery for cholangitis with juxtapapillary duodenal diverticula. METHODOLOGY: We retrospectively studied 17 patients who had cholangitis associated with juxtapapillary duodenal diverticula. These patients were divided into 2 groups on the basis of the operative procedure: the duodenal switch operation group (DS group) and the choledochojejunostomy group (CJ group). RESULTS: The mean operative time and blood loss were significantly lesser in the DS group than in the CJ group (p<0.0001 and p<0.0005, respectively); however, the duration of nasogastric suction requirement and time after which oral ingestion of solid diet could be safely resumed after surgery were significantly longer in the DS group than in the CJ group (p<0.0001 and p<0.0001, respectively). Gallstone formation after the surgery did not occur in both groups. CONCLUSIONS: Duodenal switch operation is useful and less invasive for cholangitis associated with juxtapapillary duodenal diverticula and for preventing cholangitis for a long period after the operation; however, gastric stasis still remains a problem with this procedure.

Pancreaticogastrostomy in patients with considerably dilated pancreatic ducts.

BACKGROUND/AIMS: Patency of pancreaticogastrostomy (PG) is one of the most important factors affecting the function of the remnant pancreas and quality of life. We evaluated the early postoperative changes in pancreatic duct dilation after pancreaticoduodenectomy (PD) and PG with duct-to-mucosa anastomosis in patients with remarkably dilated pancreatic ducts. METHODOLOGY: We retrospectively analyzed 26 patients who had remarkably dilated pancreatic ducts (diameter, ≥7 mm) and who underwent PD followed by PG. They were divided into 2 groups on the basis of the endoscopic findings of the anastomotic orifice of PG: Group A, clear pancreatic duct orifice with pancreatic juice output; and Group B, unclear pancreatic duct orifice with pancreatic juice output. RESULTS: The mean diameter of the duct of the remnant pancreas after the surgery was smaller in Group A than in Group B. With regards to postoperative pancreatic exocrine function, there was no significant difference between the 2 groups. CONCLUSIONS: Invagination with duct-to-mucosa anastomosis is a useful technique to prevent pancreatic leakage; however, it is difficult to prevent inflammation and fibrosis around the anastomotic site of PG, and this can lead to anastomotic stricture in patients with a remarkably dilated pancreatic duct (diameter ≥7 mm).

Minimal incision based on measurement of the to-be-resected specimen in laparoscopic hepatectomy.

Recent technological improvements in laparoscopic devices have significantly extended the surgeon's ability to perform laparoscopic liver surgery safely. Hand-assisted laparoscopy has been proposed in order to achieve greater safety and accessibility in laparoscopic liver surgery. Moreover, in order to expand the indications of minimally invasive liver resection and improve its safety, the "hybrid procedure" or "laparoscopy-assisted resection" has been proposed. Hand-assisted laparoscopic liver resection consists of the placement of a gas-tight port through an 8cm incision that enables a hand to be introduced into the abdomen. The "hybrid procedure" is performed through an 8-12cm midline or subcostal incision. Such a minimal abdominal incision is preferred not only for cosmetic reasons but also for obtaining adequate surgical margin. We performed laparoscopic liver resection via a minimal incision that was based on the measurement of the to-be-resected specimen intraoperatively by ultrasonography. Here, we have described our procedure and evaluated its efficacy.

Horizontal vs. vertical incision on the anterior gastric wall in pancreaticogastrostomy.

BACKGROUND/AIMS: Pancreaticogastrostomy during pancreaticoduodenectomy is associated with a very low rate of anastomotic leakage. However, gastric peristalsis is disturbed by pancreaticogastrostomy, which stabilizes the posterior stomach at that point leading to delayed gastric emptying. We evaluated which anterior gastrostomy, i.e. horizontal or vertical incision on the anterior gastric wall, is better for maintaining peristaltic movement of the anterior stomach to prevent delayed gastric emptying after pancreaticogastrostomy. METHODOLOGY: We retrospectively studied 50 patients who underwent subtotal stomach-preserving pancreaticoduodenectomy with pancreaticogastrostomy. These patients were divided into 2 groups depending on the type of anterior gastrostomy: horizontal incision (H group) and vertical incision (V group). RESULTS: The observed grade of delayed gastric emptying was lower in the V group than in the H group; however, the difference was not significant. CONCLUSIONS: We conclude that a vertical incision on the anterior gastric wall is preferable for preventing delayed gastric emptying after a pancreaticogastrostomy.

Mesh vs. non-mesh repair for inguinal hernias in emergency operations.

BACKGROUND/AIMS: Prosthetic repair has become the gold standard for elective management of inguinal hernias; however, its use in the setting of acute incarceration is still limited for fear of prosthetic-related complications, mainly infection. Thus, in this study. we conducted a comparative investigation of the outcomes of prosthetic repair vs. tissue repair in the management of incarcerated inguinal hernias. METHODOLOGY: We retrospectively analyzed 62 patients who underwent emergency operations for incarceration of an inguinal hernia. These patients were divided into 2 groups based on the surgical procedure used: a mesh repair group (M group) and a non-mesh repair group (N group). RESULTS: There were no significant differences between the 2 groups with respect to postoperative complications and the mean period of post-operative hospitalization. CONCLUSIONS: Contrary to traditional belief, the use of a prosthetic mesh in the emergency setting is not contra-indicated. Its usage for the repair of incarcerated inguinal hernias appears to be safe and acceptable. However, when perforation of the intestine occurs due to incarceration of an inguinal hernia, prosthetic repair using hernioplasty should not be performed because of the high risk of infection.

Common bile duct dilatation after cholecystectomy: open versus laparoscopic procedure.

BACKGROUND/AIMS: Cholecystectomy as a factor causing common bile duct (CBD) dilatation has been debated. The aim of this study was to investigate CBD dilatation after cholecystectomy in patients with a preoperative CBD diameter of <6mm. METHODOLOGY: We retrospectively analyzed the cases of 101 patients who underwent cholecystectomy. These patients were divided into 2 groups, the open cholecystectomy group (OC group) and the laparoscopic cholecystectomy group (LC group). RESULTS: The postoperative mean CBD diameter was 5.80±0.49mm in the OC group and 5.75±0.47mm in the LC group; the diameters were not significantly different between the 2 groups (p<0.6699). With regard to the change in body weight after surgery, in the OC group 71.1%, patients gained weight, 20% showed no change and 8.9% lost weight; the corresponding numbers in the LC group were 75%, 23.2% and 1.8% patients, respectively. Thus, there were no significant differences in terms of weight changes between the 2 groups (p<0.6607, p<0.6973 and p<0.1690, respectively). CONCLUSIONS: For patients with preoperative CBD diameters of <6mm no compensatory dilatation occurs after open or laparoscopic cholecystectomy.

Technical considerations in laparoscopic staging for advanced gastric cancer.

BACKGROUND/AIMS: Staging laparoscopy is useful for increasing the accuracy of preoperative tumor staging. Diagnostic laparoscopy has therefore been introduced to prevent unnecessary laparotomy in patients with unresectable cancers. However, the technique of laparoscopic observation remains controversial. In this study, we determined the efficacy of hand-assisted laparoscopic staging. METHODOLOGY: We retrospectively studied 44 patients who underwent conventional (LS group) or hand-assisted laparoscopic staging (HALS group). RESULTS: The T factors of the TNM staging system was accurately determined in 95% of the patients in the HALS group and 58.3% of the patients in the LS group (p<0.0060). A total of 33.3% tumors in the LS group and 10% in the HALS group were judged to be unresectable. The overall mean survival was longer in the HALS group (20.3±12.2 months) than in the LS group (15.8±11.9 months). CONCLUSIONS: Laparoscopic diagnosis and staging of advanced gastric cancer are reliable. Moreover hand-assisted laparoscopic staging enables the accurate assessment of tumor resectability.

Percutaneous drainage in conservative therapy for perforated gastroduodenal ulcers.

BACKGROUND/AIMS: The management of peptic ulcers has dramatically changed and the incidence of elective surgery for gastroduodenal peptic ulcers has markedly decreased; hence, the incidence of emergency surgery for perforated peptic ulcers has slightly increased. In select cases, conservative therapy can be used as an alternative for treating perforated gastroduodenal ulcers. In this study, we evaluated the efficacy of percutaneous abdominal drainage for the conservative treatment of perforated gastroduodenal ulcers. METHODOLOGY: We retrospectively studied 51 patients who had undergone conservative therapy for perforated gastroduodenal ulcers. These patients were divided into 2 groups on the basis of the initial treatment with conservative therapy with or without percutaneous drainage: group PD included patients who had undergone percutaneous drainage and group NPD, patients who had undergone non-percutaneous drainage. RESULTS: In the PD group, 14.3% (n=3) of the patients did not respond to conservative therapy, while this value was 43.3% (n=13) in the NPD group. The 2 groups differed significantly with respect to conversion from conservative therapy to surgery (p<0.0352). CONCLUSIONS: Conservative therapy for perforated gastroduodenal ulcers should be performed only in the case of patients meeting the required criteria; its combination with percutaneous intraperitoneal drainage is effective as initial conservative therapy.

Pancreatic duct patency after pancreaticoduodenectomy for dilated pancreatic ducts.

BACKGROUND/AIMS: It is important to prevent pancreatic leakage and maintain pancreatic duct patency after pancreaticoduodenectomy (PD). We used an implantation method and a pancreatic stent in pancreaticogastrostomy (PG) and achieved good results without pancreatic leakage; however, PG strictures were observed in some cases. Using a pancreatic stent, we evaluated the early postoperative changes in the remnant pancreatic duct diameter in patients with a mildly dilated pancreatic duct. METHODOLOGY: We retrospectively analyzed 46 patients with a mildly dilated pancreatic duct (diameter 4-7mm) who underwent PD with PG. They were divided into 2 groups on the basis of the surgical treatment they received for pancreatic stump: Group C included patients who underwent complete ligation of the pancreatic duct with a pancreatic stent (complete external drainage of the pancreatic juice), and Group I included patients who underwent pancreatic duct-to-mucosa anastomosis with a pancreatic stent (incomplete external drainage of the pancreatic juice). RESULTS: The postoperative mean diameter of the remnant pancreatic duct was significantly smaller in Group I (6.22±0.81mm) than in Group C (6.80±1.10mm) (p<0.0466). CONCLUSIONS: To prevent pancreatic leakage and maintain pancreatic duct patency, duct-to-mucosa anastomosis with a pancreatic stent is useful for patients with a dilated pancreatic duct.

Spleen enlargement after distal gastrectomy in patients without hepatitis.

BACKGROUND/AIMS: Platelet count-to-spleen diameter ratio is reported to be the best non-invasive predictor of esophageal varices in cirrhotic patients. However, spleen enlargement is frequently detected during follow-up of patients after gastrectomy. Thus, we studied the relationship of the platelet count-to-spleen diameter ratio with the development of esophageal varices after distal gastrectomy in patients without liver cirrhosis or hepatitis. METHODOLOGY: We retrospectively studied 64 patients who underwent distal gastrectomy. Their platelet counts, spleen diameters and platelet count-to-spleen diameter ratios were correlated with the occurrence rate of esophageal varices after the surgery. RESULTS: Esophageal varices were not detected during the first 6 months after surgery; however, esophageal varices were detected in 2 patients (3%) at 12 months after surgery and their mean platelet count-to-spleen diameter ratio was 2,628 ± 409. CONCLUSIONS: The platelet count-to-spleen diameter ratio is a useful parameter for non-invasive prediction of esophageal varices after distal gastrectomy. In addition, we suggest that the occurrence rate of esophageal varices increases beyond 6 months after distal gastrectomy and when the platelet count-to-spleen diameter ratio is less than approximately 2600 and thus, endoscopy should be performed to determine the presence of esophageal varices.

Cholecystitis or cholestasis after total gastrectomy and esophagectomy.

BACKGROUND/AIMS: Increased incidences of gallbladder disorders after esophagectomy and gastrectomy have been reported. Moreover, several researchers have reported increased incidences of gallbladder diseases in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis or cholestasis and determined its relationship with total parenteral nutrition; further, we compared the incidence after esophagectomy and after total gastrectomy. METHODOLOGY: We retrospectively studied 109 patients who underwent total gastrectomy or esophagectomy. These patients were divided into 2 groups, those who underwent total gastrectomy (TG group) and those who underwent esophagectomy (E group). RESULTS: The 2 groups did not significantly differ with respect to the mean duration of perioperative administration of total parenteral nutrition and the incidence rate of cholecystitis or cholestasis after esophagectomy. CONCLUSIONS: Postoperative hyperbilirubinemia after esophagectomy may not contribute to the development of gallbladder complications. We suggest that parenteral modalities such as tube feeding be initiated immediately after surgery for preventing gallbladder complications after esophagectomy. Further, a short duration of administration of total parenteral nutrition and immediate postoperative initiation of oral feeding may prevent gallbladder complications after esophagectomy and total gastrectomy.

Open pancreatic stenting with duct-to-mucosa anastomosis for pancreatic-duct obstruction after pancreaticoduodenectomy with pancreaticogastrostomy.

Pancreatic-duct dilatation is frequently observed in the patients who have undergone pancreaticoduodenectomy (PD). Pancreaticodigestive anastomotic stricture may occasionally develop after PD. Stenosis of the pancreaticoenterostomy induces obstructive chronic pancreatitis, which occurs due to primary stenosis or obstruction of the main pancreatic duct and causes in inflammation of the distal pancreas. The patency of the pancreaticoenterostomy is one of the most important factors affecting the functioning of the remnant pancreas and the quality of life. Endoscopic dilatation is one of the treatment options for stenosis of pancreaticogastrostomy (PG). However, the failure of endoscopic dilatation necessitates surgical approaches. We have described our technique of open pancreatic stenting with a duct-to-mucosa anastomosis for a case which the stenosis of PG could not be resolved by endoscopic dilatation. This technique dose not require re-resected PG or side-to-side pancreaticojejunostomy: the risk of anastomotic leakage is quite low and the procedure is minimally invasive.

Advantages of jejunal pouch in Roux-en-Y reconstruction.

BACKGROUND/AIMS: To improve the quality of life of patients after total gastrectomy, various pouch-reconstruction techniques have been developed. However, pouch reconstruction is technically challenging and remains controversial. We therefore, determined the efficacy of the addition of a jejunal pouch to Roux-en-Y reconstruction after total gastrectomy. METHODOLOGY: We retrospectively studied 68 gastric cancer patients who had undergone total gastrectomy with simple Rouxen- Y reconstruction (RY group) or with Roux-en-Y reconstruction and jejunal pouch (JP group). RESULTS: Six months after discharge from the hospital, the mean total serum albumin level was significantly lower in the RY group than in the JP group, but the mean weight loss and incidence of reflux esophagitis did not differ between the 2 groups. CONCLUSIONS: The addition a jejuna pouch to Roux-en-Y reconstruction provides better reservoir function, but does not influence the incidence of reflux esophagitis. The construction of new fundus-like jejunal plication and the smooth passage of food from the esophagus to the jejunum prevent reflux esophagitis after total gastrectomy.

Cholecystitis, cholelithiasis and hyperbilirubinemia after esophagectomy.

BACKGROUND/AIMS: A high incidence of hyperbilirubinemia and an increased incidence of gallbladder disorders after esophagectomy have been reported. Moreover, several studies have documented an increased incidence of gallbladder disease in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis and cholestasis and hyperbilirubinemia associated with total parenteral nutrition after esophagectomy. METHODOLOGY: We retrospectively studied 42 patients who underwent esophagectomy. These patients were divided into 2 groups: the hyperbilirubinemia group and the non-hyperbilirubinemia group. The incidence of cholecystitis or cholestasis after the surgery was compared between the 2 groups. RESULTS: The mean total serum bilirubin level of the hyperbilirubinemia group (2.40±0.35mg/dL) was significantly higher than that of the non-hyperbilirubinemia group (1.20±0.34mg/dL; p<0.0001). No significant differences were observed between the 2 groups with respect to the mean duration for which total parenteral nutrition was required around the time of the operation (i.e. pre- and postoperatively) and the incidence rate of cholecystitis or cholestasis after esophagectomy. CONCLUSIONS: Hyperbilirubinemia after esophagectomy was frequently observed; however, it may not contribute to gallbladder problems. We suggest that parenteral modalities such as tube feeding should be initiated soon after surgery to prevent gallbladder problems after esophagectomy.

Gastric marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy due to delayed gastric emptying and Helicobacter pylori infection.

BACKGROUND/AIMS: Marginal ulceration and delayed gastric emptying are considerable problems after pancreaticoduodenectomy. Helicobacter pylori (HP) are well known to be associated with gastritis, gastric ulcer and gastric cancer. Thus, we studied the relationship between marginal ulceration and delayed gastric emptying in the early postoperative period after pancreaticoduodenectomy with pancreaticogastrostomy. METHODOLOGY: We retrospectively studied 58 patients who underwent pancreaticoduodenectomy with pancreaticogastrostomy. On the basis of the grade of delayed gastric emptying, these patients were divided into 2 groups-WS group; without/with slight delayed gastric emptying and MS group; moderate/severe delayed gastric emptying. RESULTS: Two patients (3.4%) developed postoperative marginal ulcer, these 2 patients had no HP infection; moreover, they belonged to the MS group. Five patients in the WS group were infected with HP; although, postoperative marginal ulceration did not develop in these 5 patients. CONCLUSIONS: Delayed gastric emptying might be a stronger promoting factor of postoperative marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy rather than HP infection and prevention of delayed gastric emptying is important to reduce the occurrence rate of postoperative marginal ulcer. Our modified subtotal stomach-preserving pancreaticoduodenectomy is a useful procedure for preventing delayed gastric emptying and postoperative marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy.