Ischemic Necrosis Caused by Retroanastomotic Hernia after Subtotal Gastrectomy / 대한소화기학회지

After gastrojejunostomy, a small space can occur between the jejunum at the anastomosis site, the transverse mesocolon, and retroperitoneum, which may cause an intestinal hernia. This report presents a rare case of intestinal ischemic necrosis caused by retroanastomotic hernia after subtotal gastrectomy. A 56-year-old male was admitted to Kangwon National University Hospital with melena, abdominal pain, and nausea. His only relevant medical history was gastrectomy due to stomach cancer. Endoscopic findings revealed subtotal gastrectomy with Billroth-II reconstruction and a bluish edematous mucosal change with necrotic tissue in afferent and efferent loops including the anastomosis site. Abdominopelvic CT showed strangulation of proximal small bowel loops due to mesenteric torsion and thickening of the wall of the gastric remnant. Emergency laparotomy was performed. Surgical findings revealed the internal hernia through the defect behind the anastomosis site with strangulation of the jejunum between 20 cm below the Treitz ligament and the proximal ileum. Roux-en-Y anastomosis was performed, and he was discharged without complication. Retroanastomotic hernia, also called Petersen's space hernia, is a rare complication after gastric surgery, cannot be easily recognized, and leads to strangulation.

CD44 expression in patients with combined hepatocellular cholangiocarcinoma

PURPOSE: Combined hepatocellular cholangiocarcinoma (ChC) is a rare type of primary liver cancer, which is thought to have a poorer prognosis than hepatocellular carcinoma (HCC). Cancer stem cells are associated with tumorigenesis, tumor progression, recurrence, metastasis, and poor prognosis in several malignancies including HCC. The aim of this study was to investigate the expression pattern of cancer stem cell markers in ChC and HCC, and to evaluate whether this pattern correlated to patient prognosis. METHODS: Thirteen patients who underwent curative hepatic resection for ChC and 13 patients who underwent curative hepatic resection for HCC (matched control cases) were included. Immunohistochemical staining for cancer stem cell markers (cytokeratin [CK]7, CK19, C-kit, cluster of differentiation [CD] 44, CD133, and epithelial cell adhesion molecule) was performed and clinical outcomes were analyzed retrospectively. RESULTS: There was no significant difference in cancer stem cell marker expression between ChC and HCC. In ChC, the group that expressed CD44 showed earlier recurrence than the group that did not express CD44 (P = 0.040). CONCLUSION: The expression of cancer stem cell markers in ChC did not show a different pattern compared to that found in HCC. The expression of cancer stem cell marker CD44 was associated with poor prognosis in patients with ChC.

Primary carcinosarcoma of the gallbladder / 대한외과학회지

Carcinosarcoma of gallbladder (CSGB) is a rare malignancy characterized by malignant epithelial and mesenchymal components. Its pathogenesis is unknown and most CSGBs are associated with poor survival because the disease normally presents at an advanced stage, and as a result, curative resection is uncommon. This report describes a case that underwent curative resection. A 77-year-old woman presented with right upper quadrant pain. The preoperative diagnosis was gallbladder (GB) cancer, and thus, curative radical cholecystectomy was performed. However, pathologic examination of the surgical specimen revealed that the tumor was composed of two histologic components of squamous cell carcinoma and spindle cell sarcoma, which was consistent with a diagnosis of carcinosarcoma. The tumor was found to extend to the perimuscular connective tissue and to have metastasized to one lymph node (LN). The prognosis of CSGB remains poor despite curative resection, and thus, the authors recommend that effort be made to improve surgical outcomes.

Sarcomatoid Carcinoma of the Gallbladder with Pure Squamous Cell Carcinoma: A Brief Case Report

We report here on a rare case of sarcomatoid carcinoma that contained an epithelial component of squamous cell carcinoma. A 77-year-old woman was found to have a gallbladder mass. The gallbladder showed a diffuse infiltrative wall mass with a polypoid lesion, and the mass measured 8x7x3 cm. There were no gallstones. Histologically, the tumor was composed of two components of squamous cell carcinoma and spindle cell malignancy. The tumor extended to the perimuscular connective tissue and one regional lymph node. The postoperative course was uneventful and the patient was well without tumor recurrence at one and a half months after surgery.

Type IV-A Choledochal Cyst with Intrahepatic Bile Duct Stricture

Choledochal cysts are rare congenital anomalies of the bile ducts. They consist of cystic dilatations of the extrahepatic biliary tree, intrahepatic radicles, or both. The standard treatment of choledochal cyst is complete excision of cyst and drainage procedure. I report a case of 48-year-old women who was diagnosed with type IV-A choledochal cyst with intrahepatic bile duct stricture and large stones in extrahepatic choledochal cyst. Sixteen years ago, she received a cholecystectomy and Reux-en Y cystojejunostomy due to choledochal cyst. Because of the intrahepatic bile duct stricture I performed a left hepatectomy, complete cyst excision and hepaticojejunostomy. I report this case with a review of the literature.

Clinical Benefits of Preoperative Percutaneous Transhepatic Gallbladder Drainage in Patients Older than Sixty with Acute Cholecystitis

PURPOSE: The purpose of this study was to evaluate the clinical benefits of preoperative percutaneous transhepatic drainage (PTGBD), especially regarding morbidity and mortality, in patients aged 60 or older with acute cholecystitis. METHODS: A retrospective study was done on a series of elderly patients (>60 years old; n=132) who had been diagnosed between January 2007 and December 2009 as having acute cholecystitis. The patients were divided into 4 groups; cases in which only laparoscopic cholecystectomy (LC) was done (Group 1, n=84), cases in which LC was done after preoperative PTGBD (Group 2, n=15), cases in which only open cholecystectomy was done (Group 3, n=23), and cases in which open cholecystectomy was done after preoperative PTGBD (Group 4, n=10). We analyzed between group differences in surgical outcomes including periods of postoperative fast and postoperative hospital stay, OP. morbidity, and open conversion rate. RESULTS: Patients in Group 1 had fewer underlying medical problems and lower ASA scores than patients in groups 2, 3, or 4 (p<0.05). Mean operating time in Group 2 (113.66+/-107.5 min) was significantly longer than in group 1 (72.02.9+/-34.2 min) (p<0.05) and the open conversion rate was higher (8.33% vs 26.67%). But, blood loss (ml) and OP time in Group 2 were lower than in Group 3 or 4 (p<0.001). Postoperative recovery progression (periods of postoperative fasting and length of postoperative hospital stay) of Group 2 were better than in groups 3 or 4 (p<0.001). CONCLUSION: Pre-operative PTGBD procedures in elderly patients with acute cholecystitis is a good clinical option as a pretreatment to a cholecystitis operation.

Primary Adenosquamous Carcinoma of the Stomach

PURPOSE: A primary adenosquamous carcinoma of the stomach is relatively rare, accounting for only about 0.5% of all gastric cancers. However, its histopathologic characteristics are still unclear, and the most appropriate form of therapy has not been established yet. MATERIALS AND METHODS: We retrospectively reviewed the clinicopathologic features of 8 patients with pathologically confirmed primary adenosquamous carcinomas out of 8,268 patients who underwent gastric cancer surgery at Samsung Medical Center between September 1994 and December 2004. RESULTS: The median age of the 8 patients was 49 (41~69) years, and the male : female ratio was 5 : 3. In 3 patients, the tumor was located at the mid body of the stomach, and in 5 patients, at the lower body or antrum. The tumor sizes were 2.5~8 cm. Seven patients showed metastases to the regional lymph nodes. The UICC stage distribution were: 5 stage II, 2 stage III, and 1 stage IV. In the stage IV patient, a palliative gastrojejunostomy was performed, and he died 5 months after surgery. Of the 7 patients who underwent a radical gastrectomy and adjuvant chemotheratpy, the median survival was 34 (12~66) months, 2 patients died of cancer recurrence, and 4 patients are being followed up without evidence of recurrence. CONCLUSION: As for an adenocarcinoma of the stomach, a radical gastrectomy including regional lymph node dissection and postoperative adjuvant therapy should be performed for appropriate treatment of an adenosquamous carcinoma of the stomach.

Impact of Adjuvant Chemoradiation Therapy on the Postoperative 5-year Survival Rates for Stage-II Gastric Cancer

PURPOSE: This study was conducted to evaluate the effectiveness and the role of post-operative adjuvant chemoradiation therapy in a stage-II (UICC,1997) primary gastric cancer. MATERIALS AND METHODS: From September 1994 to December 2004, 954 stage-II gastric-cancer patients were seen, and all of them underwent a curative resection with extensive (D2) lymph-node dissection. The chemotherapy consisted of fluorouracil (400 mg/m2) plus leucovorin (20 mg/m2) for 5 days, followed by 4,500 cGy of radiotherapy for 5 weeks with fluorouracil and leucovorin on the first 4 days and the last 3 days of radiotherapy. Two five-day cycles of chemotherapy were given four weeks after the completion of radiotherapy. The Kaplan-Meier method was used to estimate the survival rates. To assess the importance of potential prognostic factors, we performed univariate and multivariate analyses using a log-rank test and Cox's proportional hazards regression model. A P value <0.05 was considered significant. RESULTS: Univariate analysis revealed that age, tumor size, gross type, surgical method, and postoperative adjuvant therapy had statistical significance. Among these factors, age, surgical method, tumor size, surgical method, and postoperative adjuvant therapy were found to be independent prognostic factors by using a multivariate analysis. The postoperative adjuvant chemotherapy group and the chemoradiation therapy group had survival benefit compared to the surgery-only group. However, the chemoradiation therapy group had no significant survival benefit compared to the chemotherapy group. CONCLUSION: The postoperative adjuvant therapy in stage-II gastric-cancer patients had significant benefit. Therefore, postoperative adjuvant chemoradiation therapy has an acceptable effect. A large-scale, randomized study is needed to evaluate the effectiveness and the role of postoperative radiation therapy.

Impact of Adjuvant Chemoradiation Therapy on the Postoperative 5-year Survival Rates for Stage-II Gastric Cancer

PURPOSE: This study was conducted to evaluate the effectiveness and the role of post-operative adjuvant chemoradiation therapy in a stage-II (UICC,1997) primary gastric cancer. MATERIALS AND METHODS: From September 1994 to December 2004, 954 stage-II gastric-cancer patients were seen, and all of them underwent a curative resection with extensive (D2) lymph-node dissection. The chemotherapy consisted of fluorouracil (400 mg/m2) plus leucovorin (20 mg/m2) for 5 days, followed by 4,500 cGy of radiotherapy for 5 weeks with fluorouracil and leucovorin on the first 4 days and the last 3 days of radiotherapy. Two five-day cycles of chemotherapy were given four weeks after the completion of radiotherapy. The Kaplan-Meier method was used to estimate the survival rates. To assess the importance of potential prognostic factors, we performed univariate and multivariate analyses using a log-rank test and Cox's proportional hazards regression model. A P value <0.05 was considered significant. RESULTS: Univariate analysis revealed that age, tumor size, gross type, surgical method, and postoperative adjuvant therapy had statistical significance. Among these factors, age, surgical method, tumor size, surgical method, and postoperative adjuvant therapy were found to be independent prognostic factors by using a multivariate analysis. The postoperative adjuvant chemotherapy group and the chemoradiation therapy group had survival benefit compared to the surgery-only group. However, the chemoradiation therapy group had no significant survival benefit compared to the chemotherapy group. CONCLUSION: The postoperative adjuvant therapy in stage-II gastric-cancer patients had significant benefit. Therefore, postoperative adjuvant chemoradiation therapy has an acceptable effect. A large-scale, randomized study is needed to evaluate the effectiveness and the role of postoperative radiation therapy.

Benign Stricture of Esophagojejunostomy after Radical Total Gastrectomy

PURPOSE: Benign anastomotic stricture after an esophagojejunostomy using EEA stapler following a radical total gastrectomy is one of the most serious complications. The purpose of this study is to evaluate the incidence, risk factors, and treatment associated with benign stricture. MATERIALS AND METHODS: From March 1998 to February 2001, 436 patients underwent an esophagojejunostomy with Roux-en-Y anastomosis using an EEA stapler followed by an endoscopy. Thirty three of the 436 patients (5.5%) developed an anastomotic stricture; included 24 of the 33 patients had a benign stricture. Nine patients with a malignant stricture were excluded. RESULTS: The median age of the 436 patients was 57 years (23~85 years). Two hundred ninety two patients were male, and 144 patients were female. The median time to diagnosing the stricture was 1.5 months (0.5~6 months). There was no statistical significance in any of the risk factors, including the diameter of the stapling device, the status of adjuvant treatment, the status of reflux esophagitis, and a clinical history of diabetes and hypertension. The strictured patients were treated with balloon dilatation, one to three times, with symptom relief. CONCLUSION: There were no statistically significant risk factors. However, further study of the vascularity of anastomoses and benign strictures needs to be considered. In the anastomotic strictured patients, endoscopic balloon dilatation appeared to be the first line of treatment.

Clinical Significance of the Ghrelin Concentrations in Plasma and Tumor Tissue from Patients with Gastric Cancer

PURPOSE: Ghrelin, produced primarily in the gastrointestinal tract, including the stomach, has been reported to reflect nutritional status and to control homeostasis by influencing food intake and adiposity. The purpose of this study is to evaluate nutritional status, as well as plasma and gastric tissue ghrelin levels, in patients with gastric cancer who underwent a gastrectomy. MATERIALS AND METHODS: Eighty patients were analyzed by the degree of weight loss (weight loss > or =5% or < 5%) and the extent of gastrectomy (subtotal or total gastrectomy). Blood samples were collected from all patients preoperatively and postoperatively especially at seven days. Gastric tissues, including tumor and normal tissues, were obtained from the resected stomach. Levels of plasma and tissue ghrelin were measured with a commercial ELISA kit. RESULTS: There were no significant differences in the clinical characteristics and ghrelin levels of plasma, gastric tumor tissue and normal tissue by the degree of weight loss. The ghrelin levels in plasma and tumor tissue showed no correlations with each other while the ghrelin level in tumor tissue was significantly lower than that in normal tissue. The degree of cellular differentiation also had an association with ghrelin production. A gastrectomy proved to decrease significantly plasma ghrelin levels, body mass index, and biochemical markers, regardless of the extent of gastric resection. CONCLUSION: These results show that gastric cancer affects the production of ghrelin in the gastric mucosa and that ghrelin is mainly produced in stomach even though it could be partially covered by endogenous ghrelin from other organs following a gastrectomy. However, we should further investigate which other factors have an impact on energy consumption, ghrelin secretion, and changes in ghrelin levels after a gastrectomy.

Cyclin G2 Expression in Gastric-cancer Tissues

PURPOSE: Cyclin G2 has been reported to be a negative cell-cycle regulator in various cancer tissues. However, the pattern of cyclin G2 expression in gastric cancer is relatively unknown. We investigated the expression of cyclin G2 in gastric cancer tissues and evaluated the clinical significance of its expression. MATERIALS AND METHODS: Well-preserved gastric cancer tissues were consecutively obtained from 172 patients who underwent gastric cancer operations at Samsung Medical Center between November 1994 and December 1997. Cyclin G2 expression in the tissues was examined immunohistochemically, and the clinicopathological features and prognostic significance according to the expression were analyzed. RESULTS: Of the 172 gastric cancer tissues, cyclin G2 expression was positive in 43 tissues (25.0%). According to the stage, cyclin G2 expression was lower in more advanced stages (P<0.001). Negative expression of cyclin G2 was positively correlated with more advanced depth of tumor invasion (P<0.05), presence of lymph-node metastasis (P<0.05) and presence of lymphatic invasion (P<0.05). The prognosis of the cyclin G2 (+) group was significantly better than that of the cyclin G2 (-) group (P<0.001). Multivariate analysis revealed that T stage, lymph-node metastasis, distant metastasis, and lymphatic invasion were independent prognostic factors, but the expression of cyclin G2 was not. CONCLUSION: Cyclin G2 was expressed in 25% of the gastric cancer tissues, and negative expression of cyclin G2 was associated with more advanced tumor progression. Cyclin G2 may be a negative cell-cycle regulator in gastric cancer, and further studies are necessary to elucidate its exact role in the mechanism of carcinogenesis.

Cyclin G2 Expression in Gastric-cancer Tissues

PURPOSE: Cyclin G2 has been reported to be a negative cell-cycle regulator in various cancer tissues. However, the pattern of cyclin G2 expression in gastric cancer is relatively unknown. We investigated the expression of cyclin G2 in gastric cancer tissues and evaluated the clinical significance of its expression. MATERIALS AND METHODS: Well-preserved gastric cancer tissues were consecutively obtained from 172 patients who underwent gastric cancer operations at Samsung Medical Center between November 1994 and December 1997. Cyclin G2 expression in the tissues was examined immunohistochemically, and the clinicopathological features and prognostic significance according to the expression were analyzed. RESULTS: Of the 172 gastric cancer tissues, cyclin G2 expression was positive in 43 tissues (25.0%). According to the stage, cyclin G2 expression was lower in more advanced stages (P<0.001). Negative expression of cyclin G2 was positively correlated with more advanced depth of tumor invasion (P<0.05), presence of lymph-node metastasis (P<0.05) and presence of lymphatic invasion (P<0.05). The prognosis of the cyclin G2 (+) group was significantly better than that of the cyclin G2 (-) group (P<0.001). Multivariate analysis revealed that T stage, lymph-node metastasis, distant metastasis, and lymphatic invasion were independent prognostic factors, but the expression of cyclin G2 was not. CONCLUSION: Cyclin G2 was expressed in 25% of the gastric cancer tissues, and negative expression of cyclin G2 was associated with more advanced tumor progression. Cyclin G2 may be a negative cell-cycle regulator in gastric cancer, and further studies are necessary to elucidate its exact role in the mechanism of carcinogenesis.

A Clinical Review for Resected Intrahepatic Cholangiocarcinoma / 한국간담췌외과학회지

BACKGROUND/AIMS: An intrahepatic cholangiocarcinoma, which has been defined as a primary adenocarcinoma from the intrahepatic bile duct to the second-order branch of the main hepatic duct, has a poor prognosis due to late diagnosis and low resectability. The purpose of this study is to define the prognostic factors that affected the survival of patients. METHODS: To evaluate the clinical manifestation and pathologic characteristics and the value of surgical management in relation to survival, we retrospectively reviewed the clinical records of 37 patients with an intrahepatic cholangiocarcinoma who had been underwent hepatic resection at the department of surgery, Hanyang University Hospital from April 1986 to April 2001. Cumulative survival rate and clinicopa-thologic factors that may influence the prognosis were analyzed statistically. Statistical significance was calculated by the Kaplan-Meier and compared by log rank test with statistical significance defined as p<0.05. RESULTS: The median survival time of the patients was 24.6 months (mean, 23.97 months), with 2 and 3-year survival rates of 33.3% and 27.3%, respectively. Univariate analysis showed that TMN stage and gross type correlated significantly with prognosis. Age, sex, tumor marker, Clonorchis Sinensis, intrahepatic duct stone and cell differentiation were not significantly correlated with prognosis. CONCLUSION: In case of the intrahepatic cholangiocarcinoma, without surgical treatment, survival time is not longer than mean 6 months from the first diagnosis. According to this study, we strongly recommend to early diagnosis and proper hepatic resection with lymph node dissection, be recommended to raise the long-term survival rate and improve the quality of life.