A Nomogram for Predicting Extraperigastric Lymph Node Metastasis in Patients With Early Gastric Cancer.

BACKGROUND: There are no clear guidelines to determine whether to perform D1 or D1+ lymph node dissection in early gastric cancer (EGC). This study aimed to develop a nomogram for estimating the risk of extraperigastric lymph node metastasis (LNM). MATERIALS AND METHODS: Between 2009 and 2019, a total of 4,482 patients with pathologically confirmed T1 disease at 6 affiliated hospitals were included in this study. The basic clinicopathological characteristics of the positive and negative extraperigastric LNM groups were compared. The possible risk factors were evaluated using univariate and multivariate analyses. Based on these results, a risk prediction model was developed. A nomogram predicting extraperigastric LNM was used for internal validation. RESULTS: Multivariate analyses showed that tumor size (cut-off value 3.0 cm, odds ratio [OR]=1.886, P=0.030), tumor depth (OR=1.853 for tumors with sm2 and sm3 invasion, P=0.010), cross-sectional location (OR=0.490 for tumors located on the greater curvature, P=0.0303), differentiation (OR=0.584 for differentiated tumors, P=0.0070), and lymphovascular invasion (OR=11.125, P<0.001) are possible risk factors for extraperigastric LNM. An equation for estimating the risk of extraperigastric LNM was derived from these risk factors. The equation was internally validated by comparing the actual metastatic rate with the predicted rate, which showed good agreement. CONCLUSIONS: A nomogram for estimating the risk of extraperigastric LNM in EGC was successfully developed. Although there are some limitations to applying this model because it was developed based on pathological data, it can be optimally adapted for patients who require curative gastrectomy after endoscopic submucosal dissection.

A Rare Case of Familial Schwannomatosis Showing Intrafamilial Variability with Identification of a Shared Novel Germline SMARCB1 Mutation.

Schwannomatosis is characterized by the presence of multiple schwannomas without landmarks of NF2. It is considered the rarest form of neurofibromatosis (NF). Here, we report the first case of familial schwannomatosis with regard to the segmental/generalized phenotype, in which the proband and the daughter present a distinct phenotype in this classification. The proband presents a generalized, painless, extradural type of schwannomatosis, while the daughter shows a segmental, painful, intradural type of schwannomatosis. Whole-exome sequencing of the affected individuals revealed a shared novel SMARCB1 gene mutation (c.92A > G, p.Glu31Gly) despite the clinical variability. We thus suggest two points in the diagnosis of familial schwannomatosis: The identified novel germline SMARCB1 variant can be reflective of a phenotypical progression from a segmental to a generalized type of schwannomatosis, or an intrafamilial variability in inherited schwannomatosis, which was not reported in previous literature. The specific combination of somatic NF2 mutations may be a major factor in regulating the severity and scope of the resulting phenotype in schwannomatosis.

Clinicopathological features and management strategy for superficial nonampullary duodenal tumors: a multi-center retrospective study.

Purpose: We investigated the clinicopathological features and management for superficial nonampullary duodenal tumors (SNADTs). The safety and feasibility of laparoscopic management, especially laparoscopic endoscopic cooperative surgery (LECS), were evaluated. Methods: A total of 59 patients with SNADTs who underwent operations from January 2009 to December 2018 at all 8 institutions of the Catholic Medical Center were identified in our comprehensive multi-institutional database. Clinicopathological and surgical data on the 4 anatomical regions of the duodenum were collected and compared. Characteristics of conventional laparoscopic procedure (laparoscopy-only) and LECS procedures were also compared. Results: There were significantly more asymptomatic patients with tumors in the first and second vs. third and fourth duodenal regions. Gastrointestinal stromal tumors (GISTs), carcinoids, and ectopic pancreatic tumors were identified in 32, 12, and 5 cases, respectively. Forty-two patients (71.2%) underwent laparoscopy. Of patients undergoing laparoscopy, the LECS group exhibited significantly more endophytic features and smaller tumor sizes (P < 0.001 and P < 0.001, respectively). Although no significant difference in the wedge resection or postoperative complication rate was seen between the 2 groups (P = 0.096 and P = 0.227, respectively), the wedge resection rate was higher, and the complication rate lower, in the LECS group than the conventional laparoscopic surgery group. Conclusion: Most of the SNADTs located in proximal duodenum were detected incidentally. GISTs were the most common diagnoses of SNADTs in all locations. In treating these tumors, laparoscopic resection is safe and feasible. Especially, LECS may be ideal for treating small endophytic tumors, minimizing over-resection and postoperative complications.

Trends in laparoscopic anti-reflux surgery: a Korea nationwide study.

BACKGROUND: In 2014, the results derived from the nationwide data of the Korean Anti-reflux Surgery Study (KARS) demonstrated short-term feasibility and safety of anti-reflux surgery. This study aimed to update the longer-term safety and feasibility of laparoscopic anti-reflux surgery up to 1-year follow-up with the KARS nationwide cohort. METHODS: The data of 310 patients with GERD who received anti-reflux surgery up to 2018 were analyzed. Baseline patient characteristics, postoperative symptom resolution, and postoperative complications were evaluated at postoperative 3 months and 1 year using the questionnaire designed by KARS. We divided the patients into two groups according to the operation period (up to and after 2014) to identify changes in the trends of the characteristics of surgical patients and operative qualities. RESULTS: The typical preoperative symptoms were present in 275 patients (91.7%), and atypical symptoms were present in 208 patients (71.0%). Ninety-seven (35.5%) and 124 patients (46.1%) had inadequate PPI responses and hiatal hernia, respectively. At postoperative 1 year, typical and atypical symptoms were either completely or partially controlled in 90.3% and 73.5.0% of patients, respectively. Moderate-to-severe dysphagia, inability to belch, gas bloating, and flatulence at postoperative 1 year were identified in 23.5%, 29.4%, 23.2%, and 22.0% of patients, respectively. The number of surgical patients continuously increased from 2011 to 2018 in Korea. The proportion of patients with hiatal hernia and comorbidities increased (p < 0.01, p = 0.053), and the operation time decreased significantly (p < 0.01) in the late period (2015-2018) as compared with the early period (2011-2014). Symptom control and complication rate were equivalent between the two periods. CONCLUSIONS: Anti-reflux surgery was effective with > 90% of typical symptom resolution and posed a comparable postoperative complication rate with those in Western studies with mid-term to long-term follow-up. This result supports the feasibility and safety of anti-reflux surgery as a treatment for GERD in the Korean population.

Efficacy of an antiadhesive agent for the prevention of intra-abdominal adhesions after radical gastrectomy: A prospective randomized, multicenter trial.

BACKGROUND: Guardix-SG is a poloxamer-based antiadhesive agent. The aim of this study was to investigate its efficacy in preventing abdominal adhesions in gastric cancer patients undergoing gastrectomy. Few clinical studies have reported that antiadhesive agent reduces the incidence of adhesion after gastrectomy. METHODS: We conducted a multicenter trial from June 2013 and August 2015 in patients with gastric adenocarcinoma undergoing radical gastrectomy. Patients were randomly assigned to the Guardix treatment or control group. Postoperative adhesions were diagnosed based on postoperative symptoms, plain x-ray films, and computed tomography. The primary endpoint of the study was the incidence of small bowel obstruction in the first postoperative year. The secondary end-point was the safety of Guardix-SG. RESULTS: The study included 109 patients in the Guardix group and 105 patients in the control group. The groups were similarly matched with pathological stage, operation type, anastomosis method, midline incision length, and the extent of lymph node dissection. Eight in the Guardix group and 21 in the control group experienced intestinal obstruction during the 1-year follow-up period. The cumulative incidence of small bowel obstruction was significantly lower in the Guardix group compared to that seen in the control group (4.7% vs 8.6% at 6 months and 7.3% vs 20% at 1 year; P = .007, log-rank test). There were no differences in postoperative complications and adverse events. CONCLUSION: Guardix-SG significantly decreased the incidence of intestinal obstruction without affecting the incidence of postoperative complications.

Radical Gastrectomy After Chemotherapy May Prolong Survival in Stage IV Gastric Cancer: A Korean Multi-institutional Analysis.

ABASTRACT: BACKGROUND: Despite the development of newer treatments, the prognosis for patients with stage IV gastric cancer remains grave. This study evaluated the efficacy of gastrectomy following response to chemotherapy in patients with stage IV gastric cancer. METHODS: A total of 419 patients who were diagnosed with stage IV gastric cancer were identified from the multi-institutional Catholic Gastric Cancer Study Group database. The patients were divided into four groups: 212 were in the chemotherapy only (CTx) group, 124 were in the chemotherapy after palliative gastrectomy (G-CTx) group, 23 were in the radical gastrectomy after chemotherapy (CTx-G) group, and 60 were in the best supportive care group. To compensate for the effects of chemotherapy, cases of chemotherapy responsive were analyzed separately. To identify factors affecting survival rates, cure rates for surgery in the surgery group were analyzed. RESULTS: The 3-year survival rate of the CTx-G group was significantly higher than that of the CTx group (42.8 vs. 12.0%, p = 0.001). Moreover, the CTx-G group's 3-year survival rate was greater than that of the G-CTx group (42.8 vs. 37.1%, p = 0.207). Chemotherapy-responsive patients in the CTx-G group had a better 3-year survival rate than those in the G-CTx group (46.1 vs. 18.4%, respectively, p = 0.011). In the surgery group, R0 resection led to a significantly better 3-year survival rate than palliative gastrectomy (61.1 vs. 16.2%, p = 0.003). CONCLUSIONS: Adjuvant surgery might improve the survival rate of patients with stage IV gastric cancer, particularly in R0 resection cases.

Safety of laparoscopic radical gastrectomy in gastric cancer patients with liver cirrhosis.

BACKGROUND: Laparoscopic gastrectomy (LG) in gastric cancer patients with liver cirrhosis (LC) has rarely been reported. In this study, we aimed to elucidate the feasibility of LG compared with that of open gastrectomy (OG) for LC patients. METHODS: Of the 75 LC patients who underwent radical gastrectomy for gastric cancer between April 2005 and March 2014, 36 patients who underwent LG were compared with 39 patients who underwent OG. Comparisons were based on clinicopathologic characteristics, surgical outcomes, and long-term survival rates. RESULTS: Comparison of LG and OG revealed no significant differences in the clinicopathologic characteristics. Five patients in the LG group and eight in the OG group showed a Child-Turcotte-Pugh score (CTPs) over A. In surgical outcomes, we observed shorter operation times (191.4 ± 63.9 vs. 225.9 ± 77.1 min, p = 0.039), reduced estimated blood loss (175.5 ± 214.1 vs. 396.9 ± 514.8 ml, p = 0.021), and shorter hospital stays (10.4 ± 4.6 vs. 13.7 ± 5.8 days, p = 0.008) in LG than OG. Regarding postoperative morbidity, 7 (19.4%) and 10 (25.6%) complications were observed in the LG and OG groups, respectively. There was no difference in complications between the two groups regardless of the CTPs. One patient with a CTPs of C succumbed to hepatic failure following LG. Long-term survival and overall and recurrence-free survival rates did not differ between the two groups. CONCLUSIONS: Even in cases with CTPs B, LG with lymph node dissection for gastric cancer patient was safer and acceptable than OG was. Therefore, LG can be considered an alternative surgical approach in gastric cancer with LC.

Technical Feasibility of Enterotomy Closure with Knotless Barbed Suture Material (V-Loc 180) in Esophagojejunostomy Using Linear Stapler during Totally Laparoscopic Total Gastrectomy for Gastric Cancer.

PURPOSE: Intra-corporeal esophagojejunostomy (EJ) using a linear stapler creates a stapler entry hole that requires secure closure during the totally laparoscopic total gastrectomy (TLTG) procedure for gastric cancer. Since a standard method has not been established yet, the feasibility of using V-loc 180 (Covidien, Mansfield, MA, USA) suture material was evaluated in this study. MATERIALS AND METHODS: During January 2012 to March 2015, 25 patients who underwent linear stapling EJ and V-loc 180 closure of remaining enterotomy were included in this study. Basic clinico-pathological characteristics, surgical outcomes, and short-term complications were analyzed. RESULTS: The mean patient age was 60.4 ± 8.5 years. Nineteen males and six females were included in this study. The mean body mass index was 25.3 ± 2.3 kg/m2. There were 22 stage-I, 2 stage-II, and 1 stage-III gastric cancer patients. The mean operation time was 240.5 ± 44.6 min, and the time for anastomosis was 38.8 ± 11.2 min. The procedures were successfully performed in all cases without any intra-operative complications. There was one case of EJ leakage that occurred at the corner of EJ staple line and not at the enterotomy closure site. CONCLUSIONS: The closure of the remaining enterotomy site using V-loc 180 suture following linear stapler EJ is technically feasible and safe during the TLTG procedure. However, further experience and results from other surgeons are necessary to generalize this procedure.

Endoscopic submucosal dissection versus surgical resection for early gastric cancer: a retrospective multicenter study on immediate and long-term outcome over 5 years.

BACKGROUND: Endoscopic submucosal dissection (ESD) is an alternative to surgical resection for treating early gastric cancer (EGC). However, there have been limited reports on the long-term outcome of ESD compared to that of surgical resection. The aim of this study was to evaluate the immediate and long-term clinical and oncologic outcomes of ESD compared to surgical resection. METHOD: We retrospectively reviewed data of patients in five centers who were treated with ESD or surgical resection for EGC within expanded criteria for ESD from 2006 to 2008. RESULT: ESD group had significantly shorter procedure times, shorter fasting period, and shorter hospital stay than the surgical resection group. Immediate complications in the surgical resection group were more common compared to those in the ESD group. Five-year cancer recurrence rate of the ESD group was 12.3 % and significantly higher than 2.1 % of the surgical resection group (P = 0.001). Five-year disease-free survival rate of the surgical resection group was 97 %, which was significantly higher than 85 % of the ESD group (P = 0.001). Metachronous lesions were equally found every year during the follow-up period in the ESD group. Five-year overall survival rates were 100 % for both groups. CONCLUSION: ESD might be an acceptable and effective treatment for EGC considering overall survival rates with fewer early complication rates and shorter duration of hospital stay compared to surgical resection. However, intensive and persistent endoscopic surveillance should be performed after ESD for early detection of metachronous lesions.

Antireflux Surgery in Korea: A Nationwide Study from 2011 to 2014.

BACKGROUND/AIMS: Although laparoscopic fundoplication is a well-established therapy for gastroesophageal reflux disease (GERD) in Western countries, the mainstay of GERD treatment in Korea is long-term proton pump inhibitor (PPI) use. The aim of the present study was to evaluate nationwide data regarding antireflux surgery in Korea. METHODS: Data from 2011 to 2014 were collected from the Korean Antireflux Surgery Study Group and then analyzed. RESULTS: A total of 87 patients underwent laparoscopic fundoplication for the treatment of GERD. Preoperatively, typical symptoms were present in 81 patients (93%) and atypical symptoms were present in 51 patients (59%). Twenty-seven patients (31%) had poor PPI responses. The average surgical time and postoperative hospital stay were 116.3±42.3 minutes and 4.3±3.1 days, respectively. At 3 months after surgery, typical symptoms were completely controlled in 86.3% of patients and partially controlled in 11.7%, whereas atypical symptoms were completely controlled in 63.3% of patients and partially controlled in 23.3%. CONCLUSIONS: This study showed that although atypical symptoms and PPI nonresponders are common, the complete control rates of typical and atypical symptoms were 86.3% and 63.3%, respectively. Laparoscopic fundoplication is an efficacious method of controlling the symptoms of GERD and has an acceptable rate of postoperative morbidity and adverse symptoms.

Comparison of the major postoperative complications between laparoscopic distal and total gastrectomies for gastric cancer using Clavien-Dindo classification.

BACKGROUND: Laparoscopy-assisted total gastrectomy (LATG) has not been as popular as laparoscopy-assisted distal gastrectomy (LADG) because of its undetermined safety and postoperative complications compared with LADG. Therefore, LATG requires further study. PATIENTS AND METHODS: A total of 663 patients who underwent LADG or LATG for gastric cancer in a single institution from April 2004 to April 2014 were included. The clinicopathologic characteristics and risk factors related to major complications (Clavien-Dindo grade ≥ IIIa) were analyzed between the LADG (n = 569) and LATG groups (n = 94). RESULTS: The incidence of major postoperative complications was significantly higher for LATG (LADG vs. LATG: 8.1 vs. 18.1 %, P = 0.002). Although postoperative bleeding was not different between the groups (3.2 vs. 3.2 %, P = 0.991), the incidence of bowel leakage was significantly higher for LATG (2.6 vs. 6.8 %, P = 0.028). Leakage from the anastomosis site was more frequent following LATG (5.3 %) compared with LADG (0.5 %) (P < 0.001). Leakage from the duodenal stump tended to be more frequent, though not significant, for LADG (2.0 vs. 1.1 %, P = 0.602). Advanced gastric cancer, LATG, and longer operation time were significant factors that affected the incidence of postoperative complications in a univariate analysis. In multivariate analysis, there were no independent risk factors, but LATG was nearly a significant, independent risk factor (odds ratio 1.89; 95 % CI 0.965-3.71, P = 0.063). CONCLUSION: More major complications were observed for LATG, particularly with esophagojejunostomy. These results show that LATG is more invasive than LADG in terms of the postoperative morbidity. More caution and experience are needed when performing LATG.

Laparoscopic resection for 125 gastroduodenal submucosal tumors.

PURPOSE: The present study aims to elucidate the treatment strategies of laparoscopic resection for gastroduodenal submucosal tumors (SMTs). METHODS: Data of 125 gastroduodenal STMs were collected retrospectively resected from August, 2004 to February, 2013. Surgical outcomes according to tumor locations, pathologic results and survival data for gastrointestinal stromal tumors (GISTs) were collected and analyzed. RESULTS: There were 55 male and 70 female patients with mean age 57.9 ± 12.7 years old. Mean tumor size of gastric SMTs was 2.7 ± 1.64 cm (range, 0.4-8.5 cm). GIST was the most common (n = 70, 56%). Regarding the tumor location, all the fundic lesions were GISTs and leiomyoma was occurred 58.8% of cardiac lesions. Ectopic pancreas and schwannomas were mostly located at body portion, 73% and 80%, respectively. SMTs located at duodenal bulb comprise 4 GISTs and 3 carcinoids. Surgical results comparing between lesions located at cardia, near-pylorus and else had no difference in operation time, hospital stay and complications. In terms of outcome of GIST, all patients underwent curative resection except one case of peritoneal sarcomatosis. There was one recurrence in a high risk group following resection. The cumulative 5-year disease free survival rate was 93.5% in all GISTs. There were two postoperative complications, one gastric outlet obstruction and one leakage following wedge resection. CONCLUSION: Laparoscopic wedge resection is a safe and feasible procedure for the small to medium sized gastroduodenal SMTs even their locations are near cardia or pylorus.

Surgical treatment for late-appearing adrenal metastasis from gastric cancer: report of two cases.

Adrenal metastasis following gastrectomy for gastric cancer is often encountered as part of advanced systemic dissemination, which is usually unresectable. Thus, there are very few published case reports describing metastasectomy for adrenal metastasis from gastric cancer. Herein we present our experience in treating two patients diagnosed and treated for adrenal metastasis 6 years following initial surgery for advanced gastric cancer (pT2bN1M0 and pT2bN0M0, respectively, according to the classification system set forth in the sixth edition of The TNM Classification of Malignant Tumours by the International Union against Cancer). They underwent successful en bloc R0 resections, followed by systemic chemotherapy with close postoperative follow-up for another recurrence, and have remained alive without recurrence for 1 year. These results suggest that active surgical treatment for resectable metastatic gastric cancer in the adrenal glands has an important role in prolonging survival in selected patients.

Very early-onset peritoneal recurrence following curative total gastrectomy for Borrmann 4 gastric cancer.

Peritoneal dissemination is one of the treatment failures following gastric cancer surgery. We present a case with very early peritoneal recurrence, detected 8 days following curative surgery. A 39-year-old man, with Borrmann-4 advanced gastric cancer with signet ring cell type, underwent curative open total gastrectomy. However, focal peritoneal nodules on the left side of the diaphragmatic surface, which did not exist at the initial operation, were incidentally found during the reoperation for a postoperative intestinal obstruction via a laparoscopic approach. The pathologic result of the biopsied nodule revealed signet ring cell carcinoma. The patient underwent combination chemotherapy for several months without tumor regression. He suffered from intestinal obstruction again due to carcinomatosis peritonei, and died 9 months following initial surgery. Through this case report, we can carefully suspect that very early progression of cancer cells to carcinomatosis can occur in just several days after an operation.

A comparison of total versus partial omentectomy for advanced gastric cancer in laparoscopic gastrectomy.

BACKGROUND: Minimally invasive surgery has been slowly introduced into the field of advanced gastric cancer (AGC) surgery. However, the appropriate extent of omentectomy during laparoscopic gastrectomy for AGC is unknown. METHODS: From July 2004 to December 2011, 146 patients with serosa-negative advanced gastric cancer were divided into the total omentectomy group (TO group, n = 80) and the partial omentectomy group (PO group, n = 66). The clinicopathologic characteristics, surgical outcomes, recurrence pattern and survival were analyzed. RESULTS: There were no significant differences in the clinicopathologic features between the two groups, except for depth of invasion; more T3 (subserosal invasion) cases (65%) were included in total omentectomy group (P = 0.011). The mean time for PO was significantly shorter (35.1 ± 13.0 min) than TO (50.9 ± 15.3 min) (P %0.001), and there were two omentectomy-related complications in the TO group: spleen and mesocolon injuries. Recurrence occurred in 14 (17.5%) and 5 (7.6%) cases in the TO and PO group, respectively (P = 0.054). Disease-free survival (TO versus PO: 81.5% versus 89.3%, P = 0.420) and disease-specific survival (TO versus PO: 89% versus 94.7%) were not significantly different between the two groups. In the case-matched analysis using propensity score matching, there was no difference in disease-free survival (TO versus PO: 83.3% versus 90.5%, P = 0.442). CONCLUSIONS: Partial omentectomy might be an oncologically safe procedure during laparoscopic gastrectomy for serosa-negative advanced gastric cancer, similar to early gastric cancer.

Impact of Intraoperative Macroscopic Diagnosis of Serosal Invasion in Pathological Subserosal (pT3) Gastric Cancer.

PURPOSE: The macroscopic diagnosis of tumor invasion through the serosa during surgery is not always distinct in patients with gastric cancer. The prognostic impact of the difference between macroscopic findings and pathological diagnosis of serosal invasion is not fully elucidated and needs to be re-evaluated. MATERIALS AND METHODS: A total of 370 patients with locally advanced pT2 to pT4a gastric cancer who underwent curative surgery were enrolled in this study. Among them, 155 patients with pT3 were divided into three groups according to the intraoperative macroscopic diagnosis of serosal invasion, as follows: serosa exposure (SE)(-) (no invasion, 72 patients), SE(±) (ambiguous, 47 patients), and SE(+) (definite invasion, 36 patients), and the clinicopathological features, surgical outcomes, and disease-free survival (DFS) were analyzed. RESULTS: A comparison of the 5-year DFS between pT3_SE(-) and pT2 groups and between pT3_SE(+) and pT4a groups revealed that the differences were not statistically significant. In addition, in a subgroup analysis of pT3 patients, the 5-year DFS was 75.1% in SE(-), 68.5% in SE(±), and 39.4% in SE(+) patients (P<0.05). In a multivariate analysis to evaluate risk factors for tumor recurrence, macroscopic diagnosis (hazard ratio [HR], SE(-) : SE(±) : SE(+)=1 : 1.01 : 2.45, P=0.019) and lymph node metastasis (HR, N0 : N1 : N2 : N3=1 : 1.45 : 2.20 : 9.82, P<0.001) were independent risk factors for recurrence. CONCLUSIONS: Gross inspection of serosal invasion by the surgeon had a strong impact on tumor recurrence in gastric cancer patients. Consequently, the gross appearance of serosal invasion should be considered as a factor for predicting patients' prognosis.

Use of video-assisted thoracoscopic surgery to retrieve a broken guidewire.

Subclavian venous catheterization was once widely used for volume resuscitation, emergency venous access, chemotherapy, parenteral nutrition, and hemodialysis. However, its use has drastically reduced recently because of life-threatening complications such as hemothorax, pneumothorax. In this case, a patient admitted for a scheduled operation underwent right subclavian venous catheterization for preoperative, intraoperative, and postoperative volume resuscitation and parenteral nutrition. The procedure was performed by an experienced senior resident. Despite detecting slight resistance during the guidewire insertion, the resident continued the procedure to the point of being unable to advance or remove it, then attempted to forcefully remove the guidewire, but it broke and became entrapped within the thorax. We tried to remove the guidewire through infraclavicular skin incision but failed. So video-assisted thoracoscopic surgery was used to remove the broken guidewire. This incident demonstrates the risks of subclavian venous catheterization and the importance of using a proper and gentle technique.

Pinch-off syndrome.

Subclavian venous catheterization was previously frequently performed, but because of life-threatening complications such as hemothorax, pneumothorax, mediastinal hematoma, and myocardial injury, its use has become less common. However, this practice has some advantages in patient mobility, secured dressing, and rapidity and adequacy of vascular access. In some situations where patient comfort is an especially important consideration, such as with totally implantable venous port insertion for chemotherapy, the subclavian route can be a good choice if an experienced and well-trained faculty is available. The authors have had recent experience with pinch-off syndrome-in other words, spontaneous catheter fracture-in 3 patients who had undergone venous port implantation through the right subclavian route. Through these cases, we intend to review the dangers of subclavian venous catheterization, the causes of pinch-off syndrome, and its clinical presentation, progress, treatments, and prevention.

Safety of intracorporeal circular stapling esophagojejunostomy using trans-orally inserted anvil (OrVil) following laparoscopic total or proximal gastrectomy - comparison with extracorporeal anastomosis.

BACKGROUND: There have been several attempts to develop a unique and easier way to perform esophagojejunostomy during laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy. The OrVil system (Covidien, Mansfield, MA, USA) is one of those methods, but its technical and oncologic feasibility have not been proven and need to be observed. METHODS: Among 87 patients who underwent laparoscopy-assisted total gastrectomy (LATG; 79 cases) and laparoscopy-assisted proximal gastrectomy with double tract anastomosis (LAPG_DT; 8 cases) from April 2004, 47 patients underwent the conventional extracorporeal method (Group I; 2004-2008) were compared with 40 patients treated with the intracorporeal OrVil system (Group II; 2009-2012). RESULTS: There was no significant difference in clinicopathologic characteristics between the two groups except tumor location; more cardia lesions were involved in group II (p = 0.012). The mean time for esophagojejunostomy (E-J), defined as the time from anvil insertion to closure of the jejunal entry site has no significant difference (Group I vs II: 22.2 ± 3.2 min vs 18.6 ± 3.5 min, p = 0.623). In terms of anastomotic complication, there was no significant difference in E-J leakage and stricture. E-J leakage occurred in 2 out of 47 (4.3%) cases in group I and 2 out of 40 (5%) in group II (p = 0.628); half of them were treated conservatively in each group and the others underwent reoperation. E-J stricture occurred in 2 (4.3%) cases in group I and 1 (2.5%) in group II (p = 0.561), which required postoperative gastrofiberscopic balloon dilatation. CONCLUSIONS: Esophagojejunostomy using the OrVil system was a feasible and safe technique compared with the conventional extracorporeal method through mini-laparotomy in terms of anastomotic complications. Moreover, it can help to reduce surgeon's stress regarding esophagojejunostomy because it needs no purse-string procedure and serves a secure operation view laparoscopically.

Toxicity from intra-abdominal injection of chlorfenapyr.

Introduction. Chlorfenapyr is commonly used for food crops in Korea. However, chlorfenapyr toxicity in humans has not yet been studied. Case. A 74-year-old man was admitted to the emergency room after he intra-abdominally injected 20 mL of chlorfenapyr in an attempt to commit suicide. Emergency surgery was performed and accumulation of approximately 500 mL of reactive fluid in the abdomen was observed. The entire small intestine showed congestion. After surgery, additional surgery to drain the fluid was performed on POD 12. But immediately after administration of general anesthesia, flat rhythm was observed by electrocardiogram (ECG) monitoring, requiring cardiopulmonary resuscitation (CPR). Discussion. The color of the bowel was purple, indicating ischemic injury. This could be attributed to direct absorption of the substance through the peritoneum, leading to chemical injury to the small intestine serosa, unlike in the case of oral ingestion. This resulted in an ischemic change in the small intestine, eventually leading to sepsis. Conclusion. Only a few cases of chlorfenapyr toxicity have been reported in the literature, and death occurred in all cases, including our case. Therefore, careful and aggressive treatments are necessary. This is the first reported case of intra-abdominal injection of chlorfenapyr.