Prediction of the minimum amount of anti-adhesive agent required for entire intra-abdominal cavity using fluorescent dye

Purpose@#Studies on the appropriate amount of anti-adhesive agents for preventing postoperative adhesion are lacking. This animal study aimed to investigate the distribution of an anti-adhesive agent in the abdominal cavity and estimate the necessary amount to cover the entire cavity. @*Methods@#Fluorescent dye Flamma-552 was conjugated to Guardix-sol to create Guardix-Flamma, which was laparoscopically applied to the abdominal cavity of two 10-kg pigs in different amounts: 15 mL for G1 and 35 mL for G2. After 24 hours, the distribution of Guardix-Flamma was examined under the near-infrared mode of the laparoscope, and the thickness was measured in tissues from the omentum, small, and large intestine by immunohistochemistry. @*Results@#The average area of the abdominal cavity in 10 kg pigs was 2,755 cm2. Guardix-Flamma fluorescence was detected in the greater omentum, ascites in the pelvis, and right quadrant area in G1, whereas in G2, it was detected everywhere. On average, the total thickness of G1 and G2 were 12.68 ± 9.80 μm and 18.16 ± 15.57 μm, respectively. Guardix-Flamma thickness applied to the omentum, small, and large intestines of G2 were 1.31-, 1.45-, and 1.49-times thicker than those of G1, respectively, and were all statistically significant (P < 0.05). @*Conclusion@#The entire abdominal cavity of the 10 kg pig was not evenly covered with 15 mL of Guardix. Although 35 mL of Guardix is sufficient to cover the same area with an average thickness of 18 µm, further studies should evaluate the minimum thickness required for an effective anti-adhesive function.

Postprandial Changes in Gastrointestinal Hormones and Hemodynamics after Gastrectomy in Terms of Early Dumping Syndrome

Purpose@#This study aimed to examine the early postprandial changes in gastrointestinal (GI) hormones and hemodynamics in terms of early dumping syndrome after gastrectomy for gastric cancer. @*Materials and Methods@#Forty patients who underwent gastrectomy for gastric cancer and 18 controls without previous abdominal surgery were enrolled. Before and 20 minutes after liquid meal ingestion, blood glucose, glucagon-like peptide-1 (GLP-1), and GLP-2 concentrations and superior mesenteric artery (SMA) and renal blood flow were measured.The patients' heart rates were recorded at 5-minute intervals. All subjects were examined for dumping syndrome using a questionnaire based on Sigstad's clinical diagnostic index. @*Results@#The postprandial increases in blood glucose, GLP-1, and GLP-2 levels as well as SMA blood flow and heart rate were greater in patients who underwent gastrectomy than in controls (all P<0.010). Patients who underwent gastrectomy showed a significantly decreased renal blood flow (P<0.001). Among patients who underwent gastrectomy, distal gastrectomy was a significant clinical factor associated with a lower risk of early dumping syndrome than total gastrectomy (hazard ratio, 0.092; 95% confidence interval, 0.013–0.649; P=0.017).Patients who underwent total gastrectomy showed a greater postprandial increase in blood glucose (P<0.001), GLP-1 (P=0.030), and GLP-2 (P=0.002) levels as well as and heart rate (P=0.013) compared to those who underwent distal gastrectomy. @*Conclusions@#Early postprandial changes in GI hormones and hemodynamics were greater in patients who underwent gastrectomy than in controls, especially after total gastrectomy, suggesting that these changes play a crucial role in the pathophysiology of early dumping syndrome.

Long-term oncologic outcomes in pathologic tumor response after neoadjuvant chemoradiation for locally advanced rectal cancer

PURPOSE: The status of tumor regression in rectal cancer after neoadjuvant concurrent chemoradiotherapy (CCRT) has significant effect on tumor recurrence and patient survival. The aim of this study was to evaluate the long-term oncologic outcomes of rectal cancer patients presenting complete response or down-staging of rectal cancer compared to patients with non-response after neoadjuvant therapy in advanced mid-to-lower rectal cancer.METHODS: We retrospectively reviewed 79 patients with stage II/III mid-to-lower rectal cancer following neoadjuvant CCRT between March 2003 and April 2012. Patients were classified into three groups according to down-staging tumor response after neoadjuvant CCRT: complete response group (CRG), partial response group (PRG), and non-response group (NRG).RESULTS: Of the 79 patients in the study, eight (10.1%), 31 (39.2%), and 40 (50.7%) were classified as CRG, PRG, and NRG, respectively. Median follow-up period was 57 months. There was significant difference in local recurrence (P=0.012) between the three groups, yet there was no significant difference in overall survival (CRG, 100%; PRG, 82.5%; NRG, 74.0%; P=0.244). There was a significant difference in disease-free survival (CRG, 100%; PRG, 90.1%; NRG, 57.7%; P=0.006).CONCLUSION: Tumor response with complete response or down-staging provided better oncologic outcomes in terms of disease-free survival and local recurrence in locally advanced rectal cancer patients.

Clinicopathologic characteristics and survival rate in patients with synchronous or metachronous double primary colorectal and gastric cancer

PURPOSE: Double primary colorectal cancer (CRC) and gastric cancer (GC) represent the most common multiple primary malignant tumors (MPMT) in Korea. The recognition and screening of hidden malignancies other than the primary cancer are critical. This study aimed to investigate the clinicopathologic characteristics and survival rates in patients with synchronous or metachronous double primary CRC and GC.METHODS: Between January 1994 and May 2018, 11,050 patients were diagnosed with CRC (n=5,454) or GC (n=5,596) at Gil Medical Center. MPMT and metastatic malignant tumors were excluded from this study. A total of 103 patients with double primary CRC and GC were divided into two groups: the synchronous group (n=40) and the metachronous group (n=63). The incidence, clinicopathologic characteristics, and survival rate of the two groups were analyzed.RESULTS: The incidence of synchronous and metachronous double primary CRC and GC was 0.93%. Double primary CRC and GC commonly occurred in male patients aged over 60 years with low comorbidities and minimal previous cancer history. There were significant differences between the synchronous and metachronous groups in terms of age, morbidity, and overall survival. Metachronous group patients were 6 years younger on average (P=0.009), had low comorbidities (P=0.008), and showed a higher 5-year overall survival rate (94.8% and 61.3%, P < 0.001) in contrast to synchronous group.CONCLUSION: When primary cancer (CRC or GC) is detected, it is important to be aware of the possibility of the second primary cancer (GC or CRC) development at that time or during follow-up to achieve early detection and better prognosis.

A comparison of short-term outcomes of laparoscopic-assisted total gastrectomy and open total gastrectomy in early gastric cancer

PURPOSE: This study aimed to compare the postoperative outcomes of open total gastrectomy (OTG) and laparoscopic-assisted total gastrectomy (LATG) and prove that postoperative outcomes of LATG can be improved through a surgeon's experience.METHODS: 62 patients who underwent OTG and 82 patients who underwent LATG were enrolled in this study. To objectively assess the postoperative outcomes, we decided to apply the Clavien-Dindo classification. This study was performed based on postoperative complications occurring within 30 days after total gastrectomy.RESULTS: There was no statistically significant difference between the two groups with regard to intraoperative transfusion (P>0.99), overall postoperative complications (P>0.99), and major postoperative complications (P=0.731). Leakage of esophagojejunostomy was the most common complication after LATG. There is no statistically significant difference in the number of overall postoperative complications between the early LATG and late LATG groups (P=0.349). However, there is significant difference in the number of major complications between the two groups (P=0.026).CONCLUSION: LATG is not inferior to OTG and improved by learning in terms of postoperative outcomes in this study.

Clinicopathologic Similarities of the Main and Minor Lesions of Synchronous Multiple Early Gastric Cancer

The detection rate of early gastric cancer (EGC) is increasing due to improvements in diagnostic methods, but synchronous multiple EGC (SMEGC) remains a major problem. Therefore, we investigated the characteristics of and the correlation between the main and minor lesions of SMEGC. We retrospectively reviewed the medical records of patients with EGC between April 2008 and May 2013. The main lesion was defined as the one with the greatest invasion depth. If lesions had the same invasion depth, the tumor diameter was used to define the main lesion. Of 963 patients who had treatment for EGC, 37 patients with SMEGC were analyzed. The main and minor lesions showed a significant positive correlation of size (r = 0.533, P = 0.001). The main and minor lesions of SMEGC showed the same vertical and horizontal locations at 70.3% and 64.9%, respectively (P = 0.002 and P = 0.002). Macroscopic types were identical in 67.6% (P < 0.001), and 32.4% had identical macroscopic type and location. The main and minor lesions had identical characteristics of invasion depth, presence of lymphovascular invasion (LVI), and differentiation in 78.4%, 83.8%, and 83.8%, respectively. Differentiation, LVI, and invasion depth (microscopic characteristics) were simultaneously the same in 62.2%. The location, macroscopic type, and 3 microscopic characteristics were matched in 27%. The main and minor lesions of SMEGC have similar clinicopathologic characteristics. Therefore, the possibility of SMEGC should not be neglected in cases of EGC, considering an understanding of the characteristics and association of lesions.

Surgical outcome and prognostic factors in patients with gallbladder carcinoma

BACKGROUNDS/AIMS: Gallbladder carcinoma is usually associated with an unfavorable prognosis, and the clinical outcome has not improved much. This study was conducted to evaluate outcomes with gallbladder carcinoma according to the type of surgery performed, and the prognostic factors for survival. METHODS: One hundred and six patients with gallbladder carcinoma, who underwent surgery for the purpose of curative resection between January 1999 and June 2012 were reviewed retrospectively. RESULTS: Out of 106 patients, curative resection was achieved in 75 (70.8%). The cumulative 1-, 2- and 5-year survival rates of the gallbladder carcinoma patients were 93.4%, 80.9% and 63.0%, respectively. Radical resections, including extended cholecystectomy, were more beneficial for long term survival of patients. The 5-year survival rate in patients who underwent curative resection (56.9%) was significantly higher than in those who underwent palliative resection (0%, p=0.000). Multivariate analysis revealed that curative resection, preoperative CA19-9, T-stage, N-stage and differentiation of histology were independently significant prognostic factors. CONCLUSIONS: Curative resection and early detection of patients with gallbladder carcinoma were the most important factors for long term survival. Radical resection improves survival for patients with localized gallbladder carcinoma and can help to access exact prognosis and treatments.

Postoperative Abdominal Infection Caused by Corynebacterium minutissimum / 감염과화학요법

Corynebacterium minutissimum is a non-spore forming, gram-positive, aerobic or facultative anaerobic bacillus. It is the causative organism of erythrasma, a common superficial infection of skin, which typically presents as reddish-brown macular patches. To date, it has rarely been found to cause invasive disease, although other non-diphtheria corynebacteria are becoming increasingly common as opportunistic pathogens. We report on a rare case of abdominal infection due to C. minutissimum in an immunocompetent adult who was successfully treated with intravenous amoxicillin/sulbactam.

The Analysis of Prognostic Factors in Patients with Decompensated Liver Cirrhosis Admitted to the Medical Intensive Care Unit / 대한구급학회지

BACKGROUND: Patients with decompensated liver cirrhosis usually resulted in admission to the intensive care unit (ICU) during hospitalization. When admitted to the ICU, the mortality was high. The aim of this study is to identify multiple prognostic factors for mortality and to analyze the significance of prognostic survival model with each scoring system in patients with decompensated liver cirrhosis who was admitted to the ICU. METHODS: From January 2008 to December 2008, 60 consecutive patients with decompensated liver cirrhosis were admitted in the ICU and retrospectively reviewed. Prognostic models used were Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), model for end-stage liver disease with incorporation of serum sodium (MELD-Na), acute physiology and chronic health evaluation (APACHE) II, and sequential organ failure assessment (SOFA). The predictive prognosis was analyzed using the area under the receiver's operating characteristics curve (AUC). RESULTS: The median follow up period was 20 months, and ICU mortality was 17% (n = 10). A total of 24 patients (40%) died during the study period. The average survival of five prognostic models was related with the severity of the disease. All of the five systems showed significant differences in the cumulative survival rate, according to the scores on admission, and the MELD-Na had the highest AUC (0.924). Multivariate analysis showed that bilirubin and albumin were significantly related to mortality. CONCLUSIONS: The CPT, MELD, MELD-Na, APACHE II, and SOFA may predict the prognosis of patients with decompensated liver cirrhosis. The MELD-Na could be a better prognostic predictor than other scoring systems.

Primary Gastric Melanoma with Rhabdoid Features: A Case Report

No abstract available.

Prevalence and Predictive Factors of Malignant Potential in Resected Gastric Subepithelial Tumors

BACKGROUND/AIMS: EUS is a useful method to differentiate malignant from benign gastric subepithelial tumors (SETs) and to determine resection. However, this results in unnecessary resections of benign gastric SETs. The aim of our study is 1. to investigate clinical factors that may predict malignancy in gastric SET and 2. to determine how many of them have malignant potential in resected gastric SETs. MATERIALS AND METHODS: We retrospectively identified 111 patients who underwent pathologic confirmation for gastric SETs by surgical (104/111, 93.6%) and endoscopic resection between February 2003 and April 2012 and analyzed the clinical, EUS findings and final pathologic diagnosis for these patients. RESULTS: The diagnostic accuracy of EUS for SETs was 58.6% (51/87) and the rate of resection for benign SETs was 31.5% (35/111). In multivariate analysis, old age (> or =65), as well as tumor size (> or =2 cm) and location (upper or middle) were significant predictive factors for malignant potential of gastric SETs. CONCLUSIONS: One-third of endoscopic and surgical resections are performed for benign SETs. Patient's age, tumor size, and location should be considered before resection of gastric SETs. In addition, more accurate tools for histologic confirmation should be developed in order to avoid unnecessary resection.

Two cases of mucinous adenocarcinoma of the stomach mistaken as submucosal tumor / 대한외과학회지

A gastric carcinoma with the endoscopic features resembling submucosal tumor (SMT) is rare, and reportedly account for only 0.1% to 0.63% of all resected gastric carcinomas. The preoperative diagnosis of SMT-like gastric carcinoma is challenging, and thus, diagnosis is usually made intraoperatively or postoperatively. Furthermore, mucinous adenocarcinoma is an uncommon histologic subtype of gastric carcinoma characterized as an elevated lesion resembling SMT due to abundant mucin pools in submucosa. Here, we report two cases in which a gastric mucinous adenocarcinoma was mistaken as a SMT.

Multiple Jejunal Myeloid Sarcomas Presenting with Intestinal Obstruction in a Non-leukemic Patient: A Case Report with Ultrastructural Observations

Myeloid sarcoma is a rare extramedullary myeloid tumor, which is frequently misdiagnosed when no evidence of leukemia is initially observed. Here, we report on a peculiar case of a 49-year-old man afflicted with multiple masses in the jejunum, the superior mesentery, and the serosa of the transverse colon, without leukemic manifestation. The tumor was composed of undifferentiated small round cells containing eosinophilic cytoplasm, which were negative for myeloperoxidase, nonspecific esterase, lysozyme, terminal deoxynucleotidyl transferase, leukocyte common antigen, CD3, CD4, CD15, CD20, CD30, CD43, CD56, CD68/PG-M1, CD79a, human melanoma black-45, c-kit, and CD34 with positivity only for CD68/KP1, CD99, and vimentin. Under electron microscopy, those cells had abundant membrane-bound cytoplasmic granules that measured 200 to 300 nm in diameter, which were consistent with granulocytic azurophilic granules. The tumor was finally diagnosed as a myeloid sarcoma. The presence of non-leukemic myeloid sarcomas showing immunonegativity for conventional myeloid-leukemic markers necessitated a diagnosis by ultrastructural observation.

Relationship between the Clinical Performance Examination and Associated Variables / 한국의학교육

PURPOSE: The purpose of this study was to identify the causal relationship between the following variables: basic science score, written examination score (Internal medicine and Pediatrics), clinical clerkship score (Internal medicine and Pediatrics), and affective factors (self-efficacy, anxiety, and perception of preparedness). METHODS: Forty-two medical students took the clinical performance examination (CPX) at the end of the first semester. One day before the CPX, the students completed a brief survey, which included 11 items that sampled their self-efficacy, preparedness and anxiety with regard to the CPX. The responses from the 38 identifiable surveys (90%), out of 42, were analyzed for this study. Structural equation modeling techniques were used to test the relationships between the variables. The students' basic science scores, clinical clerkship scores, and written examination scores were considered for this study. RESULTS: We found that self-efficacy influenced students' CPX scores indirectly through their preparedness and anxiety. Preparedness influenced students' CPX scores indirectly through their anxiety. Anxiety was predicated on self-efficacy directly or indirectly and it predicted CPX scores. The clinical clerkship scores affected the students' CPX scores indirectly. The written examination scores and basic science scores, however, did not impact the students' CPX scores directly or indirectly. The basic science scores, clinical clerkship scores, and written examination scores were not associated with self-efficacy. CONCLUSION: Our findings highlight the importance of clinical clerkship education and reasonable medical teaching methods in improving the student self-efficacy for the CPX.

Relationship between the Clinical Performance Examination and Associated Variables / 한국의학교육

PURPOSE: The purpose of this study was to identify the causal relationship between the following variables: basic science score, written examination score (Internal medicine and Pediatrics), clinical clerkship score (Internal medicine and Pediatrics), and affective factors (self-efficacy, anxiety, and perception of preparedness). METHODS: Forty-two medical students took the clinical performance examination (CPX) at the end of the first semester. One day before the CPX, the students completed a brief survey, which included 11 items that sampled their self-efficacy, preparedness and anxiety with regard to the CPX. The responses from the 38 identifiable surveys (90%), out of 42, were analyzed for this study. Structural equation modeling techniques were used to test the relationships between the variables. The students' basic science scores, clinical clerkship scores, and written examination scores were considered for this study. RESULTS: We found that self-efficacy influenced students' CPX scores indirectly through their preparedness and anxiety. Preparedness influenced students' CPX scores indirectly through their anxiety. Anxiety was predicated on self-efficacy directly or indirectly and it predicted CPX scores. The clinical clerkship scores affected the students' CPX scores indirectly. The written examination scores and basic science scores, however, did not impact the students' CPX scores directly or indirectly. The basic science scores, clinical clerkship scores, and written examination scores were not associated with self-efficacy. CONCLUSION: Our findings highlight the importance of clinical clerkship education and reasonable medical teaching methods in improving the student self-efficacy for the CPX.

Prognostic Factors Associated with Surgical Mortality Conferred by Emergency Operation in Colorectal Cancer

PURPOSE: Compared with elective surgery, emergency surgery for colorectal cancer has been reported to be associated with high mortality, though little is known about the prognostic factors associated with surgical mortality. Above all, a distinction between patients with high and low mortalities might be helpful for perioperative management. The purpose of this study was to identify prognostic factors associated with surgical mortality due to an emergency operation. METHODS: Ninety-five cases of emergency surgery for colorectal cancer were performed from 1998 through 2005. The genders and the ages of the patients, the duration of symptoms, the APACHE score, the cancer location, the presence of perforation, the operative type, and the disease stage were determined as prognostic factors. The patients were examined retrospectively to establish any relationships between the prognostic factors and surgical mortality. RESULTS: In the univariate analysis, significantly higher surgical mortality rates were found in patients who were more than 75 years old, who had an APACHE II score above 10, and who had a perforation (P0.05). Multivariate analysis showed that age and APACHE II score were related to surgical mortality. The surgical mortality rate for colorectal cancer in an emergency situation was 8.4%. CONCLUSIONS: Prognostic factors of significance associated with surgical mortality due to an emergency operation were age (> or = 75) and APACHE II score (>10). Careful attention is needed for appropriate perioperative management of patients with these risk factors.

Survival after Curative Surgery for a Colorectal Mucinous Carcinoma

PURPOSE: The clinicopathological significance of a colorectal mucinous carcinoma remains controversial. Previous reports have suggested that mucinous carcinomas affect young patients, are more advanced at diagnosis, and have a worse prognosis than non-mucinous carcinomas, but more recent reports have refuted those results. The principal aim of this study was to evaluate whether colorectal mucinous carcinomas are associated with a worse prognosis than colorectal non-mucinous carcinomas for patients who undergo curative surgery. METHODS: A total of 534 patients with colorectal carcinomas, including 42 cases of mucinous carcinomas, underwent surgery in the Department of Surgery of Gil Medical Center, Gachon Medical School, between March 1997 and February 2003. Of these, we retrospectively evaluated 33 patients with mucinous carcinomas and 407 patients with non-mucinous carcinomas who had undergone a curative resection. The age and the sex distributions, the primary location of the tumor, the stage at diagnosis, the curability, and the 3-year survival of mucinous- carcinoma patients were compared with those of non- mucinous-carcinoma patients. Thirteen patients were lost to follow-up, so we evaluated 427 patients for the overall survival rate by using the Kaplan-Meier method and the long-rank test for quality of curves. RESULTS: The proportion of mucinous carcinomas was 7.8% (42/534). There were no significant differences in sex and curability, but the mucinous-carcinoma patients were found to be younger (P=0.014), to have a Right-side dominancy (P=0.038), and to have a more advanced stage at diagnosis (P=0.004). The 3-year survival rates in stage-B patients with mucinous carcinomas and non-mucinous carcinomas were 92.3% and 80.9%, respectively (P>0.05); in stage C, they were 62.2% and 73.8%, respectively (P>0.05). The difference of the survival rates for each stage was not statistically significant. CONCLUSIONS: Many reports suggest that patients with colorectal mucinous carcinomas have worse survival than patients with non-mucinous carcinomas. However, there was no significant difference in the 3-year survival rates between patients with mucinous carcinomas and those with non-mucinous carcinomas in our study.

C-met and E-cadherin Expression in Advanced Gastric Cancer

PURPOSE: In the current study, the relation between the clinicopathological parameters and levels of the amplification of the c-met and E-cadherin genes were investigated in patients with an advanced gastric carcinoma. METHODS: The levels of amplification of the c-met and E-cadherin genes in 44 advanced gastric carcinoma patients were retrospectively investigated using RT-PCR. The relationships between the levels of amplification of these genes and the clinicopathological parameters were evaluated using univariate and multivariate analyses. RESULTS: Seventeen (38.6%) and 13 (29.5%) of the 44 advanced gastric carcinoma patients were evaluated as having amplification of the c-met gene and down-regulation of the E-cadherin gene, respectivly. The amplification of c- met gene was significantly correlated with serosal invasion, lymph node metastasis and neural invasion, whereas the down-regulation of the E-cadherin gene was significantly correlated with the diffuse type of gastric carcinoma by Lauren's calssification, and neural invasion. CONCLUSION: The levels of the c-met and E-cadherin gene amplifications may be a powerful aids in evaluating the metastatic potential and prognosis in patients with advanced gastric cancer.