The Effects of Preoperative Pain Education on the Decision to Discharge Patients Following Single-Incision Laparoscopic Appendectomy

Purpose@#Few studies have analyzed the effects of preoperative pain education on the postoperative decision to discharge. The purpose of this study was to determine the effects of pain education and management on the decision to discharge patients after single-incision laparoscopic appendectomy (SILA). @*Methods@#We analyzed 135 patients who had undergone SILA for acute appendicitis between March 2017 and April 2018 in a single medical center. Of these, 72 patients (53.3%) had received preoperative pain education (group 1), and 63 (46.7%) had not (group 2). We compared perioperative outcomes and complications between the groups. @*Results@#Baseline characteristics of sex, age, body mass index, American Society of Anesthesiologist score, and systemic inflammation factors (neutrophil-lymphocyte ratio, C-reactive protein level) did not differ significantly between the groups. There were no postoperative complications for patients in either group. Perioperative consequences and pathologic findings were not significantly different between the groups; however, length of hospital was significantly shorter in group 1. @*Conclusion@#Preoperative pain education in relation to postoperative pain management influenced the decision to shorten the postoperative hospital length of stay after SILA.

The Effects of Preoperative Pain Education on the Decision to Discharge Patients Following Single-Incision Laparoscopic Appendectomy

Purpose@#Few studies have analyzed the effects of preoperative pain education on the postoperative decision to discharge. The purpose of this study was to determine the effects of pain education and management on the decision to discharge patients after single-incision laparoscopic appendectomy (SILA). @*Methods@#We analyzed 135 patients who had undergone SILA for acute appendicitis between March 2017 and April 2018 in a single medical center. Of these, 72 patients (53.3%) had received preoperative pain education (group 1), and 63 (46.7%) had not (group 2). We compared perioperative outcomes and complications between the groups. @*Results@#Baseline characteristics of sex, age, body mass index, American Society of Anesthesiologist score, and systemic inflammation factors (neutrophil-lymphocyte ratio, C-reactive protein level) did not differ significantly between the groups. There were no postoperative complications for patients in either group. Perioperative consequences and pathologic findings were not significantly different between the groups; however, length of hospital was significantly shorter in group 1. @*Conclusion@#Preoperative pain education in relation to postoperative pain management influenced the decision to shorten the postoperative hospital length of stay after SILA.

Three-year result of efficacy for type 2 diabetes mellitus control between laparoscopic duodenojejunal bypass compared with laparoscopic Roux-en-Y gastric bypass

PURPOSE: The mechanism by which bariatric surgery facilitates diabetic control is still unknown. Duodenojejunal bypass supports the foregut theory; however, its efficacy when used alone is not yet established. METHODS: During the period from January 2008 to December 2009, patients who underwent laparoscopic duodenojejunal bypass (LDJB) or laparoscopic Roux-en-Y gastric bypass (LRYGB) for type 2 diabetes mellitus (T2DM) with or without morbid obesity were included. Patients who had a follow-up for less than 3 years were excluded. Patient baseline characteristics, change of body weight, body mass index (BMI), glycosylated hemoglobin (HbA1c), and diabetic treatments were analyzed. RESULTS: In total, 8 LDJB and 20 LRYGB patients were analyzed. The LDJB group had more number of male patients than the LRYGB group (LDJB 75% vs. LRYGB 30%, P = 0.030). Baseline BMI in the LRYGB group was higher than in the LDJB group (LDJB 27.0 ± 2.5 vs. LRYGB 32.6 ± 3.4, P < 0.001). Age, DM duration, baseline HbA1c, and C-peptide levels were similar. Longer operation time was needed to perform LDJB (LDJB 367.5 ± 120.2 vs. LRYGB 232.9 ± 41.1, P < 0.001), but no differences were observed in the hospital stay and complication rate between the 2 groups. At the third year of follow-up, the T2DM remission rate was observed in 40% of patients in the LRYGB group and 12.5% of patients in the LDJB group. CONCLUSION: LDJB is not an effective method for controlling T2DM compared with LRYGB. Foregut theory may not be the main mechanism of diabetic control during bariatric surgery.

Clinical Implications of Systemic Inflammatory Response Markers as Independent Prognostic Factors in Colorectal Cancer Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Cancer-related inflammation affects many aspects of malignancy. We confirm the effects of early postoperative systemic inflammation on cancer prognosis. MATERIALS AND METHODS: Six hundred consecutive patients underwent surgery for colorectal cancer from 2006 to 2009. Measurements of white blood cells, neutrophils, lymphocytes, monocytes, and platelet counts were performed preoperatively, daily until the fourth postoperative day, and subsequently every two days. Patients were divided into three groups based on the days spent on the leukocyte count to drop below 10,000/mm3 after surgery. RESULTS: Preoperative white blood cell (WBC) counts correlated with stage of disease. In univariate survival analyses, tumor, node, metastasis (TNM) stage, and monocyte count were associated with cancer-free survival. In addition, cancer-free survival outcomes were worse in patients who required more than four days for the normalization of WBC count. A TNM stage greater than II and the neutrophil lymphocyte ratio were associated with the duration of overall survival. In a multivariate analysis of these significant variables, TNM stage, an interval longer than four days for normalization of WBC counts and monocyte count independently associated with cancer-free survival. CONCLUSION: Postoperative early inflammatory phase and preoperative monocyte count correlate with poor colon cancer prognosis. We can conclude that preoperative and postoperative inflammatory response and period unfavorably affect the metastatic microenvironment.

Clinical Implications of Systemic Inflammatory Response Markers as Independent Prognostic Factors in Colorectal Cancer Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Cancer-related inflammation affects many aspects of malignancy. We confirm the effects of early postoperative systemic inflammation on cancer prognosis. MATERIALS AND METHODS: Six hundred consecutive patients underwent surgery for colorectal cancer from 2006 to 2009. Measurements of white blood cells, neutrophils, lymphocytes, monocytes, and platelet counts were performed preoperatively, daily until the fourth postoperative day, and subsequently every two days. Patients were divided into three groups based on the days spent on the leukocyte count to drop below 10,000/mm3 after surgery. RESULTS: Preoperative white blood cell (WBC) counts correlated with stage of disease. In univariate survival analyses, tumor, node, metastasis (TNM) stage, and monocyte count were associated with cancer-free survival. In addition, cancer-free survival outcomes were worse in patients who required more than four days for the normalization of WBC count. A TNM stage greater than II and the neutrophil lymphocyte ratio were associated with the duration of overall survival. In a multivariate analysis of these significant variables, TNM stage, an interval longer than four days for normalization of WBC counts and monocyte count independently associated with cancer-free survival. CONCLUSION: Postoperative early inflammatory phase and preoperative monocyte count correlate with poor colon cancer prognosis. We can conclude that preoperative and postoperative inflammatory response and period unfavorably affect the metastatic microenvironment.

Biliary injury after cholecystectomy in a patient with severe right liver atrophy / 대한외과학회지

We report a case of bile fistula after cholecystectomy in a patient with severe right liver atrophy, which was managed by endoscopic nasobiliary drainage and conservative treatment. The patient was a 76-year-old man with a sudden onset in the right flank and abdominal pain. Computed tomography revealed calculous cholecystitis and severely atrophied right lobe of the liver. Gallbladder was located in the superior-posterior portion of the liver as opposed to the normal position. The patient underwent cholecystectomy and showed massive bleeding and bile leakage at the gallbladder bed during operation. A bile fistula was detected three days after surgery, which was managed by interventional bile drainage. Right liver agenesis or severe atrophy is rare. Additionally, the report of combined bile duct injury after cholecystectomy in these settings is extremely rare.

Paraganglioma of the Pancreas Metastasized to the Adrenal Gland: A Case Report / 대한소화기학회지

Paraganglioma is a rare neuroendocrine tumor arising from the neural crest, which includes tissues such as the adrenal medulla, carotid and aortic body, organs of Zuckerkandl, and other unnamed paraganglia. The head, neck, and retroperitoneum are the most common sites for paraganglioma. However, paraganglioma of the pancreas is extremely rare. We report our experience of this rare disease. A 70-year old female patient admitted for a pancreas tail mass detected by computed tomography (CT) scan checked for vague left flank pain. CT with contrast enhancement showed a 4.2-cm heterogeneously enhanced lesion in the tail of the pancreas. A well defined ovoid shape mass in left adrenal gland was suggested adenoma. Distal pancreatectomy with left adrenalectomy was performed. Any lymph node enlargement was not found. Pancreas mass did not invade adjacent organ. Microscopic examination with pancreas and adrenal gland revealed that the cells were arranged in a characteristic Zellballen pattern. Immunohistochemical staining revealed positivity for neuron-specific enolase, chromogranin A, synaptophysin, and S-100 protein. On the basis of these findings, we diagnosed the tumor as a paraganglioma of the pancreas and adrenal gland. We report the first case of pancreas paraganglioma in Korea.

Clinical Features and Outcomes of Invasive Intraductal Papillary Mucinous Neoplasm: Comparison with Pancreatic Ductal Adenocarcinoma

PURPOSE: Histologically, IPMN (intraductal papillary mucinous neoplasm) includes various grades of lesion, from hyperplasia and adenoma to adenocarcinoma. The prognosis is different for each histological grade. The malignant IPMN contain in-situ and invasive carcinoma. The purpose of this study was to investigate the clinicopathologic features and outcome of invasive IPMN. METHODS: 18 patients with invasive IPMN underwent surgical treatment between October 1994 and December 2005 at Samsung Medical Center. The clinical, biochemical and pathologic features were retrospectively analyzed. Survival and the clinicopathologic features were compared between invasive IPMN and PDAC of the well differentiated type (wd, n=27) and carcinoma in-situ (CIS, n=10). RESULTS: The preoperative CA19-9 level and total bilirubin level of invasive IPMN patients was statistically higher than those of the CIS patients. The tumor size of invasive IPMN was larger than that of PDAC (wd) (P=0.038). The median survival of patients with invasive IPMN was 31.0 month. The 5-year survival rates of patients with PDAC (wd) and invasive IPMN were 35.5% and 41.7%, respectively (P= 0.237). CONCLUSION: there were no differences for invasive IPMN and PDAC (wd) except for tumor size. The survival in patients with surgical resected invasive IPMN was similar to that of the patients with surgical resected PDAC (wd).

Extra-Gastrointestinal stromal tumor of the pancreas with c-KIT gene mutation: Report of a case

Mesenchymal tumors of the pancreas are quite rare, accounting for less than 1% of all pancreatic tumors. Mesenchymal tumors in the gastrointestinal tract are mainly gastrointestinal stromal tumors (GISTs). GISTs are defined as KIT-positive mesenchymal spindle cells or epithelioid neoplasms originating from the interstitial cell of Cajal. GISTs occur mainly in the stomach, small intestine, colorectum and esophagus. However, extra-gastrointestinal stromal tumors in the bladder, gallbladder, omentum, and mesentery are rare. We report a case of GIST in the pancreas head. A 55-year-old female patient was referred to our hospital for a pancreas head mass detected by a CT scan checked for a fever with an unknown origin. She underwent Whipple's operation for the 5.5x4.4cm-sized mass located in the pancreas head. A microscopic examination revealed GIST showing positive c-KIT protein expression with <5/50 HPF mitosis. C-KIT gene analysis revealed a mutation in exon 9. To the best of our knowledge, this is the first case of extra-gastrointestinal stromal tumor of the pancreas demonstrated by histology, immunohistochemistry and genetic analysis in Korea.

Management of a Bleeding Pseudoaneurysm after Pancreaticoduodenectomy: 27 cases experience in single-center

PURPOSE: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding pseudoaneurysms after pancreaticoduodenectomy. METHOD: The medical records of 905 consecutive patients who underwent pancreaticoduodenectomies between October 1994 and February 2007 were reviewed retrospectively. In 27 cases with hemorrhagic complications, pseudoaneurysms were diagnosed as the main cause of bleeding. The clinical characteristics, course, management, and outcomes were reviewed. RESULT: In 27 cases (3.0%) of the 905, the bleeding pseudoaneurysms were diagnosed by angiography, during surgery or clinically. In 11 cases, the hemorrhage was from the pseudoaneurysm on the ligated gastroduodenal artery-stump, in five it was from the right hepatic artery, in four from the proper hepatic artery or common hepatic artery, and two from the right gastric artery. Twelve cases had pancreatic leakage. Sentinel bleedings were observed in 21 cases, there were 11 cases of bleeding from the surgical drains, eight cases from the GI tract, and in two cases from both. In 23 cases, arterial embolization was attempted and 18 cases were successful. Four cases had secondary pseudoaneurysmal bleeding. After embolization at the common or proper hepatic artery, six cases had liver abscess or infarction and there was one case of hepatic failure. CONCLUSION: Delayed massive hemorrhage after pancreaticoduodenectomy should be ruled out to determine whether it is associated with an arterial pseudoaneurysm rupture. Transcatheter arterial embolization is an effective modality for control of the bleeding from an arterial pseudoaneurysm.

Clinical Analysis of MALT Lymphoma in the Stomach

PURPOSE: The aim of our study was to analyze the clinical and histopathological characteristics of mucosa associated lymphoid tissue (MALT) lymphoma in the stomach. METHODS: We retrospectively reviewed the medical records of 22 patients with pathologically proven MALT lymphoma from Jan. 1995 to Sep. 2000 in Samsung Medical Center. The factors analyzed were operative procedures, tumor stage and histopathological characteristics. RESULTS: Of 3658 patients with gastric malignancy, 22 (0.6%) patients, 7 men and 15 women from 25 to 70 years (mean, 48.8 years), were found to have MALT lymphoma. Fourteen cases (64%) were located in the antrum, 4 (18%) in the body and 4 (18%) in the fundus or the high body. Nineteen patients were managed with total gastrectomy and splenectomy, and 3 with radical subtotal gastrectomy. Histopathologically, the tumor was limited to the mucosa in 3 patients (13.6%), to the submucosa in 13 (59.1%), and extended to the muscularis propria in 6 (27.3%). The lymph node involvement was seen in 12 patients (54.6%). There were no cases of splenic, hepatic or bone marrow involvement. H. pylori was identified in 11 patients (50%). During the mean follow-up period of 32.7 months, there were no reports of tumor recurrence or death. CONCLUSION: MALT lymphoma rarely disseminates at the time of diagnosis and rarely involves the bone marrow. Lymph node involvement, however, was relatively high. Total gastrectomy is effective in the management of patients with high grade MALT lymphoma and adjuvant chemotherapy is effective in cases of metastasis.

Clinical Analysis of MALT Lymphoma in the Stomach

PURPOSE: The aim of this study was to analyze the clinical and the histopathological characteristics of mucosa associated lymphoid tissue (MALT) lymphomas in the stomach. MATENRIALS AND METHODS: We retrospectively reviewed the medical records of 22 patients who had been treated at Samsung Medical Center from Jan. 1995 to Sep. 2000 and who had been pathologically proven to have a MALT lymphoma. The factors we analyzed were operative procedure, tumor stage, and histopathological characteristics. RESULTS: Of 3658 patients with a gastric malignancy, 22 patients proved to have a MALT lymphoma (0.6%). There were 7 men and 15 women whose ages ranged from 25 years to 70 years (mean, 48.8 years). Forteen cases were located in the antrum, 4 (18%) in the body and 4 (18%) in the fundus or the high body. Nineteen of these patients were managed with total gastrectomy and splenectomy and 3 with radical subtotal gastrectomy. Histopathologically the tumor was limited to the mucosa in 3 patients (13.6%), to the submucosa in 13 (59.1%) and extended to the muscularis propria in 6 (27.3%). Lymph node involvement was seen in 12 patients (54.6%). There was no splenic or hepatic involvement. Bone marrow involvement was not seen in any patients. H. pylori was identified in 11 patients (50%). During the mean follow-up period of 32.7 months, there were no reports of tumor recurrence or death. CONCLUSION: MALT lymphomas rarely disseminate by the time of diagnosis and rarely involve the bone marrow. Lymph node involvement is relatively high and a total gastrectomy is effective in managing patients with a MALT lymphoma.