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Obesity Surgery 07/2013; 23(7):974-5. · 3.29 Impact Factor
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ABSTRACT: : The aim of this study was to introduce our technique and evaluate the technical efficacy of Roux-en Y (RY) reconstruction after total laparoscopic distal gastrectomy (TLDG).
: We performed TLDG using our own method of RY-type anastomosis in a total of 38 consecutive patients with gastric adenocarcinomas and evaluated the techniques and postoperative outcomes.
: The mean operative time was 144.5±22.4 minutes, including reconstruction time, which was 26.2±3.5 minutes. Most patients were of pathologic stage IA (76.3%) or IB (10.5%), 3 patients were of stage II, and 2 were of stage IIIA. The length of postoperative hospital stay was 8.3±3.3 days (range, 5 to 20 d). Two cases required reoperation because of internal herniation. According to our endoscopic observation, bile reflux into the gastric remnant stump was not found.
: TLDG with RY reconstruction is technically feasible in gastric cancer patients.
Surgical laparoscopy, endoscopy & percutaneous techniques 06/2013; 23(3):349-53. · 1.23 Impact Factor
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ABSTRACT: BACKGROUND: We developed and validated a nomogram for use at a high-volume center where radical surgery with extended lymph node dissection is the standard treatment for gastric cancer. METHODS: Overall, 1,614 patients were randomly divided into the test set (n = 805) and validation set (n = 809). The scoring system was calculated using a Cox proportional hazard regression model with the survival of gastric cancer as the predicted endpoint. The concordance index (c-index) was used as an accuracy measure, with bootstrapping to correct for optimistic bias. Calibration plots were constructed. RESULTS: Based on a Cox model, we developed a nomogram that predicts the probability of 3- and 5-year survival from the time of surgery. The bootstrap-corrected c-indices were 0.87 and 0.84 in the test and validation sets, respectively. Survival was well predicted in both sets. The predictions of our nomogram discriminated better than the AJCC staging system (test set: c-index, 0.87 vs. 0.77; P < 0.0001; validation set: c-index, 0.84 vs. 0.79; P < 0.001). CONCLUSION: We developed and validated a nomogram that provided a significantly accurate prediction of postoperative survival in Korean patients with gastric cancer who underwent radical gastrectomy with extended lymph node dissection.
Gastric Cancer 05/2013; · 2.42 Impact Factor
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ABSTRACT: BACKGROUND: This study was designed to compare short-term laparoscopic total gastrectomy (LTG) with open total gastrectomy (OTG) outcomes in gastric cancer. METHODS: Seventy patients who underwent total gastrectomy via LTG or OTG were included. All cases were matched for stage, age, and sex by means of statistically generated selection of all gastrectomies performed during the same period. RESULTS: Although the operation time was not longer for LTG, the time required for esophagojejunostomy was significantly longer in LTG than in OTG (43 vs 14 min, P < .05). The incidence of anastomotic complications was higher in the LTG group as well. CONCLUSIONS: Postoperative complications such as anastomotic leakage and stenosis were observed more frequently in LTG. To improve the safety of esophagojejunostomy in LTG, technical innovations should be pursued.
American journal of surgery 04/2013; · 2.36 Impact Factor
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ABSTRACT: Abstract Background: Robotic surgery was invented to overcome difficulties associated with conventional laparoscopic surgery. However, ways in which to improve the efficacy of such surgery have not yet been discussed. This report focuses on the role of a robotic third arm in maximizing the efficacy of lymph node dissection in robot-assisted gastrectomy. Materials and Methods: Thirty-five robotic gastrectomies were performed between April 2009 and December 2010. We evaluated our surgical procedures by reviewing video recordings of robotic operations and analyzed the steps involved in lymph node dissections frame by frame. Then, we analyzed the short-term clinical outcomes to look at the impact of standardized use of the third arm on clinical outcomes. The initial 15 cases (Group A) were compared with 20 later cases (Group B) in terms of postoperative inflammation and pancreatitis. Results: The clinicopathologic characteristics, including operation type, hospital stay, morbidity, and pathological features, were not different between the two groups. However, postoperative serum amylase levels as well as drain amylase levels were significantly lower in Group B than in Group A (P<.05). The incidence of postoperative pancreatic fistula was also lower in Group B (P<.05). Conclusions: Gastrectomy with extragastric lymph node dissection using the da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA) can be performed safely and effectively with the appropriate and sophisticated use of a robotic third arm.
Journal of Laparoendoscopic & Advanced Surgical Techniques 04/2013; · 1.40 Impact Factor
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Hyung-Ho Kim,
Sang-Uk Han,
Min-Chan Kim,
Woo Jin Hyung,
Wook Kim,
Hyuk-Joon Lee,
Seung Wan Ryu,
Gyu Seok Cho,
Chan Young Kim,
Han-Kwang Yang,
Do Joong Park, Kyo Young Song,
Sang Il Lee,
Seong Yeob Ryu,
Joo Ho Lee
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ABSTRACT: A randomized controlled trial to evaluate the long-term outcomes of laparoscopic distal gastrectomy for gastric cancer is currently ongoing in Korea. Patients with cT1N0M0-cT2aN0M0 (American Joint Committee on Cancer, 6th edition) distal gastric cancer were randomized to receive either laparoscopic or open distal gastrectomy. For surgical quality control, the surgeons participating in this trial had to have performed at least 50 cases each of laparoscopy-assisted distal gastrectomy and open distal gastrectomy and their institutions should have performed more than 80 cases each of both procedures each year. Fifteen surgeons from 12 institutions recruited 1,415 patients. The primary endpoint is overall survival. The secondary endpoints are disease-free survival, morbidity, mortality, quality of life, inflammatory and immune responses, and cost-effectiveness (ClinicalTrials.gov ID: NCT00452751).
Journal of the Korean Surgical Society 02/2013; 84(2):123-30. · 0.12 Impact Factor
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ABSTRACT: BACKGROUND: We evaluated the prevalence of coexisting asymptomatic colorectal neoplasm (CRN) in patients with gastric cancer (GC). METHODS: Preoperative colonoscopic examinations were performed in 495 patients with GC who underwent gastrectomy between January 2009 and December 2010. To compare the prevalence of CRN in these patients with that in a normal population, we selected 495 sex- and age-matched persons who underwent colonoscopies for health screening. Risk factors for CRN were evaluated by univariate and multivariate analyses. RESULTS: The overall incidence of CRN was 41.8 % (414/990). The prevalence of overall CRN, high-risk CRN, and colorectal carcinoma (CRC) were significantly higher in the GC group than in the control group (overall CRN: 48.9 % vs. 34.7 %; high-risk CRN: 28.3 % vs. 13.5 %; CRC: 2.6 % vs. 0.2 %; all P < 0.001). The presence of GC [odds ratio (OR), 1.82; 95 % confidence interval (CI), 1.4-2.38; P < 0.001], age ≥50 years (OR, 2.58; 95 % CI, 1.75-3.81; P < 0.001), and male sex (OR, 2.28; 95 % CI, 1.72-3.02; P < 0.001) were risk factors for overall CRN. In patients with GC, age ≥40 years (OR, 3.22; 95 % CI, 1.24-8.37; P = 0.016) and male sex (OR, 3.21; 95 % CI, 2.17-4.76; P < 0.001) were risk factors for overall CRN. CONCLUSIONS: The prevalence of coexisting CRN, including CRC, was higher in patients with GC than in the normal population. Preoperative colonoscopy is strongly indicated in patients with GC who are male and/or ≥40 years of age.
Annals of Surgical Oncology 01/2013; · 4.17 Impact Factor
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Gastric Cancer 12/2012; · 2.42 Impact Factor
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ABSTRACT: BACKGROUND AND OBJECTIVES: Disease-specific survival (DSS) for GC patients differs in Eastern and Western countries. The aim is to compare outcomes of US and Korean patients following resection of early-stage, node-negative gastric carcinoma (GC). METHODS: All patients (1995-2005) with T1N0 gastric carcinoma, excluding gastroesophageal tumors, were evaluated. DSS was compared by adjusting for prognostic variables from an internationally validated GC nomogram. RESULTS: The cohort included 598 Korean patients and 159 US patients. Age and BMI were significantly higher in US patients. Distal tumor location was more frequent in Korea (60% vs. 52%) and proximal location in the US (19% vs. 5%, P < 0.0001). Five-year DSS did not differ significantly between Korea and the US. After multivariate analysis, DSS of Korean patients persisted, with no significant differences when compared to US patients (HR = 1.2, 95% CI: 0.3-5.2, P = 0.83). CONCLUSIONS: Despite widespread speculations that GC differs in the East and West, when we compare similarly staged, node-negative GC patients, survival did not differ significantly between Korea and the US. This suggests that GC is a heterogeneous disease and when similar subtypes of gastric cancer are compared, these differences disappear. This study suggests more similarities than previously hypothesized between US and Korean GC patients. J. Surg. Oncol © 2012 Wiley Periodicals, Inc.
Journal of Surgical Oncology 11/2012; · 2.10 Impact Factor
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ABSTRACT: BACKGROUND: The prognostic value of the three constituents of undifferentiated-type gastric adenocarcinoma remains unclear. The present study assessed the clinicopathological characteristics and prognosis of undifferentiated-type mucinous adenocarcinoma (uMAC) and signet ring cell carcinoma (SRC) compared with those of poorly differentiated adenocarcinoma (PDAC). METHODS: In total, 1,376 patients with undifferentiated-type gastric adenocarcinoma were included, consisting of 1,002 patients diagnosed with PDAC, 54 with uMAC and 320 with SRC. Clinicopathological factors and survival rates were compared among the three histological types. RESULTS: Significant differences in the distribution of pathological stages were observed among the groups. Patients with SRC had a significantly better survival rate than those with PDAC or uMAC, in both the all patients including non-curative resected patients and curative-resected groups. In addition, there was significant difference in survival between the PDAC and uMAC groups. Multivariate analysis suggested that age, gender, tumor depth, lymph node metastasis and curability significantly affected survival. Histological type was not an independent prognostic factor. There was no significant difference in the pattern of recurrence among the three groups. CONCLUSIONS: The uMAC and SRC had worse and favorable prognosis compared with PDCA, respectively. However, there were no differences in survival by pathological stage, thus histological type was not an independent predictor of prognosis.
World Journal of Surgical Oncology 11/2012; 10(1):254. · 1.12 Impact Factor
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ABSTRACT: BACKGROUND: Even for expert surgeons, esophagojejunostomy after laparoscopic total gastrectomy (LTG) is not always easy to perform. Herein, we compare various types of esophagojejunostomy in terms of the technical aspects and postoperative outcomes. METHODS: A total of 48 patients underwent LTG for gastric cancer by the same surgeon. Four types of intracorporeal esophagojejunostomies have been applied after LTG: type A, a conventional anvil head method; type B, an OrVil™ system method; type C, a hemi-double stapling technique with anvil head; and type D, side-to-side esophagojejunostomy with linear stapler. We describe and review these types of esophagojejunostomy using a step-by-step approach. RESULTS: The mean reconstruction times were longer for types A and B than for types C and D (p < 0.05). In terms of complications, there were five cases (10.4 %) of anastomosis leakage, which was more common in types A and B: two cases in each of type A and B and one case in type C. Moreover, anastomosis stricture requiring intervention was more common in types A and B (p < 0.05). CONCLUSIONS: To date, there are no reliable reconstruction methods after LTG. Therefore, special care is needed to prevent postoperative complication regardless of methods; also, technical innovations to support development of the safest methods of esophagojejunostomy are warranted.
Gastric Cancer 10/2012; · 2.42 Impact Factor
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ABSTRACT: BACKGROUND: The accuracy of endoscopic ultrasonography (EUS) for preoperative staging of gastric cancer varies. The aim of this study was to investigate the accuracy of EUS tumor (T) and node (N) staging, and to identify the histopathological factors influencing accuracy based on the detailed tumor depth of gastric cancer. METHODS: In total, 309 patients with gastric cancer with confirmed pathological staging underwent EUS examination for preoperative staging at Seoul St. Mary's Hospital, Korea, between January and December 2009.The T and N staging of EUS and the pathologic report were compared. RESULTS: The overall accuracies of EUS for T stage and the detailed T stages were 70.2% and 43.0%, respectively. In detailed stage, tumors greater than 50 mm in diameter were significantly associated with T overstaging (odds ratio (OR) = 2.094).The overall accuracy of EUS for N staging was 71.2%. Tumor size (20 mm = size <50 mm, OR = 4.389; and 50 mm = size, OR = 8.170), cross-sectional tumor location (circumferential, OR = 4.381) and tumor depth (submucosa, OR = 3.324; muscular propria, OR = 6.923; sub-serosa, OR = 4.517; and serosa-exposed, OR = 6.495) were significant factors affecting incorrect nodal detection. CONCLUSIONS: Careful attention is required during EUS examination of large-sized gastric cancers to increase accuracy, especially for T staging.
World Journal of Surgical Oncology 09/2012; 10(1):190. · 1.12 Impact Factor
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ABSTRACT: Surgeons' interest and participation in endoscopy have increased recently. The aims of the present study were to assess the learning curve for surgical training in upper endoscopy and to suggest an appropriate training program for surgeons in Korea.
Under the supervision of skilled endoscopists, 4 trainees who participated in this study performed more than 150 esophagogastroduodenoscopy procedures, according to the recommendations of the American Society for Gastrointestinal Endoscopy. The success of the procedures was defined as the fulfillment of designated time and checkpoints. A cumulative sum model was used to assess the learning curve.
During the same period, the 4 trainees completed 158, 160, 166, and 180 procedures, respectively. Plateau points occurred on the learning curve at the 81st, 90th, 98th, and 111th case in the cumulative sum model and the mean value of the plateau was the 95th case.
An intensive education tool and training module that meets the conditions of surgical residents is mandatory for the training of proficient surgical endoscopists.
07/2012; 69(4):559-63. · 1.07 Impact Factor
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ABSTRACT: We assessed the ability of positron emission tomography-computed tomography (PET/CT) to detect synchronous colonic pathology and determined the significance of 18F-fluorodeoxyglucose ((18)F-FDG) activity in the colon of gastric cancer patients.
A total of 239 gastric cancer patients who underwent PET/CT and colonoscopy preoperatively were included. FDG uptake patterns on PET/CT were classified as (1) group A, focal; (2) group B, diffuse; and (3) group C, no uptake. The PET/CT findings were compared with the results of concurrent colonoscopy.
In group A, a total of 123 polyps of >0 mm were observed. Of these, nine polyps were colonic adenocarcinomas and six were high-grade dysplasia. The incidence of colonic adenocarcinomas was significantly higher in group A than in the other two groups (p = 0.037). There was a significant correlation between SUVmax values and incidence of colonic polyps of >10 mm (r = 0.471, p = 0.04). The distribution pattern of SUVmax in polyps with adenoma (>10 mm) was less homogenous than in polyps (>10 mm) with adenocarcinoma.
The focal colonic FDG uptake in PET/CT requires colonoscopic confirmation. The suspicion of colonic malignancy increased in the presence of polyps >10 mm that showed a positive correlation with the SUVmax.
Journal of Gastrointestinal Surgery 06/2012; 16(10):1847-53. · 2.83 Impact Factor
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ABSTRACT: We developed a standardized critical pathway for gastric cancer surgery and then determined the increase of application, which resulted in an improvement in terms of measurable indices, such as hospital stay and cost.
A critical pathway was revised and used widely from the 2nd quarter of 2009. We collected clinical data, such as length of stay and complication rate, as clinical indices of quality prospectively. The total cost paid at the patient's discharge, as well as the daily hospital income, were calculated and compared by each quarter from January 2008 to December 2009.
The application rate of critical pathway was 11.8% and 87.8% in 2008 and 2009, respectively. There were no perioperative deaths. There was no difference in the complication rates between 2008 and 2009 (P=0.45). However, the mean length of stay was significantly different between the 2 years (P<0.05). Although the total cost was not different, the daily hospital income was significantly higher in the latter year (P<0.05).
An increase in the application of critical pathway for gastrectomy resulted in significant decreases in length of stay and increases in the daily hospital income without a compromise on the clinical indices.
Journal of gastric cancer. 06/2012; 12(2):126-31.
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ABSTRACT: BackgroundTo date, guidelines for follow-up after curative resection in patients with gastric cancer have not been reported. Thus, most
centers have managed the process according to institution-specific protocols. We investigated current follow-up practices
after curative resection of gastric cancer using a nationwide survey in Korea, where gastric cancer is epidemic.
MethodsFrom July to September 2007, questionnaires were sent out to 205 members of the Korean Gastric Cancer Association (KGCA).
The questionnaire packet contained a covering letter, general information, and a questionnaire about follow-up schedules and
methodologies.
ResultsForty-six percent (96/205) of the members of the KGCA returned the survey. The majority of responders indicated that patients
with early gastric cancer were followed up every 6months (64.4%) for the first year, every 12months (47.9%) for the next
4years, and every 12months (68.8%) from the fifth year after surgery on. For patients with advanced gastric cancer, follow-up
studies were carried out every 3months (43.8%) for the first year, every 6months for the next 4years, and every 12months
(75.0%) from the fifth year onward. After surgery, most responders used computed tomography for imaging, carcinoembryonic
antigen (CEA) and carbohydrate antigen (CA)19-9 as tumor markers, and serum iron among follow-up measures.
ConclusionsClinicians have a variety of approaches regarding the extent of follow-up and methodologies used after curative resection
for gastric cancer. Therefore, a multicenter randomized trial will be needed to compare routine follow-up with intensive schedules.
Our results could facilitate the design of such studies.
Annals of Surgical Oncology 04/2012; 17(1):54-64. · 4.17 Impact Factor
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ABSTRACT: This study examined the surgical outcome of non-curative resection in elderly patients with gastric cancer.
The study reviewed 278 patients who underwent non-curative resection for advanced gastric cancer. The clinicopathological features of elderly patients (≥75 years, n = 257) and younger patients (<75 years, n = 21) were compared.
Although no difference was observed in terms of preoperative performance, there were distinct differences in terms of albumin level, presence of symptoms, and the rate of comorbidities between the two groups. The postoperative morbidity and mortality rate did not differ between the two groups. Age, preoperative performance status, preoperative transfusion, and presence of comorbidity were not independent predictors of postoperative complications. However, the extent of gastric resection and combined resection were closely related to postoperative complications in patients with non-curative gastrectomy.
In a setting of non-curative resection for gastric cancer, age was not a limiting factor. Rather, the risk of postoperative morbidity should be considered carefully in total gastrectomy and combined resection. J. Surg. Oncol. 2012; 106:753-756. © 2012 Wiley Periodicals, Inc.
Journal of Surgical Oncology 04/2012; 106(6):753-6. · 2.10 Impact Factor
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Journal of Surgical Oncology 04/2012; 106(4):524. · 2.10 Impact Factor
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ABSTRACT: The clinical value of a non-curative resection for gastric cancer is still controversial. We analyzed the clinical outcomes of patients who underwent non-curative gastric resection.
Data from a total of 178 patients who underwent non-curative resection for advanced gastric cancer at Seoul St. Mary's hospital were reviewed. Factors related to the incurability were classified as peritoneal metastasis (P), liver metastasis (H), extra-abdominal metastasis (X), direct adjacent organ invasion that was unresectable (T). The clinicopathologic data, survival, and quality of life of patients were evaluated.
The overall median survival time was 12.1 months, and that for the patients with gastrectomy with chemotherapy was 14.3 months. Operation-related complications occurred in 20 patients (11.2 %). Five patients (2.8 %) died of postoperative complications within 30 days, and 43 patients (24.2 %) had symptoms and signs of gastric outlet obstruction or uncontrolled bleeding. The mean duration of postoperative hospital stay was 15.9 days for those symptomatic patients, and the symptom-relieved period was 8.6 months.
There might be a role for non-curative resection followed by chemotherapy for incurable gastric cancer, in terms of survival, and this treatment approach should be carefully considered because of the high mortality rate associated with the disease. A large, randomized, prospective study is warranted to prove the benefit of non-curative resection in patients with incurable gastric cancer.
World Journal of Surgery 03/2012; 36(8):1800-5. · 2.36 Impact Factor
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Journal of Surgical Oncology 02/2012; 106(3):354; author reply 355. · 2.10 Impact Factor
