Abstract: AIMS: The clinical significance of lymph node micrometastasis for histologically node negative gastric cancer is not well documented. This study was to assess the incidence and to clarify the risk factors of lymph node micrometastasis in patients with node negative early gastric cancer (EGC). METHODS: We investigated the lymph node micrometastasis with using an anticytokeratin immunohistochemical stain in 90 patients with node negative EGC who underwent curative resection between 1991 and 2000. RESULTS: Among 3526 nodes from 90 patients, there were 17 cytokeratin immunohistochemical stain positive nodes from nine patients. The incidence of micrometastasis was higher in patients with lymphatic invasion (p=0.012), venous invasion (p=0.026) and larger tumor (p=0.003). The independent risk factors for lymph node micrometastasis were lymphatic invasion (p=0.004, RR=22.915, 95% CI=2.709 approximately 193.828) and tumor size (p=0.029, RR=1.493, 95% CI=1.042 approximately 2.138). Although there were 10 deaths during the follow-up period of mean 67.6months (1month approximately 147months), there was no death from a cancer recurrence. CONCLUSIONS: The incidence of lymph node micrometastasis in patients with node negative early gastric cancer was 10%, and the independent risk factors for micrometastasis were lymphatic invasion and tumor size.

Abstract: AIMS: To evaluate the changing trends of clinicopathologic features, surgical procedures and treatment outcomes of gastric cancer in a large-volume center. METHODS: We divided the time period into two parts: the first is 1989-1996 (period I) and the second is 1997-2001 (period II). Then we analyzed prospectively collected data on 1816 patients treated at Kangnam St. Mary's Hospital, The Catholic University of Korea, from 1989 to 2001. RESULTS: Upper one-third cancer was seen more prevalently in period II than period I (9.4% versus 6.6%) (p=0.000) and total gastrectomy was performed more frequently in period II than period I (25% versus 18%) (p=0.000). A diagnosis of early gastric cancer was made more prevalently in period II than period I (40% versus 27%) (p=0.000). D2 lymphadenectomy was done in 74% of the period I patients and 83% of their period II counterparts (p=0.000). Between the two periods, there was a significant difference in the incidence of operation-related major complications (9.9% in period I versus 3.9% in period II) (p=0.000) and the mortality (1.8% versus 0.6%) (p=0.023). The overall 5-year and 10-year survival rates were significantly higher in period II than period I (63% and 57% in period I versus 69% and 64% in period II) (p=0.009). CONCLUSIONS: The overall survival of gastric cancer significantly increased because of the early detection and aggressive surgical approaches by experienced surgeons in a large-volume center. More effective multidisciplinary approaches are warranted to improve the prognosis of advanced gastric cancer.

Abstract: Background Laparoscopic surgery has been adopted for the treatment of gastric cancer, and many reports have confirmed its favorable outcomes. Most surgeons prefer to laparoscopy-assisted gastrectomy using minilaparotomy rather than totally laparoscopic procedures because of technical difficulties of intracorporeal anastomosis. We conducted this study to compare laparoscopy-assisted distal gastrectomy with totally laparoscopic distal gastrectomy. In addition, laparoscopic procedures were compared with open distal gastrectomy. Material and methods This prospective, nonrandomized, multicenter study enrolled 60 patients with early gastric cancer at three branch hospitals of our institutes. Twenty-five- to 30-cm-long mid-line incision, 5-cm midline or transverse incision, and 3-cm U-shaped incision were used in open distal gastrectomy, laparoscopy-assisted distal gastrectomy, and totally laparoscopic distal gastrectomy, respectively. Postoperative outcomes, immunologic changes, and operation-related costs were compared between the three groups. Results There was no difference in gender, mean age, body mass index, and tumor characteristics between the three groups. No operation-related death occurred. Estimated blood loss, number of additional analgesics use, first flatus, and soft meal diet time were significantly different between the three groups (P < 0.05). In totally laparoscopic distal gastrectomy, the time to first flatus was significantly shorter than laparoscopy-assisted distal gastrectomy (3.7 vs. 2.8 days, in laparoscopy-assisted distal gastrectomy and totally laparoscopic distal gastrectomy, respectively, P < 0.05). White blood cell count and C-reactive protein level at postoperative day 1 were significantly higher in open distal gastrectomy than the other groups; however, there was no difference between laparoscopy-assisted distal gastrectomy and totally laparoscopic distal gastrectomy. The operation-related costs were significantly greater in totally laparoscopic distal gastrectomy (P < 0.05). Conclusion Although totally laparoscopic distal gastrectomy needs more cost, totally laparoscopic distal gastrectomy provides shorter bowel recovery time than laparoscopy-assisted distal gastrectomy.

Abstract: Background The aim of this multicenter retrospective study was to establish background data for future randomized clinical trial comparing open and laparoscopy-assisted gastrectomies (LAGs). We sought to evaluate the technical feasibility of LAG by determining the morbidity and mortality and identifying corresponding predictive factors. Patients and Methods A retrospective multicenter study was carried out in Korea on 1,485 patients in who, LAG had been attempted for gastric cancer under the care of ten surgeons, at ten institutions, during the period spanning May 1998 to December 2005. Patient characteristics, operative outcomes, and postoperative morbidities and mortalities were analyzed. Results Overall morbidity and mortality rates were 14.0% and 0.6%, respectively. Complications included: wound problem (4.2%, n = 62), intraluminal bleeding (1.3%, n = 20), intra-abdominal abscess or fluid collection (1.3%, n = 19), anastomotic leakage (1.3%, n = 18), and intra-abdominal bleeding (1.3%, n = 18). By using multivariate analysis we found that the two most important risk factors associated with postoperative complications were presence of comorbidity in the patient and lack of experience on the part of the surgeon. Conclusion LAG is a technically feasible, safe, and effective method for treating patients with gastric cancer. Extra caution in patients with comorbidities, and dedication to improving surgical proficiency in LAG, may decrease the risk of complications. Through this study, we have established the inclusion criteria for LAG. For our multicenter, prospective, randomized trials (NCT00452751), potential patients should have an American Society of Anesthesiology (ASA) score of less than 3, and surgeons performing the procedures should have experience with more than 50 cases of LAG.

Abstract: Background We analyzed our preliminary clinical data for totally laparoscopic gastrectomy (TLG) in order to evaluate its effectiveness in terms of minimal invasiveness, technical feasibility, and safety. Methods Forty-five consecutive patients who underwent TLG in our institution between June 2004 and February 2006 were enrolled in this study. There were 26 men and 19 women, with a mean age of 58.8 years and a mean body mass index (BMI) of 23.2. In all cases, only laparoscopic linear staplers were used for intracorporeal anastomosis. Results The reasons that gastrectomy was performed were adenocarcinoma in 41 cases, benign disease in three cases and gastrointestinal stromal tumor in one case, and the types of surgery were distal gastrectomy (40), total gastrectomy (four) and pylorus-preserving gastrectomy (one). Among the distal gastrectomies, Billroth I (25) was the most frequent procedure, followed by uncut Roux-en-Y gastrojejunostomy (14) and Billroth II (one), respectively. The mean operation time was 314 minutes, the mean anastomotic time was 41 minutes, the mean number of staples used was eight, and the mean estimated blood loss was 150 ml. There was no case of conversion to an open procedure. The first flatus was observed at 2.9 days, and liquid diet was started at 3.7 days. The mean number of postoperative analgesic use, except for patient-controlled analgesia (PCA), was 1.4 times, and the mean postoperative hospital stay was 11 days. Postoperative complication occurred in six patients (13.3 %), but no postoperative mortality occurred. There were two cases of delayed gastric empting and one case of anastomotic leakage, anastomotic stenosis, intraabdominal bleeding, and ventral hernia each. All of the patients recovered well with conservative or surgical management. Conclusions TLG with intracorporeal anastomosis using laparoscopic linear staplers was safe and feasible, and we were able to obtain acceptable surgical outcomes in terms of minimal invasiveness.

Abstract: Background Laparoscopic wedge resection (LWR) of the stomach cannot easily be applied to tumors that are located near the esophagogastric junction (EGJ). To define the tailored approach for this type of tumors, we evaluated our laparoscopic surgical technique and clinical outcomes. Methods We successfully performed 10 LWRs for patients with submucosal tumor (SMT) located 3 cm or less from the esophagogastric junction. A presumptive diagnosis of gastrointestinal stromal tumor (GIST) was made in all the cases, based on endoscopic and radiologic examinations. The patient demographics, perioperative parameters and outcomes of 10 patients were assessed. Results Neither intraoperative complications nor conversion to open surgery was required, and we were able to perform complete tumor excision with negative surgical margins for all the patients. The laparoscopic approaches of resection included the transgastric method (n = 5) and the exogastric method (n = 5). The mean operation time was 92.5 minutes (range 60–125 minutes). No blood transfusion was given for all cases in the perioperative period. The patients’ oral intake was restored on the third postoperative day. The hospital stay ranged from three to seven days (mean: 4.9 days). Pathologic analysis of the resected specimens showed six GISTs, three leiomyomas, and one lipoma. Conclusions Laparoscopic resection of gastric SMTs located near the EGJ is a feasible and safe procedure. The laparoscopic approaches to this area should be tailored, based on the location, size and expanding pattern of the tumor.

Abstract: BACKGROUND: Laparoscopy-assisted distal gastrectomy (LADG) with lymph node dissection for advanced gastric cancer is still controversial. To evaluate the technical and oncologic feasibility and advantage of LADG with D2 lymph node dissection, the authors compared the surgical outcomes of LADG with D2 dissection and those of conventional open distal gastrectomy (ODG) for patients with early gastric cancer (EGC). METHODS: Between September 2004 and August 2005, the study enrolled 75 patients with a preoperative diagnosis of EGC. Of these 75 patients, 44 underwent LADG, and remaining 31 underwent ODG. All the patients received D2 lymph node dissection. Their clinicopathologic characteristics, postoperative outcomes, and retrieved lymph nodes were compared at each station. RESULTS: Although the operative time was significantly longer for the LADG group than for the ODG group, the perioperative recovery was shorter and, consequently, the postoperative hospital stay was significantly shorter for the LADG group (7.7 vs 9.4 days, respectively; p = 0.003). No significant differences were found in the total number of retrieved lymph nodes (37.2 vs 42.4; p > 0.05) or node stations (p > 0.05) between the two groups. CONCLUSIONS: LADG with D2 lymph node dissection is a safe and feasible procedure, and it is oncologically compatible with open gastrectomy. A large-scaled prospective randomized trial with advanced gastric cancer patients should be conducted to confirm the benefit of LADG.

Abstract: Background The purpose of the current study was to determine the role of surgery in the treatment of recurrent gastric cancer. Methods Of the 347 patients with recurrent gastric cancer, 61 patients (17.8%) who underwent surgery were evaluated retrospectively. The underlying causes and types of surgery, survival, and postoperative quality of life were analyzed. Results The most common cause of surgery was intestinal obstruction due to carcinomatosis. Complete resection was possible in 15 patients (24.6 %), including 10 gastric remnant recurrences, and 2 hepatic and 3 ovarian metastases. The survival of patients who had complete resection was significantly longer than the other groups (52.2 months for complete resections, 13.1 months for palliative procedures, and 8.7 months for laparotomy alone, respectively) (P < .05). The median hospital-free survival (HFS) durations were 9.4, 2.9, and 2.2 months for incomplete resection, bypass/enterostomy, and laparotomy only, respectively (P < .05). Conclusion Surgical treatment in recurrent gastric cancer is rarely indicated; however, if complete resection could be accomplished, long-term survival can be expected. Bypass surgery for symptom palliation did not increase the HFS.

Abstract: BACKGROUND AND OBJECTIVES: To clarify optimal treatment guidelines for residual or local recurrence after endoscopic resection (ER). METHODS: Eighty-six patients underwent gastrectomy due to incomplete ER and local recurrence after ER. The pathological findings of ER and gastrectomy specimens were analyzed. RESULTS: The cause of gastrectomy was categorized into five groups; submucosal (sm) invasion without margin involvement, positive margin, margin not evaluable, high risk of lymph node metastasis and local recurrence after ER. According to the pathological findings of gastrectomy specimens, remnant cancer and lymph node metastases were found in 56 (65.1%) and in 5 patients (5.8%), respectively. At 10 gastrectomy specimens which were sm invasion without margin involvement, the scattered residual cancer cells were found around the ulcer scar in 2 (20%) patients. In 11 of 44 margin involvement specimens, no residual cancer or lymph node metastasis was found. In patients with local recurrence, mean duration from ER to surgery was 14.8 months, and 19% of patients were found to have sm or deeper depth of invasion. CONCLUSION: Gastrectomy with lymph node dissection should be performed in patients with sm invasion with or without margin involvement. However, minimal approach other than gastrectomy could further be applied to selected patients.

Abstract: BACKGROUND: We present, here, the technique and results of our laparoscopic simple "one-stitch" suture with omental patch technique for treating 35 patients with perforated duodenal ulcer. METHODS: The laparoscopic treatment included peritoneal lavage, suture of the perforation without knotting, and then tying the suture over the omentum. Follow-up gastroscopy was performed after an eight-week course of medication with proton-pump inhibitors. RESULTS: Conversion to laparotomy was necessary for two patients, because of a large-sized perforation and the inadequate localization of the perforation site, respectively. The mean operative time was 64 minutes and the mean hospital stay was 6.8 days. Operation-related complications occurred in two patients, including one case of pneumonia and one case of gastric stasis. CONCLUSIONS: This simple "one-stitch" suture with omental patch technique is a safe and easy procedure, and it has an acceptable morbidity rate and a low conversion rate.

Abstract: Vascular compression of the duodenum is also known as superior mesenteric artery syndrome (SMA syndrome) or Wilkie syndrome. This is a rare condition that is characterized by compression of the third portion of the duodenum by the SMA as it passes over this portion of the duodenum. Duodenojejunostomy is usually considered to be the treatment of choice. We recently experienced the case of a very thin 19-year-old female with the diagnosis of SMA syndrome. We started nasogastric tube decompression and total parenteral nutrition, but that was ineffective; we then performed laparoscopic duodenojejunostomy. We herein report on this successful laparoscopic duodenojejunostomy procedure along with a review of the relevant literature.

Abstract: Many approaches have been proposed for the treatment of bezoars, such as gastroscopic fragmentation, nasogastric lavage or suction, and enzymatic therapy. Because gastroscopic removal has not always been successful, especially in large gastric bezoars, surgical removal by gastrotomy through abdominal incision has been performed. With the advent of laparoscopic surgery, it became possible to remove such lesions without large abdominal incisions. In this case, we present a 62-year-old male who had gastric phytobezoar that was successfully treated with a laparoscopic technique.

Abstract: Background Staging laparoscopy has been shown to be useful for increasing the accuracy of preoperative staging. However, controversy still exists regarding patient selection and subsequent treatment. The aim of this study was to determine the role of staging laparoscopy for a group that has a policy to perform aggressive surgery for advanced gastric cancer. Methods Twenty-four patients with clinical T3 or T4 gastric cancer expected to undergo curative resection, based on conventional preoperative diagnostic methods underwent staging laparoscopy. We examined the accuracy and the impact of staging laparoscopy on the further treatment options. Results The mean running time for the staging laparoscopy was 40.7 min (range: 25–75 min), and one complication was noted (4.2%). In regard to the tumor depth, 11 of 24 (45.8%) cases had a discrepancy after staging laparoscopy. In addition, 15 of 24 patients (62.5%) were found to have unsuspected peritoneal metastases, and 8 patients (33.3%) were excluded from laparotomy. The remaining 16 patients (66.7%), including 9 patients with localized peritoneal metastases (P1), underwent resection. The diagnostic accuracy for T factor was 81.3% in 16 laparotomy cases and overall accuracy of P factor was 91.7%. Conclusions Staging laparoscopy had a significant impact on decisions regarding the treatment plan in patients with advanced gastric cancer for a group that has an aggressive treatment strategy.

Abstract: Chilaiditi syndrome is a condition in which the colon or small intestine is interposed temporarily or permanently between the liver and the diaphragm. Usually, it is an asymptomatic and incidental radiographic finding, but it may be a potential source of abdominal problems, ranging from intermittent mild abdominal pain to acute intestinal obstruction. We report multidetector computed tomographic findings of a case of Chilaiditi syndrome presenting as small bowel obstruction due to hepatodiaphragmatic interposition of the ileal loop, which was entrapped by adhesive bands caused by Fitz-Hugh-Curtis syndrome.

Abstract: Mucormycosis is an uncommon opportunistic fungal infection that may develop in immunocompromised patients with conditions such as diabetes mellitus, leukemia, lymphoma, or human immunodeficiency virus (HIV), or after transplantation with immunosupperessive therapy. We report a case of gastric perforation caused by a mucormycosis infection in a patient with acute myelogenous leukemia (AML). The patient was treated successfully with gastrectomy and the aggressive use of intravenous amphotericin B. He is still alive 1 year after his operation