Jin-Young Park

Laparoendoscopic single site (LESS) surgery in benign gynecology: perioperative and late complications of 515 cases

OBJECTIVEnTo present 515 LESS surgeries and report the perioperative outcomes and late complications according to the Clavien-Dindo classification.nnnSTUDY DESIGNnWe performed a prospective single-center study (Canadian Task Force classification II-2). One surgeon trained in minimally invasive surgery performed 515 cases of LESS surgery from May 2008 to September 2011.nnnRESULTSnLESS gynecological surgery was performed on 515 patients (274 total hysterectomies; 26 subtotal hysterectomies; 87 adnexectomies including oophorectomy, salpingectomy, and salpingo-oophorectomy; 100 ovarian cystectomies; 17 myomectomies; 11 others). The median age and body mass index of the patients were 45 years and 22.6 kg/m², respectively. LESS surgery was successfully completed in 493 patients (95.7%) without the need for one or more ancillary ports or conversion to laparotomy. Twenty patients needed one or more additional ports and two cases were converted to laparotomy. One or more additional ports were required most frequently in ovarian cystectomy procedures (12/100, 12%). Thirty-six patients (7.0%) required intraoperative and/or postoperative transfusions. Each of these patients underwent hysterectomy (33/274, 12.0%) or subtotal hysterectomy (3/26, 11.5%). Perioperative complications (<30 postoperative days), excluding transfusions, occurred in 8 patients (1.6%) and included one case each of vault bleeding, vault abscess, stump watery discharge, rectal injury, and vesicovaginal fistula, and three cases of urinary tract injury. Late complications occurred in three patients (0.6%) and included two umbilical hernias and one vault evisceration. The overall complication rate, excluding transfusions, was 2.1% (11/515).nnnCONCLUSIONnThe rate of late postoperative complications, including umbilical port site hernia and vault evisceration, was not increased in this study, as compared to previous reports of single-port and conventional laparoscopic surgeries.

Prognostic factors and outcomes in endometrial stromal sarcoma with the 2009 FIGO staging system: A multicenter review of 114 cases

OBJECTIVEnTo assess prognostic factors associated with disease-related survival in endometrial stromal sarcoma (ESS) using the 2009 FIGO staging system.nnnMETHODSnFrom January 1990 to January 2012, 114 patients with ESS were identified at the Samsung and Asan Medical Center and data were retrospectively analyzed.nnnRESULTSnTen (8.7%) patients died of the disease and 33 (28.9%) patients relapsed. The 5- and 10-year overall survival (OS) rates for the entire cohort were 92.6% and 87.1%, respectively, and the 5- and 10-year recurrence-free survival (RFS) rates were 71.8% and 52.1%, respectively. The estimated median survival after recurrence for the 33 patients whose tumors relapsed was 133 months (95% CI, 7.7-258.4), and 5-year survival after recurrence was 68.9%. Stage I (P=0.006), estrogen and/or progesterone receptor (ER/PR) positivity (P=0.0027), and no nodal metastasis (P=0.033) were associated with a good prognosis for OS in the univariate analysis. Ovarian preservation was revealed to be an independent predictor for poorer RFS (HR, 6.5; 95% CI, 1.23-34.19; P=0.027). Positivity for ER/PR (HR, 0.05; 95% CI, 0.006-0.4; P=0.006) and cytoreductive resection of recurrent lesions (HR, 0.14; 95% CI, 0.02-0.93; P=0.042) were independent predictors of better survival after recurrence.nnnCONCLUSIONSnStage, expression of ER/PR, and nodal metastasis are significantly associated with OS in ESS. Bilateral salpingo-oophorectomy (BSO) as the primary treatment and cytoreductive resection of recurrent lesions should be considered for improving survival of patients with ESS.

Surgical Outcomes of a New Approach to Laparoscopic Myomectomy: Single-Port and Modified Suture Technique

STUDY OBJECTIVEnTo introduce a new technique of laparoscopic myomectomy (LM) using single-port access and a modified suture technique.nnnDESIGNnRetrospective review of medical records.nnnSETTINGnUniversity medical center.nnnPATIENTSnFrom October 2011 through December 2012, 55 consecutive patients underwent single-port LM using a modified suture technique with Hem-o-lock ligation clips and myoma morcellation through the umbilical incision site (Chois LM). As a historic control, patients who underwent conventional multi-port LM from January 2008 through November 2010 were included in the study.nnnINTERVENTIONSnMedical records for 157 patients (55 Chois LM and 102 LM) were reviewed retrospectively. Inclusion criteria were <3 symptomatic myomas ≤10xa0cm. Outcomes measured were operative time, estimated blood loss, complications, length of postoperative hospital stay, and postoperative pain.nnnMEASUREMENTS AND MAIN RESULTSnAge, symptoms resulting from myomas, location and type of dominant myomas, and number of myomas were similar in the 2 groups. There were no significant differences in mean diameter of the myomas between the groups (6.8 cm vs 7.0 cm; p = .40). The mean duration of the operation was shorter in the Chois LM group compared with the conventional LM group (104 min vs 152 min; p < .001). Chois LM also resulted in a statistically significant decrease in blood loss (139 mL vs 222 mL; p < .001). Postoperative pain scores were significantly lower in the Chois LM group than in the conventional LM group at 1, 6, 12, and 24 hours after surgery.nnnCONCLUSIONnChois LM with modified suture technique is associated with shorter operative time and less postoperative pain. A prospective trial is needed to confirm the results.

Outcomes of laparoscopic fertility-sparing surgery in clinically early-stage epithelial ovarian cancer

Objective Fertility-sparing surgery (FSS) is becoming an important technique in the surgical management of young women with early-stage epithelial ovarian cancer (EOC). We retrospectively evaluated the outcome of laparoscopic FSS in presumed clinically early-stage EOC. Methods We retrospectively searched databases of patients who received laparoscopic FSS for EOC between January 1999 and December 2012 at Samsung Medical Center. Women aged ≤40 years were included. The perioperative, oncological, and obstetric outcomes of these patients were evaluated. Results A total of 18 patients was evaluated. The median age of the patients was 33.5 years (range, 14 to 40 years). The number of patients with clinically stage IA and IC was 6 (33.3%) and 12 (66.7%), respectively. There were 7 (38.9%), 5 (27.8%), 3 (16.7%), and 3 patients (16.7%) with mucinous, endometrioid, clear cell, and serous tumor types, respectively. Complete surgical staging to preserve the uterus and one ovary with adnexa was performed in 4 patients (22.2%). Two out of them were upstaged to The International Federation of Gynecology and Obstetrics stage IIIA1. During the median follow-up of 47.3 months (range, 11.5 to 195.3 months), there were no perioperative or long term surgical complications. Four women (22.2%) conceived after their respective ovarian cancer treatments. Three (16.7%) of them completed full-term delivery and one is expecting a baby. One patient had disease recurrence. No patient died of the disease. Conclusion FSS in young patients with presumed clinically early-stage EOC is a challenging and cautious procedure. Further studies are urgent to determine the safety and feasibility of laparoscopic FSS in young patients with presumed clinically early-stage EOC.

Postoperative outcomes of MR-invisible stage IB1 cervical cancer

OBJECTIVEnTumor volume is a significant prognostic factor of cervical cancer. It is still unknown about outcome of biopsy-proven IB1 cervical cancer, which is invisible on preoperative magnetic resonance imaging (MRI). The aim was to evaluate retrospectively the postoperative outcomes of MR-invisible stage IB1 cervical cancers.nnnSTUDY DESIGNnBetween January 2001 and December 2007, we reviewed the medical records of 86 patients with biopsy-proven IB1 cervical cancer that was invisible on MRI. During the same period, we also reviewed the medical records of 260 patients with biopsy-proven IB1 cervical cancer that was visible on MRI. Both of these cancer groups were treated with radical hysterectomy and lymph node dissection. MR-invisible and MR-visible IB1 cancers were compared in terms of pathologic parameters and long-term survival rate.nnnRESULTSnThe median sizes and depths of stromal invasion of MR-invisible vs MR-visible IB1 cancers were 4.5 ± 7.1 mm and 33.3% ± 20.1% vs 30 ± 14 mm and 66.7% ± 26.6%, respectively (Pxa0=xa0.000). The incidences of lymph node metastasis, parametrial invasion, and lymphovascular invasion were 1.1% (1/86 cases) and 18.8% (49/260 cases; Pxa0= .000; odds ratio, 19.7), 0% (0/86 cases) and 6.5% (17/260 cases; Pxa0= .009; odds ratio, 12.4), and 4.7% (4/86 cases) and 26.9% (70/260 cases; Pxa0= .000; odds ratio, 7.6) in the MR-invisible and MR-visible IB1 cancers, respectively. Recurrence-free and overall 5-year survival rates of MR-invisible vs MR-visible IB1 cancers were 98.8% (85/86 cases) vs 91.2% (237/260 cases) and 100% (86/86 cases) vs 95.8% (249/260 cases), respectively (Pxa0=xa0.011 and .045).nnnCONCLUSIONnMR-invisible IB1 cancer provides better postoperative outcomes than MR-visible IB1 cancer because of the much lower tumor burden.

A prospective comparative study of cosmetic satisfaction for three different surgical approaches

OBJECTIVESnTo compare gynecologic patients cosmetic satisfaction with surgical wounds after different approaches: laparoendoscopic single-site surgery (LESS), conventional laparoscopic surgery (CLS) and open surgery (OS).nnnSTUDY DESIGNnThis was a prospective study. The primary outcome was the cosmetic satisfaction after LESS, CLS, or OS, measured at 1 and 6 months post-surgery using the well-validated Cosmetic Scale. Multiple linear regression analysis was used to determine whether the surgical approach was independently associated with cosmetic satisfaction or not.nnnRESULTSnOf 294 patients enrolled, 84 (28.6%), 129 (43.9%), and 81 patients (27.3%) underwent LESS, CLS, and OS, respectively. Cosmetic Scale scores in the LESS group at 1 month post-surgery was about 7 higher than in the CLS group and 9 higher than in the OS group (P<0.001). This difference was maintained also at 6 months post-surgery (P<0.001). On multiple linear regression analysis, the surgical approach was independently associated with postoperative cosmetic satisfaction (P<0.001).nnnCONCLUSIONnOur study found that cosmetic satisfaction after LESS was highest, followed by CLS, then OS. Therefore, physicians should more assertively discuss and consider LESS for gynecologic diseases.

Prognostic value of pre-treatment SCC-Ag level in patients with cervical cancer

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Acute Paraplegia After Lumbar Steroid Injection in Patients With Spinal Dural Arteriovenous Fistulas: Case Reports

Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal vascular malformations. However, SDAVFs are still underdiagnosed entities because their clinical symptoms are usually non-specific, as they include low back pain or radiating pain to the limb. There have been several reports of acute paraplegia after lumbar epidural steroid injections in patients with SDAVFs. We present 4 patients with SDAVFs who received lumbar steroid injection. Among the 4 cases, acute paraplegia developed in 2 cases that received a larger volume of injectate than the other cases. Thus, we are suggesting that the volume of injectate may be a contributing factor for acute paraplegia after lumbar steroid injection in patients with SDAVFs.

PORT-SITE METASTASIS OF ADVANCED PRIMARY PERITONEAL CANCER AFTER LAPAROSCOPIC PERITONEAL BIOPSY: A CASE REPORT

Due to the advancement in laparoscopic surgery in gynecology, laparoscopic surgery of patients with gynecologic malignancy is widely used. A 69-year-old woman who had elevated serum level of CA-125 and malignant ascites was transferred from general surgery after laparoscopic peritoneal biopsy. She complained about 2.5 cm sized abdominal wall mass which developed only 1week after surgery. With the impression of ovarian cancer with port-site metastasis, we performed debulking operation and abdominal wall mass excision. The final pathology confirmed primary peritoneal serous papillary adenocarcinoma. Whenever a female patient has elevated serum level of CA-125 and ascites cytology shows adenocarcinoma, she should be referred to gynecologic oncologists fiAnd considering the primary peritoneal or ovarian cancer, primary debulking operation by gynecologic oncolog ist is recommended.