Kyung Ho Pak

Clinical implication of FDG–PET in advanced gastric cancer with signet ring cell histology

The purpose of this study was to investigate the role of the standardized uptake values (SUV), a semi‐quantitative assessment of tumor FDG uptake, as a prognosticator for advanced signet ring cell carcinoma (SRC).

Relevance of lymph node metastasis along the superior mesenteric vein in gastric cancer

The purpose of this study was to evaluate the prognostic value of lymph node metastasis along the superior mesenteric vein (station 14v) to determine the need for 14v dissection in gastric cancer surgery.

Early experience with diagnosis and management of eroded gastric bands

Purpose Band erosion is a well-known complication of laparoscopic adjustable gastric band placement. We gained experience with laparoscopic removal of an eroded gastric band. Methods We retrospectively reviewed the operative log of our obesity surgery unit to identify all operations performed for band erosion from March 2009 to May 2011. Results During the study period, a total of six of 96 patients (6.3%), five females and one male, were diagnosed with band erosion and underwent surgical removal of the band system. The median time interval from the initial gastric band placement to the diagnosis of band erosion was 8.5 months (range, 7 to 22 months), with most band erosion occurring within the first year (5/6, 83%). The median body mass index at band removal was 28.4 kg/m2. Upper abdominal pain was the most common symptom (5/6, 83%), and other signs and symptoms were port site infection (3/6, 50%) and loss of restriction and weight regain (1/6, 17%). All eroded bands were removed using laparoscopy. Further complications after laparoscopic removal of the band system were observed in three cases. One patient showed multiple intra-abdominal abscesses requiring insertion of a pigtail catheter for drainage. The other two patients experienced sepsis with localized peritonitis, eventually requiring laparoscopic washout and drainage. Conclusion Gastric band erosion requires the removal of the gastric band. Laparoscopic removal is technically achievable in the majority of patients with eroded gastric band. The method can be challenging, has potential postoperative complications (fistula, abscess), and should be attempted only by experienced surgeons.

Elevated high-sensitivity C-reactive protein, a marker of advanced stage gastric cancer and postgastrectomy disease recurrence

Gastric cancer recurrence after curative surgery remains high. Although no preoperative marker of gastric cancer progression after radical gastrectomy exists, recent studies suggest that C‐reactive protein (CRP) is associated with cancer progression. Our study evaluated the significance of preoperative high‐sensitivity CRP (hs‐CRP) levels as a marker of disease progression after radical gastrectomy.

A novel modification of double stapling technique in Billroth I anastomosis

Although the double‐stapling technique has been used as a safe procedure in gastroduodenostomy, creating anastomosis with a circular stapler on the linear stapler line can be vulnerable for anastomotic leakage and ischemia. Therefore, we tried to modify the double‐stapling technique to avoid stapling on the staple line. J. Surg. Oncol. 2009;100:518–519.

The different role of intratumoral and peritumoral lymphangiogenesis in gastric cancer progression and prognosis

BackgroundTumor-induced lymphangiogenesis plays a crucial role in metastasis and tumor progression. However, the significance of intratumoral lymphovascular density (I-LVD) and peritumoral lymphovascular density (P-LVD) has been controversial in gastric cancer. The purpose of this study was to investigate the differences of clinicopathologic characteristics with respect to I-LVD and P-LVD in gastric cancer.MethodsSamples of I-LVD and P-LVD from 66 patients who had undergone radical gastrectomy for gastric cancer were assessed after staining with D2-40, an immunostaining marker for lymphatic endothelium. The mean number of lymphatic vessels in three hotspots was calculated in intratumoral and peritumoral areas.ResultsThe peritumoral lymphatics were enlarged with dilated lumens compared to the intratumoral lymphatics. I-LVD was positively correlated with diffuse gastric cancer subtype, tumor stage, lymphovascular invasion, tumor node metastasis stage, and overall survival (P <0.05). P-LVD was associated with lymphovascular invasion, node stage, and disease-free survival (P <0.05).ConclusionsWe conclude that P-LVD had an important role in lymph node metastasis, while I-LVD was more associated with depth of tumor invasion. However, both LVDs contributed to gastric cancer progression and prognosis.

Investigation of Endoscopic and Pathologic Features for Safe Endoscopic Treatment of Superficial Spreading Early Gastric Cancer.

AbstractSuperficial spreading early gastric cancer (EGC) is a rare disease that is treated mainly by surgery. There are few studies on the safety of endoscopic treatment for patients with superficial spreading EGC. The aims of this study were to (1) investigate the risk of lymph node metastasis of superficial spreading EGC and (2) investigate the potential criteria for endoscopic treatment of superficial spreading EGC using surgical specimens.Between 2000 and 2010, patients who received curative surgery of R0 resection at Severance Hospital (Seoul, Korea) for early gastric cancer were enrolled. The superficial spreading EGC was defined as cancer in which the longest tumor length was ≥6 cm. The medical records of the patients were reviewed retrospectively.Of the 3813 patients with EGC, 140 (3.7%) had lesions ≥ 6 cm, whereas 3673 (96.3%) had lesions < 6 cm. Patients with superficial spreading EGC had higher rates of submucosal cancer (59.3% vs 45.7%, P = 0.002), lymphovascular invasion (18.6% vs 9.8%, P < 0.001), and lymph node metastasis (15.7% vs 10.1%, P = 0.033) compared with patients with common EGC (< 6 cm). Multivariate analysis revealed that a tumor ≥ 6 cm was not strongly associated with lymph node metastasis in EGC, as compared with a tumor < 6 cm, but submucosal invasion and lymphovascular invasion were strongly associated with lymph node metastasis in EGC. In mucosal cancer without ulcers, tumors ≥ 6 cm had a higher rate of lymph node metastasis than tumors ⩽ 2 cm; however, this trend was not significant (7.7% vs 5.3%, P = 0.455).Superficial spreading EGC was not associated with an increased risk of lymph node metastasis compared with common EGC. We suggest that differentiated intramucosal superficial spreading EGC without ulceration can be treated by endoscopic submucosal dissection.

How to do single-port laparoscopic cholecystectomy using LEAN BACK technique

Single-port laparoscopic cholecystectomy has been proposed as a minimally invasive surgery with the advantages of better cosmesis and less pain. However, the complicated arrangement of the instruments can cause collisions and makes it difficult to perform cholecystectomy even by senior surgeons. Therefore, we propose a new retraction technique called ‘LEAN BACK technique’, which enables performance to improve the dissection of Calot’s triangle without collision as described (Video S1). Single port is introduced at the abdomen after 20 mm of incision has been carried out under the direct visual control at umbilicus. A 10-mm camera is gently advanced into the abdominal cavity and the gall bladder (GB) is retracted by grasper instrument for inspection of the GB and its infundibulum. By means of close vision of laparoscope, first suture can be performed over the parietal peritoneum of the diaphragm (Fig. 1a). Because the suture is not included in the diaphragm, any bleeding or damage on the diaphragm can be avoided. The end of the thread is clipped to prevent the loosening of the first suture site. The second suture is performed at the fundus of the GB. If the GB is long, suture can be done at the middle of corpus (Fig. 1b). The tension of the thread can be controlled by exposure of the infundibulum (Fig. 1c). Thread is fixed by the clip and the view of Calot’s triangle is achieved as the view that would have been made by grasper instrument (Fig. 1d). One articulating grasp instrument retracts the GB; one hook cautery progressively dissects the Calot’s triangle. This allows for common and standard dissection of the GB. After the cystic duct and arteries are dissected and skeletonized by articulating dissector instrument, they are clipped and then divided. Once cystic duct and artery have been freed, fibrous adhesion between the GB and the liver is taken down by the hook cautery. Finally, the GB is freed from its bed.

Long-term oncologic outcomes of robotic gastrectomy for gastric cancer compared with laparoscopic gastrectomy.

8 Background: Although robotic gastrectomy (RG) showed satisfactory early postoperative outcomes, the oncologic safety of RG for gastric cancer remains a concern. We aimed to evaluate the oncologic safety of RG by comparing its long term outcomes with that of laparoscopic gastrectomy (LG). Methods: From July 2005 to December 2009, we performed 313 RGs and 524 LGs to the patients with gastric cancer. We retrospectively analyzed the patients’ characteristics, operative outcomes, overall survival (OS) and relapse-free survival (RFS), then compared between RG and LG groups using a prospectively maintained database. Results: With a median follow-up of 46 (1-80) months, there was no difference in the OS (log-rank p=0.625) nor in the RFS (p=0.761) between the two groups. When we compared the two groups stage by stage, the OS and RFS also did not differ significantly. Postoperative recurrence was observed in 17 patients (5.4%) in RG and 18 (3.4%) in LG, which showed no significant difference (p=0.745). The patter...

Successful cholecystectomy during robotic gastrectomy.

Abstract Background: Surgeons have successfully combined various laparoscopic procedures with increasing technical ease. However, few reports exist regarding the feasibility of combined robotic operations. We present our institutions successful concomitant robotic surgery for early gastric cancer and coexisting gallbladder disease. Material and methods: From our prospectively collected database, seven patients who received robotic cholecystectomies during their robotic gastric cancer operations were retrospectively compared to 247 patients who underwent robotic gastrectomies alone. Preoperative patient characteristics, operative factors, postoperative length of stay, and complications were evaluated. Results: The preoperative patient characteristics and operative factors did not differ between the two groups. All robotic cholecystectomies were performed with the same ports and instruments used during robotic gastrectomies without open conversion, robot redocking or patient repositioning. Mean time to perform robotic cholecystectomies was 15.1 + 3.2 minutes. The combined group had no mortality, one wound infection, and one intraabdominal fluid collection at the gastric resection bed, which were comparable to the gastrectomy alone group. The mean postoperative length of hospital stay was unaltered by the addition of the cholecystectomy. Conclusions: Robotic cholecystectomies can safely and efficiently be combined with robotic gastric cancer surgery, yielding several benefits. Improving robotic technology and experience may allow surgeons to efficiently combine more complicated procedures.