Sung Hoon Choi

Intraoperative tumor localization using laparoscopic ultrasonography in laparoscopic–assisted gastrectomy

BackgroundDuring laparoscopic-assisted gastrectomy, it is impossible to identify early gastric cancer (EGC) lesions; therefore, a precise localization technique is needed. In this study, we used laparoscopic ultrasonography (LUS) after endoscopic clipping as a method of localizing EGC and evaluated the effectiveness of this method.MethodsA prospective study of 17 patients who had undergone laparoscopic—assisted gastrectomy was performed. Three endoscopic clips were applied just proximal to the tumor during the preoperative endoscopy. The applied clips were detected from the serosal side of the stomach using LUS. The serosal surface of the lesion was marked with dye.ResultsIn all patients, endoscopic clips were applied proximal to the lesion without complications, and the applied clips were confirmed by plain abdominal radiography. The clips were successfully detected by LUS in all patients. In the resected specimen, the serosal surface, marked with dye, was always just above the clips in the anterior wall or on the anterior wall opposite the clips applied in the posterior wall. The mean detection time was 4.7 min (range, 2–8). With this procedure, two patients underwent total gastrectomy and 15 patients underwent distal subtotal gastrectomy with gastroduodenostomy or gastrojejunostomy. Histological examination confirmed that the resection margins were tumor free in all patients. There was no operative morbidity related to the LUS procedure.ConclusionsUsing LUS to detect endoscopic clips is an easy, safe, and accurate method to localize EGC lesions in laparoscopic-assisted gastrectomy.

Robot-assisted spleen-preserving distal pancreatectomy: a single surgeon’s experiences and proposal of clinical application

BackgroundAdvanced and delicate laparoscopic techniques are usually required for safe and successful laparoscopic spleen-preserving distal pancreatectomy. The unique characteristics of robotic surgical system are thought to be useful for this minimally invasive procedure.MethodsFrom September 2007 to May 2011, patients who underwent robot-assisted, spleen-preserving, distal pancreatectomy for benign and borderline malignant tumors of the pancreas were retrospectively reviewed. Perioperative clinicopathologic surgical outcomes were evaluated.ResultsTwenty-two patients were attempted for robot-assisted, spleen-preserving, distal pancreatectomy, and in 21 patients (95.5xa0%), the spleen was saved either by splenic vessels conservation (SVC; nxa0=xa017, 81xa0%) or by splenic vessels sacrifice (SVS; nxa0=xa04, 19xa0%). Seven patients were male and 15 were female with a mean age of 43.2xa0±xa015.2xa0years. Pathologic diagnosis included MCT in five patients, SCT in five, SPT in four, IPMT in three, NET in three, and other benign conditions in two. The mean operation time was 398.9xa0±xa0166.3xa0min, but it gradually decreased as experiences were accumulated (Rsqxa0=xa00.223, pxa0=xa00.023). Intraoperative blood loss was 361.3xa0±xa0360.1xa0ml, and intraoperative transfusion was required in four patients (18.1xa0%). A soft diet was given for 1.2xa0±xa00.4xa0days, and the length of hospital stay was 7.0xa0±xa02.4xa0days postoperatively. Clinically relevant pancreatic fistula was noted in two patients (9.1xa0%) but was successfully managed conservatively. Most patients (87.5xa0%) showed patency in conserved both splenic vessels, and only two patients (12.5xa0%) had partially or completely obliterated in splenic veins in the SVC-SpDP group. Partially impaired splenic perfusion was observed in one patient in the SVS-SpDP group. The perfusion defect area decreased without any clinical symptom after 4xa0months.ConclusionsThe robotic surgical system is thought to be beneficial for improving the spleen-preservation rate in laparoscopic distal pancreatectomy. Robot-assisted approach can be chosen for patients who require spleen-preserving distal pancreatectomy.

Minimally invasive RAMPS in well-selected left-sided pancreatic cancer within Yonsei criteria: long-term (>median 3 years) oncologic outcomes.

AbstractBackgroundAlthough minimally ninvasive techniques for distal pancreatectomy with or without splenectomy have been regarded as a feasible and safe treatment option for benign and borderline malignant lesions of the pancreas, the management of left-sided pancreatic cancer remains controversial.MethodsFrom June 2007 to November 2010, 12 patients underwent laparoscopic or robotic radical antegrade modular pancreatosplenectomy (RAMPS) for well-selected left-sided pancreatic cancer. The Yonsei criteria for patient selection included the following conditions: (1) tumor confined to the pancreas, (2) intact fascial layer between the distal pancreas and the left adrenal gland and kidney, and (3) tumor located more than 1–2xa0cm from the celiac axis. We compared the clinicopathologic factors and oncologic outcomes of the minimally invasive surgery (MIS) and the conventional open surgery groups for treating left-sided pancreatic cancer.ResultsIn the MIS group, the mean tumor size was 2.75xa0±xa01.32xa0cm, and the mean number of retrieved lymph nodes was 10.5xa0±xa07.14. The resection margins were confirmed to be negative for malignancy in all patients. The MIS group and open group (nxa0=xa078) were statistically different in terms of tumor size (2.8xa0±xa01.3 vs. 3.5xa0±xa01.9xa0cm, pxa0=xa00.05) and length of hospital stay (12.3xa0±xa06.8 vs. 22.4xa0±xa021.6xa0days, pxa0=xa00.002). On survival analysis, the MIS group had longer disease-free survival (DFS) and overall survival (OS) than the open group (DFS: 47.6 vs. 24.7xa0months, pxa0=xa00.027; OS: 60.0 vs. 30.7xa0months, pxa0=xa00.046). In order to overcome the heterogeneity of subjects between the MIS and the open group, we performed statically matched comparisons using the propensity score analysis and then divided the open group into two subgroups according to the Yonsei criteria. There were no significant differences in median overall survival between the MIS group and the open group that met the Yonsei criteria (60.00 vs. 60.72xa0months, pxa0=xa00.616).ConclusionsMinimally invasive RAMPS is not only technically feasible but also oncologically safe in cases of well-selected left-sided pancreatic cancer. Our selection criteria for minimally invasive RAMPS needs to be further validated based on additional large-volume studies.

Morphometric evaluation of oesophageal wall in patients with nutcracker oesophagus and ineffective oesophageal motility

Abstractu2002 The pathogenesis of nutcracker oesophagus (NE) and ineffective oesophageal motility (IEM) is unclear. Damage to the enteric nervous system or smooth muscle can cause oesophageal dysmotility. We tested the hypothesis that NE and IEM are associated with abnormal muscular or neural constituents of the oesophageal wall. Oesophageal manometry was performed in patients prior to total gastrectomy for gastric cancer. The oesophageal manometries were categorized as normal (nu2003=u20037), NE (nu2003=u200313), or IEM (nu2003=u20035). Histologic examination of oesophageal tissue obtained during surgery was performed after haematoxylin and eosin (H&E) and trichrome staining. Oesophageal innervation was examined after immunostaining for protein gene product‐9.5 (PGP‐9.5), choline acetyltransferase (ChAT) and neuronal nitric oxide synthase (nNOS). There were no significant differences in inner circular smooth muscle thickness or degree of fibrosis among the three groups. Severe muscle fibre loss was found in four of five patients with IEM. The density of PGP‐9.5‐reactive neural structures was not different among the three groups. The density of ChAT immunostaining in the myenteric plexus (MP) was significantly greater in patients with NE (Pu2003<u20030.05) and the density of nNOS immunostaining in the circular muscle (CM) was significantly greater in IEM patients (Pu2003<u20030.05). The ChAT/nNOS ratio in both MP and CM was significantly greater in NE patients. NE may result from an imbalance between the excitatory and inhibitory innervation of the oesophagus, because more than normal numbers of ChAT‐positive myenteric neurones are seen in NE. Myopathy and/or increased number of nNOS neurones may contribute to the hypocontractile motor activity of IEM.

Is it worthwhile to preserve adult spleen in laparoscopic distal pancreatectomy? Perioperative and patient-reported outcome analysis.

BackgroundDespite the emphasis on its role, the spleen has commonly been removed in distal pancreatectomy. We designed this study to evaluate the efficacy of spleen salvage during laparoscopic distal pancreatectomy for patients with benign and borderline malignant tumors.Materials and methodsFrom February 2005 to December 2010, 40 patients underwent spleen-preserving laparoscopic distal pancreatectomy (Sp-Lap DP) and 32 patients underwent laparoscopic distal pancreatosplenectomy (Lap DPS). Medical records were retrospectively reviewed, and a specially designed questionnaire was administered to the patients for the follow-up study.ResultsThe demographics and final diagnoses were similar between the two groups. The operative time was significantly longer in the Sp-Lap DP group (303.9xa0±xa0136.0 versus 239.0xa0±xa094.9xa0min, pxa0=xa00.024). Patients in the Lap DPS group had more postoperative pancreatic fistulas of higher grade (pxa0=xa00.026). A higher grade of postoperative complications occurred more frequently in the Lap DPS group (pxa0=xa00.003). Consequently, postoperative hospital stay was significantly shorter for Sp-Lap DP than for Lap DPS patients (7.1xa0±xa02.3 versus 12.5xa0±xa010.8xa0days, pxa0=xa00.004). On the follow-up survey, episodes of common cold or flu were apparently more frequent in the Lap DPS group (pxa0=xa00.026). Despite the similar recovery period between the two groups, significantly more patients who underwent Lap DPS felt fatigue (pxa0=xa00.014) and poorer health condition (pxa0=xa00.042).ConclusionsIn addition to frequent higher-grade complications and prolonged hospital stays, Lap DPS appeared to impair patient quality of life based on follow-up survey. Even an effort to preserve adult spleen in distal pancreatectomy is worthwhile.

Predicting recurrence of pancreatic solid pseudopapillary tumors after surgical resection: a multicenter analysis in Korea.

Background:Solid pseudopapillary tumors (SPTs) of the pancreas are still considered a surgical enigma. Many clinical research trials have failed to identify prognostic factors that predict the malignant behavior of SPTs. Materials and Methods:This work was a retrospective multicenter study that included a total of 17 medical institutions. Data from 351 patients who underwent surgical resection from January 1990 to December 2008 were retrospectively collected using standardized case report forms requesting clinicopathologic features. Results:Thirty-four patients (9.7%) were male, and 317 (90.3%) were female, with a mean age of 36.8 ± 12.4 years. Recently, minimally invasive (P < 0.001) and parenchyma or function-preserving limited surgeries (P = 0.016) have been more frequently applied for the treatment of pancreatic SPTs. Ninety-eight patients (27.9%) had microscopic malignant features. Only 9 patients (2.6%) experienced tumor recurrence after the initial pancreatic SPT resection. Multivariate analysis showed that a tumor size larger than 8 cm [Exp (&bgr;) = 7.385, P = 0.018], microscopic malignant features [Exp (&bgr;) = 10.009, P = 0.011], and stage IV [Exp (&bgr;) = 42.003, P = 0.002] were significant prognostic factors for tumor recurrence. When combined with stage IV, the microscopic malignant features and 2010 World Health Organization definition of solid pseudopapillary carcinoma more successfully differentiated future recurrence risk groups (P < 0.001). Conclusions:More specific pathologic descriptions need to be employed in pathologic report forms to provide proper information to predict SPT recurrence after resection. Future studies emphasizing the standardized pathologic evaluation of pancreatic SPTs may unveil the enigmatic nature of pancreatic SPTs.

Laparoscopic modified anterior RAMPS in well-selected left-sided pancreatic cancer: technical feasibility and interim results

BackgroundLaparoscopic distal pancreatectomy with splenectomy is regarded as a safe and effective treatment for benign and borderline malignant pancreatic lesions [1, 2]. However, its application for left-sided pancreatic cancer is still debatable [3, 4]. No general consensus, no standardized technique, and no surgical indication exist in applying the laparoscopic approach to left-sided pancreatic cancer.MethodsAccording to our institutional experiences of treating left-sided pancreatic cancer, bloodless and margin-negative resection was found to be important. Bloodless and margin-negative laparoscopic distal pancreatosplenectomy would be technically possible in suspicious pancreatic cancers with these tentative conditions: (1) pancreas-confined suspicious pancreatic cancer on preoperative image study (cT2), (2) intact fascia layer between the pancreas and left adrenal gland/left kidney, and (3) tumor more than 1 cm from the celiac axis. A 59-year-old female patient was found to have suspicious left-sided pancreatic cancer. Therefore, we performed laparoscopic anterior radical antegrade modular pancreatosplenectomy (RAMPS) [5, 6] with a curative intent based on selection criteria.ResultsThe margin-negative (resectional and tangential) curative resection could be obtained by applying laparoscopic anterior RAMPS in well-selected left-sided pancreatic cancer. The operation time was 180 min and estimated blood loss was 100 ml. The diagnosis from pathology was that the tumor was ductal adenocarcinoma of the pancreas (pT3) with lymph node metastasis (pN1, 2 of 23 lymph nodes). The patient went home on the 7th postoperative day. Adjuvant chemotherapy began within 2 weeks after surgery. From June 2007 to August 2010, nine patients underwent minimally invasive (5 laparoscopic and 4 robot-assisted) anterior RAMPS based on the selection criteria. The perioperative outcomes and short-term oncologic results are summarized.ConclusionLaparoscopic modified anterior RAMPS is thought to be technically feasible for curative resection in well-selected pancreatic cancer. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. More careful study is necessary.

Pylorus- and spleen-preserving total pancreatoduodenectomy with resection of both whole splenic vessels: feasibility and laparoscopic application to intraductal papillary mucin-producing tumors of the pancreas

BackgroundTotal pancreatectomy is recommended for intraductal papillary mucinous tumors with widespread involvement of the entire pancreas. Organ-preserving and minimally invasive surgery should be applied in benign and borderline pancreatic lesions.MethodsPylorus- and spleen-preserving total pancreatoduodenectomy (PpSpTPD) with segmental resection of both splenic vessels was attempted for five patients. The technique was based on the concepts of two surgical procedures: pylorus-preserving pancreatoduodenectomy and distal pancreatectomy with segmental resection of splenic vessels (“extended” Warshaw’s procedure).ResultsThree patients underwent laparoscopic-assisted PpSpTPD and two underwent open surgery. No mortality was noted. Short-term follow-up (median, 28xa0months) suggested that all patients tolerated the insulin therapy and showed relatively good nutritional status. Only minimal to moderate perigastric fundal varices were noted without gastrointestinal bleeding.ConclusionsPpSpTPD with segmental resection of both splenic vessels is feasible and safe. Even a minimally invasive approach can be indicated in selected patients.

Robotic anterior RAMPS in well-selected left-sided pancreatic cancer.

A relatively pancreas-confined tumor with an intact fascia layer between the pancreas and left adrenal gland/kidney is thought to be a potential indication for a minimally invasive approach in treating left-sided pancreatic cancer. Usually four or five trocars are needed for conventional laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) and the surgeon is able to perform all procedures aided by two assistants who help with camera control and counter traction. However, five ports are required for the robotic approach: one for the robotic camera, three for the working robotic arms, and one for the assistant surgeon for vessel clipping, suction, and endo-linear stapling. Four patients with pancreatic cancer were selected for robotic RAMPS. Four robotic arms were used while the patient was in a supine position with the patients head and left side elevated. Pancreatic dissection was performed from right to left after division of the pancreatic neck portion. Lymph nodes around the common hepatic artery and celiac axis were dissected during this procedure. Clinicopathologic characteristics and perioperative surgical outcomes, including interim oncologic outcomes, were analyzed.

Splenic vein thrombosis and pancreatic fistula after minimally invasive distal pancreatectomy

This study aimed to investigate the clinical relevance of splenic vein thrombosis (SVT) in the splenic vein remnant following minimally invasive distal pancreatosplenectomy (DPS).