Woong Bae Ji

Laparoscopic Hernia Sac Transection and Intracorporeal Ligation Show Very Low Recurrence Rate in Pediatric Inguinal Hernia

BACKGROUND There are many variable techniques for laparoscopic inguinal hernia repair in children. The aim of this study was to examine the feasibility of the laparoscopic hernia technique, which is based on the same surgical principles as conventional open herniotomy. SUBJECTS AND METHODS Between November 2008 and August 2011, 207 pediatric patients with inguinal hernia were included in this study under informed consent. All of the patients underwent the laparoscopic technique of sac transection and intracorporeal ligation. An asymptomatic contralateral patent processus vaginalis (cPPV) was repaired using the same method. Patients were routinely followed for 2 years. Perioperative complications and recurrence rate were evaluated. RESULTS In total, 202 patients were enrolled in the final analysis. The mean follow-up period was 12.5 months. The percentage of patients with cPPV was 39.2%. The mean operation time was 26 minutes for unilateral hernias and 34 minutes for bilateral hernias. One patient had a mild hematoma in the inguinal area in the immediate postoperative period, but it resolved spontaneously within 7 days. Recurrence and metachronous hernias have not been observed thus far. CONCLUSIONS Laparoscopic hernia sac transection and intracorporeal ligation can be a safe and effective alternative for conventional herniotomy.

Analysis of the occupational stress of Korean surgeons: a pilot study

Purpose Surgeons serve one of the most challenging and stressful professions. Ineffective control of occupational stress leads to burnout of the surgeon. The aim of this study was to obtain preliminary data on the sources and the degree of stress of surgeons and to determine the feasibility of the survey. Methods A total of 63 surgeons in our three affiliated hospitals were enrolled in this study. Fifty-five questions were used to assess the demographics, characteristics and Korean occupational stress scale (KOSS), which were prepared and validated by the National Study for Development and Standardization of Occupational Stress. Results Forty-seven of the 63 surgeons participated in this study (74.6%). The mean KOSS score of the survey was 50.9 ± 8.55, which was significantly higher than that of other professions (P < 0.01). Drinking and smoking habits were not related to the KOSS score. Doing exercise was related to a low KOSS score in terms of low KOSS total score (P < 0.01). Average duty hours (P < 0.01) and night duty days per week (P = 0.01) were strongly related to higher KOSS in the linear regression analysis. Conclusion This is the first study to evaluate job stress of surgeons in Korea. This study showed that Korean Surgeons had higher occupational stress than other Korean professions. A larger study based on this pilot study will help generate objective data for occupational stress of Korean Surgeons by performing a survey of the members of the Korean Surgical Society.

Risk factors causing structural sequelae after anastomotic leakage in mid to low rectal cancer

AIM To investigate the risk factors causing structural sequelae after anastomotic leakage in patients with mid to low rectal cancer. METHODS Prospectively collected data of consecutive subjects who had anastomotic leakage after surgical resection for rectal cancer from March 2006 to May 2013 at Korea University Anam Hospital were retrospectively analyzed. Two subgroup analyses were performed. The patients were initially divided into the sequelae (stricture, fistula, or sinus) and no sequelae groups and then divided into the permanent stoma (PS) and no PS groups. Univariate and multivariate analyses were performed to identify the risk factors of structural sequelae after anastomotic leakage. RESULTS Structural sequelae after anastomotic leakage were identified in 29 patients (39.7%). Multivariate analysis revealed that diversion ileostomy at the first operation increases the risk of structural sequelae [odds ratio (OR) = 6.741; P = 0.017]. Fourteen patients (17.7%) had permanent stoma during the follow-up period (median, 37 mo). Multivariate analysis showed that the tumor level from the dentate line was associated with the risk of permanent stoma (OR = 0.751; P = 0.045). CONCLUSION Diversion ileostomy at the first operation increased the risk of structural sequelae of the anastomosis, while lower tumor location was associated with the risk of permanent stoma in the management of anastomotic leakage.

Effect of a Shortened Duration of FOLFOX Chemotherapy on the Survival rate of Patients with Stage II and III colon Cancer

Background: FOLFOX chemotherapy is widely used as an adjuvant treatment for advanced colon cancer. The duration of adjuvant chemotherapy is usually set to 6 months, which is based on a former study of 5-fluorouracil/leucovorin chemotherapy. However, the FOLFOX regimen is known to have complications, such as peripheral neuropathy. The aim of this study was to compare the survival rates and complications experienced by patients receiving either 4 or 6 months of FOLFOX chemotherapy. Methods: Retrospective data analysis was performed for stage II and III patients who underwent radical resection of colon cancer. We compared the 5-year survival rates and the occurrence of complications in patients who completed only 8 cycles of FOLFOX chemotherapy with patients who completed 12 cycles of chemotherapy. Results: Among 188 patients who underwent adjuvant FOLFOX chemotherapy for stage II or III colon cancer, 83 (44.1%) completed 6 months of FOLFOX chemotherapy and 64 (34.0%) patients discontinued after 4 months of chemotherapy. The 5-year overall survival and disease-free survival rates did not show a significant difference. Patients in the 6-month group had peripheral neuropathy more frequently (p = 0.028). Conclusions: Five-year overall and disease-free survival were not significantly different between the 2 groups. Large-scale prospective studies are necessary for the analysis of complications and survival rates.

Effects of splanchnic vasoconstrictors on liver regeneration and survival after 90% rat hepatectomy

Purpose Posthepatectomy liver failure is a serious complication and considered to be caused by increased portal pressure and flow. Splanchnic vasoactive agents and propranolol are known to decrease portal pressure. The aim of this study was to identify optimal candidates with potential for clinical use among somatostatin, terlipressin, and propranolol using rats with 90% hepatectomy. Methods Rats were divided into 5 groups: sham operation (n = 6), control (n = 20), propranolol (n = 20), somatostatin (n = 20), and terlipressin group (n = 20). Seven-day survival rates and portal pressure change were measured, and biochemical, histologic, and molecular analyses were performed. Results Portal pressure was significantly decreased in all 3 treatment groups compared to control. All treatment groups showed a tendency of decreased liver injury markers, and somatostatin showed the most prominent effect at 24 hours postoperatively. Histologic liver injury at 24 hours was significantly decreased in propranolol and terlipressin groups (P = 0.016, respectively) and somatostatin group showed borderline significance (P = 0.056). Hepatocyte proliferation was significantly increased after 24 hours in all treatment groups. Median survival was significantly increased in terlipressin group compared to control group (P < 0.01). Conclusion Terlipressin is considered as the best candidate, while somatostatin has good potential for clinical use, considering their effects on portal pressure and subsequent decrease in liver injury and increase in liver regeneration.

Surgical excision for non-familial hypertrophic Darier's disease

A 22-year-old man was admitted to the hospital with a chief complaint of skin lesions on his hands, feet and anus, which he first noticed 3 years ago while he was serving in the military. The lesions worsened when exposed to sunlight and high temperatures. After discharge from military service, he was diagnosed with condyloma accuminatum at the local clinic and received medical treatment, including an ointment and oral medicine. The anal lesion had been growing, so he visited our hospital. There were no other family members who had similar skin lesions. On physical examination, a papillary lesion with hypertrophy was found at the perianal area and skin pigmentation was found on the face, hands and feet. A biopsy was performed from the skin of perianal lesion; thereby, hypertrophic Darier’s disease was pathologically confirmed (Fig. 1). Then, he received oral administration of isotretinoin, but the anal lesion persisted. A wide excision, including the dermal layer, and reconstruction with a rotational flap were performed (Fig. 2). The perianal papillary lesion was located 2 cm from the anus and its largest diameter was approximately 15 cm. Skin excision included all involved skin lesion with a margin of about 1 cm and was performed deeply enough to remove full skin layer. There was no involvement of anocutaneous junction by the skin lesion, but the suture line was very close to it with only 1 cm distance from the junction. Rotational flap was made with additional skin incision laterally and moved close to the skin defect adjacent to the anus. On the 16th post-operative day, because partial skin necrosis with continuous exudative wound discharge was observed, skin repair and split-thickness skin grafting of the skin defect (size, about 3 cm) were performed. He was discharged from the hospital 22 days after the first operation, without any complications and with normal anal function. Darier’s disease (dyskeratosis follicularis) is a rare autosomal dominant disease characterized by keratotic papules and plaques in the seborrheic areas. It is known to be caused by an ATP2A2 mutation at chromosome 12q. Burge et al. reported in their study that 46 of 163 patients had no familial history of Darier’s disease. Medical treatments with, for example, oral retinoids and topical steroids can be effective, but flexural disease can be resistant to such treatment agents. Surgical management of hypertrophic Darier’s disease, especially when involving the perianal area, should be performed with caution regarding the risk of infectious complications that can potentially affect anal function. References

Endoscopic Obstruction in Rectal Cancers: Survival and Recurrence Patterns Following Curative Surgery

BACKGROUND It is controversial whether preoperative obstruction in rectal cancers can affect prognosis or influence recurrence patterns. We investigated the association between endoscopic obstruction with survival and recurrence patterns in patients with locally advanced rectal cancers. MATERIALS AND METHODS An observational study and multivariate analysis were conducted to identify determinants of survival and to compare recurrence patterns between patients with obstructive or nonobstructive tumors after curative resection. Endoscopic obstruction was defined as a luminal obstruction of the rectum severe enough to prevent the colonoscope from passing beyond the tumor. RESULTS Cancer was obstructive in 91 patients (16.8%) and nonobstructive in 452 (83.2%). Median follow-up was 50 (range, 3-161) months. Local recurrence occurred in 17 patients (14 nonobstructed [5.4%] and 3obstructed [5.5%]; P=1.0) and systemic recurrence in 83 (62 nonobstructed [23.8%] and 21 obstructed [38.2%]; P=.042]). Endoscopic obstruction was a significant prognostic factor in stage III rectal cancers (P=.001) but not in stage II tumors. The multivariate analysis showed that endoscopic obstruction was an independent prognostic factor for overall survival, but not for disease-free survival, in patients with stage III rectal cancers. Endoscopic obstruction was associated with multiple-site systemic recurrence that was unsalvageable (salvageable surgery, 24 nonobstructed [40%] and 2 obstructed [10%]; P=.014). CONCLUSIONS Endoscopic obstruction in patients with stage III rectal cancer predicted worse overall survival and was associated with multiple-site systemic recurrence.