Yu-Yin Liu

Clinical Impact of Positive Surgical Margin Status on Gastric Cancer Patients Undergoing Gastrectomy

BackgroundThe clinical impact of positive surgical margin on the overall survival and recurrence pattern for gastric cancer (GC) patients undergoing intension curative resection has not yet been well investigated.Patients and methodsThe clinical features of 1,565 patients with histologically proven GC who underwent intension curative resection from 1994 to 2004 were retrospectively reviewed. Among them, 129 (8.2%) had positive microscopic resection margin. The clinicopathological features and the outcome of 1,436 GC patients undergoing gastrectomy with negative resection margin were used for comparison.ResultsGC patients who underwent gastrectomy with higher T, N stage, and tumor size larger than 5xa0cm tended to have positive resection margin when compared with those with negative margin. Median follow-up duration for the 1,565 GC patients who underwent intension curative resection was 28.6xa0months. The overall survival (OS) rate significantly decreased when the patients had positive resection margin, irrespective of different stages. When GC patients underwent gastrectomy with positive resection margin, positive nodal metastasis determined the worst OS. Distant metastasis was the most common site of recurrence, followed by peritoneal and locoregional recurrence.ConclusionsAggressive tumor biology might be the main factor contributing to positive microscopic resection margin after gastrectomy. Positive resection margin had a definite unfavorable impact on the OS of gastric cancer patients undergoing gastrectomy. When GC patients underwent gastrectomy with positive resection margin, positive nodal metastasis determined the worst OS, and distant metastasis was the most common site of recurrence.

Thoracoscopic-assisted management of postpneumonic empyema in children refractory to medical response

AbstractsBackground: Empyema frequently complicates the hospitalization of children; and in advanced stages, it often requires surgical intervention. In this study, we investigated the use of video-assisted thoracic surgery (VATS) for the management of postpneumonic empyema in children who have had an unsatisfactory medical response. Methods: We did a retrospective review of the medical records of 51 consecutive patients with loculated empyema (mean age, 5 years; range, 2 months to 15 years) hospitalized at Chang Gung Memorial Hospital between 1995 and 2000. All patients underwent debridement of the necrotic lung tissue and evacuation of the loculated empyema cavity using a VATS approach. Results: The mean operating time for the 51 patients was 90 min (range, 50–210); mean blood loss was 70 cc. Fever subsided within 72 h postoperatively in all patients. On average, chest tubing was removed on the 7th postoperative day (range, 4–18 days). However, in one patient who suffered from a prolonged air leak, the chest tube was not removed until day 18. The mean postoperative stay for all patients was 13.7 days (range, 9–23). No deaths occurred, and all of the children made a good recovery. A follow-up revealed that one of the 51 children patient suffered a left upper lung abscess 7 months after discharge. Left upper lobectomy was performed in this case, and the patient was discharged uneventfully 10 days after the operation. Conclusions: VATS is a safe and effective treatment for pediatric empyema. Thoracoscopic-assisted surgery facilitates visualization, evacuation, and debridement of the necrotizing lung tissue. Early surgical intervention can avoid lengthy hospitalization and prolonged intravenous antibiotic therapy, and it can accelerate clinical recovery.n

Kinase Mutations and Imatinib Mesylate Response for 64 Taiwanese with Advanced GIST: Preliminary Experience from Chang Gung Memorial Hospital

PurposeMost gastrointestinal stromal tumors (GISTs) express constitutively activated mutation of kit or platelet-derived growth factor receptor alpha (PDGFRA), which are therapeutic targets for imatinib. Results of 64 Taiwanese with advanced GIST treated with imatinib were reported.Method and materialsBetween 2001 and May 2006, a prospective, non-randomized, and a single center trial containing 64 Taiwanese patients with advanced GIST treated with imatinib was conducted. Each tumor was investigated for mutations of kit or PDGFRA.ResultsThe median follow-up time after imatinib administration was 16.1xa0months. 12 patients (18.8%) had complete response (CR), 24 (37.5%) had a partial response (PR), 12 stationary disease (18.8%), 16 progressive disease (25.0%). The 64 Taiwanese with advanced GIST had an estimated median survival of 48.0 months and 4-year survival rate for 76.1%. Kit mutation was found in 49 of 54 (90.7%) test patients and five of them had no mutation (9.3%). No PDGFRA mutant was identified. In 40 patients harboring kit exon 11 mutations, the CR and PR rates (ORR) were 57.5% , nine patients with tumors containing kit exon 9 mutation had ORR rates of 22.2%, and five patients with no mutation had ORR rates of 60.0% (not significant; Pxa0=xa00.149).ConclusionsActivated mutation of kit constituted 90.7% genetic alteration of Taiwanese with advanced GIST and no PDGFRA mutation was detected. Imatinib induced a sustained objective response in more than half of Taiwan advanced GIST patients. ORR did not differ between patients whose GISTs had no mutation, kit exon 9, and 11 mutations.

The role of parenteral glutamine supplement for surgical patient perioperatively: result of a single center, prospective and controlled study

BackgroundWe conducted a prospective and case-controlled study to evaluate the impact of supplement of alanyl-glutamine dipeptide (Gln) in parenteral nutrition on perioperative immune and nutritional changes and clinical outcomes for patients undergoing gastrointestinal (GI) operations.Materials and methodsDuring 2006, 70 patients undergoing GI surgeries were allocated equally into two groups. One group received regular parenteral nutrition and the other received the same formulation and supplemented with the Gln; the two groups were isonitrogenous. The infusion was started from 1xa0day before operation to the sixth day after operation for 7xa0days. Blood samples were collected on the morning of thexa0day before the operation and on the morning 6xa0days after the operation and analyzed for immune and nutrition parameters.ResultsThere were no differences between the two groups in terms of clinical characteristics, operative procedures, biochemistry, nutritional status, and immune status preoperatively. After GI surgery, significant reduction in nutritional and immune parameters were observed in both groups, demonstrated by significant difference of albumin, C-reactive protein (CRP), lymphocyte count, T cell, and CD8 cell. The length of hospital stay is slightly longer in the control group patients, but not to statistical significance (16.3u2009±u200921.3 versus 12.2u2009±u20096.8xa0days, pu2009=u20090.299). In terms of morbidity, there was no difference between the two groups, but two patients in the control group had wound infection; none was noted in the Gln group (pu2009=u20091.0). No surgical mortality was noted in this study.ConclusionsPerioperative parenteral nutrition supplemented with Gln is beneficial for patients undergoing GI surgery. Gln supplementation significantly attenuated postoperative inflammation and ameliorated postoperative immunodepression as well as nutritional depression in GI surgery.

Incidence of incisional recurrence after thoracoscopy

Background: Incisional recurrence after thoracoscopic surgery has been reported infrequently. In recent years, several reports of port-site recurrence after laparoscopic oncologic procedures have been published. This study evaluates the incidence of incisional recurrence among patients with intrathoracic malignancy after diagnostic and therapeutic thoracoscopy. Methods: The medical records of all patients with intrathoracic malignancies who underwent thoracoscopic procedures between 1992 and 1998 at Chang Gung Memorial Hospital Linkou Medical Center were reviewed. Information includes preoperative tumor status, thoracoscopic findings, primary tumor location, tumor pathology, procedures performed, and perioperative complications were recorded. Results: A total of 1,069 patients with known intrathoracic malignancies underwent thoracoscopy. The mean follow-up time was 17.1 months (range, 1–68 months). Two recurrences at the incision were identified (0.19%). Both patients with incision-site recurrence had advanced intrathoracic disease at the time of thoracoscopy. The one patient had a malignant pleural effusion (T4), and the other had diffuse pleural metastasis. Conclusion: The incidence of incisional recurrence after thoracoscopic oncologic surgery is very low. When recurrence occurs at the incision, it is associated most commonly with advanced intrathoracic disease. Additional patients and a longer follow-up evaluation are required, however, to confirm this observation.

Near-infrared cholecysto-cholangiography with indocyanine green may secure cholecystectomy in difficult clinical situations: proof of the concept in a porcine model

BackgroundBiliary injuries remain a major concern in laparoscopic cholecystectomy. New intraoperative guidance modalities, including near-infrared fluorescence cholangiography, are under evaluation. Initial results showed limitations in visualizing the biliary tree in specific clinical situations. The aim of this study was to examine the feasibility and potentiality of fluorescence cholecysto-cholangiography performed with a direct injection of indocyanine green (ICG) in the gallbladder and to compare it to systemic injection in such situations.Materials and methodsSeven pigs were included in this non-survival study. In two pigs, the gallbladder was punctured by a percutaneous needle, and 1xa0mL of ICG in different concentrations (0.001, 0.01, 0.1, and 1xa0mg/mL) was sequentially injected. Visibility and pattern of the fluorescent signal around Calot’s triangle were examined and compared with those of two control pigs receiving 2.5xa0mg of intravenous ICG, 30xa0min prior to the operation. Different scenarios of cholecystitis were modeled using an injection of a mixture of blood and agarose gel around Calot’s triangle area in the remaining three pigs, and the applicability of direct intragallbladder injection methods was evaluated.ResultsThe fluorescent signal was identified immediately after intragallbladder injection, and the cystic duct became visible by 0.1 and 1xa0mg/mL of ICG. The whole cystic duct and the infundibulum of the gallbladder were clearly enhanced by intragallbladder ICG injection, but not by systemic injection. In the cholecystitis models, the cystic duct could be identified only after partial dissection, and fluorescence visualization of the gallbladder infundibulum provided crucial information to find the correct starting point of dissection.ConclusionsFluorescence cholecysto-cholangiography through direct intragallbladder ICG injection could rapidly provide an adequate visualization of gallbladder neck and cystic duct and might be a valid option to increase the safety of cholecystectomy in case of cholecystitis.

Laparoscopic Cholecystectomy for Gallbladder Disease in Patients with Severe Cardiovascular Disease

BackgroundCardiovascular disease (CVD) and gallstones are reported to be strongly associated because both diseases are frequently part of a metabolic syndrome. Laparoscopic cholecystectomy (LC) has become the standard treatment for gallbladder disease around the world. Cardiovascular disease is considered as an absolute or relative contraindication for LC; however, clinical information regarding the applicability of LC for treating gallbladder disease in CVD patients is lacking. This study aims to assess the suitability of LC for the treatment of gallbladder disease in CVD patients.MethodsThe medical records of 66 patients with severe CVD (including valvular heart disease, ischemic heart disease, and heart failure) and gallbladder disease (CVD-group) who underwent LC between 1966 and 2005 were retrospectively reviewed. Furthermore, these data were compared with the clinical features and outcomes of 8,834 patients with gallbladder disease who underwent LC but did not have severe CVD (NCVD-group).ResultsOf the 8,900 patients with gallbladder disease undergoing LC, the 66 (0.74%) who comprised the CVD-group clearly exhibited advanced age, male predominance, higher blood urea nitrogen (BUN) levels, and a longer duration of hospitalization as compared with the NCVD-group patients. A longer duration of hospitalization and a higher incidence of acute cholecystitis and chronic cholecystitis were identified as independent factors differentiating the CVD-group patients, who had previously undergone open-heart surgery, from the NCVD-group patients who underwent LC. For the CVD-group patients, adjustment of anticoagulant therapy contributed to the longer duration of hospitalization, but postoperative complications did not. Advanced age and male predominance were identified as independent factors differentiating the patients who developed ischemic heart disease that required intervention from the NCVD-group patients undergoing LC. The operative morbidity and mortality rates of LC are likely to be similar when it is used to treat selected patients with severe CVD and gallbladder disease and when it is used to treat patients with gallbladder disease and no CVD.ConclusionsLaparoscopic cholecystectomy is a suitable procedure for treating selected patients with severe CVD and gallbladder disease, and its operative morbidity and mortality rates are similar in these patients and in patients with gallbladder disease alone. Nevertheless, appropriate preoperative preparations and established operative techniques in the hands of an experienced surgeon are mandatory.

Extra-long Montgomery T tube in major airway stenosis

BACKGROUNDnWe evaluated the efficacy and safety of the extra-long Montgomery T tube for the management of major airway obstruction in tertiary care patients in Taiwan.nnnMETHODnEleven patients with major airway stenosis treated with an extra-long Montgomery T tube between April 2004 and December 2006 were retrospectively reviewed. Five patients had tracheostomy stenosis, two had intubation stenosis, one had traumatic stenosis, one had corrosive stenosis, one had laser burn stenosis and one had tubercular stenosis. All patients underwent three-dimensional airway reconstruction and endoscopic evaluation of airway stenosis. After determining the severity and location of airway stenosis, rigid bronchotherapy and Montgomery T tube placement were performed by rigid bronchoscopy.nnnRESULTSnThe overall procedural success rate was 100 per cent. Three (27 per cent) patients were weaned from artificial ventilation, and all patients exhibited improved respiratory and functional status. No major post-operative complications or mortality were observed. At follow up (mean, 21.5 months), the decannulation rate was 27 per cent, and eight (73 per cent) patients had stable T tube ventilation. In four patients, granulation over the end of the T tube was controlled by endoscopic procedures. Three patients with stents above the vocal folds showed aspiration and required further intervention (i.e. one nasogastric feeding tube for nutrient supplement, one feeding jejunostomy and one stent shortening to decrease aspiration).nnnCONCLUSIONnThe extra-long Montgomery T tube is an effective and safe method for treating major airway obstruction in the supra-glottic to lower tracheal region.

What we see is not what we get in catamenial haemoptysis

Catamenial haemoptysis is rare entity, a part of thoracic endometriosis syndrome. We present a young woman who was timely diagnosed, successfully treated using video‐assisted thoracoscopic surgery and pathologically confirmed the case. The change in lung parenchyma over time in the computed tomography is highlighted.

Superselective intra-arterial hepatic injection of indocyanine green (ICG) for fluorescence image-guided segmental positive staining: experimental proof of the concept.

BackgroundIntraoperative liver segmentation can be obtained by means of percutaneous intra-portal injection of a fluorophore and illumination with a near-infrared light source. However, the percutaneous approach is challenging in the minimally invasive setting. We aimed to evaluate the feasibility of fluorescence liver segmentation by superselective intra-hepatic arterial injection of indocyanine green (ICG).Materials and methods Eight pigs (mean weight: 26.01xa0±xa05.21xa0kg) were involved. Procedures were performed in a hybrid experimental operative suite equipped with the Artis Zeego®, multiaxis robotic angiography system. A pneumoperitoneum was established and four laparoscopic ports were introduced. The celiac trunk was catheterized, and a microcatheter was advanced into different segmental hepatic artery branches. A near-infrared laparoscope (D-Light P, Karl Storz) was used to detect the fluorescent signal. To assess the correspondence between arterial-based fluorescence demarcation and liver volume, metallic markers were placed along the fluorescent border, followed by a 3D CT-scanning, after injecting intra-arterial radiological contrast (nxa0=xa03). To assess the correspondence between arterial and portal supplies, percutaneous intra-portal angiography and intra-arterial angiography were performed simultaneously (nxa0=xa01).ResultsBright fluorescence signal enhancing the demarcation of target segments was obtained from 0.1xa0mg/mL, in matter of seconds. Correspondence between the volume of hepatic segments and arterial territories was confirmed by CT angiography. Higher background fluorescence noise was found after positive staining by intra-portal ICG injection, due to parenchymal accumulation and porto-systemic shunting.ConclusionsIntra-hepatic arterial ICG injection, rapidly highlights hepatic target segment borders, with a better signal-to-background ratio as compared to portal vein injection, in the experimental setting.