PURPOSE: This study evaluated the functional and oncological outcomes of proximal gastrectomy (PG) in comparison with total gastrectomy (TG) for upper-third early gastric cancer (EGC). MATERIALS AND METHODS: The medical records of upper-third EGC patients who had undergone PG (n=192) or TG (n=157) were reviewed. The PG group was further subdivided into patients who had undergone conventional open PG (cPG; n=157) or modified laparoscopy-assisted PG (mLAPG; n=35). Patients who had undergone mLAPG had a longer portion of their intra-abdominal esophagus preserved than patients who had undergone cPG. Surgical morbidity, recurrence, long-term nutritional status, and the incidence of reflux esophagitis were compared between the groups. RESULTS: The rate of postoperative complications was significantly lower for PG than TG (16.7% vs. 31.2%), but the five-year overall survival rate was comparable between the two groups (99.3% vs. 96.3%). Postoperative levels of hemoglobin and albumin were significantly higher for patients who had undergone PG. However, the incidence of reflux esophagitis was higher for PG than for TG (37.4% vs. 3.7%; P<0.001). mLAPG was related to a lower incidence of reflux esophagitis after PG (P<0.001). CONCLUSIONS: Compared to TG, PG showed an advantage in terms of postoperative morbidity and nutrition, and there was a comparable prognosis between the two procedures. Preserving the intra-abdominal esophagus may lower the incidence of reflux esophagitis associated with PG.
Esophagitis, Peptic* ; Esophagus ; Gastrectomy* ; Humans ; Incidence ; Laparoscopy ; Medical Records ; Nutritional Status ; Postoperative Complications ; Prognosis ; Recurrence ; Stomach Neoplasms* ; Survival Rate

Prophylactic para-aortic lymphadenectomy is not recommended in curable advanced gastric cancer. However, there are few reports on therapeutic para-aortic lymphadenectomy after palliative chemotherapy in far advanced gastric cancer. We report three cases of laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy after palliative chemotherapy for the first time in Korea. Three gastric cancer patients with isolated para-aortic lymph node (PAN) metastasis showed partial response to capecitabine-based chemotherapy, and laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy was performed with curative intent. The mean total operation time was 365 minutes (range, 310 to 415 minutes), and the mean estimated blood loss was 158 mL (range, 125 to 200 mL). The mean number of retrieved PAN was 9 (range, 8 to 11), and all pathologic results showed no metastasis of para-aortic region. All patients recovered and were discharged without any significant complications.
Gastrectomy ; Humans ; Korea ; Laparoscopy ; Lymph Node Excision ; Lymph Nodes ; Neoplasm Metastasis ; Stomach Neoplasms

BACKGROUNDS/AIMS: Biliary cystadenoma (BCA) and cystadenocarcinoma (BCCA) are rare cystic hepatic neoplasms. Prior reports concerning the proper surgical treatment and long-term survival are scarce. We report our experience and survival outcome of 30 patients over the last 25 years. METHODS: We retrospectively reviewed the clinicopathologic data of the pathologically confirmed 18 BCA and 12 BCCA patients, who underwent operations from 1983 to 2006, at the Seoul National University Hospital. RESULTS: The patients consisted of 8 men and 22 women with a mean age of 51 years. With abdominal computed tomography scans, 73.3% (n=22) were preoperatively diagnosed as BCA or BCCA, and differentiating BCCA from BCA was accurate in 58.3% patients. R0 resection was achieved in 90% (n=27). The differentiating factors included the presence of mural nodule (4/18 vs. 8/12; p=0.009) and mucinous content (2/9 vs. 8/1; p=0.005), and tumor size tending to be larger in BCCA (11.7 cm vs. 7.9 cm; p=0.067). Overall 5-year and 10-year survival rates of BCCA were 72.9% and 60.9%, respectively. Of patients with BCCA, 4 experienced recurrence. In case of recurrence, patients tended to be younger than 50 years (p=0.061) and the lesions tended to be larger than those without recurrence (p=0.088). CONCLUSIONS: Preoperative differentiations of BCA from simple cyst, and BCCA from BCA are still difficult. Complete removal of the tumor, via major hepatectomy, should be considered, especially in the younger age group with large tumor.
Biliary Tract ; Cystadenocarcinoma ; Cystadenoma ; Female ; Hepatectomy ; Humans ; Liver Neoplasms ; Male ; Mucins ; Recurrence ; Retrospective Studies ; Survival Rate

PURPOSE: The present study was conducted to investigate the low compliance rate of the critical pathway (CP) and whether CP is effective for treatment of gastric cancer in radical gastrectomy. METHODS: The medical records of 631 patients who had undergone radical gastrectomy with D2 lymph node dissection were reviewed. This study compared data from patients in early gastric cancer (EGC) and advanced gastric cancer (AGC) groups, which were further subdivided into general care (non-CP) and CP groups. RESULTS: The mean length of preoperative hospital stays were significantly different between the EGC and AGC patients (P < 0.05). However, there was no difference in the mean length of postoperative hospital stays between non-CP and CP groups among either EGC patients or AGC patients (P > 0.05). The postoperative and total cost of hospitalization was not statistically different between either of the groups (P > 0.05); however, the mean preoperative costs were significantly different (P < 0.05). CONCLUSION: We conclude that use of the CP following gastrectomy is unnecessary. To decrease the length of hospital stay and associated costs, preoperative examination and consultation should be performed before admission.
Compliance ; Critical Pathways ; Gastrectomy ; Hospitalization ; Humans ; Length of Stay ; Lymph Node Excision ; Medical Records ; Stomach Neoplasms

BACKGROUNDS/AIMS: Hepatic resection has only guaranteed long-term survival in patients with colorectal liver metastasis (CRLM) even in the era of effective chemotherapy. The definite role of neoadjuvant chemotherapy (NCT) is to improve outcomes of unresectable CRLMs, but it its role has not been defined for initially resectable CRLMs (IR-CRLMs). METHODS: We reviewed the medical records of 226 patients, who had been diagnosed and treated for IR-CRLM between 2003 and 2008; the patients had the following pathologies: 10% had more than 4 nodules, 11% had tumors larger than 5 cm, and 61% had synchronous CRMLs. Among these patients, 20 patients (Group Y) were treated with NCT, and 206 (Group N) did not receive NCT according to their physician's preference. The median follow-up time was 34.1 months. RESULTS: The initial surgical plans were changed after NCT to further resection in 20% and to limited resection in 10% of 20 patients. Complication rates of Groups Y (30%) were indifferent from Group N (23%) (p=0.233), but intraoperative transfusions were more frequent in Group N (15%) than in Group Y (5%) (p=0.006). There was one case of hospital mortality (0.44%). Disease-free survival rates in Groups Y and N were 23% and 39%, respectively, and patient survival rates were 42% and 66% (p>0.05). By multivariate analysis, old age (> or =60 years), differentiation of primary tumor (poorly/mucinous), resection margin involvement, and no adjuvant chemotherapy were associated with poor patient survival; the number of CRLMs (> or =4) was associated with poor disease-free survival. CONCLUSIONS: NCT had neither a positive impact nor a negative impact on survival, even with intraoperative transfusion, as observed on operative outcomes for patients with IR-CRLM. Further study is required to elucidate the role of NCT for treatment of patient with IR-CRLMs.
Chemotherapy, Adjuvant ; Disease-Free Survival ; Follow-Up Studies ; Hospital Mortality ; Humans ; Liver ; Medical Records ; Multivariate Analysis ; Neoplasm Metastasis ; Survival Rate

In previous decades, pediatric liver transplantation has become a state-of-the-art operation with excellent success and limited mortality. Graft and patient survival have continued to improve as a result of proper selection criteria for both donors and recipients, improvement in medical, surgical and anesthetic management, organ availability, balanced immunosuppression, and early identification and treatment of postoperative complications. Most of all, refinements of the technique has directly related to good outcome. Therefore rapid establishment of surgical knowhow is mandatory. In pediatric liver transplantation, the utilization of split-liver grafts and grafts for living donors has provided more organs for pediatric patients and has had a significant impact on graft and patient survival. This has been one of the brilliant outcomes of surgical evolution. In addition, new surgical technique of minimal invasive live donor surgery has been recently widening the living donor liver transplantation for children. Although the recent outcome has been rapidly improved and the volume of living donor liver transplantation has been larger and larger in Korea, pediatric liver transplantation has been performed in a very limited large volume centers. Therefore, this review focuses on surgical technique in order to share the experiences and to improve the outcome of pediatric liver transplantation.
Child ; Humans ; Immunosuppression ; Korea ; Liver ; Liver Transplantation ; Living Donors ; Patient Selection ; Postoperative Complications ; Tissue Donors ; Transplants

PURPOSE: Insulinoma is a rare disease for which early diagnosis followed by proper surgical management provides a chance for cure. Analyses of clinicopathological features of patients can help optimize the surgical approach in the treatment of insulinoma. METHODS: The records of 13 patients (seven male, six female mean age 44.3 years; age range 17~62 years) who were diagnosed clinically and pathologically with insulinoma and who underwent surgery between March 1997 and April 2007 at the Department of Surgery, Seoul National University Hospital. Hospital in English please were retrospectively examined. RESULTS: All patients had findings compatible with Whipple's triad. Mean fasting blood sugar was 40.5 mg/dl, serum insulin level was 33.5µU/ml, and insulin-to-glucose ratio was 0.6. A prolonged starvation test was performed on six patients. Tumors were localized in 10 patients with a computed tomography (CT) scan and in three patients with CT angiography. Five tumors were located in the pancreas head and uncinate process, five in the body, and four at the body-tail border and tail. Patients underwent resection of tumorby enucleation, distal pancreatectomy, pylorus-preserving pancreaticoduodenectomy, laparoscopic distal pancreatectomy, and duodenum-preserving resection of pancreas head. Four immediate postoperative complications (fluid collection, pancreatic fistula, delayed gastric emptying) occurred. No symptoms or recurrences were apparent during the median 15 month follow-up. CONCLUSION: Insulinoma is difficult to diagnose correctly without a prolonged duration of symptoms. Localization of insulinoma can be aided by a CT scan and/or CT angiography. Less aggressive operative procedures such as simple enucleation might be a sufficient and feasible procedure for curative resection of benign insulinomas.
Adenoma, Islet Cell ; Angiography ; Blood Glucose ; Early Diagnosis ; Fasting ; Female ; Follow-Up Studies ; Head ; Humans ; Insulin ; Insulinoma* ; Male ; Pancreas ; Pancreatectomy ; Pancreatic Fistula ; Pancreaticoduodenectomy ; Postoperative Complications ; Rare Diseases ; Recurrence ; Retrospective Studies ; Seoul ; Starvation ; Surgical Procedures, Operative ; Tail ; Tomography, X-Ray Computed

PURPOSE: The aims of this study were to define the necessity and effectiveness of patient safety education during surgical clerkship to develop competency for managing and preventing medical errors. METHODS: Fifty 3rd-year students participated in the patient safety education program during a 4-week surgical clerkship. The students were divided into 4 groups: control group, pretest-only group, education-only group, and pretest and education group. Students were assessed using short essays and an oral exam for reasoning skills, clinical performance exams for patient education and communication skills, and multisource feedback and direct observation of error reporting for real-world problem-solving skills. The results were analyzed with SPSS 14.0K. The reliability (Cronbach alpha) of the entire assessment was 0.893. RESULTS: There was no difference in scores between early and late clerkship groups. Reasoning skills were improved by the pretest. Reasoning, patient education, and error reporting skills were much more developed by patient safety education. Real-world error identification, reporting, and communication did not change after the 4-week course. CONCLUSIONS: Patient safety education during surgical clerkship is necessary and effective. Error prevention and competency management in the real world should developed.
Clinical Clerkship ; Clinical Competence ; Humans ; Medical Errors ; Patient Education as Topic ; Patient Safety ; Safety Management

PURPOSE: Reactivation of hepatitis B virus (HBV) replication after hepatic resection might be a significant risk factor for prognosis in patients with chronic hepatitis B. The purpose of the present study was to investigate the changing pattern of serum HBV DNA titer after hepatic resection and to assess the incidence of reactivation of HBV replication. METHODS: Among HBV-positive patients who underwent hepatic resection for hepatocellular carcinoma, thirty-six patients with preoperative serum HBV DNA titer > or =3 log(10)copies/mL were enrolled. Serum DNA titers were examined before the operation, on the second and seventh postoperative days, and one month after the operation. RESULTS: The serum DNA titer decreased on the second postoperative day (p=0.078). The DNA level, however, had substantially returned to preoperative values by the seventh postoperative day (p<0.001). For most patients, the postoperative DNA titer reached its zenith on the seventh postoperative day or one month after the operation. The zenith level was higher (by 0.49+/-0.25 log10copies/mL) than preoperative levels although this difference just missed significance (p=0.068). Although postoperative reactivation of HBV replication emerged in 6 patients, only one of those patients developed postoperative hepatitis. Overall, four patients developed postoperative hepatitis and all of them had high postoperative HBV DNA levels (over 6 log(10)copies/mL). CONCLUSION: Although serum HBV DNA titers tended to increase postoperatively, routine antiviral therapy might be unnecessary because of the low incidence of postoperative hepatitis. High postoperative DNA levels, however, might be a risk factor for hepatitis, and postoperative follow-up of serum HBV DNA levels might be necessary in HBV-positive patients with hepatic resection.
Carcinoma, Hepatocellular ; DNA ; DNA Replication ; Follow-Up Studies ; Hepatectomy ; Hepatitis ; Hepatitis B ; Hepatitis B virus ; Hepatitis B, Chronic ; Humans ; Incidence ; Prognosis ; Risk Factors

The European Association for the Study of the Liver (EASL) in 2001 and the American Association for Liver Diseases (AASLD) in 2005 followed the Barcelona - Clinic Liver Cancer (BCLC) staging classification and treatment schedule. Surgical resection can be offered for patients who have a single lesion if they are not cirrhotic or have cirrhosis and still have well-preserved liver function, normal bilirubin and hepatic vein pressure <10 mmHg (level II). But the Japanese Practice Guideline reported by the Japanese Society of Hepatology in 2007 recommended surgical resection for 2 or 3 tumors no more than 3 cm in diameter, even in cases with 4 or more lesions. The differences in practice guidelines between these two areas come from different cultural situations, especially in the availability of transplantation. Our results from hepatic resection in 834 patients with HCC from 1992 to 2004 at Seoul National University Hospital were as follows: 1) After surgical resection, the favorable prognostic group are patients with tumor size less than 10 cm in size without major vessel invasion. 2) Surgical resection is recommended in the favorable group of patients with oligonodular tumors. 3) Surgical resection is not indicated for patients with major vessel tumor invasion or portal hypertension. In the AASLD guidelines, liver transplantation is an effective option for patients with HCC, corresponding to the Milan criteria: solitary <5 cm or up to three nodules <3 cm (level II), and a living donor transplantation can be offered for HCC if the waiting time is long enough to allow tumor progression leading to exclusion from the waiting list (level II). Japanese Practice Guidelines restrict liver transplantation to patients under the age of 65. The role of salvage liver transplantation is still controversial. Early detection and the development of therapeutic agents for metastases by microvascular tumor invasion are important for increasing survival of HCC patients.
Appointments and Schedules ; Asian Continental Ancestry Group ; Bilirubin ; Carcinoma, Hepatocellular ; Fibrosis ; Gastroenterology ; Glycosaminoglycans ; Hepatic Veins ; Humans ; Hypertension, Portal ; Liver ; Liver Diseases ; Liver Neoplasms ; Liver Transplantation ; Living Donors ; Neoplasm Metastasis ; Transplants ; Waiting Lists