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Metabolic surgery can promote integrated physiologic improvement to ameliorate metabolic illness, particularly type 2 diabetes. Nevertheless, the therapeutic scope has been limited by unexpectedly inconsistent surgical outcomes. Therefore, the purpose of this study is to overcome the obstacles by determining the core mechanism of conflicting results. The surgical anatomy, clinical course, and outcomes of various metabolic surgeries, including modified types of duodenal-jejunal bypass procedures, were compared to comprehend specific surgical patterns from distinctive perspectives. Patients in exclusively nonobese groups are subjected to avoid compounding by weight fluctuations. During intestinal anastomosis, the epithelial identity of the succeeding intestine is replaced by that of the proximal epithelium through altered crosstalk between the epithelium and opposing mesenchymal cells. The rapid turnover rate and compensatory proliferation of the succeeding intestine accelerate the propagation of the replaced epithelium. Propagation of replaced epithelium could provoke inconsistent outcomes of metabolic surgery. The major determinants of the conflicting results of metabolic surgery are inadequate duodenal exclusion and inappropriate length of the biliopancreatic limbs. The replaced enteroendocrine cells during regeneration provoke inconsistent outcomes of metabolic surgery. The critical factors are the type and density of enteroendocrine cells distributed at the terminal end of the preceding proximal intestine.

The most plausible contributing factor to non-obese type 2 diabetes may be imbalanced incretin release from the intestinal epithelium in response to nutrients. Rerouting intestinal continuity through bypass surgery to modulate incretin release is therefore a reasonable treatment. We believe that a major determinant of metabolic outcomes is entire duodenal exclusion without leaving any duodenal epithelium and exclusion of sufficient length of jejunum. More importantly, the procedure should be implemented with safety and without sequelae. To achieve this, we invented a novel procedure with acceptable surgical safety and excellent and durable metabolic outcomes. Post-surgical intestinal adaptation should be considered to achieve successful outcomes.

Summary Background CT radiation is arguably carcinogenic. Results from single-centre studies, mostly retrospective, have advocated lowering the CT radiation dose for the diagnosis of appendicitis. However, adoption of low-dose CT has been slow. We aimed to assess the effectiveness of low-dose CT compared with standard-dose CT in the diagnosis of appendicitis in adolescents and young adults. Methods We did this pragmatic, multicentre, randomi s ed controlled non-inferiority trial at 20 South Korean teaching hospitals with little experience with low-dose CT. Patients aged 15–44 years with suspected appendicitis were randomly assigned (1:1), via computer-generated random assignments (permuted block sizes of two, four, six, and eight) concealed in sequentially numbered envelopes, to receive low-dose CT (2 mSv) or standard-dose CT (≤8 mSv). Randomisation was stratified by site. Group allocation was concealed from patients, outcome assessors, and adverse event adjudicators; care providers, site pathologists, and data collectors were aware of allocation. The primary endpoint was the negative (unnecessary) appendectomy rate among all appendectomies, with a non-interiority margin of 4·5% for low-dose versus standard-dose CT. Primary analy s is was by modified intention to treat, which included all patients who received an appendectomy in the group to which they were assigned. This trial is registered with ClinicalTrials.gov, number NCT01925014. Findings Between Dec 4, 2013, and Aug 18, 2016, we assigned 1535 patients to the low-dose CT group and 1539 patients to the standard-dose CT group. 22 (3·9%) of 559 patients had a negative appendectomy in the low-dose group versus 16 (2·7%) of 601 patients in the standard-dose group (difference 1·3%, 95% CI −0·8 to 3·3; p=0·0022 for the non-inferiority test). We recorded 43 adverse events in 43 (2·8%) of 1535 patients in the low-dose group and 41 adverse events in 40 (2·6%) of 1539 patients in the standard-dose group. One life-threatening adverse event of anaphylaxis caused by an iodinated contrast material occurred in the low-dose group. Interpretation Radiation dose of appendiceal CT for adolescents and young adults can be reduced to 2 mSv without impairing clinical outcomes. In view of the vast number of appendiceal CT examinations done worldwide, use of low-dose CT could prevent a sizeable number of radiation-associated cancers in the future. Funding Korea Health Industry Development Institute, Seoul National University Bundang Hospital, Dasol Life Science, and Bracco Imaging Korea.

Purpose: Despite acceptance of laparoscopic totally extraperitoneal (TEP) repair for repair of inguinal hernia, it is still considered to require a prolonged learning curve. We hypothesized that there would be differences in the learning curve for laparoscopic TEP repair among beginner surgeons with or without a supervisor. The current study was conducted to observe the learning curve for laparoscopic TEP repair performed by a surgeon without a supervisor. Methods: A retrospective analysis of the consecutive 143 patients was conducted to document patients’ demographics, hernia types, operative time, and operative outcomes after the operation. Patients were divided into 7 consecutive groups, each comprising 20 patients. Results: The mean age of the study population was 52.5 years (± 18.9 SD), ranging from 16 to 89 years. The learning curve of this technique was almost horizontal throughout the time course. The mean operative time was quite stable among each group. Comparison of the mean operation time and the length of hospital stay among each group did not show significant differences. There was one recurrence in group V. Conclusion: The learning curve for laparoscopic TEP repair is not that prolonged if there is an experienced specialized supervisor and opportunities to observe the entire procedure performed by the supervisor are available. It is not the laparoscopic instrument skills but the way the procedure is performed that is important for successful outcomes.

Purpose: Despite advancements in surgery, laparoscopic totally extraperitoneal (TEP) repair for inguinal hernia in patients with previous lower abdominal surgeries has been a burden to surgeons. This study was conducted in order to assess the feasibility of laparoscopic intraperitoneal onlay m esh (IPOM) hernia repair as an alternative method for these cases. Methods: From May 2006 to November 2010, 48 IPOM repairs were performed in 43 patients. All medical records were reviewed retrospectively. Results: Mean age of patients was 61 years old and male to female ratio was 37:6. Five were direct and 43 were indirect hernias. There were 15 recurrent inguinal hernias after either open or laparoscopic hernia repair, and five of 15 were recurrent cases more than two times. Mean operative time was 44.5 minutes, and mean postoperative hospital stay was 1.41 days. There were two cases of postoperative swelling at the groin area and two patients complained of pain that required oral pain-killers during out-patient follow-ups. Recurrence developed in one case. Conclusion: Even though laparoscopic IPOM repair is not a preferred m ethod for inguinal hernia, it can be applied as an alternative method in specific cases involving difficulties in approaching the usual plane of repair.

Surgery is the most effective treatment of morbid obesity and leads to dramatic improvements in type 2 diabetes mellitus (T2DM). Gastrointestinal metabolic surgery has been proposed as a treatment option for T2DM. However, a grading system to categorize and predict the outcome of metabolic surgery is lacking. The study setting was a tertiary referral hospital (Taoyuan City, Taoyuan County, Taiwan).We first evaluated 63 patients and identified 4 factors that predicted the success of T2DM remission after bariatric surgery in this cohort: body mass index, C-peptide level, T2DM duration, and patient age. We used these variables to construct the Diabetes Surgery Score, a multidimensional 10-point scale along which greater scores indicate a better chance of T2DM remission. We then validated the index in a prospective collected cohort of 176 patients, using remission of T2DM at 1 year after surgery as the outcome variable.A total of 48 T2DM remissions occurred among the 63 patients and 115 remissions (65.3%) in the validation cohort. Patients with T2DM remission after surgery had a greater Diabetes Surgery Score than those without (8 ± 4 versus 4 ± 4, P.05). Patients with a greater Diabetes Surgery Score also had a greater rate of success with T2DM remission (from 33% at score 0 to 100% at score 10); A 1-point increase in the Diabetes Surgery Score translated to an absolute 6.7% in the success rate.The Diabetes Surgery Score is a simple multidimensional grading system that can predict the success of T2DM treatment using bariatric surgery among patients with inadequately controlled T2DM.

This study aims to identify whether reinforcing the staple line during laparoscopic sleeve gastrectomy (LSG) has advantages. We searched MEDLINE (PubMed; till August 2011), EMBASE (till August 2011), and the Cochrane Central Register of Controlled Trials (Central) in the Cochrane Library (till August 2011) using common keywords related to sleeve gastrectomy and reinforcement. The keywords were as follows: “sleeve gastrectomy” and “reinforcement,” or “reinforcing,” or “reinforce,” or “leak,” or “leakage,” or “staple,” or “stapling,” or “oversew,” or “oversewing,” or “oversewed.” The language of publication was limited to English only. Of the 358 articles meeting our initial criteria, eight full texts (two randomized control trial [RCT] and six cohort studies), involving 1,345 participants (828 patient cases and 517 controls) were included in the final analysis. Comparing the reinforcement of the staple line to no reinforcement of the staple line, the odds ratio (OR) for overall complications was 0.521 (95 % confidence intervals [CI], 0.349–0.777). In addition, the OR for staple line leak was 0.425 (95 % CI, 0.226–0.799) and for staple line hemorrhage was 0.559 (95 % CI, 0.247–1.266). The current study showed that reinforcing the staple line during LSG has the following advantages: decreased incidence of postoperative leak and overall complications. More prospective studies with better evidence are needed.

BACKGROUND Laparoscopic totally extraperitoneal (TEP) repair has been accepted as a popular procedure for inguinal hernia repair, but surgeons still encounter technical difficulties owing to unfamiliar pelvic anatomy and limited working space. We sought to estimate the learning curve for laparoscopic TEP repair without supervision. METHODS We retrospectively analyzed the medical records of patients scheduled for laparoscopic TEP repair of an inguinal hernia from December 2000 to October 2007. RESULTS We reviewed medical records for 700 patients. The cases were divided into 8 groups: 20 patients each in groups I-V and 200 patients each in groups VI-VIII. No significant difference in demographic characteristics was identified among the groups. The mean duration of surgery significantly decreased (p < 0.001) in relation to experience; it reached a plateau of less than 30 minutes (mean 28 min) after 60 cases. The mean length of stay in hospital was 0.97 days, reaching a plateau after 20 cases. Six patients were converted to other techniques: 1 patient each in groups III and VIII and 4 patients in group VII. Three recurrences were detected; however, 2 were excluded because the patient had bilateral inguinal hernias. CONCLUSION We estimate the learning curve for laparoscopic TEP repair is 60 cases for a beginner surgeon. The presence of an experienced supervisor during the first 60 cases can help prevent unnecessary complications and shorten the duration of surgery.

Purpose: To compare the outcomes between laparoscopic total extraperitoneal (TEP) repair and prolene hernia system (PHS) repair for inguinal hernia. Methods: A retrospective analysis of 237 patients scheduled for laparoscopic TEP or PHS repair of groin hernia from 2005 to 2009 was performed. Results: The mean age was 52.3 years in TEP group and 55.7 years in PHS group. Of 119 TEP cases, 98 were indirect inguinal hernia, 15 direct type, 5 femoral hernia and 1 complex hernia; Of 118 PHS cases, 100 indirect, 18 direct type. All in TEP group were performed under general anesthesia and 64% of PHS group were performed under spinal or epidural anesthesia. Preoperatively, 10 cases of recurrent inguinal hernia were involved in our study (4 in TEP, 6 in PHS group). The mean operative time was similar in both groups (74.8 in TEP, 71.2 in PHS group), however mean hospital stay (1.6 days in TEP, 3.2 days in PHS group, P = 0.018) and mean usage of analgesics (0.54 times in TEP, 2.03 times in PHS group, P ＜ 0.01), complications (36 cases in TEP, 6 cases in PHS group, P ＜ 0.01) showed statistical differences. There is only 1 case of postoperative recurrence inguinal hernia in PHS group but it has no statistical significance (P = 0.314). Conclusion: Compared to PHS repair, laparoscopic TEP repair has some advantages; shorter hospital stay, less frequent need of analgesics; as well as more postoperative complications such as hematoma, seroma, scrotal swelling.

Purpose: The necessity of nasogastric decompression after abdominal surgical procedures has been increasingly questioned for several years. Traditionally, nasogastric decompression is a mandatory procedure after classical pancreaticoduodenectomy (PD); however, we still do not know whether or not it is necessary for PD. The present study was designed to assess the clinical benefit of nasogastric decompression after PD. Methods: Between July 2004 and May 2007, 41 consecutive patients who underwent PD were enrolled in this study. Eighteen patients were enrolled in the nasogastric tube (NGT) group and 23 patients were enrolled in the no NGT group. Results: There were no differences in the demographics, pathology, co-morbid medical conditions, and pre-operative laboratory values between the two groups. In addition, the passage of flatus (P = 0.963) and starting time of oral intake (P = 0.951) were similar in both groups. In the NGT group, 61% of the patients complained of discomfort related to the NGT. Pleural effusions were frequent in the NGT group (P = 0.037); however, other post-operative complications, such as wound dehiscence and anastomotic leakage, occurred similarly in both groups. There was one case of NGT re-insertion in the NGT group. Conclusion: Routine nasogastric decompression in patients undergoing PD is not mandatory because it has no clinical advantages and increases patient discomfort.

Complete reduction of an indirect inguinal hernia sac during laparoscopic totally extraperitoneal (TEP) repair is not always possible when the sac extends to the scrotum or adheres to adjacent tissues. Laparoscopic TEP repair would be much easier to perform in such cases by transecting the hernia sac. Therefore, the purpose of this study was to determine the safety and efficacy of transection of the hernia sac during laparoscopic TEP.Five hundred twenty laparoscopic TEP repairs were performed on 498 patients by a single surgeon from July 2003 to December 2008. The patients were classified into two groups: the transected sac (TS) group with 269 patients (275 cases) and the completely reduced sac (RS) group with 230 patients (245 cases).Statistical analysis between the TS and RS groups showed no significant differences in postoperative pain, length of hospital stay, and recurrence, except for postoperative seromas, which were more frequent in the TS group (24 of 275) than the RS group (6 of 245; P = .002). And the mean operative time was longer in the TS group (23.62 ± 10.25 minutes) than the RS group (21.49 ± 8.17 minutes; P = .010).Although transection of the hernia sac during laparoscopic TEP repair may cause seromas, our study demonstrated that transection of the hernia sac did not cause significant postoperative complications, including recurrence. Transection of the hernia sac is an alternative technique for laparoscopic TEP repair in cases with difficult hernia sac reduction.

Type 2 diabetes mellitus (T2DM) has become an epidemic health problem worldwide. Compared to Western countries, in Asia, T2DM occurs in patients with a lower body mass index (BMI) due to central obesity and decreased pancreatic β-cell function. The efficacy of laparoscopic mini-gastric bypass (LMGB) in obese patients with T2DM has been proven by numerous studies. Treatment outcomes of LMGB for non-obese T2DM patients are also estimated to be excellent. The aim of the present pilot study was to evaluate the efficacy and safety of LMBG in non-obese T2DM patients (BMI 25-30 kg/m(2)).Ten consecutive patients underwent LMGB at our hospital from August 2009 to October 2009. Preoperative data including glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), and 2 h postprandial glucose (2-h PPG) were compared with data collected at 1, 3, and 6 postoperative months.All procedures were completed laparoscopically. Mean age of the patients was 46.9 years, mean BMI was 27.2 kg/m(2), mean operative time was 150.5 min, and mean postoperative hospital stay was 5.3 days. Neither mortality nor major complications occurred. Mean preoperative glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), 2-h PPG, and C-peptide level were 9.7%, 222 mg/dl, 343 mg/dl, and 2.78 ng/ml, respectively. At the sixth postoperative month, HbA1c, FPG, 2-h PPG, and C-peptide level measured 6.7%, 144 mg/dl, 203 mg/dl, and 2.18 ng/ml.This preliminary study demonstrated the resolution of hyperglycemia in 70% of non-obese T2DM patients (BMI 25-30 kg/m(2)). Although long-term follow-up data are required, early operative outcomes were satisfactory in terms of glycemic control and safety of the procedure.

Successful treatment requires reliable preoperative assessment of the highly variable extension of intraductal papillary mucinous neoplasms (IPMNs). We aimed to determine the role of intraductal ultrasonography (IDUS) in predicting the extension of IPMN, and in selecting the method of pancreatic resection and the long-term outcome after surgery.Randomized prospective study. Forty consecutive patients who underwent IPMN resection were included in the study. Patients were randomly assigned to an IDUS group or control group, in which IDUS was not performed.Preoperative assessment by IDUS had an 85% (17 of 20) diagnostic accuracy for tumor extension of IPMN compared with 50% (10 of 20) in cases assessed by other imaging methods without IDUS (P=0.018). In 9 of 15 patients with invasive carcinoma, the tumor was located in the pancreatic head, and 11 had a main duct-type tumor. Recurrent disease was identified in 5 of 15 (33%) patients with invasive IPMN at a mean follow-up of 50 months; of them, 1 underwent preoperative IDUS and 4 were assessed by other imaging methods. None of the 25 patients with noninvasive IPMN had recurrent disease at follow-up. The overall cumulative 3-year survival rate was 79%.Preoperative IDUS was useful in determining the type of surgery and the extent of resection, especially in main-duct IPMN.

Background: Cancer stem cells are a small population of tumor cells capable of self-renewal that give rise to all the components of a heterogenous tumor. Recently, this concept has been extended into various solid tumor after the first documentation in acute myeloid leukemia. CD133 and CD 24 were identified as cancer stem cell markers in other solid tumors such as breast cancer, brain cancer, pancreatic cancer and head and neck cancer. The aim of this study was to examine the expression CD133 and CD24 in gastric cancers. Furthermore, their clinical significance was evaluated. Methods: Immunohistochemistry for CD133 and CD24 was performed on the tissue microarray of 388 gastric cancers. We retrospectively analysed the prognostic factors depending on the expression of CD133 and CD24. Results: In gastric cancers, 251 of the 381 cases (66%) tested were positive for CD133 expression and 122 of the 386 cases (32%) tested were positive for CD24 expression. CD133 expression was more present in well differentiated cancer (p=0.003). However other prognostic factors were not related with CD 133 & CD24 expression The survival rate according to CD133 & CD24 expression was not significant. Conclusions: We can figure out the potential presence of cancer stem cells in gastric cancers through confirming the positive expression of CD133 & CD24. However CD expressions didn°Ot show close relationship with prognostic factors and survival rate of gastric cancer.

Purpose: Although the TNM stage is the most important prognostic factor for gastric cancer, there is a need for new prognostic factors, because the prognosis varies among patients of the same stage. The aim of this study was to clarify the prognostic significance of E-cadherin, -catenin, c-erb B2, and p53 in patients with gastric cancers. Materials and Methods: Loss of membranous expression of E-cadherin & -catenin, abnormal c-erb B2 membranous expression, and overexpression of p53 were investigated immunohistochemically using 96 cases of paraffin embedded tissue of gastric car- cinomas at Soonchunhyang University in 2002. These were correlated with the clinicopathological parameters such as age, depth of invasion, lymph node metastasis, histology, Lauren classification, and survival were analyzed retrospectively. There were 61 males and 35 females (1.7:1) with a mean age of 57.5 years (range:36~73 years). Results: The percentage of abnormal expression of E-cadherin, -catenin, c-erbB-2, and p53 were 76/96 (79.2%), 62/96 (64.6%), 48/96 (50%), and 45/96 (46.9%), respectively. Abnormal expression of E-cadherin occurred more frequently in serosa-invasive than serosa-noninvasive groups (p occured regardless of the stage. Abnormal expression of -catenin, c-erb B2, and p53 were not related with clnicopathological para- meters. The prognosis was associated with lymph node metastasis (p=0.0087) and serosa invasion (p=0.0277) in an univariate analy- sis. Lymph node metastasis is an independent prognostic factor in patients with gastric cancers(p=0.0047). Conclusion: Although this study was performed with small number of cases and shortage of the follow-up time, E-cadherin showed the possibility as one of prognostic factors in gastric cancer.

Mun Gyu Kim, Si Young Ok, Sang Ho Kim, Se Jin Lee, Sun Young Park, Eun Hyo Koh, Heon Yong Bae, Kyung Yul Hur Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine; Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine; Department of General Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea

To assess the changes in diabetic retinopathy (DR) in Type 2 diabetes (T2DM) patients after bariatric surgery.Consecutive 20 patients with T2DM who underwent bariatric surgery and were followed for at least 12 months were enrolled. The case history was reviewed retrospectively, and laboratory data were assessed at baseline and every 3 months postoperatively. Two retinal specialists evaluated the severity of DR with dilated fundus examination preoperatively and postoperatively. Factors associated with DR progression were assessed.During the follow-up period, 2 of 12 patients without DR and 2 of 3 patients with mild nonproliferative DR before surgery developed moderate nonproliferative DR. All five patients with moderate nonproliferative DR or worse preoperatively had progression requiring intervention. Preexisting DR (P = 0.005) and albuminuria (P = 0.01) were identified as associated with DR progression. Six patients (30%) entered remission of T2DM, but remission of T2DM could not halt the DR progression.Diabetic retinopathy progression can occur in patients with or without before DR after bariatric surgery, regardless of remission of T2DM. All patients with T2DM should be examined regularly by an ophthalmologist postoperatively, and more carefully patients with previous DR or albuminuria.

Laparoscopic mini-gastric bypass surgery is a safe and simple surgical intervention for treating morbid obesity and diabetes mellitus and is now being performed more frequently. Radiologists must be critical in their postoperative evaluation of these patients. In this pictorial review, we explain and illustrate the surgical technique, normal postoperative anatomy, and associated complications as seen on imaging examinations, including fluoroscopy and computed tomography.

Bariatric surgery is an efficient procedure for remission of type 2 diabetes (T2DM) in morbid obesity. However, in Asian countries, mean body mass index (BMI) of T2DM patients is about 25 kg/m2. Various data on patients undergoing gastric bypass surgery showed that control of T2DM after surgery occurs rapidly and somewhat independent to weight loss. We hypothesized that in non-obese patients with T2DM, the glycemic control would be achieved as a consequence of gastric bypass surgery. From September 2009, the 172 patients have had laparoscopic single anastomosis gastric bypass (LSAGB) surgery. Among them, 107 patients have been followed up more than 1 year. We analyzed the dataset of these patients. Values related to diabetes were measured before and 1, 2, and 3 years after the surgery. The mean BMI decreased during the first year after the surgery but plateaued after that. The mean glycosylated hemoglobin level decreased continuously. The mean fasting and postglucose loading plasma glucose level also decreased. After LSAGB surgery in non-obese T2DM patients, the control of T2DM was possible safely and effectively. However, longer follow-up with matched control group is essential.

Many studies have reported that laparoscopic total extraperitoneal (TEP) repair for recurrent inguinal hernia after an open hernioplasty was safe and effective. This study was conducted to evaluate TEP repair for recurrent inguinal hernia through a retrospective analysis of our data.We performed a retrospective analysis of the medical records of patients who were scheduled for laparoscopic TEP repair from December 2000 to December 2008. A total of 1065 cases of laparoscopic TEP repairs were performed for 944 patients by a single surgeon, and 100 cases of recurrent inguinal hernias were enrolled.The mean operation time was longer in the recurrent hernia group than that in the primary hernia group (P0.001), and peritoneal tearing occurred more frequently in the recurrent hernia group (P0.001). Direct hernia was more frequent in the recurrent hernia group (P0.001). The mean number of hospital days and complications, such as seroma and postoperative pain, were similar in both groups. Three cases of recurrence occurred (0.28%): 2 occurred in the recurrent hernia group (2%) and the other occurred in the primary hernia group (0.1%).Laparoscopic TEP repair is safe and effective for treating recurrent inguinal hernia after an open hernioplasty, because the recurrence rate was low (2%) and other complications were similar for both groups. Direct inguinal hernia was more frequent in patients who had recurrent inguinal hernia.

Background: Palliative treatment including stenting is limited in patients with Klatskin tumor. Argon plasma coagulation (APC) is a new local treatment modality for the devitalization and debulking of tumors. Argon plasma coagulation could be a candidate method for relief of biliary strictures in patients with non-resectable Klatskin tumor in whom biliary stenting has failed. This study provides an evaluation of the technical feasibility, safety, and effect of APC as a palliative strategy in patients with non-resectable Klatskin tumor. Methods: In vitro studies were performed in order to investigate the dimension of coagulation necrosis in 11 human gallbladders. The currents were applied in normal air conditions and a bowl filled with normal saline in five and six specimens, respectively. Argon plasma coagulation was also performed on three patients with Klatskin tumor who showed no effective drainage via percutaneous transhepatic approach with a cholangioscope. Results: A coagulation current was delivered to the specimen even if in normal saline. The maximum depth and diameter of necrosis was 3 and 6.5 mm under normal air conditions, compared with 2 and 5 mm in water conditions. No perforation of the gallbladder wall occurred in any of the lesions. The dimension of the necrosis increased with increasing impact time and energy settings. Argon plasma coagulation application was possible on tumors of patients without severe complication. Conclusion: Argon plasma coagulation seems to be applicable, effective and relatively safe in palliative treatment for advanced non-resectable Klatskin tumor via cholangioscopy. Longer follow ups and comparative trials with other treatment modalities are, however, required.

The first gastric bypass surgery was performed by Mason and Ito in 1966. They divided stomach horizontally and created a loop gastroenterostomy between proximal gastric pouch and jejunum. However, the proximal gastric pouch in this procedure was high up in the abdomen, close to the gastroesophageal junction. This caused bile reflux and led to esophagitis. In addition, the high location of anastomosis also led to technical difficulties. Also, the transverse pouch led to dilation of fundus and failure of effective weight loss.

Background The advantages of laparoscopic hernia repair on reducing postoperative pain and an earlier return to normal activities with similar recurrence rate have been confirmed by various studies. The objective of this study was to assess the effectiveness of laparoscopic totally extraperitoneal repair. Methods Patients who underwent laparoscopic inguinal hernia repair between December 2000 and December 2010 were enrolled retrospectively. Patient demographics, operative and postoperative course, and outpatient follow-ups were studied. Results Of the 1371 cases in 1178 patients, 1328 cases (96.8%) were laparoscopic totally extraperitoneal repair and 43 cases (3.2%) represented other laparoscopic procedures--intraperitoneal onlay mesh or transabdominal preperitoneal techniques. There was only 1 conversion from a laparoscopic procedure to open surgery. The number of recurrent hernias was 129 (11.0%). Most of the recurrent hernias were secondary to open hernia repair. The mean operative time was 26 ± 18 minutes for unilateral hernias and 39 ± 29 minutes for bilateral hernias. The incidence of intraoperative complications was 3.8%. The overall postoperative morbidity rate was 15.3%, mainly representing seroma and pain. The recurrence rate was 0.5%. Conclusions If performed by experienced laparoscopic surgeons, laparoscopic totally extraperitoneal repair is an excellent mode of hernia repair for most types of inguinal hernias.

Since laparoscopic liver resection was first introduced in 2001, Korean surgeons have chosen a laparoscopic procedure as one of the treatment options for benign or malignant liver disease. We distributed and analyzed a nationwide questionnaire to members of the Korean Laparoscopic Liver Surgery Study Group (KLLSG) in order to evaluate the current status of laparoscopic liver resection in Korea. Questionnaires were sent to 24 centers of KLLSG. The questionnaire consisted of operative procedure, histological diagnosis of liver lesions, indications for resection, causes of conversion to open surgery, and postoperative outcomes. A laparoscopic liver resection was performed in 416 patients from 2001 to 2008. Of 416 patients, 59.6% had malignant tumors, and 40.4% had benign diseases. A total laparoscopic approach was performed in 88.7%. Anatomical laparoscopic liver resection was more commonly performed than non-anatomical resection (59.9% vs 40.1%). The anatomical laparoscopic liver resection procedures consisted of a left lateral sectionectomy (29.3%), left hemihepatectomy (19.2%), right hemihepatectomy (6%), right posterior sectionectomy (4.3%), central bisectionectomy (0.5%), and caudate lobectomy (0.5%). Laparoscopy-related serious complications occurred in 12 (2.8%) patients. The present study findings provide data in terms of indication, type and method of liver resection, and current status of laparoscopic liver resection in Korea.

This study evaluated the outcomes of laparoscopic totally extraperitoneal (TEP) simultaneous bilateral hernia repair with regard to the effectiveness and the complications compared with those of unilateral laparoscopic TEP hernia repair.One hundred twelve patients underwent laparoscopic TEP for bilateral inguinal hernia and 767 patients underwent laparoscopic TEP for a unilateral hernia from March 2004 to January 2010.The mean age of the patients was older in bilateral group than that in the unilateral group, and the proportion of female patients was lower in the bilateral group. The distribution of the types of hernia was different in both the groups (P0.001). The mean operation time and the mean patient cost for TEP in the bilateral group were 1.5 times longer and more expensive than that in the unilateral group. However, there were no differences in the mean number of hospital days and postoperative complications. There was 1 recurrence in the bilateral group, but it had no statistical significance (P=0.127).Laparoscopic TEP repair is safe and feasible for treating bilateral inguinal hernia. Bilateral repair also has some advantages such as no additional admission, a decreased operation time, and cost-effectiveness.

Gastrointestinal metabolic surgery has been proposed for the treatment of not well-controlled type 2 diabetes mellitus (T2DM) patients with a body mass index (BMI)35 kg/m(2). This study aims to describe recent experience with surgical treatment of T2DM in Asian centers.Patients aged 20 to 70 years with not well-controlled T2DM [glycated hemoglobin (HbA1C)7.0%] and BMI 35 kg/m(2) were included at five institutes between 2007 and 2010. The end point is T2DM remission, defined by fasting plasma glucose110 mg/dl and HbA1C6.0%.Of the 200 patients, 172 (86%) underwent gastric bypass, 24 (12%) underwent sleeve gastrectomy, and the other 4 underwent adjustable banding. Laparoscopic access was used in all the patients. Gender (66.5% female), age (mean 45.0 ± 10.8), and HbA1C (mean 9.3 ± 1.9%) did not differ between the procedure among the groups. Until now, 87 patients had 1-year data. One year after surgery, the mean BMI decreased from 28.5 ± 3.0 to 23.4 ± 2.3 kg/m(2) and HbA1C decreased to 6.3 ± 0.5%. Remission of T2DM was achieved in 72.4% of the patients. Patients with a diabetes duration of5 years had a better diabetes remission rate than patients with duration of diabetes5 years (90.3% vs. 57.1%; p = 0.006). Patients with BMI 30 kg/m(2) had a better diabetes remission rate than those with BMI 30 kg/m(2) (78.7% vs. 62.5%; p = 0.027). Individuals who underwent gastric bypass loss more weight and had a higher diabetes remission rate than individuals who underwent restrictive-type procedures. Multivariate analysis confirmed that the duration of diabetes and the type of surgery predict the diabetes remission. No mortalities were reported and two (1.0%) patients had major morbidities.Gastrointestinal metabolic surgery is an effective treatment for not well-controlled T2DM treatment. Diabetes remission is significantly higher in those with duration of diabetes less than 5 years and BMI 30 kg/m(2).

It is often difficult to assess the clinical significance of scrotal or operative site swelling after a laparoscopic total extraperitoneal (TEP) repair of an inguinal hernia. Specifically, surgeons are often faced with the dilemma of determining whether such a swelling is a recurrent hernia or just a swelling only.A total of 1,065 laparoscopic TEP inguinal hernia repairs were performed on 944 patients by a single surgeon between December 2000 and December 2008, and we reviewed these data.The overall incidence of swelling formation was 6.5% (70 of 1,065 cases). Swellings were more frequent in males, and in association with the following diagnoses: indirect inguinal hernias, larger hernia defects, scrotal hernias, omental incarcerations, and the presence of residual distal sacs. Fifty-eight (83%) of 70 patients who had swelling after laparoscopic TEP did not need any intervention for swelling and the swelling resolved spontaneously.Although postoperative swellings are a common complication after laparoscopic TEP repairs of inguinal hernias, swellings are minor complications, are not associated with hernia recurrence, and generally subside spontaneously.

Mesh fixation is essential in laparoscopic total extraperitoneal (TEP) repair of inguinal hernia; however, fixation sometimes causes post-operative pain. This study investigated a novel method of laparoscopic TEP repair without mesh fixation.This study reviewed data from about two-hundred and forty-one laparoscopic TEP repairs on 219 patients, which were performed between December 2004 and October 2005.There were no statistically significant differences in the recurrence rate, seroma formation, and hospital stay. However, the mean operation time was shorter in the internal plug mesh group than the fixation group (p = 0.009), and post-operative pain only occurred in 4 cases in the internal plug mesh group in comparison to 29 cases in the mesh fixation group (p = 0.014).An internal plug mesh without fixation might reduce post-operative pain after laparoscopic TEP repair of an inguinal hernia. Internal plug mesh without fixation may be an alternative method in laparoscopic TEP repair, especially for those involving indirect hernias.

and safe procedure that adds useful information to imaging techniques and may help to avoid surgery in patients with diffuse metastatic disease. Elastography is useful in the differential diagnosis of submucosal lesions and adds important information about tissue elasticity. We recommend that physicians keep in mind the possibility of gastric metastasis in patients with ovarian carcinoma and a gastric mass. In such cases, elastography can be added to EUS to guide the diagnosis, and EUS-FNA is mandatory for the cytological diagnosis.

Despite the development of surgical techniques, postoperative pancreatic fistula is still one of the main causes of serious morbidity after pancreaticoduodenectomy. Nevertheless numerous studies have been done, studies on preventing pancreatic fistula are lacking. This study is focused on the effectiveness of negative pressure external drainage for pancreaticojejunostomy in pancreaticoduodenectomy patients.Seventy-six patients were scheduled for pancreaticoduodenectomy at Soonchunhyang University Hospital from January of 2003 to August of 2007. Negative suction drainage group (n = 41) and no negative suction drainage group (n = 35) were compared by patient characteristics, parameters related to operation, and complications.There were no statistical differences between both groups in patient demographics and parameters related to operation. The complication rates were significantly lower in negative suction drainage group in terms of postoperative bleeding (P = 0.012), choledochojejunostomy leak (P = 0.014), and pancreatic fistula (P = 0.018).This retrospective study showed that external stenting with negative pressure suction drainage of the pancreatic duct has significantly reduced the rate of pancreatic fistula in duct-to-mucosa pancreaticojejunostomy with improved surgical outcomes.

A liposarcoma is the most common soft tissue sarcoma in adults with an incidence of about 20% of all soft tissue sarcomas. Although incidence differs from a region of origination, a case arisen from mesentery has rarely been reported. We experienced a case of liposarcoma arising from the mesentery of a 51-year-old male patient. He was treated by wide excision. Histologically, the tumor was composed of a mixed well-differentiated liposarcoma with myxoid and spindle cell type.

AIM: To verify that CD markers are available for detecting cancer stem cell populations and to evaluate their clinical significance in colon cancer. METHODS: Immunohistochemistry for CD133, CD24 and CD44 was performed on the tissue microarray of 523 colorectal adenocarcinomas. Medical records were reviewed and clinicopathological analysis was performed. RESULTS: In colorectal adenocarcinoma, 128 of 523 cases (24.5%) were positive and 395 cases (75.5%) were negative for CD133 expression. Two hundred and sixty-four of 523 cases (50.5%) were positive and 259 cases (49.5%) were negative for CD24 expression. Five hundred and two of 523 cases (96%) were negative and 21 cases (4%) were positive for CD44 expression. Upon clinicopathological analysis, CD133 expression was present more in male patients (P = 0.002) and in advanced T stage cancer (P = 0.024). Correlation between CD24 expression and clinicopathological factors was seen in the degree of differentiation (P = 0.006). Correlation between CD44 expression and clinicopathological factors was seen in the tumor size (P = 0.001). Survival was not significantly related to CD133, CD24 and CD44 expression. CONCLUSION: CD markers were related to invasiveness and differentiation of colorectal adenocarcinoma. However, CD expression was not closely related to survival.

The dramatic increase in the prevalence of obesity and its accompanying comorbidities are major health concerns in Korea. Obesity is defined as a body mass index ≥25 kg/m2 in Korea. Current estimates are that 32.8% of adults are obese: 36.1% of men and 29.7% of women. The prevalence of being overweight and obese in national surveys is increasing steadily. Early detection and the proper management of obesity are urgently needed. Weight loss of 5% to 10% is the standard goal. In obese patients, control of cardiovascular risk factors deserves the same emphasis as weight-loss therapy. Since obesity is multifactorial, proper care of obesity requires a coordinated multidisciplinary treatment team, as a single intervention is unlikely to modify the incidence or natural history of obesity.

The prevalence of obesity worldwide is increasing at an alarming rate. Obesity causes various complications, shorten the life of patients and can degrade the quality of life, so that appropriate treatment is essential. Behavioral modification and supportive therapy, pharmacologic and surgical treatments are available. The number of bariatric surgeries has steadily increased during the past decade as a result of the increasing prevalence of morbid obesity, inconsistent weight loss with nonoperative therapy, and increasing evidence that bariatric procedures result in significant and durable weight loss, improve comorbid conditions. There are some principal points about bariatric surgery: who is the best candidate and which is the most optimal procedure? Also, it is important to assess patients’ operative and nutritional risks and to establish the best model for postoperative care. The authors review thoroughly multiple medical literatures and current practice trends on perioperative evaluation and management of bariatric surgery.

Purpose: We wanted to measure and compare the patient demographics and perioperative outcomes between patients with incarcerated and patients with non-incarcerated inguinal hernia. Methods: We conducted a retrospective analysis of 945 patients who were scheduled for laparoscopic total extraperitoreal (TEP) repair of inguinal hernia from May 2002 to May 2010. There were 66 patients who had incarcerated hernia and 879 patients who had non-incarcerated hernia. Results: The mean age was younger in the incarcerated hernia group than in the non-incarcerated hernia group (41.67 vs. 48.50 years, P ＜ 0.01), and all the incarcerated inguinal hernias patients were male. Most of the incarcerated hernias (63 out of 66 cases, 95%) were indirect hernias. The mean hospital stay showed no difference between the two groups (1.03 vs. 0.93 days, P = 0.142) but the operation time was longer for the incarcerated group than that for the non-incarcerated group (33.36 vs. 24.59 minutes, P ＜ 0.01). Postoperative swelling (including seroma) was more frequent in the incarcerated group (14 out of 66 cases, 21%, P ＜ 0.01), but postoperative pain was similar in both groups (3.0 vs. 8.9%, P = 0.095). There was one recurrence in the non-incarcerated group, but this had no statistical significance. Conclusion: Laparoscopic TEP repair for the patients with chronic incarcerated inguinal hernias was safe and feasible. However, a well-designed study is needed to confirm if it is suitable for acute incarcerated inguinal hernias.

Purpose: Laparoscopic sleeve gastrectomy (LSG) is rapidly gaining ground as one of the surgical procedures in bariatric surgery with emerging long-term follow-up data. The aim of the present study was to report our initial experience of LSG in morbidly obese patients. Methods: Sixty-four consecutive patients underwent LSG from April 2009 to July 2010 at our bariatric surgery center. Patients eligible for LSG were those with a body mass index (BMI) of ＞37 ㎏/㎡, and ＞32 ㎏/㎡ with co-morbidities. LSG was performed using 5 trocars and endo-staplers with guidance of 34 Fr bougie. Perioperative management was standardized. The clinical data were prospectively collected and retrospectively analyzed. Results: Among 64 patients, 19 were male and 45 were female, mean age was 35 years (range 20∼57), mean preoperative BMI was 38.8 ㎏/㎡ (range 32∼57), and mean preoperative body weight was 108 ㎏ (range 75∼164). Mean operative time was 118 minutes (range 65∼340) and mean length of hospital stay was 3.4 days (range 1∼82). Staple line leak occurred in 1 patient, kinking of the gastric tube occurred in 2 patients. There was no open conversion and no postoperative mortality. After 170 days of follow-up, 24.4 ㎏ of body weight loss and 52.7% of excess weight loss (%EWL), on average, was noted. Conclusion: Though long-term follow-up is needed, our early operative outcome was satisfactory in terms of %EWL and safety of the procedure. LSG was a safe and effective treatment strategy for morbidly obese patients.

Purpose: We retrospectively reviewed the medical records to estimate the feasibility and surgical outcome of laparoscopic herniorrhaphies in patients with previous lower abdominal surgery. Methods: Between December 2000 and December 2008, a total of 1,101 cases of laparoscopic herniorrhaphies were performed in 974 patients, among them 47 cases (4.27%) of laparoscopic herniorrhaphy in 40 patients who had undergone previous lower abdominal surgery were enrolled to this study. Results: Most patients (23 of 24) who had a history of appendectomy successfully underwent laparoscopic totally extraperitoneal (TEP) repair. Six patients who had history of a prostatectomy and 2 patients with a Pfannenstiel incision underwent an intraperitoneal only mesh (IPOM) repair after a failed TEP repair. Five patients had lower midline incisions due to panperitonitis, among them TEP repairs were performed in 3 patients and IPOM was performed after failed TEP repairs in 2 patients who had undergone surgery due to trauma-induced rupture of the bladder. Conclusion: Laparoscopic TEP hernia repair could be possible and reasonable in patients after an appendectomy; however, it is difficult in patients with previous pelvic surgeries. Additional studies are needed to determine whether or not laparoscopic TEP repair for inguinal hernias is feasible in patients who have undergone other general surgical procedures.

Purpose: The use of automatic circular staplers for gastroduodenostomy after distal gastrectomy is now widely accepted. We compared the clinical outcomes of two different methods. Materials and Methods: Between March 2005 and February 2008, 134 patients with gastric cancer underwent distal gastrectomies. Seventy-six consecutive patients received end-to-side gastroduodenostomies (ES) between March 2005 and September 2006. The remaining 58 consecutive patients received end-to-end gastroduodenostomies (EE) between November 2006 and February 2008. We analyzed the surgical outcomes between the two groups (ES versus EE) on the basis of prospectively collected data. Results: Among the clinical factors, there were no differences between the two groups. The overall complication rates were 19.7% in the ES group and 13.8% in the EE group (P=0.489). With respect to anastomosis-related complications, 2 cases had bleeding and 2 cases had stenoses in the ES group, while 2 cases in the EE group had bleeding. Re-operation was needed in the case of intraluminal bleeding in the ES group. There were no mortalities in our study. Conclusion: The two methods for gastroduodenostomy were safe and technically feasible. Although there was no statistical difference in the overall complications, including anastomosis-related complications, we demonstrated better outcomes with respect to anastomotic stenosis in the EE group.

Hypercapnia augments cardiac output and can initiate a sympathetically mediated release of catecholamines to increase cardiac output. Many studies of hemodynamic changes by hypercapnia under general anesthesia with inhalation anesthetics besides sevoflurane. This study examined the hemodynamic changes by increasing end-tidal carbon dioxide (EtCO2) under sevoflurane-N2O anesthesia.Twenty patients were enrolled in the study. We studied stable, mechanically ventilated patients under general anesthesia maintained with O2 2 L/min - N2O 2 L/min - sevoflurane (1.5-2.5 vol%). Hypercapnia were obtained by reducing tidal volume and respiratory rate. EtCO2 was adjusted to 30, 40, 50 mmHg with each concentration maintained for 15 min. Global hemodynamic variables were monitored with a pulmonary artery catheter.There were no changes in mean arterial pressure or heart rate by hypercapnia. Acute moderate hypercapnia increased cardiac output (4.9 +/- 1.7, 5.5 +/- 1.7, 6.2 +/- 2.1 L/min; P0.05), cardiac index (3.0 +/- 0.9, 3.4 +/- 0.9, 3.8 +/- 1.1 L/min/m2; P0.05), pulmonary artery pressure (16.9 +/- 3.7, 19.6 +/- 4.2, 23.0 +/- 4.7 mmHg), but did not decrease systemic vascular resistance (1,558.3 +/- 500.4, 1,423.5 +/- 678.6, 1,156.8 +/- 374.0 dynes.sec/cm5; P0.05).When we changed patient EtCO2 to 30, 40, and 50 mmHg, there were no changes in mean arterial blood pressure and heart rate, but systemic vascular resistance decreased, and cardiac output, cardiac index and mean pulmonary arterial pressure increased significantly.