• Journal of Gastric Cancer
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• v.7 no.1
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• pp.42-46
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• 2007

Usually in the subtotal gastrectomy, the left and the right gastric arteries, as well as the left and the right gastroepiploic arteries are ligated. Thus, to avoid a blue stomach surgeons preserve the spleen and the short gastric arteries. When a radical subtotal gastrectomy with splenectomy is performed, meticulous caution is necessary; otherwise, the subtotal gastrectomy might have to be changed to a total gastrectomy to prevent a blue stomach. We report the case of a 67-year-old woman who had distal stomach cancer with a splenic solitary mass, for which splenic meatastasis could be excluded. We planned and performed a laparoscopy-assisted radical subtotal gastrectomy with splenectomy as the diagnostic and therapeutic option. In this case, to avoid a remnant stomach infarction or total gastrectomy we saved the left gastric artery and vein with clearing perivascular soft tissue, lymphatics, and lymph nodes. Thus the radical therapeutic goal was reached, and serious complications were avoided.

• Journal of Gastric Cancer
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• v.7 no.2
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• pp.74-81
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• 2007

Purpose: Routine pancreatico-splenectomy with total gastrectomy should no longer be considered as the standard surgical procedure for gastric cancer because of the lack of proven surgical benefit for survival. The aim of this study is to evaluate the clinicopathologic factors and the survival of patients with locally advanced gastric cancer and they had undergone combined pancreatico-splenectomy with a curative intent. Material and Methods: We retrospectively reviewed a total of 118 patients who had undergone total gastrectomy with distal pancreatico-splenectomy from 1990 to 2001. The patients were divided into 2 groups: 90 patients who were free from cancer invasion (group I), and 28 patients with histologically proven cancer invasion into the pancreas (group II). The various clinicopathologic factors that were presumed to influence survival and the survival rates were analyzed. Results: The rate of pathological pancreatic invasion was 23.7%. The tumor stage, depth of invasion, pancreas invasion, lymph node metastasis, lymph node ratio, curability and the hepatic and peritoneal metastasis were statistically significance on univariate analysis. Among these factors, the tumor stage, lymph node ratio and curability were found to be independent prognostic factor on multivariate analysis. The 5-years survival rates were 36.2% for group I and 13.9% for group II. The morbidity rate was 22.1%, and this included pancreatic fistula (5.1%), intra-abdominal abscess (4.2%) and bleeding (4.2%). The overall mortality rate was 0.8%. Conclusion: Combined distal pancreatico-splenectomy with total gastrectomy with a curative intent was selectively indicated for those patients with visible tumor invasion to the pancreas, a difficult complete lymph node dissection around the distal pancreas and spleen, and no evidence of liver metastasis or peritoneal dissemination.

• Journal of Gastric Cancer
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• v.4 no.2
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• pp.75-81
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• 2004

Recently detection of early gastric cancer (EGC) has been increasing and the treatment strategies for gastric cancer have been changing. The purpose of this study was to compare clinical outcomes between laparoscopically assisted (LADG) and hand-assisted laparoscopic gastrectomy (HALDG) and open distal gastrectomy for early gastric cancer. This review is directed toward providing gastric surgeons with recent advances in the treatment of EGC. We investigated the English language literature for the past 12 years through computer searches which focused on : 1) Patient demographics, 2) Operation time, 3) Intra-operative blood loss, 4) Depth of invasion, 5) CBC, 6)Weight loss, 7) Analgesic requirement, 8)Time NPO, 9) Length of hospital stay, 10) Tumor stage, 11) Lymph node (LN) dissection, 12) Position of LN resected, 13) Complications. Improved operative techniques and surgical instrumentation have facilitated the development of minimally invasive gastric cancer surgery. The short-term benefits of laparoscopic gastrectomy included less surgical trauma, less pain, rapid return of gastrointestinal function, and shorter hospital stay, with no change in operative outcome. Laparoscopic gastrectomy was better accepted by the patients as a good procedure and promptly brought the patients back to their previous lifestyle and activities of daily living. But the advantages of HALDG for gastric cancer, extended lymph node dissection and intracorporeal anastomosis are feasible and easier with the presence of the internal hand. The hand-assisted laparoscopic (HALDG) method reported the best results in lymph node dissection.This method is an alternative to total laparoscopic radical gastrectomy. LADG and HALDG, when compared with conventional open gastrectomy, have several advantages. When performed by a skilled surgeon, LADG and HALDG are safe and useful techniques for patients with early-stage gastric cancer. Their appropriateness for gastric cancer surgery require further study.

• Journal of Gastric Cancer
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• v.7 no.4
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• pp.206-212
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• 2007

Purpose: The number of laparoscopy assisted distal gastrectomies (LADG) is gradually increasing for the treatment of early gastric cancer (EGC) patients as a surgical modality for improving quality of life. However, there are few reports on laparoscopy-assisted total gastrectomy (LATG), mainly because this procedure is performed relatively infrequently, and the procedure is more complicated than LADG. This study was performed to evaluate the technical feasibility, safety, and surgical results of LATG with lymphadenectomy through a review of our experience. Materials and Methods: From July 2003 to June 2007, 77 LATG with Roux-en-Y esophagojejunostomy were performed for patients with a preoperative diagnosis of EGC. The clinicopathological features and surgical outcomes were analyzed. Results: There were 49 males and 28 females in the study with a mean age of 61 years (range $30{\sim}85$ years). The mean operation time was 210 minutes (range $100{\sim}400$ minutes) and the operation time was gradually decreased as the case numbers increased. There were 13 operative morbidities (16.9%) and no operative mortalities. The restoration of bowel motility was noted at 3.2 postoperative days; a soft diet was started at 4.4 postoperative days and the duration of hospital stay was 10 days. There were 20 mucosal lesions, 32 submucosal lesions, 15 proper muscle lesions, 7 subserosal lesions and 3 serosal lesions. A total of 20 patients were treated by D2 lymph node dissection, 55 patients were treated by D1+$\beta$ lymph node dissection, and two patients were treated by D1+$\alpha$ lymph node dissection. The mean number of retrieved lymph nodes was 42 (range $11{\sim}86$). Lymph node metastases were noted in 12 patients. Conclusion: This study indicated LATG could be applied safely and effectively for patients with EGC. However, a prospective study comparing laparoscopy-assisted versus open gastrectomy for short-term and long-term surgical outcome is needed.

• Journal of Gastric Cancer
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• v.4 no.4
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• pp.242-251
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• 2004

Purpose: Recently, because of the increasing numbers of early gastric cancer patients and improvements in their survivals, greater attention has been directed towards the quality of life and nutritional status of gastric cancer patients after surgery. However, conventional reconstructions, Billroth- I, -II (B-I and B-II) or Roux-en-Y, have proven to have certain limitations, such as a small reservoir, and a malabsorption for iron, fat, calcium, and carotene. To overcome these limitations, we used a jejunal pouch interposition(JPI) after a distal gastrectomy not only to substitute for the small reservoir but also to maintain a physiologic pathway for ingested foods. Materials and Methods: A total of 196 gastric cancer patients who underwent a distal gastrectomy between March 2001 and February 2004 were divided into 3 groups: JPI group (n=100), B-I group (n=29), and B-II group (n=67). We assessed the patient's nutritional status, gastric emptying time, and gastrofiberscopic findings. Results: The percents of body weight loss at 6 months, 1 year, and 2 years postoperatively in the JPI group ($5.14\%,\;3.01\%,\;2.37\%$) were significantly less than those of the conventional B-I ($8.41\%,\;6.69\%,\;5.90\%$) and B-II groups ($7.50\%,\;7.65\%,\;5.86\%$) (P=0.011, 0.000, 0.013). The laboratory findings showed no significant differences between the 3 groups, except for a higher total protein level in the JPI group after 6 months postoperatively. Especially, stage I and II cancers in the JPI group showed much higher total protein levels after 1 year postoperatively. The gastric emptying times in the $\^{99m}$Tc- semisolid scans at 6 months, 1 year, and 2 years postoperatively were 102.5, 83.1, and 58.1 minutes in the JPI group, 95.5, 92.0, and 58.5 minutes in the B-I group, and 53.9, 69.1, and 50.2 minutes in the B-II group, respectively. Also, the symptomatic gastric stasis detected with a gastrofiberscope during the early postoperative period (6 months) was gradually improved. Conclusion: From a nutritional aspect, a jejunal pouch interposition after a distal gastrectomy could be an alternative reconstruction method, especially in stage I and II gastric cancer patients, in spite of the longer operation time and the probable delayed gastric emptying.

• Bulletin of Food Technology
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• v.15 no.1
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• pp.16-26
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• 2002

이 논문은 대두 이소플라본 섭취가 난소를 절제한 쥐의 골격 손실에 미치는 영향을 투여량에 따라 조사한 것이다. 실험 초기에 암컷의 Wistar rats(7개월령; n=55)을 절제 후 봉합시킨 군(SH; n=14)과 난소절제군(OVX; n=41)으로 각각 구분하여 사육하고 80일 후에 각 5마리씩을 해부하여 난소절제로 인한 골손실 진행여부를 확인하였다. 그 후 난소절제 쥐(OVX)를 9마리씩 4그룹으로 나누고 대두 이소플라본(IF, 대두단백질이 없는 실험식이에 혼합하여 공급)을 각각 0, 20, 40, 80mg/ (kg body.d)씩 84일간 공급하였다. 동시에 SH rats에게도 이소플라본이 없는 실험식이를 섭취시켰으며 164일 후에 해부하였다. 예상했던 대로 골 무기질 밀도(대퇴골, 골간부위와 골간단부위) 및 골 표면적에 대한 다공성 골 면적의 비(대퇴골 원위부 골간단에서)가 OVX군이 SH군보다 낮았다(P<0.05). OVX군은 SH군보다 혈장 osteocalcine 농도가 높았으며 소변으로의 deoxypyridinoline 배설량이 많았다(P<0.05). 164일째 osteocalcine 과 deoxypyridinoline 농도는 OVX군에서보다 IF40 및 IF80군에서 더 낮았다(P<0.05). 그럼에도 불구하고 골 무기질 밀도와 다공성 골 면적이 OVX군에서보다 IF군들에서 더 낮아지지는 않았다. 그러므로 난소를 절제한 성숙한 쥐에게 대두 이소플라본을 매일 섭취시키는 것은 골격조직의 재흡수를 감소시킬 수 있으나 이미 진행된 골감소증(osteophenia)을 회복시킬 수는 없는 것으로 나타났다.

• Journal of Gastric Cancer
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• v.9 no.4
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• pp.215-222
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• 2009

Purpose: Billroth II gastroenterostomy is a typical reconstruction method after distal gastrectomy for gastric carcinoma, but it has problems, especially frequent reflux esophagitis. Various methods have been tried to address this problem. Among them are Braun enteroenterostomy and Roux-en-Y gastroenterostomy, which are performed separately according to the size of the gastric remnant. The aim of our study was to determine whether these applications are compatible. Materials and Methods: Between September 2003 and April 2007, we performed Roux-en-Y gastroenterostomy operations (14 patients) when the size of the gastric remnant was <10%, Braun enteroenterostomy (17 patients) when the size was between 10 and 20%, and Billroth II gastroenterostomy (14 patients) when the size was between 20 and 40% after subtotal gastrectomy for gastric cancer by a single surgeon at our hospital. We analyzed the results of each treatment. We evaluated the symptoms and endoscopic findings using questionnaires and hospital records. To evaluate nutritional states, we reviewed albumin and hemoglobin levels and body weight changes. Results: All operations were performed safely mortality was 0% and postoperative complications were 8.9%. On endoscopy, reflux gastritis was observed to occur in 7.63%, 18.65% and 40.0%, respectively, of patients who had undergone Roux-en-Y, Braun and Billroth II operations (P=0.13). Reflux esophagitis was observed in 1 patient in the Roux-en-Y group and 1 patient in the Braun group. Endoscopic gastrostasis was observed in 2 patients in the Roux-en-Y group, one of which was thought to cause reflux esophagitis. Patients in the Roux-en-Y group and Braun groups ingested a lower volume of food than did those in the Billroth II group (respectively, 7.1%, 0.0% and 28.7%) and complained less of postprandial discomforts (respectively, 14.3%, 23.5% and 57.1%) and reflux symptoms (respectively 0.0%, 11.8% and 42.9%). Conclusion: The application of Braun enteroenterostomy and Roux-en-Y gastroenterostomy to the small gastric remnant may be effective for reducing reflux symptoms and abdominal discomfort after distal gastric resection. We recommend Roux-en-Y gastroenterostomy when the size of the gastric remnant is <10%, and Braun anastomosis in the others. It will need to be determined which reconstructive procedure is better for many different conditions.

• Journal of Gastric Cancer
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• v.6 no.2
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• pp.103-108
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• 2006

Purpose: The circular stapled Billroth I gastrectomy has been gradually popularized because of several advantages. Thus, this study aims to identify what to be supplemented for the safety of this technique by examining the potential complication after the circular stapled Billroth I gastrectomy. Materials and Methods: This study selected 594 patients who underwent the circular stapled Billroth I gastrectomy because of the gastric cancer in our department of surgery from Jan. 1998 to Dec. 2004 as the subjects. As of Jan. 2001 when the bleeding on the anastomosis site was visually checked through the small incision at the opposite curvature to the lesion of the stomach to be resected and so the operation was completed, the patients were divided into the Group I (n=219) and Group II (n=375), which were the patients before and after Jan. 2001, respectively. Then, the clinical characteristics and postoperative anastomotic complications of both groups were compared. Results: For the comparison of complications between two groups, the anastomotic leakage was found in four cases in Group I and three cases in Group II (p=0.196). The stenosis on the anastomosis region was not observed in both groups. The bleeding on the anastomosis region illustrates the statistically significant difference between Group I and Group II, with 43 cases and 2 cases, respectively (P=0.0019). Conclusion: The circular stapled Billroth I gastrectomy is recommended because of several advantages of this technique. However, the bleeding on the anastomosis site may be indicated as the critical issue. Accordingly, the visual check on the bleeding on the anastomosis site during the operation will improve the safety of circular stapler.

• Journal of Chest Surgery
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• v.31 no.1
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• pp.46-51
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• 1998

Treatment of esophageal perforation when diagnosed late remains controversial. Ten consecutive patients since 1990 were treated late(later than 24 hours) for esophageal perforation with primary repair. Four perforations were iatrogenic, 3 were spontaneous, 2 were foreign body aspiraton and 1 was trauma. The interval from perforation to operation was 116 hours in mean and 48 hours in median value. The principles of repair included (1) a local esophagomyotomy proximal and distal to the tear to expose the mucosal defect and intact mucosa beyond, (2) debridement of the mucosal defect and closure, (3) reapproximation of the muscle, and (4) adequate drainage. The repair was buttressed with parietal pleura or pericardial fat in 9 patients. Associated distal obstruction was treated with dilation and esophagomyotomy intraoperatively. There was one mortality and cause of death was massive gastric bleeding due to gastric ulcer on 33rd day after operation. Five patients had leak at the site of repair and these cases were treated completely with conservative treatment except a mortality case. In conclusion, in the absence of malignant or irreversible distal obstruction, meticulous repair of perforated esophagus and adequate drainage are preferred approach, regardless of the duration from the injury to the operation.

• Journal of Gastric Cancer
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• v.6 no.3
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• pp.154-160
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• 2006

Purpose: According to the 2nd English Edition of the Japanese Gastric Cancer Association (JGCA) in 1998, in case of distal gastric cancer, the 14v (superior mesenteric vein) lymph node (LN) is included in the N2 group. However, in Korea, a modified radical gastrectomy is performed, and a 14v LN dissection is not done as a routine procedure. Thus, we investigated the rate of metastatic 14v LNs, evaluated the necessity of dissection of the 14v LN, and searched for indications of 14v LN dissection. Materials and Methods: From April 2004 to August 2005, we enrolled the patients who were diagnosed as having advanced gastric cancer in the distal third portion of the stomach. We peformed a distal gastrectomy with D2 lymph node dissection as defined in the 2nd English edition of the JGCA classification. We calculated the positive rate of metastatic LNs of each station and analyzed the relationship between the positive rates of No.6 LNs and 14v LNs. We also compared the positive 14v LN group with the negative 14v LN group. Results: The total number of patients was 50, the mean age was 56 (range $30{\sim}80$) years, and sex ratio (Male/Female) was 1.63 : 1. In 47 (94%) cases, distal a gastrectomy with gastroduodenostomy was done, and in the remaining 3 (6%) cases, a distal gastrectomy with gastrojejunostomy was done. The most frequently metastatic LNs were nos. 3 and 6 (54%). The metastatic rate of the f4v LN was 10%, which was similar to that of LN no. 9. In the comparison of the 14v positive group with the 14v negative group, there were significant differences in the numbers of metastatic LNs (mean 25.4 vs 4.91, P<0.001) and the numbers of metastatic no. 6 LNs, (mean 6.8 vs 1.42, P<0.001), and if no. 6 LNs were metastatic, the possibility of metastasis to the 14v LN was 19.2%. In the 14v positive group, all cases were more than stage 3 by the UICC 6th edition. Conclusion: In cases of advanced cancer with metastasis to the no. 6 IN, there was a good chance of metastasis to the 14v LN. Thus, in the operative field, if the tumor is advanced to more than stage 3 by the UICC classification and the no. 6 LN is metastatic, a 14v LN dissection is necessary. However, the usefulness of a 14v LN dissection should be evaluated prospectively through an analysis of tumor recurrence and long-term survival.