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Background: To present the experience of management of leaks following laparoscopic sleeve gastrectomy for morbid obesity in Show-Chwan memorial Hospital. Patients and Methods: Laparoscopic sleeve gastrectomy is considered one of the surgical options for morbid obesity. It is effective, with an average loss of 50% of excessive weight after 2 years of follow-up. The first laparoscopic sleeve gastrectomy was performed in January 2010 at Show-Chwan Memorial Hospital. Between January 2010 and October 2016, 300 patients underwent laparoscopic sleeve gastrectomy for morbid obesity. There were 218 women and 82 men with a mean age of 35.4 years. Preoperative mean body weight was 90.7 kg and mean body mass index (BMI) was 37.3 kg/m2. Results: Mean operative time was 85 minutes. Mean hospital stay was 3.5 days. There were no deaths. There were 5 complications (1.67%): leakage of gastroesophageal junction. One patient was conservative treatment. Two patients were successfully treated by self-expandable metallic stents and the other two patients were treated with esophageal stent also, but failed and further treated with fibrin (Histoacryl) injection to the leak site to try to seal the fistula. In six months follow-up, mean BMI decreased from 37.3 to 29.2 kg/m2, and mean excess weight loss reached 42.8%. Conclusions: Laparoscopic sleeve gastrectomy is a beneficial operation in terms of excessive weight loss, with acceptably complications. The leaks were located in gastroesophageal junction mostly, and could be resolved with esophageal stent. For the patients failed in esophageal stents, we try Histoacryl injection to improve it.

Objective: The objective of this study was to evaluate augmented reality-assisted single-incision laparoscopic adrenalectomy (AR-SILA) and compare with pure SILA. Materials and Methods: Between January 2009 and March 2012, a total of 19 patients had received SILA. Eight cases were AR-SILA and the others were pure SILA. Results: Eight AR-SILA procedures and 11 SILA were successfully completed. There was no significant difference between the two groups in terms of age, body mass index, and tumor size. Operative times were shorter in the AR-SILA group (102.5 ± 12.8 vs. 150.9 ± 46.3, P = 0.005). The mean blood loss in the AR-SILA group was slightly less than that in the SILA group (60.0 ± 25.6 vs. 109.1 ± 80.1, P = 0.129). There was neither postoperative mortality nor morbidity at the time of discharge and during follow-up. Conclusion: AR-SILA provides important intraoperative information for surgeons to recognize where the pathological lesions and vessels are located beyond the surgeon's direct vision. It made SILA safer and easier.

Purpose: Perforated peptic ulcer is an emergency condition. Laparoscopic ulcer repair is a feasible and safe procedure. The aim of this study was to research the efficacy of laparoscopic repair of peptic ulcer and to discuss the causes of conversion from laparoscopy to laparotomy. Methods: We collected 34 patients with perforated peptic ulcer underwent laparoscopic surgery from October 2003 to October 2008. Thirty four patients with perforated peptic ulcer underwent laparoscopic intervention and 6 cases were converted to laparotomy. The demographics, laboratory data, perioperative data, morbidity and mortality were compared. Results: In demographics of two groups, there were no significant differences in sex, age, location, and mean duration of symptoms of acute abdominal pain. However, there were significant differences in median size of perforation, mean duration of history of peptic ulcer related pain, and the experiences of surgeon. There were no significant differences in the laboratory data and perioperative data of two groups. In morbidity and mortality of two groups, there were no significant differences in leakage, wound infection, intra-abdominal abscess, ileus, urinary tract infection, pneumonia, and mortality, but there was significant difference in overall morbidity in two groups. Conclusions: Laparoscopic repair of perforated peptic ulcer is safe and could be used in routine clinical practice. However, patients with larger perforations (>10 mm), longer duration of history peptic ulcer related pain (>2 years), and learning curve of surgeon could be associated with conversion rate. It is associated with higher morbidity in patients with conversion from laparoscopy to laparotomy.

Background: Ten-millimeter ports are often used in laparoscopic surgery. It could be difficult to close the ports sites, especially in obese patients. We described a new method to close ten-millimeter port-site wounds, effective and easily to perform. Methods: Forty cases of laparoscopic bariatric surgery were performed from April 2010 to September 2011 at IRCAD Taiwan. Among them, 30 patients received trocar hole closed with SURGICEL&reg Original Hemostat and the other 10 patients received trocar hole closed with autologous fat. The results were recorded. Results: In group of SURGICEL&reg Original Hemostat, includes 21 female and 9 male, age range from 18 to 54 with average 39.5 years. Average BMI is 42.4 (range from 32.6 to 55). The operations include 27 cases of laparoscopic sleeve gastrectomy, 2 cases of laparoscopic gastric bypass, and 1 case of laparoscopic mini-bypass. Group of autologous fat includes 3 female and 7 male, age range from 20 to 49 with average 38.6 years. Average BMI is 39 (range from 32.8 to 64.5). The operations include 9 cases of laparoscopic sleeve gastrectomy, and 1 case of laparoscopic mini-bypass. No complications of trocar wound including infection, hematoma, and hernia were found for a mean follow-up of 6 months. Conclusions: For obese patients, closure of port sites can be difficult. We described a method of closing 10-mm port-sites wounds, which are easy, effective, and not required any special instruments.

Gastrointestinal stromal tumors (GISTs), are different from other mesenchymal tumors by immunohistochemistric biomarkers and are often encountered in the alimentary tract and less commonly originating from omentum, mesentery and peritoneum. They usually present as subepithelial tumors in the gastrointestinal tract or intraabdominal masses with malignant potential. The tumors might cause symptoms such as pain, intraluminal or extraluminal GI tract bleeding and obstruction but might also present as incidental findings. Gastroscopy, Ultrasonography and CT scan are employed for preoperative evaluation. The surgical principles are to excise the tumor with safe margin microscopically. Minimally invasive procedures are revolutionary innovation in surgery. Asian Institute of TeleSurgery training center is established in mid Taiwan in 2008 with the cooperation between Show Chwan Health Care System and European Institute of TeleSurgery in Strasbourg, France. We retrospectively reviewed 24 primary stomach GISTs operated at our institution in the past four years. The patients were divided into laparoscopy group (18 patients) and laparotomy group (6 patients) depending on the main surgical methods. The patients’ age, gender, hospital stay, operative time, blood loss, tumor size and complication rate were used for stastical analysis. There were significant differencesin tumor size and blood loss between the two groups with a p value of less than 0.05. In the past 4 years, 75% of primary gastric GISTs in our hospital were managed by laparoscopic surgery. Our experience showed that laparoscopic surgery is feasible for primary stomach GISTs in selective cases.

Summary Invasive pulmonary aspergillosis (IPA) is a rare, life-threatening infection in liver transplant recipients. Here, we report a case of primary cutaneous aspergillosis with following lung involvement in a liver transplant recipient. The survival rate of patients with IPA can be increased by early diagnosis using high-resolution computed tomography, a combination of two effective antifungal agents, temporal reduction or cessation of immunosuppressive drugs, and surgical intervention with video-assisted thoracoscopic surgery.

Ectopic pancreatic tissue is an uncommon developmental anomaly. The condition mostly occurs in the gastrointestinal tract and is usually asymptomatic. It rarely causes symptoms of inflammation, bleeding and perforation, and has potential for malignant change. Though it is an uncommon condition, cases of ectopic pancreas have been reported worldwide. Preoperative diagnosis of ectopic pancreas is challenging because of its nonspecific symptoms and signs. Owing to the revolution of minimally invasive surgery, submucosal tumors of the stomach can be resected by laparoscopic techniques. We have earlier reported on a case of ectopic pancreas in the stomach treated by robotics-assisted laparoscopic wedge resection. Herein, we report a case of ectopic pancreas in the prepyloric region of the stomach. A 44-year-old female presented with a two-week history of epigastralgia with radiation to the back. She received endoscopy check-up which disclosed a mass in the stomach. By endoscopic findings, a submucosal lesion in the prepyloric region with umbilical folding on the mucosa was identified. The umbilical folding on the mucosa hint the orifice of the duct of ectopic pancreas into the gastric mucosa suggestive of ectopic pancreas. Contrast-enhanced abdominal computed tomography showed a 5 cm cystic mass with heterogeneous content. To sum it up, the patient was diagnosed as ectopic pancreas in the stomach. She underwent laparoscopy-assisted antrectomy with Billroth I anastomosis (excision of the antrum and prepyloric region with reconstruction of gastrointestinal continuity by gastroduodenostomy) and had an uneventful hospitalization course. The histopathology of the resected tumor demonstrated ectopic pancreatic tissue in the gastric wall. To the best of our knowledge, excision of gastric ectopic pancreas using laparoscopy-assisted antrectomy with Billroth I anastomosis has never been reported in the literature.

Purpose: Chilaiditi’s syndrome is the hepatodiaphragmatic interposition of the colon. Its diagnosis poses challenge to clinicians, and misdiagnosis may results in unnecessary exploratory laparotomy being performed. The purpose of this study was to report our experience in diagnosis, management, and clinical outcome of patients with Chilaiditi’s syndrome. Methods: Nine cases of Chilaiditi’s syndrome from April 2005 to January 2007 at one institute. The clinical characteristic, imaging studies, management and results were recorded. Results: Six patients presented with abdominal distension (2 patients with abdominal pain; 5 patients with constipation), while Chilaiditi’s syndrome in the other three patients were found incidentally. All patients underwent chest X-ray. The Chilaiditi’s sign could be detected in seven patients; while the other two patients presented with no specific finding. Abdominal plain films (KUB) were all reviewed. Most of the patients (n = 8) showed ileus and one patient showed no specific finding. Impacted stool could be detected in five of nine patients. Abdominal ultrasound was performed in two patients. Gallstones were detected in one of them while the other revealed no specific finding. Six of nine patients underwent CT of abdomen, one of them revealed bowel loops in bilateral subphrenic space. One patient underwent subtotal colectomy because of volvulus of sigmoid colon. Five patients were treated with laxative and enema successfully and had been remained asymptomaticcally for a mean follow-up of 6.6 months. The other three cases were under observation. Conclusions: Presence of haustral folds of bowel loops may help us in diagnosing Chilaiditi’s syndrome. The left lateral decubitus abdominal plain film can also help to differentiate between pneumoperitoneum to Chilaiditi’s sign. Most of the cases with Chilaiditi’s syndrome can be resolved with conservative treatment and surgical intervention was reserved for patients with sign of systemic toxicity or peritonitis.

Summary Background/Introduction The da Vinci robotic surgical system was developed to overcome the limitations of conventional laparoscopic surgery. Purpose/Aims We retrospectively reviewed our experience in performing robot-assisted laparoscopic hernioplasty (RALH) during robot-assisted laparoscopic radical prostatectomy (RALP) based on a single surgeon’s experience. Methods From December 2005 to December 2008, a total of 100 patients with prostate cancer underwent RALPs by a single surgeon. We retrospectively reviewed the medical records and analyzed the patients’ ages, body mass indices (BMI), levels of prostate-specific antigen, the biopsy percentage, the Gleason score and clinical stages of the biopsy specimens in 11 patients who had a RALP and a RALH simultaneously. The diagnosis of preoperative inguinal hernia (IH) was based on the results of a clinical physical examination, abdominal computed tomography or magnetic resonance imaging. The postoperative IHs were detected by the appearance of a protruding mass in the inguinal area on coughing, which was noticed during a physical examination. The total operative time, blood loss, type of the hernia, postoperative hospital stay, and the incidence of an IH after a RALP were evaluated. Results Of the 100 patients, 89 (89%) received a RALP only, 11 underwent a RALP and a RALH simultaneously, 7% had a preoperative IH and 4% had a subclinical IH, which were found during operations. Three patients (3%) developed an IH during follow-up. There were no significant differences between the RALP group and RALP combined with the RALH group in terms of age, BMI, tumor stage, and operative time. Blood loss and the time required for urethrovesical anastomosis were significantly higher in the subclinical IH group than in the preoperative IH group. Conclusions The incidence of an IH after a RALP was 3% with a mean follow-up of 32.42 ± 11.76 months in this study. Subclinical IHs were relatively easier to notice during a RALP because of a high degree of pneumoperitoneum, the realistic 3D imaging and the steady view of the da Vinci robotic system. Thus, such a robotic procedure can be regarded to facilitate a more precise detection of occult IHs during a RALP, and it possibly decreases the incidence of IHs after a RALP.

SummaryBackground: Stump appendicitis is a rare delayed complication of appendectomy. Several diseases present with right lower abdominal pain, and therefore it is occasionally difficult to make a differential diagnosis, especially in patients with a history of appendectomy. In this paper we present our experiences with acute appendicitis following an appendectomy. Patients and Method: We selected five cases from January 2002 to December 2010. The clinical characteristics, imaging studies, treatment, and outcome were recorded. Results: All patients presented with abdominal pain (4 patients with fever). The mean duration of onset was 2 days. All patients had a history of ruptured appendicitis (2 patients showed a combination with generalized peritonitis). The mean duration since the previous appendectomy was 7.54 years. 4 patients underwent an abdominal ultrasound, and all patients underwent abdominal computed tomography, showing again a ruptured appendicitis. 4 of 5 patients had a stump appendicitis. All of the patients showed a good prognosis following surgery. Conclusions: The stump following an appendectomy should be shortened as much as possible. However, sometimes recurrent appendicitis with perforation will develop in patients with complete resection of the appendix. Stump appendicitis is associated with a history of ruptured appendicitis.

Neutrophilic leukocytosis above 50 × 109/l exclude leukemia, defines a leukemoid reaction (LR). It is associated with several diseases. Although it simulates leukemia, most of the causes are benign. Tumor-related LR is more common. It is associated with ranulocyte colony-stimulating factor (G-CSF) secreted by the tumor cells. A 38-year-old woman, presented with advanced breast cancer and leukocytosis (79.9 × 103/uL) was found. After completion of MRM, the condition of leukocytosis subsided. Two months later, tumor local relapse was found and white blood cells (WBC) rose again. After completion of wide excision, the condition of leukocytosis subsided again. We think this case was associated with leukemoid reaction.

To evaluate the clinical benefits and disadvantages of adding metoclopramide to tramadol for patient-controlled analgesia (PCA).Forty adult patients, undergoing elective arthroplasties, were recruited into this prospective, randomized, double-blind study. During general anesthesia all patients received 2.5 mg x kg(-1) of tramadol as a loading dose at the beginning of wound closure. In the postanesthesia care unit (PACU) patients were randomly allocated to receive PCA containing either 20 mg tramadol + 1 mg metoclopramide per millilitre (n = 20, Group T+M) or tramadol 20 mg per millilitre (n = 20, Group T). The PCA setup was 1 mL/bolus with a lockout interval of five minutes. A blinded investigator assessed the vital signs, visual analogue scale, and severity of postoperative nausea and/or vomiting in the PACU. The PCA demand and delivery, overall satisfaction rate and adverse effects were recorded in the PACU and on postoperative days one and two.Nausea/vomiting scores were more severe (1.7 +/- 1.0 vs 0.2 +/- 0.5, 2.3 +/- 1.2 vs 0.6 +/- 0.6, 1.9 +/- 0.9 vs 0.2 +/- 0.5, at 12 hr, 18 hr, 24 hr, respectively, P0.05) and more frequent (7/20 vs 1/20, 5/20 vs 0/20 for nausea and vomiting respectively, P0.05) on postoperative day one in Group T compared to Group T+M. However, the incidence of sedation was higher in Group T+M (7/20 vs 1/20, P0.05).The incidence and severity of nausea/vomiting decreased if metoclopramide was added to tramadol for PCA. An increased incidence of sedation was noticed with this drug combination.

Background Findings related to the influence of the −160C → A promoter polymorphism and haplotypes of the E-cadherin (CDH1) gene have not been consistent in previous studies regarding the risk for sporadic gastric cancer. Investigators in most previous studies detected those genotypes using restriction fragment length polymorphism analysis. Therefore, we conducted a case–control study to investigate the association of the CDH1 − 160C → A promoter polymorphism and haplotypes for cancer risk related to sporadic diffuse and intestinal gastric cancer by direct sequencing analysis. Methods We included 107 diffuse gastric cancer cases, 60 intestinal gastric cancer cases and 134 controls. The genotypic polymorphisms in the −160 promoter region, exons and intron–exon boundaries of CDH1 were detected by direct sequencing analysis. Genotype frequencies were compared. The CDH1 − 160C → A promoter polymorphism and four polymorphisms (48 + 6 T → C, 2076C → T, 2253C → T and 1937–13 T → C) were included in the haplotype analyses, which were estimated using the expectation–maximization algorithm. Results Compared to controls, the frequency of the −160A allele was significantly higher in diffuse gastric cancer cases (P = 0.005), but it was not significantly different in intestinal gastric cancer cases (P = 0.119). Two sets of three-marker haplotypes (−160C → A, 48 + 6 T → C, 2076C → T and −160C → A, 1937–13 T → C, 2253C → T) were associated with the risk of diffuse gastric cancer (P = 0.011 and P = 0.042, respectively). Conclusion Based on direct sequencing analysis, our findings suggest that the CDH1 − 160C → A promoter polymorphism and haplotypes play significant roles in cancer risk for sporadic diffuse gastric cancer, but not for intestinal gastric cancer, in a Taiwanese population.

Operation in minimally invasive surgery is more difficult since the surgeons perform operations without haptic feedback or depth perception. Moreover, the field of view perceived by the surgeons through endoscopy is usually quite limited. The goal of this paper is to allow surgeons to see wide-angle images from endoscopy without the drawback of lens distortion. The proposed distortion correction process consists of lens calibration and real-time image warping. The calibration step is to estimate the parameters in the lens distortion model. We propose a fully automatic Hough-entropy-based calibration algorithm, which provides calibration results comparable to the previous manual calibration method. To achieve real-time correction, we use graphics processing unit to warp the image in parallel. In addition, surgeons may adjust the focal length of a lens during the operation. Real-time distortion correction of a zoomable lens is impossible by using traditional calibration methods because the tedious calibration process has to repeat again if focal length is changed. We derive a formula to describe the relationship between the distortion parameter, focal length, and image boundary. Hence, we can estimate the focal length for a zoomable lens from endoscopic images online and achieve real-time lens distortion correction.

Acute appendicitis is the most common etiology of the acute abdomen, generally requiring urgent surgical intervention. The lifetime incidence of acute appendicitis is approximate 7%. In 1886, Fitz described the natural course of appendicitis. He began advocating early appendectomy to prevent perforation with subsequent complications of sepsis, shock and potential mortality. In 1894 McBurney introduced the right lower quadrant incision to approach the appendix. The open appendectomy (OA) through a McBurney incision came into favour more than a century ago. It is a simple, safe, quick, and effective operation that can be performed by a general surgeon with the basic surgical instruments.

Background Hemobilia is a rare but lethal biliary tract complication. There are several causes of hemobilia which might be classified as traumatic or nontraumatic. Hemobilia caused by pseudoaneurysm might result from hepatobiliary surgery or percutaneous interventional hepatobiliary procedures. However, to our knowledge, there are no previous reports pertaining to hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy. Case presentation A 65-year-old male was admitted to our hospital because of acute calculous cholecystitis and cholangitis. He underwent cholecystectomy, choledocholithotomy via a right upper quadrant laparotomy and a temporary T-tube choledochostomy was created. However, on the 19th day after operation, he suffered from sudden onset of hematemesis and massive fresh blood drainage from the T-tube choledochostomy. Imaging studies confirmed the diagnosis of pseudoaneurysm associated hemobilia. The probable association of T-tube choledochostomy with pseudoaneurysm and hemobilia is also demonstrated. He underwent emergent selective microcoils emobolization to occlude the feeding artery of the pseudoaneurysm. Conclusions Pseudoaneurysm associated hemobilia may occur after T-tube choledochostomy. This case also highlights the importance that hemobilia should be highly suspected in a patient presenting with jaundice, right upper quadrant abdominal pain and upper gastrointestinal bleeding after liver or biliary surgery.

Corrosive tracheobronchitis and lung perforation after caustic aspiration are not very common. We present a case of life-threatening acute respiratory system corrosion after aspiration of caustic alkaline crystals during a suicide attempt. The patient survived the severe burns of the tracheobronchial tract and the liquefaction necrosis of the lung lobe by aggressive airway protection procedures and surgical resection of the destroyed lung. We report this rare, clinical condition and discuss the possible mechanism and its management.

Rupture of hepatocellular carcinoma (HCC) is a life-threatening complication. Peritoneal metastasis of HCC after spontaneous rupture was seldom noted. We report a case of intraperitoneal metastasis of HCC after spontaneous rupture. A previously asymptomatic 72-year-old man was admitted due to dull abdominal pain with abdominal fullness. He had a history of HCC rupture 10 mo ago and transarterial embolization was performed at that time. Abdominal computer tomography (CT) scan showed a huge peritoneal mass over the right upper quadrant area. Surgical resection was arranged and subsequent microscopic examination confirmed a diagnosis of moderately-differentiated HCC.

Minimally invasive surgery has revolutionized the treatment of gastrointestinal tumors. Submucosal tumors of the stomach can be resected using laparoscopic techniques. We report here a case of ectopic pancreas tissue in the gastric wall that was removed using robotic-assisted laparoscopic resection. The patient was a 15-year-old female who presented with abdominal discomfort and tarry stools. Laboratory analysis showed iron deficiency anemia. Preoperative endoscopy revealed a submucosal lesion in the posterior wall of the gastric high body. Intraoperative upper endoscopy clearly located the lesion. A robotic-assisted laparoscopic wedge resection of the putative gastric submucosal tumor was performed. The pathology results showed an ectopic pancreas. The patient had an uneventful recovery and we believe that this is a valid treatment option for this benign condition.

Robotic surgical systems have recently been used to perform laparoscopic procedures in several diseases. We report the initial 2 cases of robotic-assisted laparoscopic adrenalectomy from Taiwan. Both cases were performed transperitoneally using the ZEUS surgical system (Intuitive Surgical Inc., Mountain View, CA, USA). This system consists of 3 interactive robotic arms and a remote control unit, allowing the surgeon to control the 2 instrument arms and 1 camera arm via a surgical console. The key component of the ZEUS surgical system is the MicroWrist (Computer Motion Inc., CA, USA) technology, which allows the surgeon to roll, pitch and grip laparoscopic tools freely and provides the surgeon with a 3-dimensional view of the operative field. Postoperative courses were uneventful and the patients were discharged on the third and fourth postoperative days, respectively. No intraoperative or postoperative complications were encountered. These cases suggest that robotic-assisted laparoscopic adrenalectomy is technically feasible, and that the role of robotic surgery in urologic laparoscopy is likely to expand in Taiwan.

To study Helicobacter pylori (H. pylori) infection in relation to E-cadherin (E-cad) promoter polymorphism and hypermethylation in GCs.Specimens were taken from representative cancerous lesions and adjacent non-cancerous epithelia of 67 resected GCs. H. pylori was detected by real-time PCR of the cagA gene from non-neoplastic epithelium. E-cad promoter polymorphism and hypermethylation were determined by restriction fragment length polymorphism analysis and methylation-specific PCR, respectively. Expression of E-cad protein was determined by immunohistochemistry.H. pylori was found in 57% of patients with GC. H. pylori infection was more frequently found in tumors with the -160C/C genotype than those with the -160C/A and -160A/A genotypes (74% vs 47%, P = 0.02). H. pylori infection was associated with E-cad methylation in non-neoplastic epithelium; however, no significant difference in H. pylori was observed between methylated and unmethylated cancerous lesions.Patients with the -160C/C genotype might require H. pylori infection to promote the inactivation of CDH1, suggesting that H. pylori infection might affect GC in an initial stage because polymorphism is germ line. Mechanism of hypermethylation of CDH1 promoter in GC is complex, and H. pylori infection might affect it in an initial stage.

The role of the familial breast cancer susceptibility genes, BRCA1 and BRCA2, in the homologous recombination pathway for DNA double-strand break (DSB) repair suggests that the mechanisms involved in DNA DSB repair are of particular etiological importance during breast tumorigenesis. However, there is currently no evidence for an association between breast cancer and the other DSB repair pathway, the nonhomologous end-joining (NHEJ) pathway. It is possible that, because this DNA repair pathway is so crucial for mammalian cells to maintain genomic stability, any severe defects in it would result in serious outcomes, such as genomic instability and cell death, and block subsequent cell outgrowth and tumor formation. Thus, only subtle defects arising from low-penetrance alleles would escape lethality accumulating essential genetic changes and be associated with cancer formation, and the tumorigenic contribution of these alleles would become more obvious if individual putative high-risk genotypes of each NHEJ gene act jointly. Furthermore, this joint effect might be modified by specific environmental factors, and we hypothesized that estrogen exposure might be one such factor because estrogen is suggested to cause DNA DSBs, triggering breast tumorigenesis. Because single nucleotide polymorphisms (SNPs) are the most subtle genetic variation in the genome, to examine these hypotheses, we have genotyped 30 SNPs in all five NHEJ genes (Ku70, Ku80, DNA-PKcs, Ligase IV, and XRCC4) in 254 primary breast cancer patients and 379 healthy controls. Support for these hypotheses came from the observations that (a) two SNPs in Ku70 and XRCC4 were associated with breast cancer risk (P0.05); (b) a trend toward increased risk of developing breast cancer was found in women harboring a greater number of putative high-risk genotypes of NHEJ genes (an adjusted odds ratio of 1.46 for having one additional putative high-risk genotype; 95% confidence interval, 1.19-1.80); (c) this association between risk and the number of putative high-risk genotypes was stronger and more significant in women thought to be more susceptible to estrogen, i.e., those with no history of full-term pregnancy; and (d) the protective effect conferred by a history of full-term pregnancy was only significant in women with a lower number of putative high-risk genotypes of NHEJ genes. Based on comprehensive NHEJ gene profiles, this study provides new insights to suggest the role of the NHEJ pathway in breast cancer development and supports the possibility that breast cancer is initiated by estrogen exposure, which causes DNA DSBs.

We previously established that a 5 mg x kg(-1) intraoperative dose can reduce the nausea/vomiting associated with tramadol patient-controlled analgesia (PCA). This study was conducted to identify the most appropriate initial dose to improve the quality of tramadol PCA.During general anesthesia, 60 patients undergoing knee arthroplasty were randomly allocated to receive 1.25 mg x kg(-1) (Group I), 2.5 mg x kg(-1) (Group II), 3.75 mg x kg(-1) (Group III), or 5 mg x kg(-1) (Group IV) tramadol. The emergence condition was recorded. The titration of additional tramadol 20 mg + metoclopramide 1 mg doses by PCA every five minutes was performed in the postanesthesia care unit (PACU) until the visual analogue scale (VAS) score wasor = 3. An investigator blinded to study group recorded the VAS and side effects every ten minutes.In the PACU, significantly more tramadol (8.4 +/- 3.1 vs 4.3 +/- 2.1, 2.5 +/- 1.8, and 0.4 +/- 0.3, P0.05), and a higher incidence (15/15 vs 5/15, 3/15, and 2/15, P0.05) of PCA use was observed in Group I compared to Groups II-IV. VAS was significantly higher in Group I than in Groups II-IV at zero and ten minutes (P0.05). Unexpected delayed emergence anesthesia (30 min) was observed in Group III (n = 1) and in Group IV (n = 2). Sedation was more important in Groups III and IV than in Groups I and II (P0.05).When considering efficacy and side-effect profile, 2.5 mg x kg(-1) of tramadol is the optimal intraoperative dose of this drug to provide effective postoperative analgesia with minimal sedation.

Background: Totally implantable access ports (TIAP) could be done in two methods: puncture of subclavian vein and cephalic vein cutdown. Cephalic vein cutdown method has fewer complications but has higher failure rates. We present a method to decrease the failure rates. Methods: We use the continuously injection with diluted heparin solution via catheter while introducing the TIAP catheter into the cephalic vein. Results: From January 2005 to January 2009, 20 patients were performed. This method was successfully applied in 11 patients with no complications. The other 9 patients were unsuccessfully and further underwent guidewire assisted. Conclusions: Continuously injection with diluted heparin solution via catheter while inserting TIAP catheter into the cephalic vein is safe and simple. It could be used for difficulties of insertion of TIAP and increased the successful rates of cephalic vein cut-down method.

Alessandra D’Avanzo, Sareh Parangi, Eugene Morita, Nancy D. Perrier, Hurng± Sheng Wu, Allan E. Siperstein, Quan± Yang, Duh Patrick A. Treseler and Orlo H. Clark From the Endocrine Surgical Fellow, UCSF and aFederico IIo University of Naples, Naples, Italy, Department of Surgery, Beth Israel Medical Center, Boston, Mass, Department of Nuclear Medicine UCSF/Mt. Zion Medical Center, Department of Surgery, Wake Forest University School of Medicine, Taichung Veterans General Hospital± Division of General Surgery, Taichung 407, Taiwan, Department of General Surgery, The Cleveland Clinic Foundation, Department of Veteran Affairs, San Francisco, CA, Department of Pathology, UCSF/Mt. Zion Medical Center, Department of Surgery, UCSF/Mt. Zion Medical Center, San Francisco, CA, USA

Objective To investigate whether the increased homocysteine levels occur in the first 6 months postoperatively, when nutritional intake is the most inadequate and weight reduction is the most drastic. Patients and Methods Fasting glucose, insulin, lipoprotein, homocysteine, folic acid and vitamin B12 levels and oral glucose tolerance test (OGTT) were determined in 12 morbidly obese subjects (3 men and 9 women with a mean age of 31±3 years, mean±SEM) before, 6 and 12 months after banded gastroplasty. Results Gastroplasty resulted in significant weight loss, from 12±16 to 92±6 and 88±7 kgs, 6 and 12 months postoperatively (all p

an Surgical Outcomes Research Group, SSORG et al (2011) Treatment of acute diverticulitis laparoscopic lavage vs. resection (DILALA): study protocol for a randomised controlled trial. Trials 12:186 60. Swank HA, Vermeulen J, Lange JF, Dutch Diverticular Disease (3D) Collaborative Study Group et al (2010) The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg 10:29 61. Levack M, Berger D, Sylla P et al (2011) Laparoscopy decreases anastomotic leak rate in sigmoid colectomy for diverticulitis. Arch Surg 146(2):207– 210 62. Forgione A, Leroy J, Cahill RA et al (2009) Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy. Ann Surg 249(2):218– 224 63. Bashankaev B, Wexner SD (2009) Surgery: new indication for laparoscopic sigmoidectomy. Nat Rev Gastroenterol Hepatol 6(7):388–390 coloproctology 2013 · 35:107–107 DOI 10.1007/s00053-013-0359-z © Springer-Verlag Berlin Heidelberg 2013

Primary retroperitoneal mucinous cystadenomas (RMCs) are very rare and their biological behavior and histogenesis remain speculative. An accurate preoperative diagnosis of these tumors is difficult because no effective diagnostic measures have been established. We describe a 29-year-old woman with abdominal pain and a palpable mass. Computed tomography (CT) of the abdomen revealed a retroperi-toneal cystic mass which was resected successfully at laparotomy. Histopathological examination of the resected mass confirmed the diagnosis of RMC. There was no evidence of disease 2 years after surgery.

AIM: To study the role of CDH1/E-cadherin (E-cad) gene alteration profiles including mutation, loss of heterozygosity (LOH), promoter polymorphism and hypermethylation in mechanisms of CDH1 inactivation in gastric carcinoma (GC). METHODS: Specimens were collected surgically from 70 patients with GC. Allelotyping PCR and detection of LOH, denaturing high pressure liquid chromatography and DNA sequencing, restriction fragment length polymorphism analysis, methylation specific PCR, and immunohistochemical staining were used. RESULTS: Promoter polymorphism was not a major mechanism of E-cad inactivation. Only one truncating mutation was found in a diffuse type tumor (3%). Both LOH and promoter hypermethylation were major mechanisms of E-cad inactivation, but interestingly, there was a negative association between the fraction of allelic loss (LOH) in tumors and hypermethylation of CDH1. Therefore LOH and hypermethylation were two different tumorigenic pathways involved in GC. CONCLUSION: Given the findings that somatic mutation was extremely low and the relationship between LOH and hypermethylation was inverse, any two combinations of these three factors cannot fulfill the classical two-hit hypothesis of CDH1 inactivation. Thus, other mechanisms operating at the transcriptional level or at the post-translational level might be required to induce E-cadherin inactivation.

AIM: To retrospectively establish the diagnostic criteria of gallstone ileus on CT, and to prospectively apply these criteria to determine the diagnostic accuracy of CT to confirm or exclude gallstone ileus in patients who presented with acute small bowel obstruction (SBO). Another purpose was to ascertain whether the size of ectopic gallstones would affect treatment strategy. METHODS: Fourteen CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria. These criteria were applied in a prospective contrast enhanced CT study of 165 patients with acute SBO, which included those 14 cases of gallstone ileus. The hard copy images of 165 CT studies were reviewed by a different group of two radiologists but without previous knowledge of the patient’s final diagnosis. All CT data were further analyzed to determine the diagnostic accuracy of gallstone ileus when using CT in prospective evaluation of acute SBO. The size of ectopic gallstone on CT was correlated with the clinical course. RESULTS: The diagnostic criteria of gallstone ileus on CT were established retrospectively, which included: (1) SBO; (2) ectopic gallstone; either rim-calcified or total-calcified; (3) abnormal gall bladder with complete air collection, presence of air-fluid level, or fluid accumulation with irregular wall. Prospectively, CT confirmed the diagnosis in 13 cases of gallstone ileus with these three criteria. Only one false negative case could be identified. The remaining 151 patients are true negative cases and no false positive case could be disclosed. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93%, 100%; and 99%, respectively. Surgical exploration was performed in 13 patients of gallstone ileus with ectopic stones sized larger than 3 cm. One patient recovered uneventfully following conservative treatment with an ectopic stone sized 2 cm in the long axis. CONCLUSION: Contrast enhanced CT imaging offered crucial evidence not only for the diagnosis of gallstone ileus but also for decision making in management strategy.

Background Mucoceles resulting from cystadenomas of the appendix are uncommon. Although rare, rupture of the mucoceles can occur with or without causing any abdominal complaint. There are several reports associating colonic malignancy with cystadenomas of the appendix. Herein, we report an unusual and interesting case of right inguinal hernia associated with left colon cancer. Case presentation A case of ruptured mucocele resulting from cystadenoma of the appendix was presented as right inguinal hernia in a 70-year-old male. The patient underwent colonoscopy, x-ray, ultrasound and computed tomography. Localized pseudomyxoma peritonei associated with adenocarcinoma of the descending colon was diagnosed. The patient underwent segmental resection of the colon, appendectomy, debridement of pseudomyxoma and closure of the internal ring of right inguinal canal. He is free of symptoms in one year follow-up. Conclusion Synchronous colon cancer may occur in patients with appendiceal mucoceles. In such patients, the colon should be investigated and colonoscopy can be performed meticulously in cases of ruptured mucoceles and localized pseudomyxoma peritonei. Surgical intervention is the current choice of management.