Backgrounds/Aims:Systematic investigations into the prognostic impact of the longitudinal tumor location in gallbladder cancer (GBC) remain insufficient. To address the limitations of our pilot study, we conducted a multicenter investigation to clarify the impact of the longitudinal tumor location on the oncological outcomes of GBC. Methods:A retrospective multicenter study was conducted on 372 patients undergoing radical resections for GBC from January 2010 to December 2019 across seven hospitals that belong to the Daejeon-Chungcheong branch of the Korean Association of Hepato-Biliary-Pancreatic Surgery. Patients were divided into GBC in the fundus/body (FB-GBC) and GBC in the neck/cystic duct (NC-GBC) groups, based on the longitudinal tumor location. Results:Of 372 patients, 282 had FB-GBC, while 90 had NC-GBC. NC-GBC was associated with more frequent elevation of preoperative carbohydrate antigen (CA) 19-9 levels, requirement for more extensive surgery, more advanced histologic grade and tumor stages, more frequent lymphovascular and perineural invasion, lower R0 resection rates, higher recurrence rates, and worse 5-year overall and disease-free survival rates. Propensity score matching analysis confirmed these findings, showing lower R0 resection rates, higher recurrence rates, and worse survival rates in the NC-GBC group. Multivariate analysis identified elevated preoperative CA 19-9 levels, lymph node metastasis, and non-R0 resection as independent prognostic factors, but not longitudinal tumor location. Conclusions:NC-GBC exhibits more frequent elevation of preoperative CA 19-9 levels, more advanced histologic grade and tumor stages, lower R0 resection rates, and poorer overall and disease-free survival rates, compared to FB-GBC. However, the longitudinal tumor location was not analyzed as an independent prognostic factor.

Purpose:This study aimed to investigate the current status of bariatric and metabolic surgery in Daejeon and Chungcheong province and to describe the early experiences after public medical insurance coverage in 2019. Materials and Methods:Between January 2019 and August 2019, 64 cases of bariatric and metabolic surgery were performed in patients with morbid obesity or uncontrolled type 2 diabetes. We prospectively collected and analyzed data regarding the patients' demographics and comorbidities, surgical results, and early complications. The patient information before and after the insurance coverage was also compared. Results:The number of surgeries in 9 years has been caught up only in the last 8 months after insurance coverage (58 vs. 64 patients). The mean body mass index was 37.7±5.8 kg/m2 (range, 22.7-52.1 kg/m2). The most frequently performed surgery was sleeve gastrectomy (53 cases, 82.8%), followed by Roux-en-Y gastric bypass (9 cases, 14.1%), and adjustable gastric banding (2 cases, 3.1%). Postoperative complications occurred in 6 patients (9.4%), and there was no mortality. The mean operation time (225.3±85.4 vs. 156.1±61.8 min, P<0.001) and postoperative stay (5.9±4.5 vs. 4.3±2.0 days, P=0.013) after the insurance coverage were significantly shorter than those before the insurance coverage. Conclusion:We could assess the patients who had bariatric and metabolic surgery in Daejeon and Chungcheong province after public medical insurance coverage in 2019.

Current Status of Metabolic and Bariatric Surgery in Daejeon/Chungcheong Area Dong-Wook Kim, Dae Hoon Kim, Jeong Goo Kim, Myoung Won Son, Geum Jong Song, Seong-il Oh, Han Mo Yoo, Moon-Soo Lee, Sang Kuon Lee, Sang-Il Lee, Ye Seob Jee, Si Eun Hwang, Sang Eok Lee Departments of Surgery, Dankook University Hospital, Cheonan, Chungbuk National University Hospital, Cheongju, The Catholic University of Korea, Daejeon St. Mary’s Hospital, Daejeon, Soonchunhyang University Cheonan Hospital, Cheonan, Cheongju St. Mary’s Hospital, Cheongju, Eulji University Hospital, Chungnam National University Hospital, Daejeon Sun Hospital, Konyang University Hospital, Daejeon, Korea

PURPOSE AND METHODS:The anal sinuses, small furrows above the pectinate line, sometimes form perianal abscesses in adults. We examined the pattern of fetal growth of the anal sinus and sphincters using 22 mid-term (8-18 weeks) and 6 late-stage (30-38 weeks) fetuses.RESULTS:In mid-term fetuses, the external and internal sphincters gradually increased in thickness, depending on specimen size (from 0.2 to 1.5 mm), whereas the anteroposterior diameter of the anal canal at the epithelial junction was relatively stable (0.5-1.0 mm) irrespective of specimen size. Anal canal diameter increased less than twofold between mid-term and late-stage fetuses, from 0.5-1.0 to almost 2 mm, whereas sphincter thickness increased over tenfold, from 0.2-1.5 to almost 3.5 mm. The anal sinus often showed balloon-like enlargement when the sphincter muscle bundles were tightly packed in mid-term, but not in late-stage fetuses.CONCLUSIONS:Large concentric mechanical stress from the sphincters in late-stage fetuses apparently prevented the anal sinus from expanding in a balloon-like manner. Conversely, to avoid anal stenosis, the growing sinuses maintained a luminal space of the anal canal in response to stress from rapidly growing sphincters. The inferiorly extending sinus usually provided temporal double canals separated by a thick column. In the presence of double lumens, anal canal duplication is likely to develop without any abnormalities of the anal epithelium and sphincters.

Severe portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to high associated risks and morbidity. Meanwhile, improvement in operative techniques, resulting in higher success rates has removed PVT from the list of contraindications in deceased donor liver transplantation (DDLT). In this report, we describe a surgical technique for DDLT using polytetrafluoroethylene graft from the inferior mesenteric vein for portal inflow in patient with portomesenteric thrombosis.

PURPOSE AND METHODS:To identify site-dependent and individual differences in neuronal nitric oxide synthase (nNOS)-positive nerves of the myenteric plexus, we examined full-thickness walls of the stomach, pylorus, duodenum, ileum, colon, and rectum in 7 male and 8 female cadavers (mean ages, 80 and 87 years, respectively).RESULTS:The areas occupied by nNOS-positive nerve fibers in the myenteric plexus were fragmentary and overlapped with areas occupied by vasoactive intestinal polypeptide-positive fibers. The nNOS-positive fiber-containing areas per 1-mm length of intermuscular space tended to be larger at more anal sites, with positive areas four times greater in the rectum than in the stomach. Interindividual differences in rectal areas were extremely large, ranging from 0.017 mm(2) in one 80-year-old man to 0.067 mm(2) in another 80-year-old man. Similarly, the numbers of nNOS-positive ganglion cell bodies per 1-mm length in the rectum ranged from 4 to 28. These areas and numbers were weakly correlated (r = 0.62; p = 0.02). Interindividual differences in the rectum appeared not to depend on either age or gender.CONCLUSIONS:Anatomic studies using donated cadavers carried the advantage of obtaining any parts of intestine within an individual, in contrast to surgically removed specimens. We speculated excess control of evacuation with laxatives as one of causes of atrophy of the rectal myenteric plexus.

A term "mesoesophagus" has been often used by surgeons, but the morphology was not described well. To better understand the structures attaching the human abdominal and lower thoracic esophagus to the body wall, we examined serial or semiserial sections from 10 embryos and 9 fetuses. The esophagus was initially embedded in a large posterior mesenchymal tissue, which included the vertebral column and aorta. Below the tracheal bifurcation at the fifth week, the esophagus formed a mesentery-like structure, which we call the "mesoesophagus," that was sculpted by the enlarging lungs and pleural cavity. The pneumatoenteric recess of the pleuroperitoneal canal was observed in the lowest part of the mesoesophagus. At the seventh week, the mesoesophagus was divided into the upper long and lower short parts by the diaphragm. Near the esophageal hiatus, the pleural cavity provided 1 or 2 recesses in the upper side, while the fetal adrenal gland in the left side was attached to the lower side of the mesoesophagus. At the 10th and 18th week, the mesoesophagus remained along the lower thoracic esophagus, but the abdominal esophagus attached to the diaphragm instead of to the left adrenal. The mesoesophagus did not contain any blood vessels from the aorta and to the azygos vein. The posterior attachment of the abdominal esophagus seemed to develop to the major part of the phrenoesophageal membrane with modification from the increased mass of the left fetal adrenal. After postnatal degeneration of the fetal adrenal, the abdominal esophagus might again obtain a mesentery. Consequently, the mesoesophagus seemed to correspond to a small area containing the pulmonary ligament and aorta in adults.

CD10, a marker of immature B lymphocytes, is expressed in the developing epithelium of mammary glands, hair follicles, and renal tubules of human fetuses. To assess mesenchymal and stromal expression of CD10, we performed immunohistochemical assays in whole body sections from eight fetuses of gestational ages 15-20 weeks. In addition to expression in urinary tract and intestinal epithelium, CD10 was strongly expressed at both gestational ages in fibrous tissues surrounding the airways from the larynx to lung alveoli, in the periosteum and ossification center, and in the glans of external genitalia. CD10 was not expressed, however, in other cavernous tissues. These findings suggest that mesenchymal, in addition to epithelial cells at specific sites, are likely to express CD10. The glomeruli, alveoli, and glans are all end products of budding or outgrowth processes in the epithelium or skin. However, in contrast to the CD34 marker of stromal stem cells, CD10 was not expressed in vascular progenitor cells and in differentiated vascular endothelium. The alternating pattern of CD10 and CD34 expression suggests that these factors play different roles in cellular differentiation and proliferation of the kidneys, airway and external genitalia.

We identified 2 human embryos, with crown-rump lengths (CRLs) of 22 mm and 23 mm and a gestational age of approximately 7 weeks (O'Rahilly's stage 21–22), with liver agenesis and omphalocele. Serial histological sections were prepared of the entire body of one specimen, whereas sections of the neck, including the upper part of the heart, were missed for the other specimen as a result of tissue damage during the abortion. In addition, isolated omphalocele was assessed in another embryo (CRL = 25 mm) for comparison with atypical omphalocele in the embryos with liver agenesis. The 2 embryos with liver agenesis were characterized by (1) the absence of the anterior part of the diaphragm; (2) abnormality in the venous pole of the heart; (3) a normal stomach in the left upper abdominal cavity; and (4) normal pancreas development with normal midgut rotation. The most likely cause of liver agenesis, when combined with isolated omphalocele, was a defect in the anterior extension or migration of the septum transversum rather than a mechanical separation of the hepatic diverticulum from the septum transversum.

Although several studies have reported that the peritoneum does not contribute to the formation of a fascia between the urogenital organs and rectum, Denonvilliers' fascia (DF), a fascia between the mesorectum and prostate (or vagina) in adults, is believed to be a remnant of the peritoneum. Remnants of the peritoneum, however, were reportedly difficult to detect in other fusion fasciae of the abdominopelvic region in mid-term fetuses. To examine morphological changes of the pelvic cul-de-sac of the peritoneum, we examined 18 male and 6 female embryos and fetuses. A typical cul-de-sac was observed only at 7 weeks, whereas, at later stages, the peritoneal cavity did not extend inferiorly to the level of the prostatic colliculus or the corresponding structure in females. The cul-de-sac had completely disappeared in front of the rectum at 8 weeks and homogeneous and loose mesenchymal tissue was present in front of the rectum at the level of the colliculus at 12-16 weeks. We found no evidence that linearly arranged mesenchymal cells developed into a definite fascia. Therefore, the development of the DF in later stages of fetal development may result from the mechanical stress on the increased volumes of the mesorectum, seminal vesicle, prostate and vagina and/or enlarged rectum. Therefore, we considered the DF as a tension-induced structure rather than a fusion fascia. Fasciae around the viscera seemed to be classified into (1) a fusion fascia, (2) a migration fascia and (3) a tension-induced fascia although the second and third types are likely to be overlapped.

The roles of the liver and intestines in lymphocyte differentiation in human fetuses were assessed by immunohistochemical analysis of the thymus, bone marrow, liver, spleen, intestines, and lymph nodes of 15–16 week human fetuses using primary antibodies against IgM, CD3, CD7, CD8, CD10, CD20, CD45RO, HLA‐DR, and CD68. The density of immunoreactive lymphocytes was high in the thymus and lymph nodes, but much lower in the bones, liver, spleen, and intestines. The medulla of the thymus contained IgM‐positive mature B lymphocytes as well as CD20‐positve B lymphocytes. In contrast, CD10‐positive immature B lymphocytes were restricted in the cortex. There were no site‐dependent differences among axillary, mediastinal, mesenteric, and pelvic lymph nodes. CD68‐positive cells were observed at all sites examined. Many HLA‐DR‐positive round cells were present in the thymus, with fewer in the liver and spleen. The absolute number of lymphocytes was estimated to be ≥10‐fold higher in lymph nodes than in liver. Although limited by analysis of only one fetal stage, these findings suggest that mesenteric nodes are likely to be more important than the liver, spleen, and intestines for lymphocyte proliferation and differentiation in human mid‐term fetuses. Anat Rec, 297:1478–1489, 2014. © 2014 Wiley Periodicals, Inc.

Backgrounds/Aims Pancreaticoduodenctomy (PD) is associated with high rates of postoperative morbidity and mortality. Although many studies have shown that early postoperative enteral nutrition improves postoperative outcomes, limited clinical information is available on postoperative early oral feeding (EOF) after PD. The aim of this study was to evaluate the clinical feasibility, safety, and nutritional effects of EOF after PD. Methods Clinical outcomes were investigated in 131 patients who underwent PD between 2003 and 2013, including 81 whose oral feeding was commenced within 48 hours (EOF group) and 50 whose oral feeding was commenced after resumption of bowel movements (traditional oral feeding [TOF] group). Postoperative complications, energy intake, and length of stay (LOS) were reviewed. Results Demographic factors were similar in the two groups. The EOF group had a significantly shorter LOS (25.9±8.5 days vs. 32.3±16.3 days; p=0.01) than the TOF group. The rates of anastomotic leak (1.2% vs. 16%, p=0.00) and reoperation (3.7% vs. 20%, p=0.01) were significantly lower in the EOF group. In the clinically acute phase from postoperative day 1 to day 5, the mean daily calorie intake (847.0 kcal vs. 745.6 kcal; p=0.04) and mean daily protein intake (42.2 g vs. 31.9 g; p=0.00) in the EOF group were significantly higher than that in the TOF group. Conclusions Postoperative EOF is a clinically safe, feasible, and effective method of nutritional support after PD.

In the embryonic heart, the primitive atrium is considered to receive the bilateral sinus horns including the upper terminal of the inferior vena cava (IVC).To reveal topographical anatomy of the embryonic venous pole of the heart, we examined horizontal serial paraffin sections of 15 human embryos with crown-rump length 9-31 mm, corresponding to a gestational age of 6-7 weeks or Carnegie stage 14-16.The IVC was often fixed to the developing right pulmonary vein by a mesentery-like fibrous tissue.Rather than the terminal portion of the future superior vena cava, the IVC contributed to form a right-sided atrial lumen at the stage.The sinus venosus or its left horn communicated with the IVC in earlier specimens, but in later specimens, the left atrium extended caudally to separate the sinus and IVC.In contrast, the right atrium consistently extended far caudally, even below the sinus horn, along the IVC.A small (or large) attachment between the left (or right) atrium and IVC in adult hearts seemed to be derived from the left (or right) sinus valve.This hypothesis did not contradict with the incorporation theory of the sinus valves into the atrial wall.Variations in topographical anatomy around the IVC, especially of the sinus valves, might not always depend on the stages but partly in individual differences.

Backgrounds/Aims Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is an uncommon subtype of primary liver cancer that has rarely been reported in detail. This study was performed in order to evaluate the clinicopathological characteristics and prognostic factors of cHCC-CC in single center. Methods The clinicopathological features of patients diagnosed and operated with cHCC-CC at Chonbuk National Hospital between July 1998 and July 2007 were retrospectively studied by comparing them with patients with only hepatocellular carcinoma (HCC) who had undergone a hepatic resection during the same period. Results Ten out of 152 patients who had undergone a hepatic resection were diagnosed with cHCC-CC and thus included in this study (M : F=8 : 2, median age: 52±11.1 years). According to the parameters of the 7th American Joint Committee on Cancer T staging, there were 76 (50.0%), 44 (28.9%), 9 (5.9%), 18 (11.8%) and 5 (3.3%) patients with T stages 1, 2, 3a, 3b and 4, respectively. The overall survival period was longer in the HCC only group (68±40.4 months) than in the combined cHCC-CC group (23±40.1 months) (p<0.0001). The 5-year survival rate was 10% in the cHCC-CC group and 60% in the HCC group (p<0.0001). The disease free survival for patients with cHCC-HCC and HCC were 16±37.4 and 51±44.3 months, respectively (p<0.0001). Univariate analysis revealed that age, gender, transarterial chemoembolization (TACE), and T stage were statistically significant in terms of patient's overall survival. However, there were no significant clinicopathological factors identified by the multivariate analysis. Conclusions Even after the hepatic resection in the HCC, the prognosis is poorer if the patient has cholangiocellular components compared to the usual HCC.

Purpose Computer-assisted three-dimensional reconstruction of the fetal human pancreas was prepared to reconsider topographical relation between the dorsal/ventral anlagen and the vascular supply. Methods Tissue sections from the upper abdominal viscera of three fetuses were examined. Sections were immunohistochemically stained to determine pancreatic polypeptide expression, a marker of the ventral pancreas. Results The immunohistochemical findings were used to create three-dimensional computer-assisted reconstructions to identify pancreatic arteries. The narrowest part of the pancreas, or the neck, corresponding to a part of the dorsal pancreas, was located on the left side of the common bile duct, portal vein and gastroduodenal artery (GDA). The posterior arterial arcade accompanied the ventral pancreas, whereas the anterior arcade did not. In contrast to the GDA, the splenic artery was clearly separated from the neck in fetuses. The GDA appears to be the primary and stable arterial supply for the neck of the pancreas. Conclusions This observation may have implications for the preservation of the neck with the GDA during pancreaticoduodenectomy for benign and low-grade malignant diseases.

At 8-16 weeks of gestation, Spiegel's lobe of the caudate lobe appears as a sac-like herniation of the liver parenchyma between the inferior vena cava and ductus venosus or Arantius' duct. In 5 of 11 fetuses at 20-30 weeks of gestation, we found that an external notch was formed into the posterior aspect of the caudate lobe by a peritoneal fold containing the left gastric artery. This notch appeared to correspond to that observed in adults, which is usually seen at the antero-inferior margin of the lobe after rotation of the lobe along the horizontal or transverse axis. However, the notch did not accompany two of the three fetuses in which the left hepatic artery originated from the left gastric artery. Notably, until 9-10 weeks of gestation, the inferior and left part of Spiegel's lobe rode over the hepatoduodenal ligament and protruded medially into the lesser sac (bursa omentalis) behind the stomach. Thus, the fetal Winslow's foramen was located at the "superior" side of the ligament. However, as seen in adults, the protruding Spiegel's lobe was located at the posterior side of the lesser omentum. Therefore, a hypothetical rotation along the transverse axis in the later stages of development seems necessary to explain this repositioning. Considering that Spiegel's lobe develops faster than surrounding structures, it is likely that the lesser sac resulting from the rotation of the gastrointestinal tract, which actively contributes to facilitate the growth of the Spiegel lobe.

Purpose: The role of nutrition support for the management of enterocutaneous fistula is primarily one of supportive care to prevent malnutrition and thereby halt further deterioration of an already debilitated patient.This therapy is best managed by a nutritional support team (NST).For activation of the NST, physicians must become more aware of the need for nutrition support in patients, and so referrals are required from physicians.This study examined the referrals to the nutritional support team for patients with postoperative enterocutaneous fistula.Methods: Between March 2007 and May 2009, we reviewed 34 patients with postoperative enterocutaneous fistula and who was referred to the NST.Results: The mean age of the patients was 61.1±11.5 years.Twenty seven cases were males and 7 were females.The routes of nutrition support were EN+PN: 32 (55.2%),PN: 16 (27.6%),EN: 8 (13.0%) and oral intake +PN: 2 (3.4%).The direct referrals were 45 (77.6%) and the indirect referrals though the nutritional screening system were 13 (22.4%).The referrals for EN were 40 (69%) and those for PN were 18 (31.0%).The recommendations by the NST were accepted in 48 (82.8%) of the cases.The EN recommendations were accepted in all 40 (100.0%) of the cases.The PN recommendations by direct referral were accepted in 6 of 7 cases, but only 2 of 11 cases were accepted according to indirect referral.Conclusion: More aggressive and thorough follow-up on whether or not to accept the NST recommendation is required.This study shows that regular scheduled nutrition support service orientations for the different staff and departments of the hospital should be held each year.(KJPEN 2010;3(1):45-49)

This study was done to evaluate the prognostic factors that may affect the survival of patients with recurrent hepatic metastasis after curative resection of gastric cancer.

Serum response factor (SRF) is a transcription factor that controls cell growth, differentiation, and tumor progression as well as muscle development and function. Reduced expression of cell adhesion molecules has been reported to be associated with tumor metastasis. The aim of this study was to evaluate the expression and a role of SRF in liver metastasis of primary colorectal carcinomas. We examined the expression of SRF, E-cadherin, and beta-catenin by the use of immunochemical staining in 43 cases as a set of primary colorectal carcinomas and liver metastases. We also examined the role of SRF in colorectal carcinoma by overexpression of SRF in a colon cancer cell line. In metastatic carcinoma surgical samples, there was a marked increased expression of SRF as compared to expression in primary colorectal carcinoma surgical samples (P<0.05). E-cadherin expression was significantly decreased in metastatic liver carcinoma samples as compared to primary colorectal carcinoma samples (P<0.001). Frequent nuclear translocation of beta-catenin protein in primary and metastatic carcinoma cells was observed. Overexpression of SRF in SW480 cells resulted in a decreased expression of E-cadherin and an increased expression of non-phosphorylated nuclear beta-catenin. Overexpression of SRF in colorectal carcinoma cells enhanced cell motility and invasiveness. These results indicate that overexpression of SRF in colorectal carcinoma cells is associated with modulation of E-cadherin/beta-catenin expression and may play an important role in colorectal cancer metastasis.

Purpose: We have evaluated changes of body composition for patients that underwent a radical gastrectomy for stomach cancer by the use of available bioelectrical impedance analysis during the first year following surgery. We plan to utilize these findings in nutritional and physiological studies. Materials and Methods: We evaluated clinical changes in body composition in patients using the bioelectrical impedance method (Inbody 4.0, Biospace, Korea), between November 2003 to November 2004. A total of 98 patients agreed to enroll in this study among all of the patients that underwent a radical gastrectomy. Results: The average weight decreased by 6.7%, and 9.4%, within the first and 6 months after surgery, respectively (P