Self-expandable Metallic Stent for the Management of Acute Malignant Large-bowel Obstruction

Purpose: The purpose of this study was to review our experience with the use of self-expandable metallic stents as the initial interventional management for acute malignant large-bowel obstruction. Methods: The records of 35 patients who underwent placement of a colonic stent for acute malignant obstruction at our institution between January 2003 and December 2004 were reviewed. Results: Stents were placed for palliation in 19 patients and as bridge to surgery in 16 patients. Technical success of stent placement was achieved in all patients (100%), but clinical failure occurred in two patients due to limited expansion of the metallic stent. One of them who had clinical failure underwent an emergency operation, and the other needed no further procedure because of his death. Complications occurred in 4 patients (12%), including one pelvic abscess associated with colon perforation, two minor bleedings, and one anal pain. All the patients in the bridge-to-surgery group underwent an elective colon resection without stoma. In the palliative group, stent reocclusion was observed in three patients during the follow-up (median: 65 days; range: 27∼440 days), two of which were managed by reinsertion of a stent. In the remaining patients, the stent was patent until death or the last follow up date (median: 65 days). Conclusions: Placement of a self- expandable metallic stent is a safe and effective procedure for immediate decompression of acute malignant large- bowel obstruction. It provides a chance of elective surgery for patients with resectable disease, as well as relief of symptoms for those with unresectable disease.ope

악성 림프종에 의한 성인에서의 회맹부 장중첩증

Adult intussusception is rare but can prove to be challenging surgical situation. The etiology of adult intussusception is different from that of children, and because of the possibility of malignancy, surgical treatment is highly recommended. We present a case report of malignant lymphoma that caused ileocolic and colocolic intussusception in an adult. At first event of intussusception, the patient refused to undergo additional treatments due to improved symptoms. Three months later, the patient was transferred to our hospital due to recurrent and unresolved abdominal pain. The patient underwent a right hemicolectomy and was diagnosed with malignant B-cell lymphoma that involved the ileocecal valve. Physicians should consider malignancy as a potential cause of intussusception in adult, and should quickly provide adequate surgical intervention.ope

Sphincter Preserving Operation by Coloanal Anastomosis: Long Term Survival

Purpose: Abdominoperineal resection (APR) was the conventional operation for the last 100 years, however it decreased recently for the improvement of sphincter preserving operations, especially of hand-sewn coloanal anastomosis (CAA). The aim of this study is to evaluate oncological results for the CAA. Methods: From January 1992 to August 2000, 107 consecutive patients with rectal cancer within 7 cm from anal verge who underwent a curative resection were evaluated retrospectively by operations (APR, CAA, and stapled low anterior resection, LAR). No temporary stoma was made for CAA and LAR. Results: The mean age is 57.4 and the distance from the anal verge was 4.12 cm (±1.55) for 65 males and 4.13 cm (±1.67) for 42 females (p＞0.05). The age, gender, tumor location, size, resection margin, and stage were not statistically significant according to the operations. The CAA increased from 8% (early) to 64% (late), and the APR decreased from 59% (early) to 16% (late). The 5 year survival rate was 70.1% (84.3% for Dukes B and 40.8% for Dukes C). Survivals were not statistically significant according to the type of operation. The local recurrence rate was 7.4% (13.8% for stapled low anterior resection, 7.0% for APR, and 2.8% for CAA). Of the patients with a CAA, 54% had received preoperative radiation therapy (45∼55 Gy). In the late period, tumors located within 5 cm from the anal verge with fat or perirectal lymph nodes involved received preoperative radiation, and the sphincter-preserving rate was 80%. Conclusions: CAA is an effective technique, with a safe oncologic result, for sphincter preservation in very low rectal cancer.ope

Clinical Analysis of 40 Patients with Familial Adenomatous Polyposis (FAP)

Purpose: This study was carried to find the clinical characteristics of incidence and the phenotype of familial adenomatous polyposis (FAP). Methods: This retrospective analysis was performed on 40 patients who were diagnosed as having FAP and who underwent surgery due to FAP from June 1985 to April 2005. The operative method, extra- colonic symptoms, and number of polyps were analyzed. Results: From June 1985 to April 2005, 0.65% (40 patients) of all surgically treated colon-cancer patients were diagnosed as having FAP. Seventeen patients had familial history, and 23 patients were neither aware of any familial history nor had taken any tests. The primary symptoms were hematochezia, diarrhea, mucous discharge, constipation, and abdominal pain, but 5 patients had no specific symptoms. The mean age was 38.0 years. A total colectomy with ileostomy was performed in 19 cases, a total colectomy with ileorectal anastomosis in 2 case, and a total proctocolectomy with ileal J pouch anal anastomosis in 17 cases. One case was only diagnosed as having a FAP without surgical treatment, and one cases had palliative surgery due to carcinomatosis. Thirty-five cases had more than one hundred polyps, and 5 cases had less than one hundred polyps with a higher mean age of 62.2 (50∼74) years and having no familial history. Extracolonic manifestations, were congenital hypertrophy of the retinal pigment epithelium, submandibular tumor, thyroid cancer, and intraabdominal desmoid tumor. The polyps could develop in other organs, such as the stomach or the duodenum. Because they can progress to cancer, a gastroduodenoscopy needs to be done. As for result, 17 cases underwent endoscopic gastroduodenoscopy, and among them, 9 cases had multiple adenomas. Conclusions: FAP has been considered as a rare disease. Because of its association with early development of colorectal cancer, measures for early detection of the disease and for identification of other family members at risk should be performed. Furthermore, early prophylactic treatment should be undertaken to reduce the incidence of cancer in these conditions. For early detection and better outcome, clinical and radiological examination and treatment for extracolonic manifestations and extracolonic tumor (thyroid cancer, desmoid tumor, medulloblastoma, hepatoblastoma) are necessary.ope

In-vitro Chemosensitivity Test for Colorectal Cancer using an Adenosine-triphosphate-based Chemotherapy Response Assay (ATP-CRA)

Purpose The adenosine-triphosphate-based chemotherapy response assay (ATP-CRA) is a well-documented and validated technology for individualizing chemotherapy in cancer patients. We evaluate the feasibility of ATP-CRA in colorectal cancer patients. This study will illustrate the assay's success rate, the mean coefficient of variation, and the turnaround time as a validation tool for a chemosensitivity test. Methods A total of 118 patients, treated by surgery between June 2004 and September 2005 were evaluated for chemosensitivity to seven anticancer agents (5-fluorouracil (5-FU), oxaliplatin, irinotecan, epirubicin, etoposide, gemcitabine, and paclitaxel) by using an ATP-CRA. To allow a comparison between samples, we calculated the chemosensitivity index (CI) based on the percentage cell death rate (CDR,%) at each test drug concentration. Results The assay success rate was 85.5% (118/138), and the mean coefficient of variation, indicating intra-assay error level, was 9.2%. CDR measured at a therapeutic peak plasma concentration ranged from 0% to 93.6% with a median of 31.0% for 5-FU, 28.5% for oxaliplatin, 34.0% for irinotecan, 25.0% for epirubicin, 21.0% for etoposide, 22.0% for gemcitabine, and 25.2% for paclitaxel. According to the CI, the most sensitive drug varied from patient to patients 10.9% for 5-FU, 10.9% for oxaliplatin, 24.7% for irinotecan, 11.8% for epirubicin, 22.4% for etoposide, 1.1% for gemcitabine, and 23.3% for paclitaxel. Conclusions Our data suggest that the ATPCRA is a feasible in-vitro chemosensitivity test in colorectal cancer and that patients show heterogeneous chemosensitivity. A study evaluating the predictive value of ATP-CRA directed therapy is needed to determine the clinical usefulness of the test.ope

Associations of colorectal cancer incidence with nutrient and food group intakes in korean adults: a case-control study

This study aimed to examine the associations between intakes of various nutrients and food groups and colorectal cancer risk in a case-control study among Koreans aged 20 to 80 years. A total of 150 new cases and 116 controls were recruited with subjects' informed consent. Dietary data were collected using the food frequency questionnaire developed and validated by the Korea Centers for Disease Control and Prevention. Multivariate logistic regression models were used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for colorectal cancer incidence. High intakes of total lipid (ORT3 vs T1 = 4.15, 95% CI: 1.33-12.96, p for trend = 0.034), saturated fatty acid (ORT3 vs T1 = 2.96, 95% CI: 1.24-7.04, p for trend = 0.016) and monounsaturated fatty acid (ORT3 vs T1 = 3.04, 95% CI: 1.23-7.54, p for trend = 0.018) were significantly associated with increased incidence of colorectal cancer. High dietary fiber (ORT3 vs T1 = 0.22, 95% CI: 0.08-0.56, p for trend = 0.002) and vitamin C (ORT3 vs T1 = 0.38, 95% CI: 0.14-1.05, p for trend = 0.021) intakes were significantly associated with reduced colorectal cancer incidence. From the food group analysis, bread (ORT3 vs T1 = 2.26, 95% CI: 0.96-5.33, p for trend = 0.031), red meat (ORT3 vs T1 = 7.33, 95% CI: 2.98-18.06, p for trend < 0.001), milk·dairy product (ORT3 vs T1 = 2.42, 95% CI: 1.10-5.31, p for trend = 0.071) and beverage (ORT3 vs T1 = 3.17, 95% CI: 1.35-7.48, p for trend = 0.002) intakes were positively associated with colorectal cancer risk. On the other hand, high intake of traditional rice cake (ORT3 vs T1 = 0.35, 95% CI: 0.14-0.86, p for trend = 0.024) was linked with lower colorectal cancer incidence. In conclusion, eating a diet high in total lipid, saturated fatty acids and monounsaturated fatty acids is associated with higher incidence of colorectal cancer, whereas a diet high in dietary fiber and vitamin C was found to lower the incidence in Korean adults. Interestingly high traditional rice cake consumption is associated inversely with colorectal cancer incidence, warranting a future study.ope

Recurrences after local excision for early rectal adenocarcinoma

PURPOSE: The role of local excision in treating rectal cancer patients continues to be controversial. The aim of this study was to evaluate the long-term oncological results of local excision for early rectal adenocarcinomas and review the outcomes of salvage therapy on rectal cancer patients. MATERIALS AND METHODS: Between March 1992 and September 2005, 35 consecutive patients with early-stage primary rectal adenocarcinomas were treated by local excision with curative intent. The mean tumor distance from the anal verge was 5 cm (range, 1-10 cm). RESULTS: The median follow-up was 66 months (range, 17-161 months). Pathological examination revealed 23 cases of T1 and 12 cases of T2. Recurrence had developed in 10 patients (6 local recurrences, 4 systemic recurrences). Purely extrapelvic recurrence was observed in only two (5.7%) patients. Of the eight recurrent patients with surgical salvage, five survived with no evidence of disease at the time of this analysis. The 5-year local recurrence-free and disease-free survival rates were 79.6% and 67.9%, respectively. CONCLUSION: Local excision alone of early-staged rectal adenocarcinomas, even in the ideal candidate, is followed by a relatively higher local recurrence rate than previously reported and may not be a valid modality. Either the use of adjuvant therapy with local excision, even in patients with T1 lesions or the use of preoperative therapy followed by local excision has good promise.ope

Contributing Factors on Lymph Node Yield after Surgery for Mid-Low Rectal Cancer

PURPOSE: The purpose of the present study was to evaluate the contributing factors to the lymph node status as well as to define the impact of preoperative concurrent chemoradiotherapy (CCRT) on the number of lymph nodes retrieved in mid-low rectal cancer. MATERIALS AND METHODS: We retrospectively analyzed 277 patients who underwent curative surgical resection for mid-low rectal cancer between 1998 and 2007. Eighty-two patients received long course preoperative CCRT followed by surgery. RESULTS: A mean of 13.12±9.28 lymph nodes was retrieved. In a univariate analysis, distance from the anal verge, pT stage, pN stage, lymphovascular invasion, preoperative CCRT had significant influence on the number of lymph nodes retrieved. In a multivariate model, patients in the CCRT group had fewer retrieved lymph nodes than the non-CCRT group (p<0.001). Both univariate and multivariate analyses showed that the ypN0 group had fewer retrieved lymph nodes than the ypN1-2 group (p=0.027) in the CCRT group. CONCLUSION: Preoperative CCRT was an independent risk factor for failure to harvest an appropriate number of lymph nodes, and node-negative patients who received CCRT had fewer lymph nodes harvested.ope

An extragastrointestinal stromal tumor in the omentum with peritoneal seeding mimicking an appendiceal mucinous cancer with carcinomatosis

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. These tumors tend to present most frequently in the stomach, followed by the small intestine. GISTs can also arise from the omentum, retroperitoneum, mesentery, or pleura and are termed extragastrointestinal stromal tumors (EGISTs) when they do so. EGISTs arising from the omentum are very rare. Due to the limited incidence of EGISTs in the omentum, the diagnostic criteria are not well established, and making a correct diagnosis may be difficult. In this report, we present a case of an EGIST of the omentum with peritoneal metastasis that was initially suspected to be an appendiceal mucinous carcinoma with carcinomatosis on positron emission tomography/computed tomography imaging.ope

Feasibility and Safety of a Fold-Over Diverting Ileostomy Reversal After Rectal Cancer Surgery: Case-Matched Comparison to the Resection Technique

PURPOSE: Compared to the stapling technique, the fold-over technique (FO) has the benefit of avoiding the sacrifice of the bowel segment. The aim of this study was to compare short-term outcomes between the FO and a conventional resection. METHODS: Between June 2008 and March 2012, a total of 242 patients who underwent a diverting ileostomy reversal after rectal cancer surgery were selected. Among them, 29 patients underwent the FO. Using propensity scores to adjust for body mass index, previous abdominal surgery history, rectal cancer surgery type (open vs. minimally invasive), and reason for ileostomy (protective aim vs. leakage management), we created a well-balanced cohort by matching each patient who underwent the FO, as the study group, with two patients who underwent a stapled or a hand-sewn technique with bowel resection (RE), as the control group (FO : RE = 1 : 2). Morbidity and perioperative recovery were compared between the two groups. RESULTS: Twenty-four and forty-eight patients were allocated to the FO and the RE groups, respectively. The mean operation time was 91 ± 26 minutes in the FO group and 97 ± 34 minutes in the RE group (P = 0.494). The overall morbidity rates were not different between the two groups (12.5% in FO vs. 14.6% in RE, P = 1.000). The rate of postoperative ileus was similar between the two groups (8.3% in FO vs. 12.5% in RE, P = 0.710). Although time to resumption of soft diet was shorter in the FO group than in the RE group, the lengths of hospital stay were not different. CONCLUSION: The FO and the conventional resection have similar short-term clinical outcomes for diverting ileostomy reversal.ope