Mirizzi Syndrome with Cholecystobiliary Fistula

BACKGROUND: Mirizzi syndrome is a rare presentation of long-standing cholelithiasis. It occurs when gallstones become impacted in either the gallbladder neck or the cystic duct, causing an obstruction of the common hepatic duct by extrinsic compression. Furthermore, impacted stones may cause pressure necrosis of the adjacent bile duct and produce a cholecystobiliary fistula. Although the definition of this syndrome varies somewhat among authors, Csendes et al. defined four evolving stages of patients with Mirizzi syndrome and cholecystobiliary fistulas. The aim of this study was to observe the clinical characteristics and to review the literature for better management in this clinical situation. METHODS: We retrospectively observed 7 patients who had been diagnosed with Mirizzi syndrome and cholecystobiliary fistulas perioperatively at Hanyang University Hospital. RESULTS: The 6 male patients and the one female patient had an average age of 58 years (range, 39 to 74 years). Jaundice was present in all patients. Six patients complained of abdominal pain, and two patients had acute inflammatory signs, such as fever/chill. Preoperative evaluations suggested Mirizzi syndrome in only two patients. A cholecystectomy was performed in all patients, followed by repair of the common hepatic duct and T-tube choledochostomy in three patients. A hepaticojejunostomy was required for the three difficult patients. The Csendes et al. classification was type I in one patient, type II in four, and type III in two. CONCLUSIONS: Since preoperative diagnosis of Mirizzi syndrome remains difficult, a high index of suspicion is required to diagnosis the condition, and awareness of the cholecystobiliary fistula condition is of the utmost importance for safe and optimal management.

Clinical Analysis of Desmoid Tumor

Desmoid tumor is a infrequent, but particular type of fibromatosis (dysplastic lesion of connective tissue), usually originating in the fascial sheath or musculoaponeurotic tissue of the body. It is characterized by its propensity for slow, incessant growth and by its nonmetastastic but locally aggressive behavior. While rarely associated with this tumor, morbidity and mortality occur when there is encroachment on vital structures. Because of the scarcity of data, the relatively small number of patients and the pathological resembrance to low-grade fibrosarcoma, desmoid tumor may be easily misdiagnosed and wrong conclusions regarding its biological behavior may be drawn. Also, the optimal treatment for this tumor remains controversial. At present, the most successful method of control of desmoid tumor is complete excision with a clear margin of normal tissue surrounding the tumor. To better delineate the natural history and the result of managing patients with this disease, we have reviewed all patients with desmoid tumor treated at our hostital from 1985 to 1996, and the following results were obtained : The male-to-female ratio was 1 : 2.7, and a childbearing-aged female preponderance was present like most reports. Seven of 22 patients(32 %) developed local recurrence. The recurrence of desmoid tumor was not related to patient's sex/age, location/size of the tumor, and previous operative history. Even though desmoid tumor is not pathologically malignant, it should be regarded as clinical malignancy and be treated by wide excision with pathologically-proven safe resectional margin.

Clinicopathological Analysis of Krukenberg Tumor Arising from Stomach Cancer

BACKGROUND: The Krukenberg tumor (KT) is a metastatic or primary ovarian tumor of the signet-ring cell type. The incidence of this tumor is higher in Korea than in Western countries due to the higher incidence of gastric cancer in Korea. This tumor arises more commonly in the relatively young age group, especially women in the prememopausal period. We tried to find the clinicopathological (CP) characteristics of this tumor and also tried to confirm the appropriateness of the classification by the Japanese Research Society for Gastric Cancer which classifies a KT as P2. METHODS: We observed 23 cases of KT which were diagnosed from July 1984 to December 1997 at the Department of General Surgery, Hanyang University Hospital and analyzed their CP factors. RESULT: The age distribution ranged from 30 to 67 years old, and the mean age was 43.3 years old. The most common symptom was lower abdominal pain. The tumor occurred at the bilateral ovaries in 17 cases (74%). Two patients who manifested a KT without other metastatic findings during gastric cancer surgery survived 20 months and 8 months (still alive), whereas 21 cases with peritoneal seeding (PS)(P2) and 6 cases which manifested a KT combined with PS had mean survival durations (MSD) of 7.4 months and 7.2 months, respectively. The MSDs for three patterns of recurrence were 21.4 months for KT cases (8 cases), 21.4 months for PS cases (47 cases), and 5.0 months for KT combined with PS cases (7 cases). In patients under the age of 50 years old who showed signet-ring cell type gastric cancer, the incidence of a KT as a coincidental finding or as a form of recurrence was 24.1% when the tumor showed serosal invasion. CONCLUSIONS: The prognosis for a patient with a KT was relatively better than that for patient with other forms of PS, which is due to the difference in the resectability of these two forms of P2 cancer.This indicates a need to reconsider the P2 classification. If the gastric cancer with a signet-ring cell type and more than T3 in women under the age of 50 years old, we have to consider the necessity for a preventive oophorectomy because of the high incidence of KTs under such conditions.

Remnant Gastric Cancer

Remnant gastric cancer is defined broadly as cancer that develops in the remnant stomach after the resection of nonmalignant or malignant lesions. Generally speaking, remnant gastric cancer is defined as its interval between previous gastrectomy and the detection of remnant gastric cancer must be over 10 years in the previous malignant or nonmalignant lesions. From Aug. 1988 to Dec. 1995, fifteen patients who were operated as remnant gastric cancer (broad definition) in Hanyang Universty Hospital was reviewed as follows. Sex distribution was 12 cases in male and 3 cases in female. Peak incidence of age was 5th and 6th decades.The T.N.M. staging was at first operation: benign disease in 6 cases, stage I in 4 cases, stage IIIa in 1 case, stage IIIb in 2 cases and unknown stage in 2 cases, and at 2nd operation; stage I in 3 cases,stage II in 1 case, stage IIIa in 2 cases, stage IIIb in 5 cases, stage IV in 4 cases. The interval between first and second operation was as follows : less than 5 years in 4 cases, 5 to 10 years in 2 cases, 10 to 15 years in 3 cases, and over 20 years in 6 cases. The procedure at first operation was Billroth II procedure, and the procedure at 2nd operation was as follows: total gastrectomy with Roux-en-Y esophagojejunostomy in 12 cases,total gastrectomy with loop esophagojejunostomy in 2 cases,dismentling partial gastrectomy with Roux-en-Y gastrojejunostomy in 1 case. In our opinion,early diagnosis of remnant carcinoma following gastric surgery by the endoscopic follow up and aggresive surgery are important to improve disease free interval and patient survival.

Comparative Studies on Clinicopathologic Characteristics and surgical Results in Senile and Young Patients with Gastric Cancer

The diagnosis of gastric cancer in young age group was sometimes missed .The operative risk in senile age group was high because of combined other organ diseases. We tried to determine the difference in their correct clinicopathologic features and the prognosis of young and senile patients with gastric cancer. Clinicopathologic characteristics and surgical results were compared in 40 senile gastric cancer patients who were aged 65 years or above, and in 48 young gastric cancer patients who were aged 40 years or less. In clinicopathologic features, the senile group was characterized by a high incidence of well differentiated adenocarcinoma and intestinal type by Lauren classification. The young age group was characterized by high incidence of undifferentiated type adenocarcinoma and diffuse type by Lauren classification . The others were unremarkable. When the survival rate was compared in all cases between young and senile group, the young age group showed a more favorable prognosis than the senile group, but without statistical difference ( P=0.0058 ) . Also, the survival rate according to UICC stage showed no statistical difference when the same stage of the two different groups were compared . Both group showed better survival in curative surgery cases than in noncurative surgery cases.Our findings ruled out any relationships between age and length of survival time in patients undergoing curative gastrectomy for gastric cancer.

Reasonable Time for Removal of the Nasogastric Tube after a Radical Gastrectomy

The necessity for routine prophylactic nasogastric tube decompression after a gastrectomy is still in controversy. Several reports have indicated that nasogastric tube decompression is unnecessary and that the tube may even be harmful with serious discomforts. A D2 gastrectomy (which means a D2 lymph node dissection during gastric cancer surgery) for a gastric carcinoma is an extensively destructive procedure which takes a longer operation time than a conventional gastrectomy, destroys both sympathetic and parasympathetic nerve fibers in the upper retroperitoneum, and may interfere with the gastrointestinal motility after the operation. Therefore, we have carried out a retrospective study with 206 gastrectomized gastric-cancer patients to evaluate the necessity of nasogastric tube decompression and whether the tube influences the gas-passing time, the morbidity, and mortality after operation.