Prognostic Implications of Primary Tumor Resection in Stage IVB Colorectal Cancer in Elderly Patients

PURPOSE: The aim of this study was to identify prognostic factors in stage IVB colorectal cancer in elderly patients, focusing on the influence of treatment modalities, including palliative chemotherapy and primary tumor resection. METHODS: A cohort of 64 patients aged over 65 years who presented with stage IVB colorectal cancer at the Gangneung Asan Hospital between July 1, 2001, and December 31, 2009, was analyzed. Demographics, tumor location, tumor grade, performance status, levels of carcinoembryonic antigen (CEA), level of aspartate aminotransferase (AST), and distant metastatic site at diagnosis were analyzed. Using the treatment histories, we analyzed the prognostic implications of palliative chemotherapy and surgical resection of the primary tumor retrospectively. RESULTS: The cohort consisted of 30 male (46.9%) and 34 female patients (53.1%); the median age was 76.5 years. Primary tumor resection was done on 28 patients (43.8%); 36 patients (56.2%) were categorized in the nonresection group. The median survival times were 12.43 months in the resection group and 3.58 months in the nonresection group (P < 0.001). Gender, level of CEA, level of AST, Eastern Cooperative Oncology Group performance status, tumor location, and presence of liver metastasis also showed significant differences in overall survival. On multivariate analysis, male gender, higher level of CEA, higher AST level, and no primary tumor resection were independent poor prognostic factors. In particular, nonresection of the primary tumor was the most potent/poor prognostic factor in the elderly-patient study group (P = 0.001; 95% confidence interval, 2.33 to 21.99; hazard ratio, 7.16). CONCLUSION: In stage IVB colorectal cancer in elderly patients, resection of the primary tumor may enhance survival.

A Case of a Mucinous Adenocarcinoma Arising from a Rectal Diverticulum

The occurrence of an adenocarcinoma arising from a rectal diverticulum that causes mechanical ileus is very rare. Recently, we diagnosed a case of a mucinous adenocarcinoma in a rectal diverticulum after an emergent abdominal perineal resection and permanent colostomy by laparotomy. Here, we present a case report and a review of the literature.

Laparoscopic versus Open Primary Repair for Perforated Peptic Ulcer / 대한내시경복강경외과학회지

PURPOSE: Simple closure, regardless of using an omental patch, continues to be the preferred option for many surgeons. It is a easy, quick and safe operation, and it can be applied to all situations by every surgeon. The purpose of this study was to investigate the feasibility of routinely using laparoscopic repair for treating perforated peptic ulcer. METHODS: A retrospective review was carried out on 68 consecutive patients who underwent patch repair for a perforated peptic ulcer; 11 underwent laparoscopic repair and 57 underwent open repair. Laparoscopic repair was performed by one surgeon at the same hospital between March, 2006 and February, 2009. Both groups were compared according to the Mann-Whitney U-test. A p value <0.05 was considered to be significant. RESULTS: Statistical significance (p<0.05) between two groups (laparoscopic vs. open) was present regarding to the postoperative morbidity (0 vs. 16 cases, respectively), the hospital stay (4.8 vs. 12.7 days, respectively), the postoperative day of resuming an oral diet (3 vs. 5.7 days, respectively). The mean operative time of laparoscopic repair (78 minutes) was shorter than that of open repair (82 minutes) but this was not statistically significant (p=0.81). We excluded using a pain scale or assessing the use of analgesics in this study because of the popularity of IV PCA (intravenous patient-controlled analgesia). CONCLUSION: Laparoscopic primary repair is a safe emergency procedure for treating perforated peptic ulcer patients.

Inguino-Femoral Hernia in Women

PURPOSE: Inguino-femoral hernias in women are less common than that in a man, and we have had limited experience for hernia repair in women. The purpose of this study was to evaluate the characteristics of inguino-femoral hernias in females and to establish the choice of specific treatment for inguino-femoral hernia in females. METHODS: This retrospective study was based on the medical records of 566 patients who underwent 657 cases of herniorrhaphies for treating inguino-femoral hernia in adult females from January 1998 to June 2006. We evaluated the incidence of hernia, the operative technique and the length of the operation, the complications and the postoperative recurrence rate. The operative findings and median time to reoperation for a recurrent hernia were also evaluated. RESULTS: During the 8.5-year period, we performed 2,931 herniorrhaphies in 2,274 patients. Of these, 657 herniorrhaphies were done in females (22.4%). The types of hernia in females were indirect inguinal hernia (67.3%), direct inguinal hernia (10.2%), the pantaloon type (10%) and femoral hernia (14.9%). Femoral hernia was more frequent in females (14.9%) compared to males (3.5%) (P<0.001). The overall rate of reoperation due to incarceration in the females was higher (2.5%) than that in the men (1.1%)(P<0.001). Femoral hernias in females was found at reoperation in 39.7% compared with 17.2% in the males (P<0.001). CONCLUSION: The incidence of inguino-femoral hernia in females was higher than the results of most published studies and the reoperation rate was higher in females. The increased frequency of femoral hernia at reoperation in females suggests avoiding injuries to the posterior wall of the inguinal canal and the need for exploration of the femoral canal at the time of the primary operation.

Composite Neuroendocrine Carcinoma with Adenocarcinoma of the Stomach Mimicking Double Primary Cancer

A 67-year-old man presented with a 3-month history for intermittent epigastric pain and postprandial discomfort. Upper gastrointestinal endoscopy and contrast-enhanced axial computed tomographic scan demonstrated two separate tumors of the gastric antrum and the duodenal second portion, suggestive of the preoperative diagnosis of a double primary cancer. Pancreaticoduodenectomy with lymph node dissection was performed, and the microscopic features and immunohistochemical profiles of the resected specimen confirmed the diagnosis of the composite neuroendocrine carcinoma with adenocarcinoma of the stomach (mixed exocrine-endocrine carcinoma).

Delayed Perforation of the Gallbladder after Blunt Abdominal Trauma

Isolated injury of the gallbladder rarely occurs after blunt abdominal trauma and, if so, is usually associated with damage to other intra-abdominal organs clearly necessitating surgical intervention. Blunt abdominal trauma is often overlooked because there may be no visible signs on the abdominal wall. It is important to closely follow patients and look for early signs of organ damage, as isolated injury of the gallbladder often follows a vague and insidious clinical course. A combination of special investigations may be required to confirm the diagnosis of this relatively rare but serious injury. Our case was a 38-year-old female, admitted to the hospital with a history of blunt abdominal trauma secondary to a fall. Initial computed tomographic scan demonstrated an edematous gallbladder; a follow-up computed tomographic scan showed a 5-cm collection of fluid around the gallbladder, suspicious for gallbladder perforation. Diagnostic laparoscopy followed by laparoscopic cholecystectomy was performed without complications. The postoperative course was uneventful and the patient was discharged on postoperative day three.

Deep Femoral Artery Aneurysm Presenting as Lower Limb Swelling: A Case Report

We report a rare case of lower limb swelling due to compression of the superficial femoral vein by a solitary deep femoral artery aneurysm. The patient was a 58-year-old man presenting with acute swelling of the right lower limb caused by deep venous thrombosis. A multi-detector computed tomographic scan (CT) confirmed the diagnosis of a deep femoral artery aneurysm and revealed no evidence of aneurysms or occlusive lesions in the other arteries. Aneurysmectomy and ligation of the deep femoral artery were successfully performed. Preoperative multi-detector CT scanning is a valuable, non-invasive diagnostic tool to delineate not only the state of the aneurysm, but also that of the distal arterial tree.

Spontaneous Rupture of a Primary Splenic Cyst Causing Hemoperitoneum

A 14-yr-old male presented with a hemoperitoneum caused by a spontaneous rupture of a primary splenic cyst. The laparotomy showed a ruptured spleen at the lower pole from one of the multiple cyst-like lesions, measuring approximately 2 cm in diameter. After the splenectomy, a microscopic examination confirmed the diagnosis of a primary splenic cyst lined with a mature, well-differentiated squamous epithelium. A hemoperitoneum caused by a spontaneous rupture of a primary splenic cyst is a rare but potentially lethal complication, because most patients with a splenic rupture present with some degree of hypovolemia.

Primary Splenic Tuberculosis Presenting as a Large Solitary Mass

Tuberculosis may be difficult to diagnose when it presents in an uncommon extrapulmonary site. Although there has been a resurgence of abdominal tuberculosis in immunocompromised patients, which is largely due to the extensive use of immunosuppressive drugs and the increasing incidence of a human immunodeficiency virus infection, splenic tuberculosis is rare, particularly in the immunocompetent patients. Almost all cases of splenic tuberculosis present as multiple hypoechoic foci on sonography or multiple focal hypodense lesions on contrast enhanced computed tomographic scan. To our knowledge, splenic tuberculosis is an extremely rare condition. An 80-year-old man was found to have a large solitary splenic mass mimicking a splenic neoplasm on sonography and contrast enhanced computed tomographic scan. A diagnostic splenectomy revealed a large solitary mass in the spleen, which was consistent with splenic tuberculosis microscopically. We report a rare case of splenic tuberculosis in an elderly man presenting as a large solitary splenic mass on sonography and contrast enhanced computed tomographic scan.

Torsion of the Gallbladder: Report of a Case

Torsion of the gallbladder is a rare entity that is difficult to diagnose preoperatively. The condition occurs most often in the elderly. Although its etiology is unknown, a constant finding is the presence of the gallbladder on a mobile mesentery (floating gallbladder). Torsion, or volvulus, of the gallbladder occurs when it twists axially, with the subsequent occlusion of bile and/or blood flow. Herein, a case of torsion of the gallbladder is presented where preoperative computed tomographic scan and laparoscopy were successfully used to diagnose and treat this condition without the usual requirement of open exploration. Given the possibility of laparoscopic cholecystectomy and the increasing incidence with which torsion of the gallbladder is being witnessed today, the importance of a preoperative computed tomographic scan is emphasized when there is a high index of clinical suspicion.

Computed Tomographic Findings of Anomalies of Intestinal Rotation in Adult Patients

Anomalies of the intestinal rotation mainly produce clinical manifestations in infants and children, but are uncommon in adults. We report three adult patients who presented with a surgical abdomen and the characteristic computed tomographic findings associated with anomalies of the intestinal rotation. Two patients presented with acute appendicitis, and one presented with an intestinal obstruction caused by colon cancer. In all patients, the computed tomographic findings were suggestive and were helpful for making a preoperative diagnosis of the anomalies of intestinal rotation: (1) a left-sided colon and/or (2) mesenteric vascular inversion. A computed tomographic scan is useful not only for providing an accurate diagnosis of a suspected surgical abdomen but also for detecting associated rotational anomalies, which may require a separate surgical correction.

Posterior Tibial Artery Aneurysm: A Case Report

Aneurysms of the infrapopliteal arteries are rare and they are commonly associated with trauma. We report here on a rare case of a true aneurysm of the posterior tibial artery in a sixty-year-old female. There was no history of trauma, and the serologic tests for the possibility of vasculitis were all negative. The color Doppler ultrasound examination and the multi-detector computed tomographic scan confirmed the diagnosis of a posterior tibial artery aneurysm and these tests revealed no evidence of aneurysms or occlusive lesions in the other arteries. Aneurysmectomy and end-to-end microvascular anastomosis were performed successfully. Preoperative multi- detector computed tomographic scanning is a valuable, noninvasive diagnostic tool to delineate not only the state of the aneurysm, but also that of the distal arterial tree.

Celiac Artery Aneurysm Associated with Chronic Pancreatitis: Case Report

Celiac artery aneurysms are extremely rare. Among the numerous conditions that can lead to a celiac artery aneurysm, acute or chronic pancreatitis has been described as one of the less common causes. A 54-year-old alcoholic man with a 7-year history of recurrent pancreatitis and iron deficiency anemia presented with a 15-day history of gastrointestinal bleeding. The contrast-enhanced axial CT scan and abdominal arteriography demonstrated that a 3-cm sized aneurysm had developed on the celiac artery and there were multiple calcified densities in the pancreas; these findings were suggestive of a diagnosis of celiac artery aneurysm with gastrointestinal bleeding that was caused by chronic pancreatitis. Aneurysmectomy without revascularization was performed successfully. We report here on a rare case of celiac artery aneurysm that was caused by chronic pancreatitis.

Isolated Gallbladder Injury after Blunt Abdominal Trauma

An isolated injury of the gallbladder rarely occurs after blunt abdominal trauma and is usually associated with damage to other intra-abdominal organs, which clearly necessitating surgical intervention. Blunt abdominal trauma is often overlooked because there may be no visible signs on the abdominal wall. It is important to closely follow up patients and look for early signs of organ damage as an isolated injury of the gallbladder often follows a vague and insidious clinical course. A combination of special investigations, including a contrast enhanced computed tomographic scan, may be required to confirm the diagnosis of this relatively rare, but serious injury, and if a lesion is suspected, a laparoscopy can be successfully used to confirm the diagnosis and treat this condition without the usual requirement of open exploration. Unfortunately, in our case, a laparoscopy could not be performed due to the patient having undergone previous surgery for early gastric cancer. Herein, the case of a 56-year-old male presenting with an isolated gallbladder injury immediately after violent blunt abdominal trauma, diagnosed on the basis of a computed tomographic scan, which was treated successfully, is reported.

Mesenteric Buerger's Disease

Thromboangiitis obliterans (Buerger's disease) is an uncommon vaso-occlusive, inflammatory disease, occurring in young smokers. It predominantly produces occlusion of small to medium-sized arteries and veins, especially the distal arteries and veins of the upper and lower extremities. Buerger, in his original description, noted that vascular obliteration could involve the mesenteric vessels, but no true series have been reported. Instead, publications have focused on case reports and most reported cases had significant peripheral vascular manifestations of Buerger's disease before developing mesenteric involvement. Considering the difficulty in early diagnosis and poor prognosis, young smokers with established or suspicious clinical manifestations of extremity Buerger's disease presenting with gastrointestinal manifestations should be carefully evaluated with a high index of suspicion. If mesenteric Buerger's disease is suspected clinically or angiographically, early surgical intervention including diagnostic laparoscopy is recommended to prevent or limit bowel gangrene. We report two cases of Buerger's disease with mesenteric involvement.

Endovascular Treatment in the Trauma Patients with Vascular Injury

PURPOSE: The role of vascular and interventional radiology in trauma patients is evolving. Endovascular treatments are helpful in treating vascular injuries in trauma patients. In some situations, endovascular treatments are as effective or more effective than surgery, but less invasive. We performed this study to evaluate the efficacy of endovascular treatments in the trauma patients with vascular injury. METHOD: Between September 2000 and September 2003, a total of 10 consecutive trauma patients with vascular injury who received endovascular treatments were included in this study. RESULT: Of the 10 patients, the most common injured arteries were the iliac arteries (5 patients), and the most common associated injuries were pelvic (8 patients) and long bone (6 patients) fractures. Transarterial embolization was performed in 9 patients, and stent-graft placement in 1. Clinical success was achieved in all 10 patients. After endovascular treatments, 3 patients with fluid collections were treated with ultrasound-guided, percutaneous drainage. Two of 10 patients died of complications other than hemorrhage. CONCLUSION: This initial experience suggests that endovascular treatment for trauma patients with vascular injury is safe and effective, and that it can also reduce the unnecessary laparotomies in these difficult cases.

Protein S Deficiency Presenting as Severe Peripheral Arterial Insufficiency

Among the numerous conditions that can lead to a hypercoagulable state, protein C and S deficiencies have been frequently described. Although protein C and S deficiencies have frequently been associated with venous thromboembolic events, instances of arterial thromboses have been reported, especially in young patients. The exact incidence of protein C and S deficiencies in patients with peripheral arterial insufficiency has not been established. Given the paucity of adequate studies to define the natural history and arteriographic findings of these patients, treatment has not been well delineated. We report a young female patient who presented with severe peripheral arterial insufficiency and underwent an unusual clinical course associated with protein S deficiency.

Repeat CT Scan for Non-operative Management of Blunt Splenic Trauma

PURPOSE: This study was performed to evaluate the value of repeated CT scans for the non-operative management of patients with clinically stable blunt splenic trauma. METHODS: 49 consecutive patients with blunt splenic trauma were prospectively studied. Of these, 29 (59.2%) were initially managed non-operatively according to their clinical status and initial CT findings. A repeat CT scan was obtained within 7 days of admission. RESULTS: Of the 29 non-operatively managed patients, 5 (17.2%) required delayed surgical intervention: 3 presented with a change in thier clinical status, whereas the other 2 did not. In all 5 patients, a repeat CT scan revealed a deteriorating appearance of the splenic injury: active bleeding or an increased hematoma in 3, with splenic artery pseudoaneurysms in the other 2. CONCLUSION: This initial experience suggests that a repeat CT scan can provide valuable clinical information in selected cases on the diagnosis and management of a splenic injury to document the healing or progression of the injury.

Necrotizing Fasciitis Secondary to Perforated Appendicitis

Necrotizing fasciitis is a rapidly progressing soft-tissue infection that affects the subcutaneous fascia and dermis, and characteristically spares the underlying muscle. Most cases represent a synergistic or mixed bacterial infection of aerobes and anaerobes. A variety of etiologies have been reported. Herein, two cases of necrotizing fasciitis of the right thigh secondary to perforated appendicitis, an extremely rare complication, are reported. Both cases recovered following aggressive surgical and medical therapies. The delay in diagnosis and radical surgical excision are frequent and significant contributory factors in the high reported mortality rate. A high index of suspicion, followed by prompt surgical intervention with broad-spectrum antibiotic therapy, seems to be the most important prognostic factor in these difficult cases.

Endovascular Management of Iliofemoral Deep Venous Thrombosis due to Iliac Vein Compression Syndrome in Patients with Protein C and/or S Deficiency

The purpose of this study was to evaluate the early outcome of endovascular management in patients with iliofemoral deep venous thrombosis (DVT) due to iliac vein compression syndrome (IVCS) and protein C and/or S deficiency. Between September 2000 and January 2003, catheter-directed thrombolysis was performed in 11 patients with a diagnosis of acute iliofemoral DVT: 7 with protein C and/or S deficiency and 4 without protein C and/or S deficiency. After thrombolysis, the diagnosis of IVCS was confirmed in 6 patients: 4 with protein C and/or S deficiency and 2 without protein C and/or S deficiency. Further intervention consisted of angioplasty and stent placement was performed. Four patients with IVCS and protein C and/or S deficiency were included in this study. The immediate technical and clinical success rates were 100% in all 4 patients. There were no complications or clinically detectable pulmonary emboli. This initial experience suggests that endovascular management of iliofemoral DVT due to IVCS in patients with protein C and/or S deficiency is safe and effective.