Clinical Results of Transanal Endoscopic Microsurgery (TEM)

PURPOSE: Local treatment of rectal tumors have become an alternative to the classic radical operation. However, conventional transanal procedures are limited to tumors located in the lower rectum and the precision of the excision is restricted by the limitation of the surgeon's visualization during the procedure. This report will present our surgical management and functional results after TEM, a new minimally invasive technique for the treatment of rectal tumors. METHODS: From December 1994 to January 2000, 136 patients underwent TEM. All patients were evaluated preoperatively with sigmoidoscopy or colonoscopy with biopsy. The indications for TEM were benign rectal tumors and T1 and T2 malignant rectal tumors with well or moderately differentiation. All patients were followed up 1 month postoperatively and every 3 months thereafter. RESULTS: The mean operation time was 56.5 minutes (25~150 minutes) and the mean postoperative hospital stay was 3.6 days (2~10 days). On the basis of the postoperative evaluations, 56 of the 136 patients proved to have benign tumors while the remaining 80 patients had malignant tumors. One hundred thirty five patients were removed with adequate resection margins. One patient had cancer cell involvement at the resection margin. There were no serious complications. After a mean observation time of 29 months (12~42 months), there were five noted recurrences. Functional results were excellent; 24 of the 136 patients complained of impaired continence or defecation disorders in a review one month postoperatively. These problems improved during the first 6 months after the surgery. CONCLUSIONS: We feel that TEM is an adequate method for removal of benign rectal tumors, and properly selected early rectal cancers.

Short-term Results of Radiofrequency Ablation for Liver Metastasis of Colorectal Cancer

PURPOSE: Radiofrequency ablation (RFA) is emerging as a new therapeutic method for the management of hepatic malignancy. We report our experience on the use of his technique for the management of liver metastasis of colorectal cancer. METHODS: All 32 colorectal cancer patients with synchronous or metachronous liver metastasis treated with RFA from May 1999 to May 2001 were reviewed using retrospective method including chart review and telephone interview. All patients were followed up postoperatively to assess complications, complete necrosis, local recurrence, and survival rate. RESULTS: Forty-one RFA sessions were performed on 70 metastatic tumors in 32 patients. There were no treatment- related death. Two complications related with RFA treatment, one intrahepatic bleeding and one intrahepatic abscess, occurred in 41 sessions of RFA (6.2%). With a median follow-up of 13.5 months, tumors recurred in 7 of 70 lesions (10.0%) from 5 patients due to incomplete necrosis and intrahepatic new lesion or distant metastasis in 13 patients of 27 patients (51.9%) after complete necrosis. There were 5 deaths and the 2 year survival rate was 80.9%. Disease free survival was 90.1%, 75%, 26.4% in 6 months, 12 months and 24 months, respectively. Seven patients underwent liver resections successfully with the application of RFA for the residual lesions in the remaining contralateral lobe. In these patients, with 9.0 months median follow up, the disease recurred in 2 patients due to incomplete necrosis, while recurring in 2 patients after complete necrosis and 3 patients were survived without recurrence or distant metastasis. CONCLUSIONS: Radiofrequency ablation is a safe, well-tolerated, and effective treatment for liver metastasis in colorectal cancer patients. The procedure can be used to treat the residual tumor load in the contralateral lobe following liver resection in those considered unresectable at first presentation. This new therapeutic strategy seems to increase surgical resectability in patients whose mass is determined unresectable. To approve the efficacy of RFA, more long- term follow up should be attempted.

Flexible Rectal Stent for Obstructing Colonic Neoplasms

Acute lower gastrointestinal obstruction due to colorectal neoplasm is a common clinical problem, which frequently requires emergency operation. Morbidity and mortality associated with emergency operation is relatively high, and almost all requires a multi-stage operation. Recently flexible rectal stent has been emerged as an alternative for the management of acute lower gastrointestinal obstruction due to colorectal neoplasm. Thus we analyzed the results of flexible rectal stent treatment for acute lower gastrointestinal obstruction due to colorectal neoplasm. METHODS: From June 1996 to May 1999 47 patients with acute malignant lower gastrointestinal obstruction were included in this study, medical records of these patients were reviewed retrospectively. RESULTS: Of 47 patients 19 were male and 28 were women, with a mean age of 57.3 years (33~77 years). Male to female ratio was 1:1.47. Causes of acute intestinal obstruction were as follows: rectal cancer, 17 patients; sigmoid colon cancer, 18 patients; descending colon cancer, 3 patients; ascending colon cancer, 1 patient; stomach cancer, 5 patients; gall bladder cancer, 1 patient; and uterine cervix cancer, 1 patient; and ovarian cancer, 1 patient. Stent insertion was indicated as palliative treatment in 22 patients and preoperative decompression in 25 patients. Successful stent insertions were achieved in 40 patients (85.1%). Stent insertion was successful in 20 patients (91.0%) among the 22 patients treated for palliation. Stent insertion was successfully achieved in 20 patients (80.0%) among the 25 patients. Stent insertion failure was observed in 7 patients (14.9%). Stent failed due to the complete obstruction, 3 patients; long segmental lesion, 1 patient; anatomic abnormality, 1 patient; multiple lesions, 1 patient, and ultra-low rectal lesion, 1 patient. Colonoscopy-assisted stent insertion was performed in 5 patients. Post-stent complications occurred in 12 patients among the 40 patients (30.0%): stent migration, 8 patients; expansion failure, 2 patients; fecal incontinence, 1 patient; and malposition, 1 patient. The interval between stent insertion and operation was from 1 to 30 days with a median of 7 days. Elective operations were performed as follows: anterior resection, 6 patients; low anterior resection, 7 patients; Miles' operation, 3 patients; sigmoid colostomy, 3 patients; and transverse colostomy, 1 patient. Mean distal resection margin of specimen was 2.3 cm. No postoperative complication was seen. CONCLUSIONS: Multi-stage operation can be avoided with flexible rectal stent without increasing postoperative complications. Complication rate was relatively high in patients whom stent were inserted for palliative intent. Combined colonoscopy increased the successful rate in difficult cases. Immediate operation should be considered for the patients with long segmental lesion, multiple lesions, ultra-low rectal lesion, and when perforation is suspected.

Clinical Analysis of Total Colectomy for Chronic Idiopathic Constipation

The aim of this study was to analyse clinical feature and outcome of patients following total abdominal colectomy and ileorectal anastomosis. METHODS: All of 8 patients subjected to surgery during 5 year period from May 1995 to December 1999 were reviewed using retrospective method. RESULTS: All patients had slow colonic transit and 7 patients (male to female, 1:1.6) with a mean age of 54 (range, 27~70) years underwent total abdominal colectomy and ileorectal anastomosis and one patient had right hemicolectomy. Major symptoms were abdominal pain and bloating and mean bowel action was 18.5 days, mean suffered time before operation was 26.3 years. Colonic transit study, defecography and rectal manometry were done in all cases. Pelvic floor dysfunction was combined in 5 patients. Median follow up was 2.7 years. There was one mortality case due to postoperative pneumonia and ARDS in a 70 year old patient. Except one mortality case, there was significant success rate, overall 71%. CONCLUSIONS: Colectomy with ileorectal anastomosis produces a satisfactory outcome in the majority of patients undergoing surgery for chronic idiopathic constipation.

Combined Interpretation of Pretransplant Anti-hepatitis C Virus(HCV) Antibody by 3rd Generation ELISA and HCV-RNA by Polymerase Chain Reaction (PCR) for the Prediction of Posttransplant Liver Dysfunction / 대한이식학회지

Currently accurate test for identification of HCV infection is not yet developed. We examined 1) the relationship between the result of anti-HCV by 3rd generation ELISA (ELISA/3) and of HCV-RNA by PCR from pre-transplant stored serum in 89 living donor renal transplant recipients and 2) the correlation between the result of each or combined tests and the development of post-transplant liver dysfunction (LDF). LDF was defined as the increment of serum transaminase over 100 I.U./ml in two consecutive tests. Patients with clinically or biopsy proven LDF by cyclosporine were excluded. Pre-transplant HCV infection rate assessed by ELISA/3 and PCR was 20.2 and 29.2% respectively. Patients with PCR (+) developed LDF frequently compared with negative partners (50 vs. 27%, p=0.0367). Significant disparity between ELISA/3 and PCR was present. In 71 ELISA/3 (-) patients, 16(22.5%) were positive for PCR. However 8 (44.4%) were negative for PCR in 18 ELISA/3 (+) patients. ELISA/3 (+) or PCR (+) patients developed LDF frequently rather than ELISA/3(-)/PCR(-) ones(50.0 vs. 23.6%, p=0.0106). We could explain these data with 5 possibilities; 1) end-stage renal failure patients had a blunt antibody production, 2) serum sample may be collected during the window period for antibody formation, 3) even ELISA/3 could not detect fine molecular response during the early HCV infection(false negative), 4) significant false positive or serum contamination in PCR test, and finally 5) self-clearing of HCV antigen may be present in the body. In conclusion, HCV detection by PCR method and antibody test by ELISA/3 must be complementary for the accurate evaluation of HCV infection during the recipient evaluation and posttransplantation follow-up period.