Laparoscopy-assisted Surgical Removal of a Retained Wireless Capsule Endoscopy: A case report

Occult bleeding of the gastrointestinal tract is a major cause of iron deficiency anemia. Even with endoscopic evaluation of the upper and the lower gastrointestinal tract in these patients, in 30~50% of the cases, the cause of bleeding still remains undiscovered. Wireless capsule endoscopy (WCE) is a novel method of evaluating the small bowel mucosa by using a small capsule equipped with a camera and transmission device. Complications of WCE include impaction within the gastrointestinal tract, sometimes requiring surgical removal. The authors report a case of capsule impaction in the small bowel in a patient evaluated for anemia due to occult gastrointestinal tract bleeding. The patient is a 19 year-old female with a history of anemia since age 4. The stool guaiac test was positive, but upper and lower gastrointestinal tract endoscopy showed no abnormalities, so WCE was done. A short segment of circular ulcers with lumen narrowing were seen in the distal jejunum. Seven days after ingestion of the capsule, the patient denied passage of the capsule. Small bowel enteroclysis was performed, and the capsule was seen along with a segment of lumen narrowing distal to the site of retention. Surgery was done, and upon laparoscopic examination, the entire bowel appeared normal. Retrieval of the capsule was done along with a resection of an 8 cm segment of the small bowel. Three linear ulcers were seen in the resected bowel specimen. Pathology revealed no evidence of Crohn's disease or tuberculosis. The patient is still on iron supplements, but her hemoglobin level remains stable at 11~12 g/dl.

A case of colonic lymphoid tissue invasion by Gymnophalloides seoi in a Korean man

A 65-year old Korean man, living in Mokpo-city, Jeollanam-do, Republic of Korea, visited a local clinic complaining of right upper quadrant pain and indigestion. At colonoscopy, he was diagnosed as having a carcinoma of the ascending colon, and thus, a palliative right hemicolectomy was performed. Subsequently, an adult fluke of Gymnophalloides seoi was incidentally found in a surgical pathology specimen of the lymph node around the colon. The worm was found to have invaded gut lymphoid tissue, with characteristic morphologies of a large oral sucker, a small ventral sucker, and a ventral pit surrounded by strong muscle fibers. This is the first reported case of mucosal tissue invasion by G. seoi in the human intestinal tract.

Transanal Endoscopic Microsurgery after Preoperative Concurrent Chemoradiation Therapy in Selected Distal Rectal Cancer Patients

PURPOSE: Preoperative concurrent chemoradiation (CCRT) therapy may allow higher rates of tumor resectability and sphincter-saving procedures. Transanal endoscopic microsurgery (TEM) has become increasingly common in the management of selected patients with early rectal cancer. The aim of this study is to evaluate the clinical outcomes of selected patients with distal rectal cancer treated with TEM after CCRT. METHODS: Between June 2000 and August 2004, 7 patients with clinically T2 or T3 rectal cancer underwent TEM after CCRT. Pretreatment and preoperative clinical stages were estimated by using endorectal ultrasound or computed tomography and digital rectal exam. CCRT was performed with radiation therapy of 4,500 cGy/25 fractions over 5 weeks with 5-FU based chemosensitization. TEM was performed 4~7 weeks following the completion of therapy. RESULTS: The mean age was 54.9 (35~70) years and the median follow-up period was 23.0 (5~57) months. The lesions were located between 2 to 6 cm above the anal verge (median 3.0 cm). Pre- treatment T staging was estimated as T3 in 1 case and T2 in 6 cases, and post-treatment T staging was estimated as complete remission (CR) in 2 cases, T1 in 3 cases, and T2 in 2 patients. Pathologic evaluation revealed tumor downstaging in 6 patients, including 3 patients (42.9%) with CR. In all cases, there was no tumor on the resection margin. There have been no recurrences during the follow-up period. CONCLUSIONS: TEM after CCRT therapy appears to be an effective alternative treatment to radical resection for highly selected patients with T2 and T3 distal rectal cancer.

Decision of Salvage Treatment after Transanal Endoscopic Microsurgery: Clinical Experience on 36 Cases of Rectal Cancer

PURPOSE: Local excision, including transanal endoscopic microsurgery (TEM), has become an alternative to the classic radical operation for early rectal cancer. However, radical resection for rectal cancer is necessary for advanced tumor, poor differentiation, a narrow resection margin, and positive lymphovascular invasion. This study presents the factors related to recurrence in patients who required secondary radical surgery after TEM, but did not undergo the operation. METHODS: From November 1994 to December 2004, 167 patients underwent TEM for rectal cancer. Thirty-six of those patients were included in this study. Inclusion criteria were poor differentiation, a mucinous carcinoma, invasion to a proper muscle layer, lymphovascular invasion, and a positive resection margin. RESULTS: Twelve of the 36 patients underwent a secondary radical operation, but 24 of them did not due to poor general condition or refusal. One of 12 patients (8.3%) who underwent a secondary radical operation had a systemic recurrence. Five of 24 patients (20.8%) who did not receive surgery had recurrences; 3 of 5 were local recurrence, and the others were distant metastases. Among the 24 patients who did not undergo a secondary radical operation, there were no recurrences in 2 cases of poor differentiation or mucinous carcinoma and in 2 cases of positive resection margin. There were 2 cases of recurrences in the 7 patients (25.0%) who had lymphovascular invasion, 1 case in the 1 patient (100%) who had a T3 lesion, 3 cases in the 17 patients (12.5%) who had T2 lesions. CONCLUSIONS: In high-risk patients, TEM followed by radical surgery is most beneficial in preventing local recurrence. A radical operation is strongly recommended especially if pathologic results after TEM shows T3 lesions or lymphovascular invasion.

Expression of beta-catenin in Colorectal Cancer with Liver Metastasis

PURPOSE: Decreased expression of beta-catenin has been known to be associated with tumor metastasis. However, the clinical relationship between the degree of expression and the prognosis in colorectal cancer (CRC) remains unclear. In this study, we evaluated the prognostic value of beta-catenin expression in CRC patients with liver metastasis. METHODS: Paraffin embedded blocks were obtained from 70 patients who underwent potentially curative resection for CRC with liver metastasis. Samples from normal colon mucosa, primary CRC and metastatic liver lesion were prepared in tissue microarrays and were stained by immunohistochemistry with monoclonal antibody against beta- catenin. The membranous beta-catenin expression was assessed and the beta-catenin expression difference between primary CRC and metastatic liver lesion was analysed in relation to overall survival as well as disease free survival rates. RESULTS: In beta-catenin expression, preserved expression (score >6) was observed in 42.0%, and 21.9% of primary CRC tumor samples and tumor samples from metastatic liver lesion respectively. The degree of beta-catenin expression in metastatic liver lesion was significantly lower than that in primary CRC (P=0.022). According to the difference of beta-catenin expression score between primary CRC and liver metastasis, patients were classified as group 'A' and 'B'. Group 'A' was defined as patients showing remarkably decreased expression of beta-catenin in metastatic liver lesion in that the difference of the score was three or more. Group 'B' was defined as patients showing maintained or increased beta-catenin expression in metastatic liver lesion in comparison to primary CRC, in that the difference of beta-catenin expression score was less than three. Overall survival rate and disease free survival rate were significantly better in group 'B' than group 'A' (P=0.02, P=0.002). CONCLUSIONS: Decreased expression of beta-catenin in metastatic liver lesion may be a poor prognostic marker in colorectal cancers with liver metastasis. A further large-scaled investigation is necessary to define the role of beta-catenin in CRC.

Clinical Review of Primary Small Bowel Tumors

PURPOSE: The aims of this study were to identify the clinicopathological features and treatment outcome of primary small bowel tumors. METHODS: Sixty-five patients, with primary small bowel tumors, treated at the Samsung Medical Center, between November 1994 and February 2002, were retrospectively analyzed. The mean follow-up was 20.8 months, ranging from 2 to 93 months. RESULTS: The mean age of the patients was 55.5 years, ranging from 26 to 84 years, with 42 men and 23 women. The most common symptom was abdominal pain (58.5%), followed by bleeding and an abdominal mass. The mean duration of the symptoms was 4.6 months, ranging from 2 days to 24 months. Diagnostic studies were performed by an abdominal CT scan, small bowel series, enteroclysis and angiography. The primary sites of the tumors were the jejunum and the ileum in 33 and 32 patients, respectively. Thirteen (20.0%) patients had benign tumors, including 8 (12.3%) benign stromal tumors, 2 lipomas, 2 hamartomatous polyps and 1 cavernous hemangioma. Fifty-two (80.0%) of the patients had malignant tumors, including 26 (40.0%) malignant stromal tumors, 21 (32.3%) lymphomas and 5 (7.7%) adenocarcinomas. Surgery was performed on all patients; a resection and anastomosis in 45 (69.2%), a right hemicolectomy in 10 (15.3%), an ileocecectomy in 5 (7.6%) and a wedge resection in a further 5 (7.6%). Metastasis was found on initial presentation in 21 (40.4%) patients. Combined liver, bladder and colon resections were performed in 7 (10.7%) patients. Four (6.1%) patients died during the perioperative period. The overall 3 year survival rate of the patients with malignant small bowel tumors was 58.6%. CONCLUSION: Performing aggressive surgical manipulation in suspected small bowel tumors, and the use of postoperative adjuvant therapy in lymphomas, will result in better outcomes for patients.

Genetic Polymorphism of Xenobiotics Metabolizing Enzymes and Individual Susceptible Genes to Colorectal Cancer Patients in Korea

Individual susceptibility to cancers may result from several factors including differences in xenobiotics metabolism, DNA repair, altered oncogenes and suppressor genes, and environmental carcinogen exposures. To determine the frequencies of the genotypes of phase I (CYP1A1 and CYP2E1) and phase II (GSTM1 and NAT2) metabolizing enzymes and to identify the high-risk genotypes of these metabolic enzymes to colon cancer in Korean, we have analyzed 113 colorectal cancer patients and corresponding age and sex matched healthy controls using polymerase chain reaction-restriction fragment length polymorphi(PCR-RFLP). In analysis of phase I enzymes, m1/m2, m2/m2 and Val/Val genotypes in CYP1A1 enzyme polymorphisms and C1/C2 genotype in CYP2E1 polymorphism were associated with high relative risks to colorectal cancers (Odds ratio; 1.51, 1.59, 1.76 and 1.38, respectively). Among the phase II enzymes polymorphisms, GSTM (-) genotype of GSTM1 enzyme and slow acetylator (S/S) of NAT2 enzyme had 1.48 and 1.34 times of relative risks to colorectal cancers, respectively. In combined genotyping of phase I enzymes and GSTM1 polymorphisms, the patients with m1/m2 and GSTM (-), Val/Val and GSTM (-), and C1/C2 and GSTM (-) combined genotypes had higher relative risk than the patients with each baseline of combined genotypes (Odds ratio; 2.15, 5.81 and 2.20, respectively). In combined genotyping of phase I enzyme and NAT2 polymorphisms, the combined genotypes of m1/m2 with slow acetylator and C1/C2 with slow acetylator were more susceptible to colorectal cancer (Odds ratio; 3.5 and 4.5, respectively). These results suggest that the combined genotypes of Val/Val and GSTM (-), m1/m2 and slow acetylator, and C1/C2 and slow acetylator were more susceptible to colorectal cancer in Korean. And genotyping of xenobiotics metabolizing enzymes could be useful for predicting an individual susceptibility to colorectal cancer.

Therapeutic Results of Transanal Endoscopic Microsurgery and Radical Surgery for T1, T2 Rectal Cancer

PURPOSE: Transanal endoscopic microsurgery (TEM) has gained increasing acceptance as a treatment of choice for early rectal cancer. The purpose of this study was to compare the results of TEM and radical surgery in patients with T1 and T2 rectal cancer. METHODS: From October 1994 to December 2000, 74 patients with T1 and T2 rectal adenocarcinoma treated with TEM were compared with 100 patients with T1N0M0 and T2N0M0 rectal adenocarcinoma treated with radical surgery. Retrospective analysis was made regarding to recurrence and survival rate. Neither group received adjuvant chemo-radiation. There was no significant difference in age, gender, tumor location and follow-up period between two groups, except tumor size. RESULTS: Of 74 patients in TEM group, 52 patients were T1 (70.3%) and 22 patients were T2 (29.7%). Of 100 patients in radical surgery group, 17 patients were T1 (17.0%) and 83 patients were T2 (83.0%). Five-year local recurrence rates were 4.1% for T1, 19.5% for T2 after TEM, 0% for T1 and 9.4% for T2 after radical surgery. There was no statistical difference between T1 rectal cancer (P=0.95), but in T2 rectal cancer, it was higher after TEM than after radical surgery (P=0.04). Five-year disease free survival rates showed no statistical difference between two groups (TEM group: 95.9% for T1, 80.5% for T2, radical surgery group: 94.1% for T1, 83.3%for T2; P=0.35, P=0.12). Five-year survival rate were 100% for T1, 94.7% for T2 after TEM and 92.9% for T1, 96.1% for T2 after radical surgery. There were no significant statistical difference between two groups (P=0.07, P=0.48). CONCLUSIONS: In T1 rectal cancer, there were no difference in recurrence and five-year survival rate between TEM and radical surgery group. In T2 rectal cancer, five-year survival rate showed no statistical difference between two groups, but TEM carried higher risk of local recurrence. Therefore careful selection of the patients is required for TEM and when proper muscle invasion is proven after TEM, further treatment should be considered.