Clinical Manifestations of Childhood Intussusception with Ubiquitous Ultrasonography: Comparison with Small Bowel and Ileocecal Type

We analyzed the clinical characteristics and outcome of ileocecal and small bowel intussusceptions (ICI and SBI) in the pediatric patients. From August 2003 to July 2010, 144 children with intussusception were included in this study. We retrospectively reviewed the clinical records and imaging study findings. A total of 86 children with ICI and 58 children with SBI were diagnosed. Children with SBI were older than ICI (36.6+/-24.6 months vs. 24.2+/-21.6 months, p=0.002). Typical symptoms such as irritability, abdominal mass, bloody stool were more frequent in ICI than SBI (p<0.05) patients. In the ICI group, intussusceptums were reduced with air reduction (84.5%), surgery (17.4%), and spontaneity (1.2%). All patients in the SBI group were reduced spontaneously. SBI occurred in older age and was reduced spontaneously more frequently than ICI. Conservative management with close observation with follow-up by ultrasonography is recommended for SBI.

Pneumothorax occurring during laparoscopic anterior resection of sigmoid colon cancer: A case report

Pneumothorax during laparoscopic surgery is a potentially fatal complication.We present a case of left-sided pneumothorax complicating laparoscopic anterior resection of the sigmoid colon cancer.After signs suggestive of pneumothorax were recognized during carbon dioxide pneumoperitoneum, chest X-ray confirmed the diagnosis.Oxygen saturation and vital signs were maintained by increasing the inspired oxygen fraction and deflating the pneumoperitoneum.The pneumothorax resolved spontaneously after surgery and there were no complications.This case shows the importance of vigilance on the part of the anesthesiologist during laparoscopic surgery.

Clinicopathological Characteristics of Sporadic Colorectal Cancer with DNA Microsatellite Instability

PURPOSE: Sporadic colorectal cancers, with DNA microsatellite instability (MSI), have been characterized by a predilection area of proximal colon, younger age onset, exophytic growth and larger tumor size. MSI colorectal cancers have recently been had a good survival rate. The aim of this study is to determine the MSI status in sporadic colorectal cancers, and compare their clinical and pathological characteristics with those of MSS (Microsatellite Stable) cancers. METHODS: Between March 1995 and December 1997, deep frozen fresh tissue of 107 eligible colorectal cancer patients, who underwent surgical resections, were used for analysis. Hereditary nonpolyposis colorectal cancer, and familial adenomatous polyposis, patients were excluded. All the patients were registered on a colorectal cancer database, and followed up completely with regular visits for a potential recurrence. Genomic DNA was prepared by the SDS-proteinase K and phenol chloroform extraction methods. The DNA was amplified by PCR at five microsatellite loci (BAT26, BAT25, D2S123, D5S346, and D17S250) to evaluate the MSI. The PCR products were separated in 6% polyacrylamide gels, containing 5.6 M urea, followed by autoradiography. The MSI was defined as being over 2 marker positive, and the MSS as 1 marker positive, all marker negatives were classed as MSS. The survival rates were calculated by the Kaplan- Meier methods. RESULTS: MSI was noted at 16/107 (15%), with mean ages for the patients of 51.8 vs. 58.6 years old for MSI and MSS, respectively. For the patients under 40 years old 5 (31.3%) vs. 6 (6.6%) had MSI and MSS, respectively (P<0.01). The cancer was located in the right colon in 12 of each of the MSI and MSS (P<0.01). There were no MSI rectal cancer tumors. The average tumor sizes were 7.6 3.6 cm vs. 5.3 2.2 cm (P<0.01) for MSI and MSS, respectively, but there were no correlations with the frequency of associated polyps, recurrence and distant metastasis between MSI and MSS. The cells were well differentiated (12.5% vs. 17.6%), moderately differentiated (68.8% vs. 76.9%), poorly differentiated (6.2% vs. 3.3%), and mucinous type (12.5% vs. 2.2%), with MSI and MSS, respectively. The overall survival rates were 93.8% vs. 73.8% for MSI and MSS (P=0.07), respectively. CONCLUSIONS: Sporadic colorectal cancer, with DNA microsatellite instability (MSI), was located predominantly in the proximal colon, in the younger age onset, and larger size of tumor. The survival rate of the patients with MSI tumors were good, but with no statistical significance.

Prognostic Significance of p53, nm23 and VEGF Expression in Primary and Hepatic Colorectal Cancer Metastases Following Surgical Resection

PURPOSE: The aim of this study is to analyze a correlation between related molecular markers and prognosis after curative resection for primary and hepatic metastasis for colorectal cancer. METHODS: A total 63 patients who have been resected curatively for primary and metastatic colorectal cancer between 1989 and 2000. All patients were completely followed up and recurrence and survival rates were analyzed. All paraffin embedded tumor tissues in primary and metastatic tumors were used for microtissue array and immunohistochemical staining of p53, nm23 and VEGF. RESULTS: Mean follow up period was 30.9 months. Recurrence was noted in 39/63 (61.9%) and 5 year survival rates was 27.7%. 5 year survival rates according to protein expression in primary tumor: p53+/-: 24.6% vs 27.3%, nm 23 +/-: 17.6% vs 38.9%, VEGF +/-: 38.8% vs 21.6% (P=0.16, 0.06, 0.9, respectively). 5 year survival rates according to protein expression in metastatic tumor, p53 +/-: 18% vs 59.2%, nm 23 +/-; 38.2% vs 15.8%, VEGF +/-: 38.8% vs 21.6% (P=0.03, 0.35, 0.96, respectively). A patients recurred within 1 year after surgery (group I, N=23) were compared with patients who recurred 1 year after (group II, N=16). nm23 expression in primary tumor in each group of patients: ; 15/23 (65.2%), : 4/16 (25 %), : 8/23 (34.8%), : 12/16 (75%), respectively (P= 0.013). But, p53, VEGF expression in primary tumor showed no statistical significance. nm23 expression in metastatic tumor revealed no statistical significance between two group of patients. CONCLUSIONS: p53 expression in metastatic tumor and nm 23 expression in primary tumor can predict poor prognosis after curative resection for primary and metastatic colorectal cancer. Molecular marker expression in primary and hepatic colorectal cancer can give us a reliable prognostic values.

Radiofrequency Ablation of Hepatic Metastasis from Colorectal Cancer; Early Experience

PURPOSE: The aim of this study is to describe the safety and efficacy of radiofrequency ablation (RFA) in the treatment of unresectable liver metastasis from colorectal cancer. METHODS: From January 1999 to December 2000, we undertook 48 RFA procedures in 36 patients with unresectable metastatic liver tumor from colorectal cancer. RFA was performed either via celiotomy (n=23) or using a percutaneous approach (n=25) under ultrasound guidance using a LeVeen needle electrode and a RF 2000 generator. Patients were followed with spiral computed tomographic scans at 1 week after RFA. RESULTS: RFA was performed in 15 patients with synchronous hepatic metastasis and 21 with metachronous hepatic metastasis. The mean tumor size was 3.1 cm (range; 0.5~7.2 cm). In 2 patients, complete ablation failed due to anatomic tumor location. Nine patients (25%) exhibited post RFA complications (9 cases of fever, 8 of abdominal pain, and 1 of hematoma) which showed spontaneous resolution and there was no treatment-related death. At a mean follow up of 10.1 months, 12 patients (33.3%) had recurred in the liver and 3 (8.6%) at the RFA site, while 16 (44.4%) remained clinically free of disease. CONCLUSION: Although RFA is a relatively safe procedure in patients with unresectable hepatic metastasis from colorectal cancer, the possible development of new metastatic disease after RFA is currently a limitation in this form of treatment. Further study on the efficacy of RFA versus other treatment modalities is needed.

Malignant Tumors of the Anus: Spectrum of Disease, Treatment and Outcomes

PURPOSE: This retrospective study was performed to evaluate clinicopathologic findings, outcomes according to the treatment modality, and prognostic factors in anal cancer. METHODS: Among the 64 patients who were diagnosed as anal cancer at our department from September 1986 to December 1999, 55 patients were analysed retrospectively. Nine patients who refused the treatment or whose medical record could not be retrieved were excluded. Concurrent chemoradiotherapy was performed for twenty-seven patients with squamous cell carcinoma. The chemotherapy with 5-FU and cisplatin and the radiotherapy were started at the same time. 750 mg/m2/day of 5-FU was infused intravenously for 5 days and 100 mg/m2 of cisplatin was started on the second day of therapy. The second cycle chemotherapy was given for 5 days before the radiotherapy was completed. A dose of 5,400cGy was given to the primary lesion and whole pelvis including inguinal area. Eight patients with squamous cell carcinoma were treated by surgery including abdominoperineal resection, local excision, or wide excision. Abdominoperineal resection was the primary treatment modality for melanoma of anus. RESULTS: Among 55 patients with anal cancer, the dominant histologic type was squamous carcinoma (n=35), followed by cloacogenic carcinoma (n=6) and melanoma (n=6). The clinical stages by AJCC were classified as stage I: 4 cases, stage II: 15 cases, stage III: 29 cases, stage IV: 7 cases. The overall 5-year survival rate of anal cancer was 60%. The 5-year survival rate in squamous carcinoma was 79.9% for the concurrent chemoradiotherapy group (n=27) and 54.7% for the surgical resection group (n=8), which was statistically insignificant. Variables affecting the survival rate with statistical significance were age, the initial tumor size, and the state of lymph node and distant metastasis. CONCLUSIONS: The concurrent chemoradiotherapy for patients with squamous cell carcinoma of the anus offered the same outcomes equivalent to surgical modality and preserved anal sphincter function. Melanoma of the anus exhibited poor prognosis and more systemic recurrence regardless of treatment modality. On univariate analysis for risk factors, age, tumor size, and lymph node and distant metastasis had statistical significance.

Clinical Usefulness of PET Scan during Follow up after Curative Resection for Colorectal Cancer

PURPOSE:The aim of this study is to assess the potential role of PET in patients with unexplained rising CEA levels after curative resection of colorectal cancer or for differential diagnosis of the result by conventional radiologic study. METHODS:18 patients with abnormal CEA levels and normal results of conventional methods of tumor detection and 7 patients who needed differential diagnosis after conventional X-ray were studied with PET. The PET results were compared with pathologic findings or conventional radiologic and clinical follow-up for 6 months. RESULTS:PET showed increased uptake in 17 of 25 patients. Using PET in 18 patients with elevated carcinoembryonic antigen levels, 12 patients showed increased uptake of FDG. Among them, 11 positive findings were turned out to be a true recurrence and there was one false positive finding. Six patients with elevated carcinoembryonic antigen levels showed normal PET scan. But conventional X-ray or repetition of PET confirmed the recurrence in 2 patients among them. Using PET in 7 patients for differential diagnosis of conventional X-ray, 3 patients showed hot uptake of FDG and all of them were turned out to be a true recurrence. There were no abnormal findings in 4 patients but one patient among them showed a hepatic recurrence. It was confirmed by abdominal MRI. Overall, sensitivity was 82.4% and specificity was 87.5% CONCLUSIONS:When conventional examinations are normal except CEA elevation or equivocal, PET is a valuable imaging tool for the detection of recurrence.

Stent Insertion as a Bridge to One Stage Operation in Malignant Obstruction of Left Colon (6 cases)

Surgical treatment of acute malignant obstruction of the left colon is problematic due to the poor general state of patients, lack of bowel preparation, and the urgency of the procedure itself. A multistage approach including emergent diverting colostomy has traditionally been the method of surgical treatment for acute left sided colonic obstruction secondary to the tumor. However, these treatment efforts have been marred by an inability to complete the sequence of operations due to numerous medical co-morbidities in the patients. The use of a self expanding metallic stent to relieve colorectal malignant obstruction has been recently, described for the palliative purpose of relieving the obstruction and for converting emergency surgery into elective surgery following routine preoperative bowel preparation. Either a covered or uncovered expandable colorectal stent (Choo colorectal endoprosthesis; Sooho Medi-Tech, Seoul, Korea) was inserted by endoscopic and fluoroscopic guidance in 6 patients with acute malignant left-sided colonic obstruction. We present these 6 patients who underwent self expandable metallic stent insertion for the treatment of left sided malignant colonic obstruction as a bridge to a single operation.

Prognostic Factors Affecting Survival Rate Following Hepatic Resection for Metastatic Colorectal Cancer

PURPOSE: Hepatic resection for metastatic colorectal cancer has recently become a widely acceptable treatment modality due to its low surgical mortality and the significant improvement of 5 year survival rates seen after resection. However the use of this treatment modality remains controversial. The aim of study was to assess the survival benefits in patients who had undergone a hepatic resection for metastatic colorectal cancer as well as to determine the prognostic factors. METHODS: A retrospective study was conducted of 94 patients who had undergone curative hepatic resection for synchronous or metachronous metastatic colorectal cancer at Department of Surgery, Yonsei University College of Medicine, between June 1989 and June 2000. Cases demonstrating extrahepatic metastasis at the time of initial surgery were excluded. The survival rate was calculated using the Kaplan-Meier and Cox regression hazard model. The mean follow up period was 35 months. RESULTS: There were 58 (61.7%) and 36 (38.3%) cases of synchronous and metachronous metastasis, respectively. The 5 year survival rate was shown to be significantly lower in patients with more than 3 metastases (P=0.05), 4 or more regional lymph node metastases in primary colorectal cancer (P=0.02), bilobar metastasis (P=0.002), extra hepatic recurrence (P=0.03) and recurrence within 1 year after hepatic resection (P=0.001). Bilobar metastasis (P=0.004) and recurrence within I year (P=0.001) has been demonstrated independent factor for 5 year survival. The overall 5 year survival rate was 30.4%. CONCLUSION: Patients with multiple, bilobar hepatic metastasis demonstrated a poor survival rate. Extrahepatic recurrence within 1 year following hepatic resection was also related with a poor outcome. Therefore, in patients with poor prognostic factors, curative surgical resection accompanied by a multimodality treatment is necessary for the improvement of survival.

Pattern of Recurrence after Curative Resection for Rectal Cancer

PURPOSE: The aim of this study was to evaluate the rate and pattern of recurrence of rectal cancer as well as analyze the risk factors affecting recurrence following resection with curative intent. METHODS: 460 patients underwent curative resection for adenocarcinoma of the rectum at our clinic from 1994 to 1998. Among these, 132 patients (29.1%) whose recurrence was confirmed by clinical and radiologic examination or reoperation were studied retrospectively. The risk factors that determined the recurrence patterns were analysed with univariate and multivariate analyses. RESULTS: The mean time to recurrence was 22.0 months. The locoregional recurrence rate was 5.7% (25/440). The systemic recurrence rate was 18.4% (81/440). 12 patients (2.7%) had two or more sites of recurrence at the time of diagnosis. The most common locoregional recurrence was a pelvic recurrence (2.3%; 10/440), followed by anastomosis (2.0%; 9/440) and presacral (0.9%; 4/440). The most common site of systemic recurrence was the liver (7.0%; 31/ 440), followed by the lung (5.9%; 26/440) and peritoneum (3.2%; 14/440). The mean time from recurrence to death was 16.0 months. Logistic regression analysis demonstrated that nodal metastasis (P=0.002), vascular invasion (P=0.027), elevated CEA level (P=0.011), and microscopic invasion to the lateral margin (P=0.008) were risk factors for postoperative recurrence. When the recurrence patterns were compared to stage, the systemic recurrence rate was 3.0% in stage I, 15.3% in stage II, and 28.9% in stage III. The locoregional recurrence rate was 3.0% in stage I, 6.0% in stage II, and 6.8% in stage III. CONCLUSION: Even though an excellent local control was obtained following curative resection of rectal cancer, the main cause of recurrence was a systemic failure in advanced rectal cancer. More effective systemic chemotherapy is required for the prevention of systemic recurrence.

Mechanical Bowel Preparation for Elective Colorectal Surgery: A Prospective Randomized Study Comparing Two Liters and Four Liters of Polyethylene Glycol-Based Oral Lavage Solutions

PURPOSE: This study was undertaken to determine whether a mechanical bowel preparation with 2 liters polyethylene glycol solution combined with a Bisacodyl 20 mg (Group II) increases the acceptability of bowel preparation and reduces discomfort compared with 4 liters of polyethylene glycol solution (Group I). METHODS: We conducted a prospective randomized single-blinded study. Eighty patients undergoing an elective colorectal surgery in Severance hospital from April 1999 to September 1999 were included in this study. The patients' tolerance, cleansing ability and surgeon's satisfaction were assessed by a structured questionnaire. Postoperative complications were also evaluated. RESULTS: The patients' tolerance of the group II (2 liters polyethylene glycol solution combined with a Bisacodyl 20 mg) was better than that of the groups I (4 liters of polyethylene glycol solution). The cleaning ability and surgeon's satisfaction were not different between two groups (p=0.225, p=0.322). The incidence of postoperative complications was 2.3 percent in Group I and 2.7 percent in Group II. CONCLUSIONS: The mechanical bowel preparation with two liters of polyethylene glycol solution with a Bisacodyl 20 mg was more comfortable to patients and equally efficient compared with the mechanical bowel preparation with the 4 liters of polyethylene glycol solution regimen before elective colorectal surgery.

Prospective Randomized Trial Comparing Intravenous 5 Fluorouracil and Oral Doxifluridine as Preoperative Concurrent Chemoradiation for Locally Advanced Rectal Cancer

PURPOSE: Preoperative radiation treatment with concomittant intravenous infusion of 5-fluorouracil has been known to be effective in shrinking and downstaging the tumor. Treatment with Doxifluridine (synthetic 5-deoxynucleoside derivative) medication prolongs drug exposure to tumor tissue, so it can be considered synergistic to concurrent radiotherapy. Intravenous 5-FU and oral Doxifluridine were compared with respect to tumor response, toxicity, and quality of life of patients. METHODS: Twenty eight patients with rectal cancer, staged as over T3N1 or T4 by transrectal ultrasonography between July 1997 and December 1998 were included. Intravenous 5-FU (450 mg/m2/day) and leucovorin (20 mg/m2) was given for five consecutive days during first and fifth weeks of irradiation therapy (50.4 Gy) (N=14). Oral Doxifluridine (700 mg/m2/day) and leucovorin (20 mg/m2) was given daily during radiation treatment (N=14). Quality of life was scored according to twenty two activity items (good: >77, fair: >58, poor: <57). Surgical resection was performed four weeks after completion of concurrent chemoradiation treatment. Tumor response was classified as CR (Complete Response), PR (Partial Response: 50% diminution of tumor volume or downstaging), or NR (No Response). RESULTS: Tumor response was CR: 3/14 (21.4%), PR: 7/14 (50%) and NR: 4/14 (28.6%) in IV arm versus CR: 2/14 (14.2%), PR: 6/14 (42.9%) and NR: 6/14 (42.9%) in oral arm (p=0.16, 0.23, 0.24, respectively). Quality of life was poor (36.4% vs 33.3%), fair and good (63.6% vs 66.7%, respectively) between IV arm and oral arm. Systemic recurrence during follow up periods was 1/14 (7.1%) in IV arm and 2/14 (14.3%) in oral arm, respectively (p=0.307). One local recurrence was observed in oral arm. Hematologic toxicity was 3/14 (21.4%) in IV arm versus 4/14 (28.5%) in oral arm, respectively. Gastrointestinal toxicity was 2/14 (14.3%) versus 5/14 (35.7%) and stomatitis was observed in IV arm (1/14, 7.1%) CONCLUSION: Oral doxifluridine based chemotherapy shows a comparable tumor response and oncologic results, but there was no benefits as far as quality of life and toxicity were concerned.