Feasibility of Single-Incision Plus One Port Laparoscopic Low Anterior Resection for Rectal Cancer

Purpose@#Single-incision laparoscopic surgery is a recently developed minimally invasive surgical technique. We aimed to compare the feasibility and safety of single-incision plus one port laparoscopic low anterior resection (S+1-LAR) with those of multi-port laparoscopic low anterior resection (M-LAR) for mid-to-low rectal cancer. @*Methods@#We retrospectively reviewed patient characteristics and surgical outcomes by assessing data collected from the medical records of patients who underwent elective laparoscopic low anterior resection for mid-to-low rectal cancer at the Gangneung Asan Hospital. @*Results@#From April 2015 to April 2019, 52 patients underwent S+1-LAR (n=28) or M-LAR (n=24) for midto-low rectal cancer at Gangneung Asan Hospital. There were no significant between-group differences in clinical characteristics. The mean postoperative 1-day pain score was significantly lower in the S+1-LAR group. Surgical outcomes and postoperative complications did not differ significantly between the two groups. @*Conclusion@#S+1-LAR is a feasible and safe technique and is comparable with M-LAR in terms of surgical outcomes of patients with mid-to-low rectal cancer.

Treatment of a Total Obstructive Anastomosis Stricture Using a Transanal Laparoscopic Approach and Intraoperative Colonoscopic Balloon Dilatation

An anastomosis stricture with a total obstruction is rare and treatment options are variable. We describe our experience with a combination of a single port transanal laparoscopic approach and intraoperative colonoscopic balloon dilatation. The patient was a 48-year-old man with rectal cancer. A laparoscopic single port lower anterior resection and diverting ileostomy were performed followed by a colon study and ileostomy takedown. The colon study and sigmoidoscopy revealed total obstruction of the rectum at the anastomosis level. We employed a transanal approach using a single port to correct this. We located the anastomosis stricture site and generated a lumen using a dissector and electocautery method to insert the balloon device. Colonoscopic balloon dilatation was subsequently successful. The patient was discharged with no postoperative complications. A laparoscopic single port transanal approach with an intraoperative colonoscopic balloon dilatation is a viable alternative approach to treating an anastomosis stricture of the rectum.

Ascending Colon Cancer with Pathologically Confirmed Tumor Thrombosis of Superior Mesenteric Vein: A Case Report

Colon cancer is very rarely accompanied by tumor thrombosis of the superior mesenteric vein (SMV). A 46-year-old patient had been diagnosed with SMV tumor thrombosis related to colon cancer without hepatic metastasis and underwent right hemicolectomy with SMV tumor thrombectomy. Tumor thrombosis was pathologically confirmed as metastatic colon cancer. There has been no recurrence for 12 months with 12 cycles of adjuvant-chemotherapy.

The Primary Thyroid Lymphoma Treated by Surgery without Chemotherapy: Two Cases Reports / 대한내분비외과학회지

Primary thyroid lymphoma (PTL) is a relatively rare disease, accounting for less than 0.5~5% of all thyroid malignancies. We encountered two cases of a primary thyroid lymphoma with Hashimoto's thyroiditis; one in a 63-year-old man and the other in a 79-year-old woman. The first case was a mucosa-associated lymphoid tissue lymphoma, and the other was a diffuse large B-cell lymphoma. Both patients underwent surgery and radiotherapy after being diagnosed using fine-needle aspiration cytology (FNAC). Both patients recovered well with no recurrence throughout the study period. The role of the surgeon in the treatment and diagnosis of thyroid lymphoma has been reduced due to the development of FNAC and combination therapy with chemotherapy and radiotherapy. On the other hand, surgery can be an effective treatment option for PTL confined to the thyroid, for achieving a definitive diagnosis, and in the treatment of patients with an airway obstruction.

A Concurrence of Adenocarcinoma with Micropapillary Features and Composite Glandular-Endocrine Cell Carcinoma in the Stomach

We report a unique case of synchronous double primary gastric cancer consisting of adenocarcinoma components with micropapillary features and composite glandular-endocrine cell carcinoma components. The patient was a 53-year-old man presenting with a 6-month history of epigastric pain and diarrhea. A subtotal gastrectomy was performed. Histologically, one tumor was composed of micropapillary carcinoma components (50%) with tight clusters of micropapillary aggregates lying in the empty spaces, admixed with moderately differentiated adenocarcinoma components. MUC-1 was expressed at the stromal edge of the micropapillary component. The other tumor was composed of atypical carcinoid-like neuroendocrine carcinoma (50%), adenocarcinoid (30%), and adenocarcinoma components (20%). The neuroendocrine components were positive for CD56, synaptophysin, chromogranin, and creatine kinase. The adenocarcinoid components were positive for both carcinoembryonic antigen and neuroendocrine markers (amphicrine differentiation). This case is unique, due to the peculiar histologic micropapillary pattern and the histologic spectrum of adenocarcinoma adenocarcinoid-neuroendocrine carcinoma of the synchronous composite tumor.

Uncomplicated jejunal diverticulosis with pneumoperitoneum

Small bowel diverticulosis is a rare finding within all bowel diverticuloses and jejunal diverticulosis is even rarer. Their relative clinical rarity and varied presentation may make diagnosis both delayed and difficult. We experienced a case of jejunal diverticulosis, which was diagnosed intraoperatively. A 55-year-old woman was admitted to Emergency Department with pneumoperitoneum on plain chest and abdominal film from a local clinic. She was hemodynamically stable with minimal tenderness on the left upper quadrant of the abdomen but no rebound tenderness. At surgery, small bowel torsion and jejunal diverticulosis were confirmed. Over 30 variable sized small bowel diverticula were noted on the mesenteric side of the proximal jejunum. The affected segment of the jejunum was about 180 cm. On exploration, we could not find any perforation site. No postoperative complications were observed, and the patient made a full recovery. Jejunal diverticulosis is rare, but it should not be regarded as insignificant.

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.

Surgical Outcomes after Total Colectomy with Ileorectal Anastomosis in Patients with Medically Intractable Slow Transit Constipation

PURPOSE: The aim of this study was to evaluate outcomes of a total colectomy with ileorectal anastomosis in patients with slow transit constipation. METHODS: A retrospective review of 37 consecutive patients with slow transit constipation who underwent a total colectomy between 1994 and 2008 was undertaken. Preoperative and postoperative Wexner's constipation scores were collected and used to evaluate the outcomes after surgical treatment. Also patients' postoperative satisfaction scores were collected using a 4-point scale. RESULTS: The 37 patients consisted of 31 women and 6 men, with a median age of 41 years (range, 17 to 71 years). Pre- and post-operative Wexner's scores were collected from 33 patients (89.1%), and the mean preoperative Wexner's score was 19.3 (range, 11 to 24), which decreased to an average post-operative score of 2.3 (range, 0 to 8). Neither intraoperative complications nor postoperative mortalities were noted. Five patients (13.5%) had early postoperative complications, and the most common complication was postoperative ileus (10.8%). Seven patients (18.9%) had late postoperative complications, and postoperative ileus (10.8%) was also the most common. Twenty seven of 33 patients were satisfied with their surgical outcome (81.8%). CONCLUSION: A total colectomy with ileorectal anastomosis might be an effective surgical procedure with acceptable morbidity to treat medically intractable slow transit constipation.

The Results of Simultaneous Bilateral Internal Iliac Artery and Inferior Mesecteric Artery Ligation during Open Abdominal Aortic Aneurysm Surgery

PURPOSE: Bilateral internal iliac artery (IIA) ligation with inferior mesenteric artery (IMA) ligation has been performed during open abdominal aortic aneurysm surgery and endovascular aneurismal repair (EVAR). We reviewed both the acute and long term effects of bilateral IIA ligation with IMA ligation. METHODS: A retrospective cross sectional review was performed on 315 patients who underwent open aneurysmal repair and EVAR between 1997 and 2008. Both IIAs of all the patients' were patent before aortic reconstruction. The patency of the IIAs and the presence of bowel ischemia was evaluated by the medical records on the operative findings, the sigmoidoscopy and the computed tomography. Telephone interviews were performed to assess buttock claudication. RESULTS: The mean age was 68.4 years and 259 patients were male. Unruptured aneurysm was found in 233 patients, ruptured aneurysm was found in 72 patients and impending rupture was found in 10 patients. Unilateral ligation of the IIA was required in 78 patients (24.8%), and bilateral ligation was performed in 43 patients (13.7%). Sigmoid colon ischemia occurred in 8 patients (2.5%), and the IIA was patent in 7 patients. Buttock claudication occurred in 10 out of 178 patients who were contactable on telephone, and the IIA was patent in 8 of these 10 patients. Bowel ischemia and buttock claudication were not significantly associated with the patency of the IIA (P>0.05). CONCLUSION: Bilateral IIA ligation with IMA ligation was able to be performed without significantly increasing the incidence of bowel ischemia and buttock claudication. Performing endovascular aneurysmal repair may be considered when bilateral graft extension to the external iliac artery is required.

TEE-guided Excision of Intravenous Leiomyomatosis with Right Atrium Extension through an Abdominal Approach: A Case Report

Intravenous leiomyomatosis (IVL) is a rare, benign tumor that originates from the uterus. IVL is usually confined to the pelvic venous system, but it travels into the inferior vena cava (IVC) in 10% of cases and even into the heart in 3% of cases. We present a case of successful resection of recurrent IVL with right atrium extension. We used only an abdominal incision and transesophageal echocardiography (TEE) guidance. A 40-year-old female patient visited our hospital with recurrent IVL. She had a history of total abdominal hysterectomy and right salpingo-oophorectomy due to IVL performed one year prior. On computed tomography (CT) and ultrasonography, IVL was found to involve both ovarian veins, the left renal vein, and the IVC extending to the right atrial junction. Using intraoperative TEE monitoring, we could see that IVL was not attached to the vascular wall. After creating a midline abdominal incision, we removed the tumor through the enlarged ovarian vein and ovary. The patient had an uneventful recovery and was discharged home on the ninth postoperative day.

Results of Infrainguinal Chronic Arterial Occlusion: Difference in Medical and Surgical Management

PURPOSE: In order to evaluate the result of medical treatment and compare with surgical management in infrainguinal arterial occlusion, we analyzed 145 cases of infrainguinal chronic arterial occlusion that admitted our department during recent 5 years. METHOD: Patients were grouped into 2 according to their treatment. Group 1 was patients who underwent arterial bypass surgery (n=84) and group 2 with conservative management of exercise and medication (n=61). In case of significant iliac arterial stenosis, balloon angioplasty or stent insertion were added in both groups (17 in group 1, 16 in group 2). Changing of clinical manifestation and ankle-brachial index, claudication distance, rate of major amputation and mortality were compared between groups. RESULT: There was a big difference in the rate of improving claudication distance at the end of one year after treatment (86.5% in group 1 vs 40.0% in group 2) but 5.4% of group 1 and 32.0% of group 2 showed aggravation of the symptoms. Improved ankle-brachial index (ABI) noted in 88.1% of group 1 but in group 2, 39.3% showed increasing of ABI only under the conservative management. The proximal inflow procedure had more significant effect in improving ischemic symptoms and ABI in group 2 compare to group 1. One fourth of group 1 and 18.2% of group 2 showed spontaneous healing of their toe gangrene but 3.1% of group 1 and 54.5% of group 2 needed major amputation because of disease progress. New gangrene developed during their follow up and this also ended with major amputation in group 2. The difference of mortality rate between groups might be due to old age and associated cardiac disease. CONCLUSION: Better results in improving ischemic symptoms and ABI with low rate of amputation and mortality encourage us to do an aggressive surgery. But significant portion of conservative group especially in patients with inflow procedures also showed improving symptoms, and this suggest us a need of significant consideration of medical and exercise treatment in selected cases.

A Case of Lymphatic Metastasis to Ampulla of Vater from Gastric Adenocarcinoma / 대한내과학회지

Cancer of the stomach is responsible for approximately 650,000 deaths globally each year and is probably second only to lung cancer worldwide as an overall cause of cancer-related mortality. Similar to the situation with most adenocarcinomas of the gastointestinal tract, carcinomas of the stomach can spread by local extension to adjacent normal structures and can develop lymphatic, peritoneal, and distant metastases. The tumor cells, can also permeate diffusely into the lymphatic plexus of the bowel, more often at the level of the upper duodenum hut sometimes down into the distal ileum and the large bowel. We report a case of lymphatic metastasis of gastric adenocarcinoma to the ampulla of Vater with review of the literature.

Clinical study on lupus nephritis / 대한신장학회잡지

No abstract available.