Oncologic Results according to Operative Method after a Curative Resection for Low Rectal Cancers

PURPOSE: Although the current trend is to use a sphincter- saving operation (SSO) for management of distal rectal cancer, an abdominoperineal resection (APR) is widely performed in low rectal cancers. Numerous studies have reported that lateral margin is an important prognostic factor for recurrence in low rectal cancers. In regard to curability, the presence of an involved lateral margin after a resection of a low rectal cancer is currently accepted as being an indicator of a non-curative resection. Indeed, the higher rate of positive lateral margins after APRs than after a SSO may explain the inferior oncologic outcomes of APRs. Therefore, the purpose of this study was to analyse the oncologic results of 'curative' APRs and SSOs. METHODS: This retrospective study included 111 patients who had undergone surgical treatment between 1995 and 2000 with either an APR (n=65) or a SSO (n=46). The oncological outcomes of the patients who had undergone an APR were compared with those of the patients who had undergone a SSO. Univariate and multivariate analyses were used to evaluate the data. RESULTS: The distal resection margin and the mean distance between the tumor low margin and the dentate line were significantly different between the two groups. However, the disease-free and the overall survivals, as well as the frequency of local recurrence and that of overall recurrence, after rectal excision did not differ between the two groups. Multivariate analyses showed that the method of surgery was not a significant independent factor in predicting either disease-free survival or overall survival. However, advanced stage III was a significant predictor of outcome after the operation. CONCLUSIONS: The type of operation did not affect the oncological outcome after a 'curative' resection for distal rectal cancer.

Regional Distribution of Peptide YY Concentrations in Human Lower Gastrointestinal Mucosa

PURPOSE: Peptide YY is composed of 36 amino acids, and its functions are suppression of gastric acid secretion, delay of gastric emptying, increase of intestinal motility, inhibition of pancreatic exocrine secretion, and enhanced postprandial colonic absorption of water and electrolyte. PYY is released from PYY cells, which are mainly distributed in the ileum and colon, in response to the presence of intraluminal lipids. This study was designed to determine the regional distribution of PYY in the normal human ileum, colon, rectum, and anal canal by studying mucosal concentrations. METHODS: Fresh tissues were obtained from specimens of segmental resections of the small bowel, colectomies, ileostomies, and abdominoperineal resections for the management of colonic or rectal carcinomas or benign diseases of the bowel. Only specimens devoid of advanced luminal obstruction were included. Mucosa was separately recruited by microdissection of frozen sections. Radioimmunoassays were performed using the methods of Adrian et al. RESULTS: The concentration of PYY was highest at 25 cm proximal to the ileocecal valve in the ileum (307.6 pmol/ g) and in the upper rectum at the colon (653.1 pmol/g). The concentration of PYY was 27.3 pmol/g in the anal canal distal to the dentate line. A clear differential distribution of PYY was shown in the ileum and colon. CONCLUSIONS: This study showed PYY was present in large amounts in the mucosa of the ileum and colon, with high concentrations in locations 25 cm proximal to ileocecal valve and in the upper rectum, respectively. The trend of regional differences in PYY in the colonic mucosa probably reflects local differences in functions, such as absorption and storage. Also, the peak concentration in the ileum at 25 cm proximal to ileocecel valve suggests that this region is the most abundant production site of PYY in the ileum.

Primary Cecal Lymphoma

PURPOSE: Primary colonic lymphomas are very rare disorders and the most common location of a colonic lymphoma is the cecum. However, the prognosis for patients with a primary cecal lymphoma is not well understood clear. This study was undertaken to assess the prognosis for patients with a primary cecal lymphoma. METHODS: A retrospective analysis of our patients, who were categorized into two groups, cecal lymphoma (10 cases) and non-cecal lymphoma (10 cases), was performed from January 1985 to December 2001. The prognostic factors were analyzed. RESULTS: The most common presenting symptoms and signs of cecal lymphomas were abdominal pain (80.0%), nausea/ vomiting (80.0%), and abdominal mass (40.0%). The preoperative biopsy- proven diagnostic rate of cecal lymphoma was 10.0%. The mean size of cecal lymphomas was significantly smaller than that of non-cecal lymphomas (6.2 cm vs. 10.0 cm). Histologically, 9 (90.0%) of the primary cecal lymphomas were classified as intermediate-grade lymphoas, and 1 (10.0%) as a high-grade lymphoma. three (30.0%) of the cecal lymphomas were Stage IE, 5 (50.0%) were Stage IIE1, and 2 (20.0%) were Stage IVE. Tumor resection and chemotherapy was used for 8 (80.0%) of the cecal lymphomas. Two regimens of chemotherapy were used: CHEP-Bleo (cyclophosphamide, doxorubicin, and epirubicin, prednisone, and bleomycin) and COP-BLAM (cyclophosphamide, vincristine, prednisone, bleomycin, doxorubicin, procarbazine). The median survival time for patients with a cecal lymphoma was 56 months, but that survival time was not significantly different from the survival time for patients with non-cecal lymphoma. CONCLUSIONS: The prognosis for patients with a primary cecal lymphoma appears to be similar to that for patients with a non-cecal lymphoma. However, the number cases in our study was very small, the more cases are needed to establish a general prognosis for patients with a primary cecal lymphoma.

Anterior Extrasphincteric Anorectoplasty with an Illuminating Intrarectal Indicator for Repair of an Anorectal Malformation

PURPOSE: This study was conducted to evaluate the functional results of an anterior extrasphincteric anorectoplasty (AEA) guided by an illuminating intrarectal indicator, in which a transperineal positioning of the anal canal was performed without cutting the perineal sphincter muscle. METHODS: Point A which would be a anal orifice in future was designated 0.3 mm anterior to the anal dimpling site. A semicircular incision was made in the front of the anus. The flap, which included from the anal skin to the upper margin of the external anal sphincter, was everted posteriorly. A quarter of the frontal upper rim of the external anal sphincter was exposed, and the center of the uppermost portion was designated as point B. From point A toward point B, a spinal needle was inserted through the anal sphincter, and needle's tract was dilated under direct identification of the sphincter muscle by electronic stimulation. An illuminating intrarectal indicator with a laparoscopic light source was pushed through the distal stoma of a sigmoid colostomy toward its distal lumen so that the blind rectal pouch was perineally exposured. On the blind pouch, a cruciate incision was made, and it was anastomosed to the anus. RESULTS: From 1991 to 2000, 11 patients with imperforate anus of high and intermediate type were operated by our method. In one case, the urethral injury was found intraoperatively and was immediately repaired. One case of anal stenosis was improved after serial Hegar dilatation. The postoperative bowel function in the Kirwan's clinical assessment at 12 th month was grade I in 9 cases and grade II in 2 case. Conclusion: This AEA with an illuminating intrarectal indicator shows acceptable clinical results and could be considered to be an effective surgical option for anorectal malformations.

Experimental Study of Mechanism about Liver Regeneration Using Non-regenerating Liver Transplantation Model in Rats / 한국간담췌외과학회지

PURPOSE: The portal blood influx appears to be essential for liver regeneration after a liver resection and transplant. It was reported that only grafts with a gastro-pancreatic-splenic portal inflow into the graft portal vein could increase in size. The aim of this study was to investigate the impact of the gastro-pancreatic-splenic portal flow on the regeneration of a graft liver in a microsurgical model of heterotopic partial liver transplantation model. METHODS: Sprague-Dawley rats weighing 200 to 300 grams were used in this study. The rats were fasted for 12 hours prior to surgery. Thirty percent of the liver was heterotopically transplanted, to connect the donor's portal vein and suprahepatic vena cava with the recipient's superior mesenteric vein and the suprarenal vena cava, respectively. The donor and original liver were weighed preoperatively and 1, 2, 3, 7 days postoperatively. In addition, the histology of the donor and recipient's liver were examined using optical microscopy, and H & E staining. The proliferative capacity of the donor and recipient hepatocytes was evaluated using immunohistochemistry. RESULTS: The liver weights of the donor and recipient were measured at serial time points after surgery. Progressive enlargement was observed in the original liver. However, in assessing the liver weight, the weight of the donor liver was significantly lower at 2 days, 3 days, and 7 days after surgery than that of the original liver. During the observation periods, prominent histopathological differences were observed between the donor and recipient liver. There was a markedly higher number of PCNA (+) cells in the original liver than in the donor liver. CONCLUSION: The gastro-pancreatic-splenic portal inflow into the graft appears to play an important role in regenerating a partial liver graft. However, several variables such as the ischemic time, bile duct ligation, a small-for-size graft, and hepatic artery reconstruction in this model should be considered.

A Study for Porcine Liver Transplantation Using Nonheart Beating Donor / 한국간담췌외과학회지

BACKGROUND/AIMS: Experimental studies using porcine non- heart beating donors to ameliorate graft injuries in liver transplantation has been conducted. Recently, it has been reported that cellular calcium may have an important role in ischemic injury, which consists of damage during ischemia and impairment at the time of reperfusion. therefore, it is possible that calcium channel blocker might prevent warm ischemic injury of the graft in liver transplantation when administered to the donor before harvesting and to the recipient at reperfusion. the purpose of this study was to investigate the protective effect of a calcium channel blocker diltiazem (DTZ) on hepatic ischemic injury using a porcine model. METHODS: Twenty pigs weighing 20 to 30 kg were enrolled in this study. Cardiac death was induced by direct cardiac injection of potassium chloride. The perfusion of UW (University of Wisconsin) solution started after 30 min of cardiac arrest. Orthotopic liver transplantation was perforated. Group A (experimental group) was administrated of DTZ at a dose of 70microgram/kg bolus iv injection before hepatic ischemia, perfused of 70microgram/L in UW solution and thereafter infused continuously 70microgram/L in 5% dextrose solution. RESULTS: Two ones death occurred among the ten transplant pigs. 24 hour survival rates were 80%. DTZ administrated group showed the hepatic blood flow and arterial ketone body ratio better compared with untreated controls (p<0.05). In addition, the increase of plasma lactate level was suppressed after ischemia (p<0.05). CONCLUSION: Our results suggest that DTZ has a protective effect on ischemic induced hepatic damage and might be useful in the prevention of primary graft failure caused by warm ischemia in liver transplantation.

The Recurrence Pattern of Small Hepatocellular Carcinoma with Tumor-free Margin / 한국간담췌외과학회지

BACKGROUND/AIMS: We studied the patterns of recurrence after resection of relatively small hepatocellular carcinoma, defined as less than 5 cm in diameter, with tumor-free margin, and risk factor for recurrence were re-evaluated for these group. METHODS: The subjects were 25 patients who had undergone tumor removal with tumor-free margin for hepatocellular carcinoma at our department from 1995 to 1998. Tumor-free survival rates of patients with various risk factors were calculated and differences between groups were evaluated. RESULTS: The tumors recurred in 17 patients (68.0%), with 11 patients (64.7% of recurrences) recurring within 1 year of surgery. Recurrent disease was nearly intrahepatic. Univariate retrospective analysis in this study showed the absence of tumor capsule to be significant risk factor. But there is no significant difference in survival rate between capsule (+) groups and capsule (-) groups. CONCLUSION: It was concluded that small hepatocellular carcinoma has no significant difference in clinicopathologic variables except tumor capsule.

Posterior Sagittal Anorectal Myectomy for Repair of Hirschsprung's Disease

PURPOSE: In small portion of patients with Hirschsprung's disease, the aganglionic stagment extends only up to the mid-rectum. This report describes an innovative and effective posterior sagittal anorectal myectomy for curative repair of ultrashort segment Hirschsprung's disease in neonates. METHODS: The procedure was performed on ten patients with ultrashort segment Hirschsprung's disease between 1995 to 1998. The procedure was performed by making a sagittal incision in midline posterior perineum to expose the posterior rectum.4 longitudinal strip of muscular layer is removed from the aganglionic portion of the anorectum from the upper rectum to the internal sphincter. The patients were followed postoperatively to determine the effectiveness of the procedure and to observe the presence of any complications. RESULTS: Seven patients (70.0%) were under three months old. Operative biopsy showed that four patients had aganglionosis in the upper rectum, three patients in the middle rectum and three patients in the lower rectum. The posterior sagittal anorectal myectomy was successful in the treatment of ultrashort segment Hirschsprung's disease- symptom recurred for one patient due to total aganglionosis and for another patients due to rectosigmoid aganglionosis. These two patients received the staplingprocedure after colostomy. Some transient complications included mucosal perforation during surgery (30.0%) and incisional wound infection (20.0%). CONCLUSION: For those neonates with ultrashort segment Hirschsprung's disease, the posterior sagittal autorectal myectomy should be considered a safe and effective method for treatment and confirmatory diagnosis. In addition, preliminary colostomy is not required prior to this procedure.