Risk Factors for Conversion in Laparoscopic Surgery for Colorectal Cancer

PURPOSE: Recently, laparoscopic surgery has been performed with increasing frequency in cases of various diseases, including colorectal cancer. However, in some cases, laparoscopic surgery should be converted to open procedures because of several factors. In this study, we tried to find the causes of and the risk factors for conversion to open procedures during colorectal cancer surgery. METHODS: From June 2002 to May 2008, laparoscopic surgery in 324 patients who were diagnosed as having colorectal cancer was performed by two surgeons. Patients were divided into two groups, non-conversion and conversion groups. We investigated the differences in age, sex, presence of preoperative colonic obstruction, tumor invasion (pT stage), and so on between the two groups. RESULTS: Of the 324 patients, 20 patients experienced an open conversion: 5 of 28 patients who had a colonic obstruction and 15 of 296 patients who had no obstruction (P=0.021). The causes of conversion during the surgery were tumor invasion, peritoneal adhesion, hemorrhage, and cancer perforation. There were 8 conversions out of 92 patients from June 2002 to May 2005 and 12 out of 232 from June 2005 to May 2008 (P=0.231). In regards to the degree of tumor invasion, 9 of 32 who were stage pT4 experienced a conversion to an open procedure (P<0.001). In multivariate analysis, the presence of a colonic obstruction and pT4 stage were meaningful risk factors for conversion to an open procedure. CONCLUSION: From this study, we can predict a higher rate of conversion to an open procedure in patients with locally advanced colon cancer, especially when a colonic obstruction is present. Therefore, a careful laparoscopic approach is needed in such patients.

The Characteristics of Crohn's Disease in Korea According to the Montreal Classification

PURPOSE: Crohn's disease is an inflammatory bowel disease with various symptoms and progressions. For effective identification of various causes and follow up of patients, we used the Vienna Classification from 1998, but we started applying the Montreal Classification in 2005. In this study, our aim was to identify the clinical characteristics of Korean patients with Crohn's disease by using the Montreal Classification. METHODS: A retrospective study was carried out among 111 patients who were evaluated at KyungHee Medical Center from March 1986 through February 2008 as having Crohn's disease. RESULTS: The male-to-female ratio was 1.8:1, and the average age was 27.2+/-9.6 yr. Abdominal pain was the major symptom, and extraintestinal manifestations were seen in 16 cases. Of the Crohn's disease patients, 25.2% were initially misdiagnosed as having tuberculosis. Concerning age at diagnosis, A2 (patients 17 to 40 yr of age) was the largest group. The most common disease location was the ileocolon (L3), and a combined upper gastrointestinal lesion (L4) was most commonly seen in L3. The most common disease behaviors were nonstricturing and nonpenetrating (B1), and although perianal lesions were most common in B1, there were no statistical correlations (P=0.061). Surgical treatments were performed in 46 cases, especially in cases involving complex disease (stricturing&penetrating) (P<0.005) and ileal disease (L1) (P=0.024). CONCLUSION: According to the Montreal Classification of Korean Crohn's disease patients, a more stable manifestation was seen in the group with lower age at diagnosis. Perianal lesions did not have any correlation with the form in which the disease manifested itself. Complex disease and ileal disease required a surgical procedure the most.

Hand-foot Syndrome Following Capecitabine (Xeloda(R)) Monotherapy for Colorectal Cancer

PURPOSE: Capecitabine (Xeloda(R)), which is a systemic prodrug of 5-fluorouracil, can be used in oral formulation for treatment of advanced colorectal cancer as a 1st line or an alternative modality to I.V. 5-fluorouracil-based chemotherapy. One of the most common side effects of this drug is hand-foot syndrome (HFS), palmar-plantar erythrodysesthesia syndrome. We planned this study to clarify the incidence and the clinical course of severe hand-foot syndrome (WHO classification, grade 3 or 4) following capecitabine monotherapy for adjuvant treatment of colorectal cancer. METHODS: From August 2006 to August 2008, 45 colorectal cancer patients were treated with capecitabine, 1,250 mg/m2, orally administered twice daily for 2 wk, followed by 1 wk of rest, given as 3-wk cycles. Seven of them discontinued the drug within 3rd cycle due to poor performance status, gastrointestinal troubles, or other causes. We retrospectively analyzed the remaining 38 patients' medical records and defined the incidence and the clinical course of HFS. RESULTS: Of the 38 patients, 17 (44.7%) suffered severe HFS after capecitabine monotherapy. Of those 17, 5 (29.4%) had severe symptoms after the 1st chemotherapy cycle, and 14 patients (82.4%) had severe symptoms within the 4th cycle. Three of the 14 female and 14 of the 24 male patients complained of severe HFS, showing a statistical male predominance (P=0.043). Eventually, we had to decrease capecitabine to 75% of the daily dose in 12 patients and to 50% in one patient, and to discontinue its use in 4 patients. CONCLUSION: Capecitabine monotherapy very frequently provokes severe HFS, especially in the early cycles of chemotherapy and in males.

Surgical Experiences with Hepatectomy for Intrahepatic Stones / 한국간담췌외과학회지

PURPOSE: Biliary stones, situated in the proximal sites from the confluence level of the right and left main bile ducts, are considered to be intrahepatic stones. Synonyms include hepatolithiasis and recurrent pyogenic cholangitis. The exact etiology of this condition is unknown, but it causes serious problems, such as obstructive jaundice, cholangitis and liver abscesses and so on. Hepatic resection is the treatment of choice for intrahepatic stones. With improving techniques in hepatobiliary surgery and aggressive surgical treatment, the outcome of intrahepatic stones has improved. The aim of this study was to evaluate the clinical outcomes after a hepatectomy for intrahepatic stones. METHODS: 77 patients underwent hepatic resections due to intrahepatic stones at the Department of Surgery, Kyung-Hee University between January 1996 and December 2002. The surgical outcome and follow-up were analyzed by a retrospective clinical review. RESULTS: The gender ratio of the patients was 1: 1.9 male to female, with a mean age of 54-years. The most common preoperative symptom was RUQ pain (81.8%). Concomitant diseases were common bile duct stones (53.2%), gallstones (23.4%), liver abscesses (7.8%), malignant neoplasms (6.5%) and choledochal cysts (5.2%). Nineteen patients (24.7%) had a history of cholecystectomy and 2 (2.6%) had had a hepatectomy at other hospitals due to intrahepatic stones. The stone locations were the right hemi-liver 18.2%, the left hemi-liver 66.2%, especially the left lateral section 44.2%, and bilaterally 15.6%. The operation methods were as follows; a right hemihepatectomy in 11 patients (14.3%), a posterior sectionectomy in 3 (3.9%), a left hemihepatectomy in 14 (18.2%), a lateral sectionectomy in 42 (54.5%), segmental resections at both lobes in 7 (9.1%) and biliary-enteric bypass in 24 (31.2%). The most common complication was wound infection (26.0%). Two patients had remaining stones and 1 had recurrent stones 4 years later. The morbidity and mortality were 42.9 and 1.3%, respectively. With a mean follow-up period of 49.6 months, 59 patients (76.6%) were free of symptoms. 15 patients (19.5%) had mild to moderate RUQ discomfort or pain, but no detectable stones on radiological studies. 3 patients (3.9%) needed admission for severe symptoms, one due to recurrent stones, but the others had no abnormal findings. CONCLUSION: There was low mortality, despite the high complication rates with hepatic resections for intrahepatic stones. Low rates of remaining stones and recurrence of intrahepatic stones can be achieved.

Comparison of Clinical Outcomes between Pylorus Preserving Pancreaticoduodenectomy and Pancreaticoduodenectomy / 한국간담췌외과학회지

PURPOSE: A pancreaticoduodenectomy (PD) and pylorus-preserving pancreaticoduodenectomy (PPPD) are the two methods commonly used to treat periampullary neoplasms. This study was designed to compare these two methods in terms of the post-operative complications, the recurrence rate, and the post-operative weight change. METHODS: The medical records of 110 patients who underwent PD or PPPD from February 1986 through to June 2002 were retrospectively reviewed. The PD was performed on 54 patients and PPPD was performed on 56 patients, respectively. The mean follow-up periods were 25.33 months in the PD group and 25.39 months in the PPPD group, respectively. RESULTS: Diabetes mellitus occurred in 9 patients (16.7%) in the PD group and 8 patients (14.3%) in the PPPD group, and gastric emptying was delayed in 14 (25.9%) and 15 (26.8%) patients of each group after surgery. Procedure related deaths occurred in 2 (3.7%) and 4 (7.1%) patients from each group. There were no statistically significant differences in the post-operative complications between the two groups. The disease recurrence rate was significantly lower in the PPPD group than in the PD group (60.5% vs. 22.9%, p=0.001). Post-operative weight loss just after surgery at 3 months and 6 months after surgery was 3.56 kg, 3.68 kg, and 3.97 kg in the PD group and 2.78 kg, 1.77 kg, and 1.8 kg in the PPPD group, respectively, without showing a statistically significant difference. CONCLUSION: The clinical outcomes of the PPPD was not different from those of the PD in terms of the post-operative complications and weight loss. The disease recurrence rate was lower in the PPPD group. These results suggest that PPPD could be the treatment choice periampullary neoplasms.