The cut-off value of transient elastography to the value of hepatic venous pressure gradient in alcoholic cirrhosis

Background/Aims@#The hepatic venous pressure gradient (HVPG) reflects portal hypertension, but its measurement is invasive. Transient elastography (TE) is a noninvasive method for evaluating liver stiffness (LS). We investigated the correlation between the value of LS, LS to platelet ratio (LPR), LS-spleen diameter-to-platelet ratio score (LSPS) and HVPG according to the etiology of cirrhosis, especially focused on alcoholic cirrhosis. @*Methods@#Between January 2008 and March 2017, 556 patients who underwent HVPG and TE were consecutively enrolled. We evaluated LS, LPR, and LSPS according to the etiology of cirrhosis and analyzed their correlations with HVPG. @*Results@#The LS value was higher in patients with alcoholic cirrhosis than viral cirrhosis based on the HVPG (43.5 vs. 32.0 kPa, P<0.001). There were no significant differences in the LPR or LSPS between alcoholic and viral cirrhosis groups, and the areas under the curves for the LPR and LSPS in subgroups according to HVPG levels were not superior to that for LS. In alcoholic cirrhosis, the LS cutoff value for predicting an HVPG ≥10 mmHg was 32.2 kPa with positive predictive value (PPV) of 94.5% and 36.6 kPa for HVPG ≥12 mmHg with PPV of 91.0%. @*Conclusions@#The LS cutoff value should be determined separately for patients with alcoholic and viral cirrhosis. In alcoholic cirrhosis, the LS cutoff values were 32.2 and 36.6 kPa for predicting an HVPG ≥10 and ≥12 mmHg, respectively. However, there were no significant differences in the LPR or LSPS between alcoholic and viral cirrhosis groups.

The Relationship of the Post-reflux Swallow-induced Peristaltic Wave Index and Esophageal Baseline Impedance with Gastroesophageal Reflux Disease Symptoms

BACKGROUND/AIMS: The post-reflux swallow-induced peristaltic wave (PSPW) index and esophageal baseline impedance (BI) are novel impedance parameters used to evaluate esophageal chemical clearance and mucosal integrity. However, their relationship with reflux symptoms is not known. We aim to evaluate the correlations of PSPW index and esophageal BI with gastroesophageal reflux disease (GERD) symptoms. METHODS: We performed a retrospective review of multichannel intraluminal impedance and pH (MII-pH) tracings in patients with suspected GERD. Reflux symptoms were also analyzed from checklists using ordinal scales. The PSPW index and esophageal BIs in 6 spots (z1–z6) were measured. Bivariate (Spearman) correlation was used to analyze the relationship between the PSPW index or esophageal BI, and the degree of GERD symptoms measured. RESULTS: The MII-pH records of 143 patients were analyzed. The PSPW index was significantly lower in patients who had heartburn and negatively correlated with the degree of heartburn (r = −0.186, P < 0.05). On the contrary, the PSPW index was not significantly correlated with the degree of dysphagia (r = −0.013, P = 0.874). Distal esophageal BI was not significantly correlated with heartburn, but negatively correlated with the degree of dysphagia (z3: r = −0.328, z4: r = −0.361, z5: r = −0.316, z6: r = −0.273; P < 0.05). CONCLUSIONS: These findings suggest that delayed chemical clearance of the esophagus may induce heartburn, but that it is not related to dysphagia. However, a lack of esophageal mucosal integrity may be related to dysphagia.

A Case of Surgical Resection in Hepatocellular Carcinoma with Pulmonary Metastasis

Hepatocellular carcinoma (HCC) is well known malignancy with poor prognosis, even after resection of the primary tumor. Sorafenib is the first-line treatment in advanced HCC, but the disease control rate of sorafenib is only 43%. Pulmonary metastasectomy in patients with pulmonary metastasis from HCC has been reported to increase long-term survival compared with systemic chemotherapy. Video-assisted thoracic surgery is considered a reliable approach to the diagnosis and treatment of pulmonary diseases with low complication rate. Pulmonary metastasectomy is not universally accepted because of frequent local recurrence, an uncontrollable primary tumor, and frequent multiple pulmonary metastases in HCC, but outcome of pulmonary metastasectomy and adjuvant sorafenib therapy has not been studied. We experienced a patient who had advanced HCC with pulmonary oligometastasis and received surgical resection of the metastatic pulmonary nodule and sorafenib chemotherapy. In advanced HCC with pulmonary oligometastasis, surgical resection of pulmonary metastasis and sorafenib chemotherapy should be considered.

Possible Antiphospholipid Syndrome Presenting as Peripartum Cardiomyopathy and Diffuse Alveolar Hemorrhage / 대한내과학회지

Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of circulating antiphospholipid antibodies in combination with at least one other clinical manifestation, such as vascular thrombosis or recurrent pregnancy loss. APS is further characterized by the presence of vasculitis affecting multiple organ systems, resulting in a wide variety of clinical outcomes. Common cardiac manifestations of APS include valve abnormalities, occlusive arterial disease, intra-cardiac emboli, ventricular dysfunction, and pulmonary hypertension, along with rare instances of dilated cardiomyopathy. Simultaneously diffuse alveolar hemorrhage and peripartum cardiomyopathy have also been reported, though these manifestations remain extremely rare. Here, we report a case of a 34-year-old woman with possible APS who presented with peripartum cardiomyopathy and diffuse alveolar hemorrhage.

A Retrospective Epidemiologic Analysis of Elderly Burn Patients at Hanil General Hospital

PURPOSE: This study aims to analyse the epidemiologic characteristics of burn in the elderly and to discusses a possible prevention program for this population. METHODS: A retrospective review of all medical records of elderly patients (above 60 years old) admitted with burns to the burn center of the Hanil General Hospital from January 1996 to December 2007 was carried out. Patient demographics, etiology, extent, and type of burn, seasonal variation, and mortality rates were reviewed. RESULTS: A total of 537 elderly patients (mean age of 69.8 years, median age of 68 years, range 60~97 years) was admitted. The gender ratio of the patients was 1:.5 with 217 men and 320 women. The most common causes were scald burn (44.9%) and flame burn (35.4%). The average total body area burned was 13.5% (range 0~95%). Twenty six patients (4.8%) died. CONCLUSION: In elderly patients, scald burns are more common in women but flame burns are more common in men. The mortality rate is higher in flame burns and men

Two cases of cecal lymphoma causing intussusception / 대한내과학회지

Adult intusussception is a rare entity and this usually has a definable cause. We describe here two cases of adult patients with ileocolic intussusception that was secondary to a lymphoma of the cecum. The one patient was a 23-year-old man. We diagnosed ileocolic intussusception by performing abdominal computed tomography. At laparotomy, a 5.0 x 5.0 cm polypoid tumor was found in the cecum. Histologic examination disclosed the diffuse large B-cell lymphoma. The other patient was a 32-year-old man. Preoperatively, we diagnosed intussusception in the ileocolic lesion by performing a barium study and computed tomography. At laparotomy, a 3.1 x 4.0 cm tumor was found in cecum, and histologic examination revealed the diffuse small noncleaved type lymphoma (Burkitt's lymphoma). So far as we are aware, this is the first report of a Korean adult patient with intussusception that was secondary to a cecal lymphoma, and it was not secondary to an ileal lymphoma.

IL-4 Induces CD4+CD25+ Regulatory T Cells from CD4+CD25- T Cells in Peripheral Blood / 대한류마티스학회지

OBJECTIVE: The CD4+CD25+ regulatory T cells (Treg) can be induced by TGFbeta and IL-10 in the periphery, and understanding the biological function of cytokine-induced Treg is critically important for the control of autoimmune diseases. We investigated the IL-4-induced CD4+CD25+ regulatory T cells in human PBMCs, which were derived from the CD4+CD25- T cells. METHODS: The CD4+CD25- T cells from human PBMC were isolated by MACS and cultured in the presence of IL-4 or absence of IL-4. The presence and phenotype of induced CD4+CD25+ T cells were determined by flow cytometry. Supressive activity of induced CD4+CD25+ T cells were assessed by culturing CD4+CD25- and CD4+CD25+ T cells with anti-CD3 monoclonal antibodies and antigen-presenting cells, followed by proliferation RESULTS: After 5 days, significant amount of CD4+CD25+ T cells were generated from the CD4+CD25- T cells cultured with anti-CD3 antibody in the presence of IL-4. These IL-4 induced CD4+CD25+ T cells presented with similar phenotype to natural occurred Treg cells, including CD45RO(hi), CD45RA(lo), CTLA-4(hi), OX40(hi), CD62L(hi) and HLA-DR(hi), and also exhibited high expression of Foxp3 molecule. In addition, the IL-4 induced CD4+CD25+ T cells can suppress the proliferative responses against anti-CD3. The regulatory property of IL-4 induced CD4+CD25+ T cell was partially abrogated after treatment with anti-IL-10 and anti-TGFbeta antibodies. CONCLUSION: These data indicate that IL-4 induced CD4+CD25+ Treg cells can be generated from the CD4+CD25- T cells in the peripheral blood, and may contribute to the important immunoregulatory function in human.

Clinicopathological Correlation of hMLH1 and hMSH2 Protein Expressions in Stage III Colon Cancer

PURPOSE: Functional loss of mismatch repair has been reported to be the reason for resistance to several chemotherapeutic drugs. The expressions of hMLH1 and hMSH2 were examined to assess whether they correlated with the biological behavior and the chemotherapeutic responsiveness in paflents with sporadic colon cancers. METHODS: Ninety-one patients with stage III primary colon cancer were included from the tumor registry of the Asan Medical Center, Seoul, Korea. All patients underwent a curative operation and postoperative chemotherapy with 5- fluorouracil and leucovorin for 6 cycles between 1993 and 1997. Immunohistochemical staining for hMLH1 and hMSH2 was performed using archival paraffin blocks. A positive expression was determined when unequivocal nuclear staining was identified in more than 10% of the cancer cells. The survival and the clinicopathologic variables regarding hMLH1 and hMSH2 expressions were assessed using the log-rank test and the Cox proportional regression method. RESULTS: Either hMLH1 or hMSH2 expression was lost in nine cases (9.9%). hMLH1 and hMSH2 expressions were significantly correlated with tumor invasion (P=0.012) and tumor differentiation (P=0.017). The disease-free survival did not differ with respect to hMLH1 and hMSH2 expressions. The number of metastatic lymph nodes and the preoperative serum CEA level were independent predictors of disease-free survival on a multivariate analysis. CONCLUSIONS: The loss of hMLH1 or hMSH2 expresscon appears to be involved in the differentiation of and the invasion by colon cancer. However, nether hMLH1 nor hMSH2 expression was correlated withthe 5-fluorouracil responsiveness.

The Significance of Perioperative Serum Carcinoembryonic Antigen Measurement in Patients with Curative Colorectal Cancer

PURPOSE: Regular monitoring of serum carcinoembryonic antigen (CEA) has been used as a tool to detect recurrence of colorectal cancer postoperatively. This study aimed to evaluate the significance of perioperative serum CEA level in patients with curative colorectal cancer. METHODS: We analyzed the data obtained from the 420 patients with colorectal cancer who underwent curative resection. Preoperative serum CEA level (ng/ml) was divided into 3 groups, i.e. groups I: or=20. Each group of preoperative serum CEA level was analyzed in accordance with location, histologic differentiation, stage of tumor, recurrence and survival. Postoperative serum CEA level was analyzed in accordance with preoperative serum CEA level and recurrence. RESULTS: Preoperative serum CEA level correlated with tumor stage (P=0.009). Ninety six patients among 420 patients showed recurred and recurrences were more common in patients with high preoperative serum CEA level (P =0.002). Systemic recurrences were more common in patients with high preoperative serum CEA levels than normal levels (P=0.029). In recurrence cases, 75 patients (78.1%) had elevated serum CEA levels and 55 patients had high preoperative serum CEA levels (P=0.008). The disease free 5-year survival rate in preoperative serum CEA group I, II, and III were 91.4%, 70.5%, and 58.3% respectively (P= 0.000) CONCLUSION: Preoperative serum CEA levels seemed to be closely correlated with distant metastasis and survival. Meticulous follow-up evaluation and generous use of adjuvant therapy are recommanded in patients with high preoperative CEA level.

CMV Colitis in a Patient with Colon Adenocarcinoma

Cytomegalovirus (CMV) colitis occurs almost exclusively in immune-compromised patients namely, HIV infection, immunosuppressant therapy after organ transplantation, anti-cancer chemotherapy, and long- term steroid user. Some patients with solid tumor have gastrointestinal CMV disease without anti-cancer chemotherapy. A 64-year-old male patient underwent surgery due to sigmoid colon cancer. On histopathologic examination of surgical specimen, CMV colitis was found in the colon. The AJCC tumor stage was II. Although CMV colitis is rarely associated with colon cancer, it maybe considered in patients with combined colitis with colorectal cancer.

Local Excision for Rectal Cancer

PURPOSE: Local excision of early rectal cancers with favorable histologic features can provide comparable survival rate to radical surgery with minimal morbidity and mortality, showing excellent functional results. But, still worried about high local recurrence rate and poor survival rates for local excision. This study was performed to investigate complications and evaluate oncological out comes after local excision for rectal cancers. METHODS: We evaluated 80 cases underwent local excision among 1681 patients with rectal cancer between January 1989 and December 2000. The mean age was 58+/-11 years and median follow up period was 24 (range: 1-82) months. Type of surgery for early rectal cancer were transanal excision in 51 cases (63.8%), transsphincteric approach in 12 cases (15%) and endoscopic submucosal resection alone in 17 cases (21.2%). RESULTS: The distance from the anal verge was 5.9+/-2.6 cm and the mean tumor size was 2.5+/-2.0 cm. Pathological depth of invasion revealed 52 Tis, 21 T1, 6 T2, and 1 T3 tumors. Cellular differentiation was well-differentiated tumor in 73% and moderately-differentiated in 27%. On histologic examination, 65% of them comprised underlying adenoma component. Leakage from the closure site was observed in two cases of transsphincteric approach. One case required abdominoperineal resection and the other was managed by temporary colostomy. Adjuvant chemoradiation was performed in 10 cases: one Tis with positive resection margin, 6 deep T1, and 3 T2 tumors. Five tumors was salvaged by immediate surgery: one T1 with positive resection margin, 3 T2 with positive resection margin, and 1 T3. During the follow up period, one local recurrence was developed after 25 months of surgery and salvaged by low anterior resection. CONCLUSION: Local excision for rectal cancer can be performed safely in strictly selected patients and meticulous surgical technique according to tumor location is mandatory to reduce postoperative complications.

Clinical Significance of Preoperative High Serum CEA Value in Patients with Colorectal Cancer

PURPOSE: The preoperative s-CEA level are correlated to the extent of the tumor and distant metastasis in patients with colorectal cancer. This study was performed to analyze patterns of distant metastasis and survival rate according to the levels of preoperative s-CEA and evaluate the significance of chest CT and bone scan as methods of preoperative staging work-up in patients with high s-CEA level (>or=20 ng/ml). METHODS: A retrospective study was performed on 1,136 colorectal cancer patients who underwent surgery in Asan medical center between 1989 and 1995. These patients were classified into 3 groups according to preoperative s-CEA level (group A: or=6,or=20). We scrutinized the patterns of metastasis and compared the survival rates between the groups. Another study was, then, conducted prospectively on the basis of the above results. One hundred and sixty nine patients with s-CEA level (>or=20 ng/ml) were routinely examined by chest CT and bone scan for preoperative metastatic work-up in addition to the conventional work-up. Statistical analysis was performed by chi-squared test, Kaplan-Meier and log-rank test. RESULTS: The preoperative s-CEA level and the tumor stages were significantly correlated (P=0.009). The distant metastasis rates in group A, B, and C were 22.7% (163/719), 49.1% (115/234), 76.5% (140/183), respectively (P=0.000). Five year survival rate of each group were significantly different in far advanced stage, stage III (0.71 vs. 0.61 vs. 0.51 : P=0.002) and stage IV (0.21 vs. 0.10 vs. 0.05 : P=0.004). In stage I and II, however, we couldn't find statistical differences. Among 169 patients with s-CEA level above 20ng/ml, 52 (30.7%) had liver metastasis. Twenty three patients (13.6%) had lung metastasis. Twenty (11.8%) cases of pulmonary metastasis were found on chest CT scan and 3 cases on chest X-ray or abdominal CT scan. Only 4 (2.4%) cases, however, had bone metastasis on bone scan. CONCLUSIONS: These results suggest that the high preoperative s-CEA level seemed to be closely correlated with distant metastasis and prognosis. A meticulous preoperative staging work-up including chest CT scan is recommended in patients with high preoperative s-CEA level.

The Clinical Significance of Carcinoembryonic Antigen and CA72-4 Assays of Peritoneal Fluid in Colorectal Carcinomas

PURPOSE: CEA and CA72-4 assays in peritoneal fluid offers the greatest advantage in increasing the sensitivity of cytologic diagnosis of carcinomas of the G-I tract. Actually, little investigations have been taken for the relations between CEA and CA72-4 levels in peritoneal fluid and the clinicopathologic characteristics of colorectal carcinomas. The intent of this study was to verify the usefulness of CEA and CA72-4 levels in peritoneal fluid for the treatment of colorectal carcinoma. METHODS: Seventy-three colorectal cancer patients who were hospitalized in our colorectal division were prospectively investigated. Thirty-five out of 73 patients had ascites. Preoperatively, the levels of serum CEA and CA72-4 were measured. At the time of laparotomy, ascites or peritoneal washings were collected from all patients and the levels of carcinoembryonic antigen and CA72-4 were measured and submitted for the analysis to the cytology laboratory. We analyzed the results with the levels of serum CEA and CA72-4, histologic differentiation, location, stage of the tumor, and obstruction due to tumor. RESULTS: The levels of serum CEA and CA72-4 were significantly correlated with those of peritoneal fluid. The elevated levels of CEA and CA72-4 of peritoneal fluid were also significantly correlated with advanced stages of colorectal carcinomas, respectively. But according to histologic differentiation, only CA72-4 levels of peritoneal fluid were elevated in poorly differentiated or mucinous carcinoma. No difference between the levels of CEA and CA72-4 of peritoneal fluid was present in accordance with the location of tumors. CONCLUSIONS: The measurement of CEA and CA72-4 of peritoneal fluid may be valuable method in discriminating between the early-stage versus the late-stage colorectal carcinoma.

Factors Affective Sexual Function after Abdominoperineal Resection for Patients with Rectal Cancer

BACKGROUND: Abdominoperineal resection (APR) combined with autonomic nerve preservation (ANP) is proven to reduce sexual dysfunction. However, Sexual dysfunction after APR combined ANP occurs as many as 59% of case. PURPOSE: The aims of this study were to assess prog nostic value of various postoperative factors affective sexual function after APR combined with ANP and to suggest a clinical relevant factors for the improvement of sexual function. METHODS: This was a cross sectional descriptive study. Data were collected using individual-based interviews from 63 patients who underwent APR during the period of Feb. 2001 and April. 2001. The tool for this study was developed by the researcher through modification of the QLQ-CR38 (European Organization for Research and Treatment of Cancer, 1999). RESULTS: The severity of sexual function showed significant differences according to occupation, intervals after operation, colostomy irrigation. Intervals of longer than 18 month after operation was associated with better sexual function. In multiple regression analysis, colostomy related problems, colostomy irrigation, colostomy complications, intervals after operation, recurrence affected sexual function significantly. CONCLUSIONS: Colostomy related problems, colostomy irrigation, colostomy complications, intervals after operation and recurrence appear to be associated with sexual function after APR.

Reappraisal of AJCC Staging System in Colorectal Cancer

PURPOSE: The TNM classification for carcinoma of the colon and the rectum provides more detail than other staging systems. This study was performed to evaluate the effectiveness of AJCC staging system (5th ed., 1997) for the colorectal cancer in predicting prognosis. METHODS: We analyzed a data base of 1,233 colorectal cancer patients (M:F=673:560) who underwent surgery in Asan Medical Center during July 1989-December 1996. Survival analysis was performed between the stages and the subgroups in same stage by using Kaplan-Meier method and log rank test. Borderline subgroup comparison between the stages was performed, also. Significance was assigned to a P value of <0.05. RESULTS: Mean age of the patients was 57 (19-90) years old. Median follow-up period was 42 (6-129) months. The number of patients in each stage were 0: 15, I: 152, II: 390, III: 465, IV: 199. The 5 year overall & disease free survival rates of each stage were 100%, 100% (in stage 0), 96.4%, 93.6% (in stage I), 82.7%, 82.2% (in stage II), 59.9%, 55.3% (in stage III), and 7.3%, 24.9% (in stage IV), respectively (P=0.000). Subgroup analysis in stage I (T1N0 vs. T2N0) and II (T3N0 vs. T4N0) revealed no differences. However, in stage III, N1 (n=246) group showed better survival than N2 (n=219) group (70.3%, 65.5% vs. 49.2%, 44.6%: P=0.000). Borderline survival analysis between stage I and II (T2N0 vs. T3N0) was significantly different (96.6%, 95.7% vs 82.7%, 82.3%: P=0.006). However, between stage II and III (T4N0 vs. T1N1), appropriate analysis was impossible due to small number of cases. CONCLUSIONS: AJCC staging system for colorectal cancer was reliable and effective in predicting prognosis. However, substages are needed in stage III.

The Significance of Diverting Ileostomy during Restorative Proctocolectomy

PURPOSE: Restorative proctocolectomy (RP) is a standard surgery in patients with ulcerative colitis and familial adenomatous polyposis. Usually, diverting ileostomy is performed to protect an ileoanal anastomosis with RP. However, there are many controversies whether diverting ileostomy might urgently be needed. This study was performed to compare postoperative complications after RP with or without diverting ileostomy. METHODS: Between July 1994 and June 2001, 77 (M : F= 45 : 32) patients underwent RP. The indication criteria for diverting ileostomy included tension at the anastomosis, positive leakage test, compromised blood flow in the ileal pouch, long-term and high-dose steroid use, and severe rectal inflammation in ulcerative colitis patients. RESULTS: Histopathologic diagnoses revealed 45 ulcerative colitis, 23 familial adenomatous polyposis, 5 rectal cancer, and 4 hereditary nonpolyposis colorectal cancer. Diverting ileostomies were performed in 40 patients (51.9%) and closed approximately 4 months later. Fourty eight complications were present in 32 patients. There was no perioperative death. There was no difference in perioperative outcome, morbidity or functional status between patients with and without ileostomy. However, in ulcerative colitis patients, anastomosis leakage was more frequent in patients without ileostomy. CONCLUSIONS: Restorative proctocolectomy can be safely performed without diverting ileostomy in most cases of RP. However, diverting ileostomy may reduce anastomosis leakage in patients with ulcerative colitis.

Sigmoid Volvulus: Is Surgical Treatment Mandatory?

PURPOSE: The standard treatment for sigmoid volvulus has been considered as a resection of involved segment after nonoperative decompression. This study was performed to investigate the clinical characteristics and compare the results of managements in patients with sigmoid volvulus. METHODS: We recruited twelve patients with sigmoid volvulus registered and treated at Asan Medical Center during 1989 and 1999. The medical records were reviewed retrospectively. Telephone inerviews were performed to inquire recent status. We analyzed clinical variables including symptoms on admission, physical findings, findings of radiologic studies, managements and their outcomes. The median age was 64 years (range:45 to 84 years). The median follow-up period was 46 months (range:2 to 94). RESULTS: Nine patients among twelve were male. Presenting symptoms were abdominal pain (92%), abdominal distension (67%), constipation (50%) and hematochezia. The diagnostic modalities utilized included plain film of the abdomen, CT scan and sigmoidoscopy. Nine cases (75%) were correctly diagnosed prior to operation, of which eight (67%) were diagnosed by plain film. The remaining three cases were by operation. In these cases, preoperative diagnoses were ischemic colitis and obstruction due to colonic malignancy. In seven cases, only nonoperative managements were employed. Nonoperative management included decompression by nasogastric tube or rectal tube insertion and use of bulk forming agents and stool softner afterwards to improve bowel habits. Five patients underwent anterior resection. We couldn't perform surgery in seven cases because of high operative risk due to underlying serious medical conditions such as bronchial asthma, malignancies and refusal by the patients after clinical improvement in 4 and 3cases, respectively. Three of them were died of underlying disease or sepsis. Recurrence occurred in two patients (50%) who underwent nonoperative management only and none in patients who underwent surgical intervention. CONCLUSIONS: In patients with sigmoid volvulus, elective surgery after appropriate nonoperative management is mandatory to prevent recurrence and fatal outcome, especially in good surgical risk patients. Considerable patients, however, did not undergo surgery due to poor physical status or refusal of surgery.

Curative Groin Dissection of Inguinal Lymph Node Metastasis from Lower Rectal Cancer: The Operative Technique and a Report of Four Cases

PURPOSE: Inguinal lymph node metastasis from rectal adenocarcinoma occurs infrequently and is generally considered as a manifestation of systemic metastasis. The prognosis is limited with all modalities of chemotherapy and radiotherapy. METHODS: Four of 610 patients with lower rectal cancer underwent curative groin dissection following identification of no other systemic metastasis. RESULTS: All patients had previously undergone abdomino-perineal resection and adjuvant chemo-radiotherapy as primary rectal cancer treatment. A synchronous inguinal lymph node metastasis was identified in one patient, whereas metachronous metastasis was found at seven, 12, and 14 months postoperatively in the remainly three patients. The survival time was from 2 to 22 months after curative groin dissection. One patient remains alive 22 months after the curative groin dissection showing neither perirectal lymph node nor systemic metastasis on primary surgery. CONCLUSION: Although radical groin dissection is rarely indicated in lower rectal cancer metastasis, it can be efficiently performed in cases without systemic metastasis. As the technique is also useful in other malignant metastasis, we introduce our operative procedure in addition to the report of the four cases.

Etiology and Management for Adult Intussusception

PURPOSE: Intussusceptions occurring in adults are relatively rare, however, surgery is usually recommended since they frequently accompany organic lesions as predisposing factor. The purpose of this study is to analyze clinical manifestations and investigate optimal treatment principles for adult intussusception. METHODS: Clinicopathogic manifestations of 28 adult intussusception patient were analyzied, retrospectively. The types of adult intussusception were classified as enteric and colonic types. Sex ratio was 15:13 and mean age was 52 (17-80) years. RESULTS: CT scan was the most accurate tool for diagnosis of adult intussusception and detection of underlying causes. The types of adult intussusception were 4 jejuno-jejunal, 7 ileo-ileal, 15 ileo-cecal, and 2 colo-colic types. The pathologic lesions were identified in 23 out of 28 cases (82%). Malignancy was the cause of adult intussusception in 5 cases (45%) of enteric type and in 6 cases (35%) of colonic type intussusception. Operations were performed in 26 cases (93%) and resection without reduction was performed in 23 cases. CONCLUSIONS: Surgical exploration without reduction may be the treatment of choice since the majority of cases have organic lesions as the etiology, with relatively frequent association of malignancies.

Clinical Characteristics of Inguinal Hernia Following Rectal Cancer Surgery

PURPOSE: The anatomic and physiologic changes after rectal cancer surgery was suggested to be a cause of inguinal hernia. But, there are only few reported cases about the inguinal hernia following rectal cancer surgery. The aim of this study is to verify risk factors and surgical techniques to prevent inguinal hernia following rectal cancer surgery. METHODS: Out of 1226 patients who underwent operations at the Department of Surgery, Asan Medical Center, between the period from June 1989 to July 1999, 12 patients who had developed inguinal hernia and their medical records were reviewed retrospectively regarding the clinical characteristics. RESULTS: The median duration of hernia following rectal cancer surgery was 12 (3-36) months. The median age was 63 (36-74) years with eight of them more than seventh decades of their life. All patients had male sex. Three of them were overweighted. Five cases had hernias on the left side, six on the right, and one case on both side. All patients had indirect inguinal hernia. Three cases had preoperative symptoms of bowel obstruction. The operations for rectal cancer were low anterior resection in eight cases, ultralow anterior resection in three cases, and abdominoperineal resection in one case. The complications in rectal cancer surgery were found in six cases. Six cases had the advanced stage. A postoperative radiation therapy was applied in five cases. Five cases had the coexisting diseases. CONCLUSIONS: Male sex and old age would be related with occuring inguinal hernia after rectal cancer surgery and, it would be necessary to give a special attention to the patients who have these factors, although the present study could not show the definite correlation between inguinal hernia and rectal cancer surgery due to a small number of cases.