Risk Factors Affecting Pancreatic Fistula after Pancreaticoduodenectomy

PURPOSE: Pancreacticoduodenectomy is the procedure of choice for managing periampullary malignancy. But pancreatojejunostomy site leakage is a very critical complication because it is hard to prevent leakage. The aim of this study is to analyze the risk factors of pancreatic leakage after pancreaticoduodenectomy. METHODS: We retrospectively reviewed 172 consecutive patients who had received pancreaticoduodenectomy at Inha University Hospital between Apr. 1996 and Mar. 2006. We analyzed the pancreatic leakage rates according to the clinical characteristics, the pathologic and laboratory findings and the anastomosis methods. RESULTS: There were differences in the mean age and pathologic findings between the two groups. There were 115 (66.9%) patients older than 60 years, while the other 57 patients (33.1%) were younger than 60 years. The incidence of developing pancreatic fistula in patients older than 60 years was 21.7% (25/115) while this was 8.8% (5/57) for the younger patients, and the difference was significant (p=0.03). The patients with a dilated pancreatic duct showed a lower rate of esser post-operative pancreatic fistula than the patients with a non-dilated duct (p=0.001). Other factors, including the anastomosis method and the pathologic diagnosis, didn't show any statistical difference. According to the pathologic diagnosis, the patients with pancreatitis and stomach cancer revealed pancreatic fistula to a smaller extent; there were 6 cases (3.5%) of pancreatitis and 22(12.8%) of stomach cancer. Among the case with pancreatic fistula, there were 0 cases of pancreatitis and 2 cases (6,7%) of stomach cancer, but the difference was not statistically significant. CONCLUSION: Our study demonstrated that pancreatic fistula is related to age and a dilated pancreatic duct. Surgeon must take these risk factors into consideration when performing pancreaticoduodenectomy. We recommend surgeons to use skillful technique to prevent pancreatic fistula.

Patterns of First Failure after Management of Hilar Cholangiocarcinoma

PURPOSE: This study was conducted to evaluate the patterns of disease progression following either resection or palliative management of hilar cholangiocarcinoma and to clarify the polarity of the resection margin. METHODS: The medical records of 78 hilar cholangiocarcinoma patients who were admitted to the Inha University Hospital between June of 1996 and May of 2006 were retrospectively reviewed. The patterns of recurrence were compared between the margin positive, margin negative and palliative management groups, and factors influencing recurrence and survival were then analyzed using the Cox proportional hazard model. RESULTS: The hilar cholangiocarcinoma recurred or progressed in 56 patients (71.8%) following the initial treatment, and the median progression free survival (PFS) time was 10.1 months. The 3-yr estimates of overall relapse and the median PFS were 90.7% and 17 months, respectively, in the resection group (n=32) and 100% and 7 months, respectively, in the palliative group (n=46) (p=0.045). There was no significant difference observed in the 3-yr estimates of overall disease progression or the median PFS according to the margin positivity or resection methods. When the disease progression pattern was analyzed, there was no significant difference observed between the groups, however, the survival analysis showed that survival was greater in the group that underwent resection with curative intent than in the palliative management group (p=0.001). Adjuvant chemotherapy or radiotherapy had no effect on recurrence or survival, and poor differentiation was the only significant prognostic factor for survival identified when the Cox proportional hazard model was used. CONCLUSION: Because no difference in the pattern of disease progression existed, aggressive surgical resection should be attempted to prevent recurrence and to increase survival, even in cases in which a suspicious positive resection margin is present.

National Cancer Incidence for the Year 2002 in Korea / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Since the revised Cancer Act of October 2006, cancer registration was reactivated, based on the Statistics Law. MATERIALS AND METHODS: The incidence of cancer during 2002 was calculated on the basis of the information available from the National Cancer Incidence Database. Crude and age-standardized rates were calculated by gender for 18 age groups (0~4, 5~9, 10~14, every five years, 85 years and over). RESULTS: The overall crude incidence rates (CRs) were 269.2 and 212.8 per 100,000 for males and females, and the overall age-standardized incidence rates (ASRs) were 287.8 and 172.9 per 100,000, respectively. Among males, the five leading primary cancer sites were stomach (CR 62.4, ASR 65.7), lung (CR 45.4, ASR 51.0), liver (CR 43.2, ASR 43.7), colon and rectum (CR 30.7, ASR 32.7), and prostate (CR 8.0, ASR 9.6). Among females, the most common cancer sites were breast (CR 33.1, ASR 26.9), followed by stomach (CR 32.8, ASR 26.0), colon and rectum (CR 23.1, ASR 18.5), thyroid (CR 19.1, ASR 15.7), and uterine cervix (CR 18.2, ASR 14.7). In the 0~14 age group, leukemia was the most common cancer for both genders. For males, stomach cancer was the most common cancer in the 15~64 age-group, but lung cancer was more frequent in men 65 or older. For females, thyroid cancer among the 15~34 age-group, breast cancer among 35~64 age-group and stomach cancer in women 65 years or older were the most common forms of cancer for each age group. The quality indices for the percentage of deaths, by death certificate only, were 4.7% for males and 4.5% for females. CONCLUSIONS: Since the National Cancer Incidence Database was started, the annual percent change of cancer cases increased by 4.8% (4.1% for males, 5.7% for females) during 1999~2002. This value reflects the increase in prostate cancer for males and breast and thyroid cancer in females during 2002. The timely reporting of improved quality of cancer registration is needed for evidence-based decisions regarding cancer control in Korea.

Gasless Endoscopic Thyroidectomy via an Anterior Chest Wall Approach Using a Flap-Lifting System

PURPOSE: Endoscopic thyroidectomy (ET) requires a proper working space for adequate visualization of anatomical structures and proper instrument manipulation. The purpose of this prospective study was to estimate the feasibility and safety of ET using an anterior chest wall approach without gas insufflation. MATERIALS AND METHODS: The working space was created under a direct and endoscopic view through a 3-cm incision on the anterior chest wall. A retracting device was then inserted to establish the working space, and subsequent procedures were performed endoscopically. All data were reviewed using a prospective database. RESULTS: We performed 30 ETs in patients with benign thyroid tumors from December 2003 to December 2005. The procedures were completed successfully in 29 patients (mean operative time: 160.6 min; range: 90-345 min). One patient with ET was converted to open thyroidectomy secondary to substernal extension of the tumor. None of the patients developed permanent postoperative hypocalcemia or recurrent laryngeal nerve paralysis. Three patients exhibited some degree of transient recurrent laryngeal nerve palsy. CONCLUSION: These data suggest that gasless ET using an anterior chest wall approach is safe and feasible in selected patients for treating benign thyroid tumors. This technique may offer good operative working space when performed by surgeons with relatively low-volume ET practices.

A Prospective Study on the Significance of Peritoneal Washing Cytology as a Diagnostic Modality in Colorectal Cancer

PURPOSE: Free intraperitoneal cancer cells exfoliated from a tumor are considered to be responsible for peritoneal dissemination. Therefore, microscopic evaluation of cells washed from the peritoneal cavity during surgery for various intraabdominal malignancies has been used to detect subclinical intraperitoneal metastases from these tumors. The purposes of this study were to detect intraperitoneal free cancer cells at the time of surgery by using peritoneal washing cytology in colorectal cancer and to evaluate their diagnostic significance. METHODS: During the 29-month period from January 2000 through May 2002, 149 randomly selected patients with primary colorectal cancer without evidence of gross peritoneal metastasis underwent peritoneal washing cytologic analysis before surgical manipulation of the tumor. Peritoneal washing cytology was compared with the pre-existing prognostic factors. RESULTS: Positive peritoneal washing for free cancer cells was found in 19 of 149 patients (12.8%). This positivity was significantly correlated with histologic grade (P=0.002), serosal invasion (P=0.025), lymph node metastasis (P=0.034), Astler-Coller classification (P=0.008), recurrence (P<0.001), and 5-year survival (P<0.001). Cancer-specific survival was significantly associated with histologic grade (P=0.025), peritoneal washing cytology (P<0.001), lymph node metastasis (P<0.001), recurrence (P<0.001), and stage (P= 0.010) in the multivariate analysis. CONCLUSIONS: The presence of free cancer cells was predictive of survival and was an independent prognostic factor. This information may be useful in stratifying patients with colorectal cancer for therapeutic trials, such as intraperitoneal chemotherapy.

Large Cell Neuroendocrine Carcinoma of Anal Canal: Report of a Case

A neuroendocrine carcinoma of the anal canal is a very rare entity; however, this type of tumor is known for its aggressive progression and poor prognosis. We describe the case of a 58-year-old female with a neuroendocrine carcinoma arising in the anal canal. The tumor was found in the anal canal with multiple liver metastases. The patient died due to massive liver metastases 11months after diagnosis and operation. For its rarity and clinical significance, we report the case with a review of the literature.

Multiple Metastses to the Small Bowel from Lung Cancer

Metastases from lung cancer to the gastrointestinal tract are not exceptional findings, but their clinical manifestations are rare. We report a new case of multiple metastases to the small bowel from primary lung cancer. A 67 year-old man presented with acute abdominal pain and vomiting. The laboratory investigations were all within normal limits except leukocytosis. Lung radiography was done and it showed infiltration at the right upper lung field without any mass. Abdominal CT-scan demonstrated a small bowel mass with ileoileal intussusception and the patient underwent emergency surgery. The postoperative lung studies and pathological analysis confirmed primary lung cancer with small bowel metastasis.

Insular (Poorly Differentiated) Carcinoma of Thyroid / 대한내분비외과학회지

Insular carcinoma of the thyroid is a rare thyroid malignancy, and this was named in 1984 by Carcangiu when he described its characteristic histology. Histologically, insular carcinoma is characterized by uniform cells arranged in distinct nests or an insular pattern that contain variable numbers of small follicles. Clinically and morphologically, it is considered to be in an intermediate position between well-differentiated carcinoma of the thyroid (papillary or follicular) and undifferentiated or anaplastic carcinoma of the thyroid. This thyroid malignancy is distinctive, aggressive and often lethal. However, most authors believe it to be an independent entity. The prognosis of this tumor is worse than that of classic differentiated thyroid carcinoma, and most authors advise aggressive therapy, which can achieve pro-longed survival in some cases. We describe here a patient (a 42 years-old woman) who was managed with completion thyroidectomy after unilateral lobectomy of the thyroid with confirmation of the permanent pathology as insular carcinoma. I-131 ablation (175 mCi) was performed on the remnant thyroid tissues after follow-up of I~131 whole-body scanning.

A Case of Simple Hepatic Cyst Complicated by Intracystic Hemorrhage

Simple liver cysts are common and benign lesions, and most of them are detected by ultrasonography (US) or computed tomography (CT) during a medical checkup. Because simple liver cysts are generally asymptomatic, they do not require treatment, although hemorrhage, infection or rupture may occur in rare cases and these cases must receive proper treatment. The diagnosis of simple liver cysts is usually easy because of their typical morphological findings on US or CT. However, when a liver cyst contains hemorrhage or it is inflamed on imaging studies, it is sometimes difficult to differentiate simple hepatic cysts from such conditions as cystadenoma and cystadenocarcinoma. In this report, we describe a case of simple liver cyst that was complicated by intracystic hemorrhage, and this malady was initially diagnosed as biliary cystadenocarcinoma. We successfully treated this lesion by left lateral segmentectomy.

Gastrointestinal Stromal Tumor of the Rectum in a Pediatric

Gastrointestinal stromal tumors are the most common subset of mesenchymal tumors that arise from the gastrointestinal tract. They most commonly arise in the stomach, followed by the small bowel and, rarely, the rectum, esophagus and colon. Gastrointestinal stromal tumors and the specific c-kit protein (CD117)-positive mesenchymal tumors, have been sporadically reported in the rectum. We report here on a 12-year-old boy who underwent low anterior resection of huge gastrointestinal stromal tumor of the rectum. The diagnosis was confirmed by immunohistochemical staining of the tumor. The specimen was revealed to be a polypoid fungating tumor that, measured 6.0 x 6.0 cm in size, which consisted histologically of spindle-shaped cells. The tumor cells were positive for c-kit, vimentin, S-100, desmin, and SMA, although the results of the CD34 test were negative. In general, Gastrointestinal stromal tumors of the rectum predominantly occur between the sixth and seventh decades and they are rarely seen in individuals less than 40 years of age. To the best of our knowledge, our case is the youngest reported patient in the English literature who had as gastrointestinal stromal tumor of the rectum.

Amyloid Goiter with Parathyroid Involvement

The amyloid deposition observed in secondary amyloidosis frequently involves the thyroid gland, but rarely is a goiter responsible for this. We report here the pathologic findings of a case of amyloid goiter with involvement of a parathyroid gland in an euthyroid patient. The patient presented with an enlarged thyroid, symptoms of upper airway obstruction and dysphagia.

Relationship between XRCC1 Polymorphism and Acute Complication of Chemoradiation Therapy in the Patients with Colorectal Cancer / 대한방사선종양학회지

PURPOSE: It is well known from clinical experience that acute complications of chemoradiation therapy vary from patients to patients. However, there are no known factors to predict these acute complications before treatment starts. The human XRCC1 gene is known as a DNA base excision repair gene. We investigated the possibilities of XRCC1 gene polymorphisms as a predictor for the acute complications of chemoradiation therapy in colorectal cancer patients. MATERIALS AND METHODS: From July 1997 to June 2003, 86 colorectal cancer patients (71 rectal cancer, 13 sigmoid colon cancer and 2 colon cancer patients) were treated with chemoradiation therapy at the Department of Radiation Oncology, Inha University Hospital. Twenty-two patients were in stage B, 50 were in stage C, 8 were in stage D and 6 patients were unresectable cases. External radiation therapy was delivered with 10MV X-ray at a 1.8 Gy fraction per day for a total dose of radiation of 30.6~59.4 Gy (median: 54 Gy). All the patients received 5-FU based chemotherapy regimen. We analyzed the acute complications of upper and lower gastrointestinal tract based on the RTOG complication scale. The initial and lowest WBC and platelet count were recorded during both the RT period and the whole treatment period. Allelic variants of the XRCC1 gene at codons 194, 280 and 399 were analyzed in the lymphocyte DNA by performing PCR-RFLP. Statistical analyses were carried out with the SAS (version 6.12) statistical package. RESULTS: When all the variables were assessed on the multivariate analysis, recurrent disease revealed the factors that significantly correlated with upper gastrointestinal acute complications. Arg399Gln polymorphisms of the XRCC1 gene, the radiation dose and the frequencies of chemotherapy during radiation therapy were significantly correlated with lower gastrointestinal complications. Arg399Gln polymorphisms also affected the decrease of the WBC and platelet count during radiation therapy. CONCLUSION: Although the present sample size was too small for fully evaluating this hypothesis, this study suggests that Arg399Gln polymorphisms of the XRCC1 genes may be used as one of the predictors for acute complications of chemoradiation therapy in colorectal cancer patients.

The Usefulness of (99m)Tc-Ciprofloxacin Imaging in the Diagnosis of Acute Cholecystitis

PURPOSE: The diagnosis of acute cholecystitis is usually made by performing ultrasonography or biliary scintigraphy. We have introduced the (99m)Tc-ciprofloxacin (infecton) scan for diagnosing of acute cholecystitis. The main aim of this study was to evaluate the efficacy of (99m)Tc-ciprofloxacin imaging in comparison with ultrasonographic findings for the diagnosis of acute cholecystitis. METHODS: Sixteen patients who were thought to have acute or chronic cholecystitis, based on the clinical and sonographic findings, were included in this study. We gave intravenous (99m)Tc-ciprofloxacin to sixteen patients and we obtained the SPECT images after one hour. The final diagnosis of acute cholecystitis was made according to the pathologic reports. RESULTS: According to pathologic reports, out of the sixteen patients, twelve patients had acute cholecystitis and four patients had chronic cholecystitis. On the (99m)Tc-ciprofloxacin scans, twelve patients had positive images showing acute cholecystitis on account of the hot uptake in the gallbladder and four patents had negative images showing chronic cholecystitis due to the negative uptake in the gallbladder. Among them, one false positive case and one false negative case were observed. With performing ultrasonography, twelve and four patients were diagnosed as having acute and chronic cholecystitis respectively. Out of them one false positive case and three false negative cases were observed. Based on the pathologic reports, (99m)Tc-ciprofloxacin imaging has a sensitivity of 91.7% and a specificity of 75%. The ultrasonography had a sensitivity of 91.7% and a specificity of 25%. CONCLUSION: As a result of comparing the sensitivity and specificity of the (99m)Tc-ciprofloxacin scan with those of the ultrasonography, the (99m)Tc-ciprofloxacin scan is considered to be useful test method to diagnose acute cholecystitis.

Experimental Study of 99mTc-Ciprofloxacin (Infecton) Imaging for the Diagnosis of the Acute Appendicitis

PURPOSE: Acute appendicitis is the most common disease requiring abdominal surgery, but for atypical clinical findings, a preoperative diagnosis is difficult and the frequency of a false positive and false negative diagnosis is high. The authors compared the diagnostic accuracy of a Technetium-99m-ciprofloxacin scan with that of the other diagnostic tools and evaluated its potential for clinical applications. METHODS: Seventeen patients were among those patients who visited the emergency room due to right lower quadrant (RLQ) pain were selected for this study. The decision for primary treatment was based on the clinical findings (RLQ pain, nausea, tenderness, rebound tenderness, leukocytosis, etc) and the radiological findings (abdominal ultrasonogram, abdominal computed tomography, etc). The 99mTc-ciprofloxacin scan was conducted regardless of the decision above. For the patients who underwent surgery, the final diagnosis of acute appendicitis was based on the pathologic result and for patients who did not undergo surgery, the final diagnosis was determined by the clinical course. RESULTS: Seventeen patients were enrolled in this study (7 males, 10 females). The patient's age ranged from 8 to 71 years and the average age was 29.2 years. The diagnostic accuracy of acute appendicitis is presented in order of the clinical findings, the radiological findings and the 99mTc- ciprofloxacin scan as follows: The sensitivity was 100%, 90.9% and 100%; the specificity rates was 33.3%, 50% and 67%; the positive predictive value was 87.5%, 90.9% and 93%; the negative predictive values was 100%, 50% and 100%; the false positive rate was 66.7%, 50% and 33.3%; the false negative rate was 0%, 9% and 0%. The respective p-values for the correlation between these results and the final diagnosis were 0.021, 0.049 and 0.002. CONCLUSION: A 99mTc-ciprofloxacin scan can decrease the false positive and the false negative rate and increase the diagnostic accuracy of acute appendicitis patients.

Distinctive Pattern of Gene Expression in Intestinal and Diffuse Gastric Cancer on cDNA Microarray

Molecular investigations have provided evidence of the involvement of multiple genetic alterations in gastric carcinogenesis. Regarding the clinical, epidemiological and genetic aspects, well and poorly differentiated gastric adenocarcinoma exhibit some differences.(1) PURPOSE: To examine the gene expression profile of stomach cancer and evaluate the differentially expressed genes between intestinal and diffuse cancer type. METHODS: Five intestinal and 5 diffuse type gastric cancer tissues and their matched normal mucosa were obtained from patients who underwent a gastrectomy. The mRNAs frome these tissues were extracted, reverse transcribed with simultaneous Cy3 and Cy5 labeling, and hybridized with the MAGIC(TM) microarray (Korean 4.6k chip). The chip was scanned using Generation III, image analysis with Imagine 5.0 and data analysis with Arraytool, R, and SAM. RESULTS: Twelve and 15 genes were found to be up- and down-regulated genes in the intestinal type, whereas these figures were 25 and 4 genes in the diffuse type, respectively. With the intestinal and diffuse type, 2 and 9, 10 and 4 exhibites up- and down-regulation greater than 2 fold, respectively. In the intestinal type genes, up-regulation was associated with metabolism, cell growth and cell communication; whereas, down-regulation was associated with metabolism and mainly unclassified functions. In the diffuse type genes, up-regulation was associated with metabolism, cell growth, cell communication and drug resistance, ; whereas, down-regulation was associated with metabolism and cell growth. Non-hierarchical clustering of the genes revealed two expression profiles, which can be used to classify the above 10 samples into two exactly distinct types. CONCLUSION: The analysis of the intestinal and diffuse gastric cancers using the cDNA microarray showed distinct gene expression profiles, consistent with their different histological and clinical features.

Correlations between the Rate of Decrease in Preoperative Bilirubin and Postoperative Complications after Biliary Drainage for Distal Common Bile Duct Cancer

PURPOSE: This study was aimed at comparing the rate of decrease in preoperative serum bilirubin after biliary drainage and the postoperative complication rate in patients with distal common bile duct (CBD) cancer. METHODS: Forty six patients who had undergone pancreaticoduodenectomy due to distal CBD cancer were included in this study. The patients were divided into the complicated and uncomplicated groups. For the patients who underwent preoperative biliary drainage, the preoperative bilirubin level and the rate of decrease in serum bilirubin were measured and compared between the two groups. RESULTS: The postoperative complication and mortality rates were 43.4% (20/46) and 6.5% (3/46), respectively. The complication rates were not different between the drainage and non-drainage groups (p=0.48). The preoperative serum bilirubin levels were also not different between the complicated and uncomplicated groups (p=0.214). In the uncomplicated group, the rate of decrease in the serum total bilirubin level tended to be higher than in the complicated group, but this was not statistically significant (mean: 0.82 vs 0.27 mg/dl/day, respectively, p=0.117). Patients with a higher preoperative bilirubin decrease rate showed a larger bilirubin decrease in the immediate postoperative period (from POD 1 to POD 7, r=0.371, p=0.05). CONCLUSION: The preoperative biliary drainage and the serum bilirubin level were not correlated with the postoperative complication rate. Patients with higher preoperative bilirubin decrease rates showed a larger bilirubin decrease in the immediate postoperative period, which can be interpreted as having a faster recovery of their liver function. Further study with a larger number of cases is required to see if the preoperative bilirubin decrease rate could be used as a prognostic indicator after pancreaticoduodenectomy.

Analysis of Prognostic Factors after Surgery for Gallbladder Cancer

PURPOSE: Gallbladder cancer, which is the most common malignancy of the biliary tract, is frequently associated with poor prognosis. The aim of this study was to evaluate outcomes with gallbladder cancer according to the surgical treatment, pathologic stage, and prognostic factors. METHOD: The medical records of 52 consecutive patients with gallbladder cancer treated at our institution from June 1996 through June 2005 were reviewed retrospectively. Survival was analyzed using the Kaplan-Meier method (mean followed period 60 months) and the log-rank test. Prognostic factors were analyzed using Cox regression. RESULTS: Mean patient age was 67 years. Fiftysix percent of patients were female. Twentyeight patients (56%) underwent curative resection (5 simple cholecystectomies and 23 radical cholecystectomies). There were no procedure-related deaths. The Overall 5-year survival was 18%. Patients who underwent curative resection had a higher 5-year survival rate (40%) than patients who underwent palliative surgery (0%; P=0.0001). The palliative surgery, high T stage, positive lymph node metastasis were significant factors predictive of worse survivial. CONCLUSION: The good long-term survival may be achieved by an early diagnosis and radical resection.

Analysis of Clinicopathological Factors Affecting Local Recurrence of Colorectal Cancer after Curative Resection

PURPOSE: Local recurrence after curative resection of colorectal cancer has an important influence on both survival and quality of life. The ability to predict local recurrence after a curative resection of colorectal cancer may be useful for an intensive follow-up program and for a decision on adjuvant radiation or chemotherapy. The aim of this study was to analyze the factors affecting the incidence of local recurrence after a curative resection of colorectal cancer. METHODS: A retrospective review of 390 patients who had a curative resection for a primary colorectal cancer by a single surgeon at the Department of Surgery, Inha University Hospital, between June 1996 and July 2002 was done. The medical records of patients diagnosed with a local recurrence were reviewed. Local recurrence was defined as any recurrence within the field of resection, regardless of the presence or absence of distant metastasis, that was diagnosed by using colonoscopy with biopsy and/or radiologic imaging. RESULTS: Local recurrences were detected in 40 patients (10.3%). The gender distribution of patients with local recurrence was 24 males and 16 females with a mean age of 59.8 years. The median time to local recurrence was 15 months. The most common site of local recurrence was the anastomosis site, followed by a regional lymph node, the pelvicoperineal area, and the presacral area. Local recurrence was related to the depth of the primary tumor (P=0.027), lymphatics or vascular invasion (P=0.003), perineural invasion (P= 0.000), nodal status (P=0.000), and distant metastasis (P= 0.002). However, there was no statistically significant relation between local recurrence and primary tumor location (P=0.053), primary tumor size (P=0.982), tumor differentiation (0.256), and preoperative CEA level (P=0.481). CONCLUSIONS: The depth of the primary tumor, lymphatics or vascular invasion, and perineural invasion were significant clinicopathologic factors of local recurrence, but tumor location, tumor size, tumor differentiation, and preoperative serum CEA level were not.

Surgical Clips Found at the Hepatic Duct after Laparoscopic Cholecystectomy: a Possible Case of Clip Migration

Surgical clip migration and subsequent stone formation in the common bile duct is a rare, but well-established complication after laparoscopic cholecystectomy. There are some suggestions about the mechanisms of the migration process, but the details are still unclear. We report here on a case in which common bile duct stones were formed around surgical clips, and other clips were found to have penetrated into the common hepatic duct, which we believe were in the process of migration after laparoscopic cholecystectomy. The patient required a laparotomy to retrieve the bile duct stones due to the distal bile duct stricture, and another laparotomy was necessary to remove the penetrating clips, which were deeply embedded in the bile duct wall. Although a variety of endoscopic and percutaneous interventional procedures are available in this era of modern medical technology, it is sometimes impractical to apply these procedures in such cases as ours, and exploratory laparotomy is sometimes required to correctly treat the patient. This case shows that the metallic surgical clips can penetrate into the intact bile duct wall through serial maceration, and we believe that careful application of clips may be the only way to prevent their migration after laparoscopic cholecystectomy.

Perianal Extramammary Paget's Disease Associated with an Anal Duct Adenocarcinoma: A Case Report

Extramammary Paget's disease occurs commonly on the external female genitalia and rarely occurs in the perianal region. Recently, we experienced a case of perianal extramammary Paget's disease associated with an anal duct adenocarcinoma. The patient was a 60-year-old man. The perianal skin lesion was eczematous and encircled the anus. A wide-excision, split-thickness skin graft and temporal T-loop colostomy were performed. Histopathologically, the tumor was a well-differentiated anal duct adenocarcinoma. There was a prominent pagetoid spread of about 6x4 cm. The tumor cell was positive for carcinoembryonic antigen, but the paget cell was negative. The patient was treated with radiation therapy and with single 5-FU chemotherapy six times. Five months later, the perianal region was nearly normal.