Changes of Serum CEA and CA19-9 Levels According to the Serum Bilirubin Level in Periampullary Cancer Patients Whipple or pylorus preserving pancreatoduodenectomy versus a biliary bypass or a biliary drainage procedure

BACKGROUND: Periampullary cancer is a relatively common malignancy, and its incidence is increasing. Prognosis in these patients depends upon resection of the tumor because surgery is the only effective treatment for irradicating the disease. There has, therefore, been a renewed interest in the role of serological markers early diagnostic tools for periampullary cancer. The potential role of serological markers is not limited only to early detection, but may also be of assistance in the difficult clinical dilemma of differentiating periampullary cancer from other diseases. Furthermore, serological markers of periampullary cancer might be used in follow-up patients after treatment, particularly after surgical resection, in order to select those with minimal disease likely to respond better to adjuvant treatment and/or radiotherapy. METHODS: From March 1989 to May 1997, 54 patients were admitted to Sanggye Paik Hospital, InJe University, and had pathologically confirmed periampullary cancer. Of those, 28 patients underwent a biliary bypass or a drainage procedure [Group I], and the others received resection procedures (Whipple's operation or pylorus-preserving pancreatoduodenectomy)[Group II]. Preoperative and postoperative serum levels of bilirubin, carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9(CA19-9) were measured in all patients. We evaluated the relation of the postoperative increase or decrease in those tumor markers to survival, and we discuss the usefulness of those markers as prognostic indicators in periampullary cancer. In this study, we focused on the changes in the CEA and the CA19-9 levels as function of the serum bilirubin concentration change. RESULTS: The bilirubin, CEA, and CA19-9 concentrations decreased significantly in Groups I and II after operation. The correlation between the decreases of the bilirubin and the CEA levels was statistically significant, but that between the bilirubin and CA19-9 had no statistical significance, in spite of the fact that the preoperative and the postoperative tumor marker concentrations had changed markedly. The reason for the statistical insignificance of the CA19-9 result may be the its relatively small sample size and the wide standard variation. The overall median and mean survival time of Group I were 4 months and 11 months, respectively, and those of Group II were 17 months and 21 months. CONCLUSION: We found that the serum the CEA and the CA19-9 levels could be used as a useful prognostic indicator change according to the serum bilirubin concentration even after a biliary drainage procedure and a biliary bypass. We conclude that various biliary bypass and drainage procedures can be effective treatments in periampullary cancer. However, because it is thought that many tumor markers are greatly affected by hyperbilirubinemia, liver dysfunction or cholestasis, further studies of the exact mechanism for the decrease or the increase in the tumor marker level as a function of the serum bilirubin concentration are mandatory. Precise information obtained by using multivariate analysis of large samples is essential for more accurate evaluation.

Cosmetic Result and Post-Operative Pain Reduction according to the Antepubic Location of Trocar Insertion in a Laparoscopic Appendectomy

BACKGROUND: Laparoscopic surgery was first applied in appendectomies. However, the use of laparoscopic surgery has become more popular in other operation than appendectomies such as cholecystectomies and herniorrhaphies. Many surgeons have abandoned the laparoscopic appendectomy because they think the procedure is tedious and has no advantage over the simple open appendectomy. However, the incisional scar is an unavoidable sequela of an open appendectomy, and post-operative pain is bothersome in many cases. METHODS: We carried out laparoscopic appendectomies in 49 consecutive patients by using antepubic trocar insertion to achieve maximum cosmetic effect and to minimize the post-operative pain. Fifteen patients (control group) underwent laparoscopic appendectomies with conventional trocar sites 2~3 cm above the symphysis pubis. Thirty-four patients (studied group) received a newly designed operation using an incision site on the symphysis pubis to maximize the cosmetic effect. We made a short subcutaneous tunnel from antepubic incision to facilitate the intra-abdominal dissection. RESULTS: When we compare the post-operative results, there was no difference between the two groups with respect to operation time, post-operative pain, post-operative hospital stay, or complications. CONCLUSIONS: A greater of the proportion patients who received the newly designed operation were satisfied with the cosmetic result.