Predictive factors and the prognosis of recurrence of colorectal cancer within 2 years after curative resection

PURPOSE: Because predicting recurrence intervals and patterns would allow for appropriate therapeutic strategies, we evaluated the clinical and pathological characteristics of early and late recurrences of colorectal cancer. METHODS: Patients who developed recurrence after undergoing curative resection for colorectal cancer stage I-III between January 2000 and May 2006 were identified. Early recurrence was defined as recurrence within 2 years after primary surgery of colorectal cancer. Analyses were performed to compare the clinicopathological characteristics and overall survival rate between the early and late recurrence groups. RESULTS: One hundred fifty-eight patients experienced early recurrence and 64 had late recurrence. Multivariate analysis revealed that the postoperative elevation of carbohydrate antigen 19-9 (CA 19-9), venous invasion, and N stage correlated with the recurrence interval. The liver was the most common site of early recurrence (40.5%), whereas late recurrence was more common locally (28.1%), or in the lung (32.8%). The 5-year overall survival rates for early and late recurrence were significantly different (34.7% vs. 78.8%; P < 0.001). Survival rates after the surgical resection of recurrent lesions were not different between the two groups. CONCLUSION: Early recurrence within 2 years after surgery was associated with poor survival outcomes after colorectal cancer recurrence. An elevated postoperative CA 19-9 level, venous invasion, and advanced N stage were found to be significant risk factors for early recurrence of colorectal cancer.

Short-term Outcomes of a Laparoscopic Left Hemicolectomy for Descending Colon Cancer: Retrospective Comparison with an Open Left Hemicolectomy

PURPOSE: Many randomized clinical trials have been performed to treat a colorectal neoplasm with the exclusion of descending colon cancer. The aim of the present study was to investigate the difference in surgical outcomes between a laparoscopic left hemicolectomy and a conventional open left hemicolectomy for descending colon cancer. METHODS: A retrospective study of ninety patients with descending colon cancer, who underwent a laparoscopic (LAP) or open left hemicolectomy (OS) between May 1998 and December 2009 at Kyungpook National University Hospital, was performed. Clinicopathological and surgical outcomes were compared between the LAP and the OS for descending colon cancer. RESULTS: The baseline characteristics, including age, gender, body mass index, history of prior abdominal surgical history and tumor location, were similar between the two groups. The mean operation time was 156.2 minutes for the LAP group and 223.2 minutes for the OS group (P < 0.001). Intraoperative blood loss was significantly greater in the OS group (37.5 mL vs. 80.4 mL; P = 0.039). The postoperative recovery in the LAP group was faster, as reflected by the shorter time to pass gas and the shorter hospital stay. Pathological examinations showed the surgery to be equally radical in the two groups. The median follow-up was 21 months and there were 3 distant metastases (8.5%) during follow-up in the LAP group, but no port-site or local recurrence. CONCLUSION: A laparoscopic left hemicolectomy is a technically safe and feasible procedure for treating descending colon cancer. Prospective multi-center trials are necessary to establish the LAP as the standard treatment for descending colon cancer.

Risk Factors of Peritoneal Recurrence after Curative Resection of Colorectal Cancer

PURPOSE: Peritoneal recurrence after curative resection of colorectal cancer has been considered to be a lethal condition and to be suitable for palliative chemotherapy. Recently, aggressive approaches such as cytoreductive surgery and perioperative intraperitoneal chemotherapy were introduced for peritoneal malignancies to improve survival. The aim of this study is to identify the risk factors of peritoneal recurrence after curative resection of colorectal cancer and to determine the indication of early postoperative intraperitoneal chemotherapy (EPIC). METHODS: From January 1997 to December 2007, a total of 2,320 patients' records with curative resection for colorectal cancer were collected through the prospective colorectal cancer registry protocol in Kyungpook National University Hospital, Korea. Of those, a total of 1,929 patients were included for analysis of the relationship between perioperative clinicopathologic variables and peritoneal recurrence. RESULTS: The study group was composed of 1,086 men and 843 women with a mean age of 61.1. In multivariate analysis, preoperative level of serum CA19-9>37 U/ml (odd ratio [OR] 3.217; 95% confidence interval [95% CI] 1.525~6.788), right colon cancer (OR 2.524; 95% CI 1.158~5.502), pT4 tumor (OR 2.131; 95% CI 1.009~4.502) and positive apical lymph node (OR 3.045; 95% CI 1.023~9.066) were independent risk factors of peritoneal recurrence after curative resection of colorectal cancer. CONCLUSION: In colorectal cancer patients with increased preoperative serum levels of CA19-9, right-sided location, serosal exposure or invasion of adjacent organ, and positive apical lymph node, more scrupulous surveillance for peritoneal recurrence was necessary during the postoperative follow-up period. In selective patients with risk factors of peritoneal recurrence, more aggressive strategies for management, such as EPIC, were able to be considered under the acceptable general condition and life-expectancy.

Laparoscopic versus Open Approaches for Sigmoid Colon and Rectal Cancer: Comparison of Intraoperative Carcinoembryonic Antigen Elevation / 대한내시경복강경외과학회지

PURPOSE: Although the overall survival and recurrence rates after open or laparoscopic surgery for colorectal cancer are similar, the potential oncological benefits of laparoscopic surgery have not been established. This study compared the effects of the two surgical approaches (open and laparoscopic) on the intraoperative inferior mesenteric vein (IMV) carcinoembryonic antigen (CEA) levels in patients who were undergoing open or laparoscopic surgery for sigmoid colon and rectal cancer. METHODS: Between December 2005 and July 2008, a total of 37 patients were enrolled in this study. Twenty one patients underwent open surgery and 16 patients were operated on laparoscopically. The baseline peripheral CEA level was measured preoperatively. The IMV blood was taken before and after mobilization of the cancer-bearing bowel segment and the CEA levels in the two groups were compared. RESULTS: The baseline CEA levels in the peripheral vein were similar in the two groups. After mobilization, the overall CEA level was elevated. The median pre-mobilization CEA levels of the open and laparoscopic group were 2.3 (range: 1.2~3.7) ng/ml and 1.5 (range: 1.0~2.6) ng/ml, respectively. Hence, the degree of CEA elevation after mobilization was significantly higher in the open surgery group compared with that of the laparoscopic approach (4.2 vs. 1.6, respectively, p=0.004). CONCLUSION: The CEA levels measured from the IMV after mobilization were elevated to a lesser degree after laparoscopic mobilization of the cancer-bearing bowel segment, as compared with that of open surgery. However, the long term oncological effects need to be examined by conducting longer, larger scale studies.

A Comparison of the Oncologic Results after Laparoscopic Abdominoperineal Resection and Ultra-low Anterior Resection with Hand-sewn Coloanal Anastomosis for Treating Distal Rectal Cancer / 대한내시경복강경외과학회지

PURPOSE: Abdominoperineal resection (APR) has been regarded as the standard procedure for the treatment of distal rectal cancer since Miles first described it in 1908. But because of the better understanding of the patterns of spreading tumor, the pelvic physiology, the development of stapling devices and introduction of total mesorectal excision (TME), the rate of sphincter preserving surgery has been increasing. The aim of this study is to compare the oncologic outcomes after laparoscopic APR and ultra-low anterior resection with handsewn coloanal anastomosis (CAA) for treating distal rectal cancer. METHODS: Between January 2003 and October 2007, 95 patients who were followed up for more than 2 years after curative laparoscopic APR or CAA for distal rectal cancer were included in this study. The clinical characteristics, pathologic findings, postoperative complications and oncologic results were retrospectively analyzed. RESULTS: There were 31 APRs and 64 CAAs. The median follow-up period was 43 (5~79) months. The mean distance between the lower margin of the tumor and the anal verge was 2.1+/-1.2 cm in APR and 3.7+/-1.4 cm in CAA (p<0.001). There were 2 (6.5%) local recurrences and 8 (25.8%) systemic recurrences after APR and 3 (4.7%) local recurrences and 10 (15.6%) systemic recurrences after CAA, respectively (p=0.641, p=0.161). The 3-year disease-specific survival rate was 86.7% in APR and 93.5% in CAA (p=0.407). The 3-year disease free survival rate was 73.7% in APR and 80.1% in CAA (p=0.161) but there were no significant differences in the oncologic results according to the stages between the two groups. CONCLUSION: The operative procedures are changing toward sphincter preservation. Laparoscopic ultra-low anterior resection and hand-sewn coloanal anastomosis is oncologically as safe as laparoscopic APR for treating lower rectal cancer. However, APR should be considered the standard treatment for distal rectal cancer when it invades the anal sphincter or the levator ani.

Diagnostic Role of F-18 FDG PET/CT in the Follow-up of Patients with Colorectal Cancer: Comparison with Serum CEA, CA 19-9 Levels and Computed Tomography / 핵의학분자영상

PURPOSE: Early detection of recurrence is an important factor for long term survival of patients with colorectal cancer. Measurement of serum levels of CEA, CA 19-9, CT and PET/CT has been commonly used in the postoperative surveillance of colorectal cancer. The purpose of this study was to compare the diagnostic ability of PET/CT, tumor marker and CT for recurrence in colorectal cancer patients after treatment. MATERIALS AND METHODS: F-18 FDG PET/CT imaging was performed in 189 colorectal cancer patients who underwent curative surgical resection and/or chemotherapy. Measurement of serum levels of CEA, CA 19-9 and CT imaging were performed within 2 months of PET/CT examination. Final diagnosis of recurrence was made by biopsy, radiologic studies or clinical follow-up for 6 months after each study. RESULTS: Overall sensitivity, specificity of PET/CT was 94.7%, 91.1%, while those of serum CEA were 44.7% and 97.3%, respectively. Sensitivity and specificity were 94.2%, 90.4% for PET/CT and better than those of combined CEA and CA 19-9 measurement (52.1%, 88.5%) in 174 patients measured available both CEA and CA 19-9 data. In 115 patients with both tumor markers and CT images available, PET/CT showed similar sensitivity but higher specificity (92.9%, 91.3%) compared to combination of tumor markers and CT images (92.9%, 74.1%). CONCLUSION: PET/CT was superior for detection of recurred colorectal cancer patients compared with both CEA, CA 19-9, and even with combination of both tumor markers and CT. Therefore PET/CT could be used as a routine surveillance examination to detect recurrence or metastasis of colorectal cancer.

Association of Vascular Endothelial Growth Factor Gene Polymorphisms with Susceptibility and Clinicopathologic Characteristics of Colorectal Cancer

Since vascular endothelial growth factor (VEGF) is known to be a potent pro-angiogenic factor, we evaluated the potential association of two VEGF gene polymorphisms (-634G>C and 936C>T) with the susceptibility and the clinicopathologic characteristics of colorectal cancer (CRC). The VEGF genotypes were determined using fresh colorectal tissue from 465 patients who had undergone a surgical resection and peripheral blood lymphocytes from 413 healthy controls by PCR/DHPLC assay. For the -634G>C polymorphism, the -634 GC or CC genotype was associated with a decreased risk of CRC (odds ratio [OR], 0.62; p=0.001) as a dominant model of C allele, whereas the 936 TT genotype correlated with advanced stage/ metastasis, a high serum level of CA19-9, and an higher grade in patients with CRC. In the haplotype analyses, haplotype -634C/936C and -634G/936T were associated with a decreased susceptibility of CRC (OR, 0.53 and 0.56; p<0.001, respectively). These observations imply that the VEGF gene polymorphisms may be associated with the susceptibility or clinicopathologic features of CRC. However, further studies of other VEGF sequence variants and their biological functions are needed to understand the role of the VEGF gene polymorphisms in the development and progression of CRC.

Outpatient-basis Chemotherapy of Oxaliplatin, 5-fluorouracil, and Leucovorin as First-line Treatment for Patients with Metastatic or Recurrent Colorectal Cancer

The objectives of the present study were to evaluate the efficacy and safety of an outpatient-basis chemotherapy of oxaliplatin, 5-fluorouracil, and leucovorin as the first-line treatment for patients with advanced colorectal cancer. Forty-three histologically confirmed patients with metastatic or recurrent colorectal cancer were enrolled. The chemotherapy consisted of oxaliplatin 85 mg/m2 as a 2-hr infusion on day 1, plus leucovorin 30 mg/m2 over 10 min, followed by bolus 5-fluorouracil 400 mg/m2 and an 8-hr infusion of 5-fluorouracil 600 mg/m2 on days 1 and 2 (modified FOLFOX4), all of which were administered on an outpatient basis every 2 weeks. The median age was 58 yr (range 33-72 yr), and 25 (58.1%) patients had metastatic diseases. Eventually, 39 patients were assessable for efficacy and all assessable for toxicity. Four (9.3%) complete responses and 11 (25.6%) partial responses were confirmed, giving an overall response rate of 34.9% (95% CI; 20.0-49.7%). The median time to progression and median overall survival for all patients was 6.1 months and 17.4 months, respectively. Grade 3/4 neutropenia occurred in 2 patients (4.7%) and febrile neutropenia was observed in 1 patient (2.3%). Modified FOLFOX4, an outpatient-basis regimen, was found to be well-tolerated and effective as the firstline chemotherapy in patients with advanced colorectal cancer.

Differential Expressions of Genes in Colorectal Cancer with Liver Metastasis by using a cDNA Microarray Chip: A Pilot Study

PURPOSE: Liver metastasis is the most common type of failure in the treatment of colorectal cancer. The identification of differential expressions of genes in colorectal cancer and liver metastasis is important to differentiate the genetic mechanism of carcinogenesis and liver metastasis from that of a normal mucosa. The aim of this study is to find candidate genes playing roles in liver metastasis of colorectal cancer by using cDNA microarray. METHODS: We screened a group of genes differentially expressed in a normal mucosa and in cancer and liver metastasis by using a 4.7 K cDNA microarray chip in 8 patients with far advanced colorectal cancer from Jan 2003 to May 2004 at Kyungpook National University Hospital. RESULTS: A comparison of mRNA expressions of genes in normal mucosa vs. cancer, normal mucosa vs. liver metastasis, and cancer vs. liver metastasis, 76 and 27 known and unknown genes were significantly over-expressed in cancer and liver metastasis, respectively. Also 62 and 26 genes were down- regulated in cancer and liver metastasis. Among those genes, TIMP-1, SRY-box9, Rattus norvegicus fibronectin 1, mitotic check point regulator, etc. were constantly up- regulated in cancer or metastasis, and hsgk, etc. were down-regulated in cancer or liver metastasis. CONSLUSIONS: The cDNA microarray chip technique could be a useful for robust screening of candidate genes involved in carcinogenesis or metastasis of colorectal cancer.

Anastomosis Protection with Mallecot in Low Rectal Anastomosis

PURPOSE: Anastomotic leakage following surgery is one of the most significant causes of morbidity and mortality. Therefore, prevention of anastomotic leakage is crucial for safe rectal surgery. The aim of this study is to determine the effect of Mallecot(R) insertion on the prevention of anastomotic leakage after low rectal anastomosis. METHODS: From January 2002 to December 2006, 264 rectal cancer surgeries were performed in one center and by one surgeon. Among them, 110 cases whose anastomosis was located below 6 cm from the anal verge were collected and reviewed retrospectively. We made a diverting stoma on 6 out of 20 patients with high risk of anastomotic leakage, and inserted Mallecot(R) on the remaining 14 patients transanally. Removal of Mallecot(R) was done at the 7th postoperative day after a digital rectal examination to identify the completeness of anastomosis had been performed. RESULTS: Totally, anastomotic leakage occurred in 8 of 110 patients (73%). Among the 90 patients without any preventive measures, 7 incidents of anastomotic leakage were observed; on the other hand, 1 of 14 patients with Mallecot(R) insertion suffered anastomotic leakage. In two of the patients with leakage, including 1 in the Mallecot(R) group, the leakage was resolved via percutaneous drainage; in the other 6 patients were reoperated. CONCLUSIONS: The importance of preventing an anastomotic leakage after low rectal surgery cannot be overemphasized to reduce morbidity and to improve the prognosis. In addition, Mallecot(R) insertion may be an alternative method for diverting stoma formation.

Comparative Evaluation of Immune Responses after Laparoscopic and Open Surgery in Patients with Colorectal Cancer

PURPOSE: The laparoscopic approach is thought to reduce postoperative immunologic and metabolic effects after surgery compared to the open approach. This study was designed to compare the systemic immune and metabolic responses after laparoscopic and open surgery in patients with colorectal cancer. METHODS: Forty-four patients with colorectal cancer were prospectively assigned to undergo either a laparoscopic (n=22) or open (n=22) approach. The postoperative immune and metabolic responses were assessed by measuring the serum level of the relative proportion of lymphocytes, the T-cell count, the natural killer cell (NK-cell) count, the human leukocyte antigen-DR (HLA-DR) expression on monocytes, the interleukin-6 (IL-6), and the C-reactive protein (CRP) at specific time intervals. RESULTS: Both approaches resulted in a significant decrease in lymphocyte count, T-cell count, NK-cell count, and HLA-DR expression on monocytes at 2, 24, and 72 hours postoperatively. However, the decrease in HLA-DR expression on monocytes was more significant in open surgery at 2 hour postoperatively (mean level, laparoscopic: 90.9% vs. open: 83.1%, P<0.001). Significant rises in IL-6 and CRP were demonstrated within 72 hour postoperatively in both groups. However, no significant difference between the two groups was seen. CONCLUSIONS: Although both laparoscopic and open surgery in patients with colorectal cancer evoked an alteration of the systemic inflammatory and immune response, our data showed that a HLA-DR expression on monocytes may be less compromised after laparoscopic approach for an immediate postoperative period. However, clearer evidence from large-scaled prospective randomized trials are needed.

Comparison of Recovery of Bowel Motility after Laparoscopic-assisted and Open Surgery for Right Colon Cancer: A Study of Gastric Emptying by Using Sitz-marker(TM) and Changes of Intraperitoneal Temperature

PURPOSE: Early recovery of gastrointestinal motility is one of the main advantages of laparoscopic intestinal surgery. However, the reasons for this advantage are still not well known. To compare recovery of bowel motility after laparoscopic-assisted and open surgery for right colon cancer, we analyzed early clinical results, including both the gastric emptying time by using a Sitz-marker(TM) and the intraperitoneal temperature. METHODS: From January 1996 to December 1999, 80 curative right hemicolectomies, which were divided into a laparoscopic-assisted surgery group (LS) with 36 patients and an open surgery group (OS) with 44 patients, were prospectively, but not randomly, studied for recovery of bowel motility. Clinical results, such as the pain score, the time to gas passage, the time to resumption of meals the hospital stay and the gastric emptying time obtained by using a Sitz-markers(TM), were evaluated. At the beginning and the end of the operation, the intraperitoneal temperature was checked at three different points. RESULTS: In the LS and OS groups, the first flatus passed at the 3.0 and the 3.67 postoperative day (POD) and oral intake resumed at the 3.9 and the 5.2 POD, respectively (P0.05), 1.7 and 4.2 at the 3rd POD (P<0.05) and 0 and 1.1 at the 4th POD (P<0.05), respectively. No difference in intraperitoneal temperature was noted. CONCLUSIONS: We found earlier recovery of bowel function after laparoscopic surgery than after open surgery, but could not identify any relationship between bowel function and the possible parameter of intraperitoneal temperature.

Surgical Treatment of Anal Fistula

Most anal fistulas are either intersphincteric or low transsphincteric and are treated by fistulotomy with a few recurrence and minimal risk of incontinence. In high and complicated fistulas, fistulotomy should not be used because of a high chance of incontinence. High transsphincteric or suprasphincteric fistulas, anterior fistulas in female, patients with coexisting inflammatory bowel disease, elderly patients with poor sphincter function, multiple simultaneous fistulas, or patients with multiple prior sphincter injuries need alternative technique to minimize the incidence of incontinence. The alternative techniques include seton placement, advancement flap closure, muscle filling procedure, fibrin glue, etc. depending on the status of fistula and patients. The various sphincter sparing techniques used widely are reviewed.

Laparoscopic Splenectomy for Chronic Idiopathic Thrombocytopenic Purpura

PURPOSE: In chronic idiopathic thrombocytopenic purpura (ITP), primary treatment is steroid therapy. However treatment with steroids effects a complete response in less than 30% of the patients whereas a splenectomy is successful in more than 60% of the patients who undergo it. The minimal access afforded by a laparoscopic splenectomy (LS) is considered highly desirable for these patients. The purpose of this study was to compare the clinical benefits of a LS with those of conventional open surgery (OS) for patients with ITP. METHODS: The results of 12 subsequent laparoscopic splenectomies performed from December 1996 to May 1998 were compared with those of 10 open splenectomies performed from September 1987 to May 1995. The indications of a splenectomy were medical intractability, recurrent ITP and/or complications of steroids. The operative time, the time to resumption of oral intake, the postoperative hospital stay, the platelet count, the postoperative response rate, the incidence of accessory spleen, and the period of complication after preoperative steroid administration were statistically analyzed (t-test, chi-square test). Also, the timing of the splenectomy was compared. RESULTS: The operative time was longer in the LS patients (LS 221 min, OS 127 min, p=0.0033), but the length of stay (LS 9.3+/-3.87 days, OS 4.6+/-1.92 days, p=0.0033) and duration of ileus (LS 2.9+/-0.32 days, OS 1.9+/-0.90 days, p=0.0002) were shorter in the LS group. There were no significant differences in platelet count, postopertative response rate, and incidence of accessory spleen between the two groups. Accessory spleens were found in 4 patients (18%). The conversion rate was 17% (only 2 initial cases). The splenectomy had been chosen as a second-line treatment in 91.7% and 60% of the LS and OS patients, respectively, and as a third-line treatment in 8.3% and 40% of those patients, but these result have no statistical significance. The time interval between diagnosis and operation also was not significantly different, between the two groups. CONCLUSION: A LS is safe and effective for the management of ITP and allowsrapid recovery. A LS should be the early treatment of choice for patients, who do not response to primary steroid therapy or who have recurrent or complicated ITP. When such patients are managed early surgical laparoscopic treatment, the side effects of steroid may be minimized.

Effects of Pinacidil, a Potassium-Channel Opener, on Biodistribution of Thallium-201 in Tumor-Bearing Mice / 대한핵의학회잡지

PURPOSE: Thallium behaves similarly to potassium in vivo. Potassium channel opener (K-opener) opens ATP-sensitive K+/-channel located at cell membrane, resulting in potassium efflux from cytosol. We have previously reported that K-opener can alter biokinetics of Tl-201 in cultured cells and in vivo. Malignant tumor cells have high Na-K ATPase activity due to increased metabolic activities and dedifferentiation, and differential delineation of malignant tumor can be possible with Tl-201 imaging. K-opener may affect tumoral uptake of Tl-201 in vivo. To investigate the effects of pinacidil (one of the potent K-openers) on the localization of the tumor with Tl-201 chloride, we evaluated the changes in biodistribution of Tl-201 with pinacidil treatment in tumor-bearing mice. MATERAL AND METHODS: Balb/c mice received subcutaneous implantation of murine breast cancer cells in the thigh and were used for biodistribution study 3 weeks later. 100 microgram of pinacidil dissolved in 200 microliter DMSO/PBS solution was injected intravenously via tail vein at 10 min after 185 KBq (5 microcurie) Tl-201 injection. Percentage organ uptake and whole body retention ratio of Tl-201 were measured at various periods after injection, and values were compared between control and pinacidil-treated mice. RESULTS: Pinacidil treatment resulted in mild decrease in blood levels of Tl-201, but renal uptakes were markedly decreased at 30-min, 1- and 2-hour, compared to control group. Hepatic, intestinal and muscular uptake were not different. Absolute percentage uptake and tumor to blood ratios of Tl-201 were lower in pinacidil treated mice than in the control group at all time points measured. Whole body retention ratio of Tl-201 was lower in pinacidil treated mice (58+/-4%), than in the control group (67+/-3%) at 24 hours after with injection of 100 microgram pinacidil. CONCLUSION: K-opener did not enhance, but rather decreased absolute tumoral uptake and tumor-to-blood ratios of Tl-201. Decreased whole body retention ratio and renal uptake were observed with pinacidil treatment in tumor-bearing mice.

Efficacy of Intra-Operative Lavage in One-stage Operation for Obstructive Left Colon Cancer

PURPOSE: Although staged operations have been thought a main treatment for obstructive left colon cancer, their disadvantages make one-stage operations popular. We tried to identify technical feasibility and oncologic safety of one-stage operation with intra-operative lavage (IOL) for the treatment of obstructive left colon and rectal cancer. METHODS: From June 1996 to May 1999, of 456 colorectal cancer patients, 25 with obstructive left colon or rectal cancer underwent surgery. In 18 of those, we intended to do a one-stage operation with IOL. Male (n=14) were predominant to female (n=4). Mean age was 61.2 (29~78) years. Lesions were located on the sigmoid colon in 8, rectum in 4, descending in 3, and rectosigmoid junction in 3 cases. Operative technique: Lymphovascular division was initiated at the origin of IMA followed by mobilization of the left colon up to the splenic flexure and distal transverse colon. Thereafter antegrade irrigation of the proximal colon with warm normal saline was done by using a corrugated tube. Anastomoses were made by hand or stapler in end-to-end or side-to-end fashion. RESULTS: Mean operative time was 221 (185~360) min. No significant post-operative complications occurred except for two wound infections and one pulmonary atelectasis. There was one unexpected conversion to Hartmann's procedure due to intra-operative fecal soilage during the lavage. Within 18 months follow-up period, 4 recurrences occurred with two of them expiring. CONCLUSIONS:: One-stage operation for the treatment of obstructive left colon cancer with IOL could avoid colostomy or reoperation, and, was technically feasible, safe, and oncologically acceptable.

Effect of Multidrug Resistance Gene-1 (mdr1) Overexpression on In-Vitro Uptake of 99mTc-sestaMIBI in Murine L1210 Leukemia Cells / 대한핵의학회잡지

PURPOSE: To determine whether Tc-99mMIBI is recognized by the multidrug resistant P-glycoprotein (Pgp), we have measured quantitatively Tc-99mMIBI uptake in cancer cells. The effects of various Pgp reversing agents on cellular Tc-99m-MIBI uptake were also investigated in the presence of multidrug resistance gene-1 (mdr1 gene) overexpression. MATERIALS AND METHODS: We measured percentage uptake of Tc-99m-MIBI at different incubation temperatures both in mdr1 positive and negative cells. The effects of verapamil, cyclosporin, and dipyridamole on cellular uptake of Tc-99m-MIBI were also evaluated with or without overexpression of mdr1 gene in cultured murine leukemia L1210 cells. RESULTS: The mdr1 gene expressing cell lines were effectively induced in in vitro with continuous application of low-dose adriamycin or vincristine. Cellular uptake of Tc-99m-MIBI was higher in mdr1 negative L1210 cells than those of mdr1 positive cells, and higher when incubated in 37 degree C than 4 degree C. In the presence of verapamil, cyclosporin or dipyridamole, Tc-99m-MIBI uptake was increased upto 604% in mdr1 positive cells. CONCLUSION: Cellular uptake of Tc-99m-MIBI is lower in leukemia cells over-expressing mdr1 gene, and MDR-reversing agents increase cellular uptake. These results suggest that Tc-99m-MIBI can be used for characterizing Pgp expression and developing MDR-reversing agents In vitro.

Outcome Analysis after Treatment of Acute Limb Ischemia

PURPOSE: Acute limb ischemia is not only a limb-threatening but also a life-threatening condition. Despite the use of surgical and/or thrombolytic therapy for this urgent treatment -requiring condition, it is still reported to carry high morbidity and mortality rates. METHODS: We analyzed the treatment outcomes of 118 limbs (11 upper limbs, 107 lower limb) with acute limb ischemia treated for 103 patients (age, median: 64, male 89 female 14) at the Department of Surgery, Kyungpook National University Hospital, from March 1993 to March 1999. The underlying causes of acute limb ischemia included 62 limbs with acute arterial embolism in 51 patients, 39 limbs with acute arterial thrombosis in 37 patients, 15 limbs with graft occlusion in 14 patients, and 2 limbs of undetermined cause of limb ischemia in 1 patient. The retrospective, nonrandomized study was done. RESULTS: The underlying causes of acute limb ischemia were arterial embolism in 52.5%, arterial thrombosis in 33.1%, bypass graft occlusion 12.7%, and undetermined cause in 1.7%. Severity of ischemia according to the SVS/ISCVS classification, 107 limbs (90.7%) were classified as category II and 9 limbs (7.6%) were in category III. For the limbs with embolisms, 47 embolectomies (including 6 cases treated with adjuvant thrombolytic therapy) and 10 arterial bypasses were performed. For the limbs with thromboses, 23 arterial bypasses, 5 thrombectomies, and 4 catheter directed thrombolytic therapies were performed. For the patients with acute graft occusion, 8 redo bypasses, 4 thrombolytic therapies, and 2 thrombectomies were performed. We experienced major limb amputations in 8.1%, hospital mortality in 13.7% and recurrence of ischemic symptoms in 16.1% during the follow-up period in the embolism patients and limb amputations in 2.7%, hospital mortality in 14.3%, and recurrence of ischemic symptoms in 8.3% of the thrombosis patients. Of the patients with category II ischemia, major limb amputation and hospital mortality rates were 4.7% and 9.2%, respectively. CONCLUSION: In dealing with acute limb ischemia, prompt and appropriate selection of treatment modalities, if needed in combined modes, is critically important in improving the treatment outcomes.

The Outcome Analysis of Reintervention for the Infrainguinal Bypasses

Retrospective analysis of reinterventions for the failed or failing infrainguinal bypass grafts were carried out to observe the outcomes and to analyze the factors impacting the outcomes of the reinterventions. During the period of 5 years, 30(16.6%) reinterventions were performed at Department of Surgery, Kyungpook National University Hospital following 181 infrainguinal bypasses for 150 patients with chronic arterial occlusive disease. The indications for the reinterventions were recurrent claudication (23.3%), rest pain (60%), ulcer or gangrene (10%), and graft infection (3.3%). The angiographic findings were categorized as graft occlusion(16), stenosis of the bypass graft or anastomotic sites(8) and inflow or run-off artery occlusive lesion(5). The reintervention procedures were surgical in 27 limbs and percutaneous transluminal angioplasty(PTA) in 3 limbs. To observe the outcomes of reinterventions, the initial technical success, requirement of further interventions, and overall limb salvage rates were analyzed according to the time intervals between primary bypasses and reintervention, reintervention procedures and types of the lesions. The overall limb salvage rates after 30 reinterventions were 83.3% with mean follow-up of 28.6 months. We observed the limb salvage rate was lower after reintervention for the patients with total graft occlusion compared to stenotic lesion(75 % vs 100% p=0.26 ), prosthetic graft occlusion(75%), infrapopliteal bypass as a primary bypass, and patients who underwent early within 30 days reintervention after primary bypasses(60%). However, further investigation is required to get statistical acceptance.

Expression of 72 kDa Type IV Collagenase in Human Colorectal Cancer

Type IV collagenases are thought to play a role in the proteolysis of the basement membrane and the extracellular matrix by the malignant cells that occur early in the development of invasive tumors. In several human tumors, including breast, colonic, ovarian, and hepatocellular carcinomas, type IV collagenase expression has been positively correlated with tumor invasiveness. In this study, we examined the expression and the activation of 72 kDa type IV collagenase in cancerous and normal tissues of the colon and, we attempted to clarify its clinical significance in 45 cases of human colorectal cancer by using northern blot analysis and gelatin zymography.This study showed that the level of 72 kDa type IV collagenase mRNA was increased in colorectal cancer and that this increase was associated with increased enzymatic activity. While there was a difference in the expression and the activation of this enzyme between T2 and T3, this enzyme activity did not show a definite correlation with cancer progress as measured by the depth of tumor invasion and lymph node metastasis.