Two Cases of Intussusception Occurring through the Stoma after Gastric Surgery / 대한소화기내시경학회지

Intussusception is a rare but potentially serious complication of gastric surgery, and 6 cases have been reported in Korea. Diagnosis can be made by endoscopy, upper gastrointestinal series or computed tomography, but it needs a high index of suspicion for diagnosis. Early diagnosis and prompt surgical intervention is mandatory to avoid mortality. We report two cases of intussusception occurring through the stoma after gastric surgery. A 58-year-old woman presented with epigastric pain and vomiting followed by hematemesis, 30 years after gastrojejunostomy for pyloric obstruction caused by duodenal ulcer. Endoscopy showed jejunogastric intussusception and CT scan was compatible with the diagnosis. She was managed by segmental resection and anastomosis of the jejunum. Another 60-year-old man presented with epigastric pain and hematemesis, 7 years after total gastrectomy with a Roux-en-Y anastomosis for advanced gastric cancer. He was diagnosed as having chronic type jejunal intussusception by endoscopy and CT scan, and intussusception was resolved spontaneously.

Early Experience of Virtual Colonoscopy on Colorectal Cancer

PURPOSE: Virtual colonoscopy (VC) is a newly developing non-invasive technique used to detect polyps and cancers of the colon. The aim of this study is to assess the efficacy of VC in the detection of synchronous polyps or cancers in preoperative patients as well as metachronous polyps of postoperative colorectal cancer patients. METHODS: Both VC and conventional colonoscopy (CFS) were performed on 40 patients with colorectal cancer (10 cases of preoperative state and 30 cases of postoperative follow-up) during Sep. 2002 to June 2003 in Daegu Catholic Medical Centre, Catholic University of Daegu, Republic of Korea. The success rate and the detection rate of polyps or cancers along with the locations and sizes of masses and the findings of anastomotic site were compared between VC and CFS. RESULTS: The entire colon was clearly visualized by CFS in all cases. In the preoperative group, VC was successfully performed in 8 out of 10 cases (80%). 8 out of 10 cancers, 4 out of 4 polyps (5 mm or more in diameter) and 3 out of 6 polyps (5 mm or less in diameter) were identified. The success rate of VC in the postoperative group were 58% of low anterior resection (LAR) from cecum to hepatic flexure, 89% of LAR, 45% of right hemicolectomy (RHC) from hepatic flexure to splenic flexure, 63% of LAR, 45% of RHC from splenic flexure to sigmoid colon, and 53% of LAR, 72% of RHC in rectum. The causes of failure were inadequate bowel distension and retained fluid. In postoperative group, VC identified only 3 of 7 polyps(5 mm or more in diameter), 1 of 10 polyps (5 mm or less in diameter) and 1 of 1 recurrent cancer. The anastomotic site was clearly seen by VC in 9 of 19 cases (47%) of LAR and 3 of 11 cases (27%) of RHC. VC also identified 28 extracolonic findings. CONCLUSIONS: Although the efficacy of VC in postoperative colorectal cancer follow up seems to be disappointing, but it can be used as an alternative method for patients with incomplete conventional colonoscopy due to anastomotic site stricture or for other failed cases. Further technological advancement of VC is needed in order for it to replace conventional colonoscopy as a postoperative follow-up test.

Clinical Evaluation and Prevention of Complications of Esophagojejunal Anastomotic Site after Total Gastrectomy

PURPOSE: Esophagojejunal anastomotic complications after a total gastrectomy include leakage, stenosis, bleeding, and abscess formation. Especially, the mortality rate for esophagojejunal anastomotic leakage is 80%. Although these complications hare been reduced by the usage of the EEA stapler, they are still serious and depend on various factors: the surgeon's experience, the stage of disease, the extent of surgical intervention, the method of operation, and the patient. Some local factors, such as vascularization of the graft, traction on the anastomosis suture line, and local infections, have been implicated as contributing to these complications. MATERIALS AND METHODS: During the period 1995~2003, of the 850 gastrectomies for gastric carcinomas, 171 were intra-abdominal total gastrectomies. All of these 171 operations were performed by one surgeon using a routine D2 lymph-node dissection and a 25-mm EEA stapler on an antecolic end-to-side esophagojejunostomy. In the 77 cases a seromuscular reinforced suture at the esophagojejunostomy site was performed, and in 94 cases, a whole layer reinforced suture with absorbible materials was used. We evaluated the incidence of complications according to age, sex, stage of patients, and combined resection. Also, we compared the incidences of complications for seromuscular and whole layer reinforced sutures. RESULTS: The complications are major leaks (2.9%), minor leaks (3.5%), stenosis, bleeding (1.8%), and abscess formation (1.8%). In the five cases of major leaks, there were four mortalities with operative methods. The other patients with stenosis, bleeding, and abscess formation were treated conservatively with success. The incidences of complications were not related with age, sex, stages, and combined resection. The incidences of complications for the whole layer reinforced suture group (2.9%) were less than those for the seromuscular reinforced group (8.8%, P=0.04). CONCLUSION: The most serious complication of esophagojejunal anastomosis is major leakage with an 80% mortality. The other complications are stenosis, bleeding, and abscess formation, for which no mortalities occurred during this study. Whole layer suture of the esophagojejunal anastomotic site is an important method for preventing leakage.

Characteristics of Recurred Early Gastric Cancer after Gastric Resection

PURPOSE: The proportion of early gastric cancer has recently increased. Although early gastric cancer has a very good prognosis following a curative resection, and recurrences rarely occur, if there is a distant recurrence the prognosis is grave. To predict to the potential of a recurrence after a gastrectomy, early gastric cancer patients were retrospectively analyzed. METHODS: 1, 131 early gastric cancers were curatively resected at the Asan Medical Center between Jan, 1990 and Sep, 1997. Recurrences were observed in 46 patients during the follow up period. The clinical characteristics of the recurred and cured groups were compared. Any statistical significance was calculated using Chi-Squared and Log rank tests, using SPSS version 10.0. RESULTS: The recurrence and 5-year survival rates of the recurred patients were and 9%, respectively. Hematogenous recurrences were the most common mode of recurrence, followed by lymph node recurrences. The mean tumor size, numbers of lesions, location of tumor, status of lymph node dissection and operation type, did not affect tumor recurrences. The grossly elevated type of tumor, submucosal layer invasion and differentiated cancer, most frequently recurred. The rate of recurrence linearly increased with increase of the nodal stage. All patients with a lymph node recurrence had lymph node metastasis at the initial surgery. CONCLUSION: In early gastric cancer patients, the elevated type, or a differentiated adenocarcinoma, may recur at a distant organ. A more careful follow-up will be required if the surgical removal of a metastatic tumor is intended, as chemotherapy is ineffective. The sentinel lymph node should be examined by a frozen biopsy at the beginning of the initial surgery, in order to determine the range of a lymph node dissection to avoid a nodal recurrence.

Detection of Peripheral Blood Telomerase Activity from Gastric Cancer Patients

PURPOSE: Telomerase activity is generally absent in primary cell cultures and normal tissues. Telomerase is known to be induced upon immortalization or malignant transformation of human cells. Telomerase activity can be increased in immature lymphocytes and activated lymphocytes, but it is not detected in the peripheral blood of normal persons. The authors analyzed peripheral blood telomerase from patients of gastric cancer to evaluate the possibility of using it for diagnosis and as a prognostic factor. MATENRIALS AND METHODS: We obtained blood samples from 11 inflammatory patients and 64 gastric cancer patients. The telomerase activity was measured using the [PCR-ELISA] method. The results were correlated with the T, N, M stage, cell differentiation, vascular, neural, and lymphatic invasion, tumor size, and tumor location. RESULTS: In the 11 inflammatory patients, telomerase activity was not detected while in the gastric cancer patients, a positive rate of 28.1% was noted. The peripheral telomerase activity was not related with tumor size, tumor site, lymphatic and vascular invasion, stage, or histologic differentiation. CONCLUSION: The peripheral blood telomerase activity for patients of gastric cancer can be utilized as a marker for the diagnosis of not only advanced gastric cancer, but also relatively early stage gastric cancer, but not as a prognostic factor.

Clinical Significance of Cellular Fibronectin as a Tumor Marker in Gastric Cancer Patients

BACKGROUND : Fibronectins (FNs) are adhesive glycoproteins that have variable primary structures owing to cell type-specific splicing of the FN precursor mRNA. FNs can be classified as plasma (p-FN) and cellular (c-FN) types, and c-FN may play a role as a marker of malignancies. CEA and CA 125 have been reported as useful tumor markers, but FNs have not studied adequately in gastric cancers. METHODS : We evaluated the clinical significance of urinary and plasma c-FN in thirty-five patients who were operated on our department due to gastric cancer from January 1997 to August 1997. The c-FN level was determined by enzyme immunoassay using a FIBRONECTIN EIA kit (Takara Shuzo Co., Kyoto, Japan). RESULTS : The levels of urine c-FN in gastric cancer patients (215.6 470.2) were higher than those in the control groups (94.1 63.0 ng/mgCr) and also showed a tendency to increase with advancing of tumor growth. A higher rate of increased urine c-FN also was identified in patients with distant metastasis than in patients without distant metastasis (6/8 vs. 10/27, p=0.05). However, p-FN didn't showed any differences according to extent of tumor invasion and/or presence of distant metastasis. Other parameters, such as age, sex, preoperative tumor size, and depth of invasion, were not correlated with urine and plasma c-FN. CONCLUSIONS : Urine c-FN may be useful as a new tumor marker in gastric cancer and can be helpful in early detection of metastasis and peritoneal seeding, but further studies and follow up are needed for complete clinical application.