Clinical characteristics of acute appendiceal diverticulitis / 대한외과학회지

PURPOSE: Diverticulitis of vermiform appendix is known as a rare cause of acute appendicitis, most of which are diagnosed after surgery. We compared appendiceal diverticulitis with acute appendicitis to study the clinical characteristics of appendiceal diverticulitis. METHODS: Among 1,029 patients who received appendectomy from January 2009 to May 2011, 38 patients with appendiceal diverticulitis (diverticulitis group) were compared with 98 randomly collected patients with acute appendicitis (appendicitis group) during the same period. Patients' characteristics, clinical features, laboratory findings, operative findings, and postoperative course were compared between the two groups. RESULTS: Thirty-eight patients (3.7%) were pathologically diagnosed with acute appendiceal diverticulitis among 1,029 cases of appendectomy. The mean age of patients in the diverticulitis group was significantly older than that of the appendicitis group (49.0 +/- 15.2 years vs. 25.4 +/- 14.2 years, P < 0.05). Mean duration of preoperative symptoms was longer in the diverticulitis group (3.6 +/- 3.8 days vs. 1.8 +/- 3.2 days, P < 0.05). The site of abdominal pain, fever, signs of localized peritonitis, accompanying gastrointestinal symptoms, and white blood cell count showed no differences between the two groups. Twenty-five patients (65.8%) of the diverticulitis group and 10 patients (10.2%) of the appendicitis group showed perforation of appendix (P < 0.05). Mean operating time and postoperative hospital stay were longer in the diverticulitis group (55.3 +/- 28.8 minutes vs. 41.4 +/- 17.8 minutes, 6.8 +/- 3.4 days vs. 4.9 +/- 1.5 days, P < 0.05). CONCLUSION: Acute diverticulitis of the appendix can be classified into quite different disease entities compared with acute appendicitis. Regarding high rates of perforation, immediate surgical treatment is needed for patients with a high index of suspicion of acute diverticulitis of the appendix.

Chronic and Recurrent Subareolar Abscess of the Breast from Underlying Causes

A subareolar abscess is the most common non-puerperal abscess of the breast. The main cause of a subareolar abscess is squamous metaplasia, which obstructs the lactiferous ducts and leads to the stasis of secretions and rupture of the ducts. However, there are other causes of subareolar abscess formation.

Small-cell neuroendocrine carcinoma of the breast / 대한외과학회지

A small-cell carcinoma is one of the histologic subtypes of primary neuroendocrine carcinomas of the breast. A small-cell carcinoma is a rare entity of the breast and exhibits similar morphologic features as neuroendocrine tumors of the gastrointestinal tract and lung. We present the imaging and pathologic findings of a primary small-cell neuroendocrine carcinoma of the breast. This is the first report of a primary small-cell carcinoma arising from the breast in Korea.

Comparison of Single Port and Conventional Laparoscopic Surgery in Acute Appendicitis / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic surgery is widely applied for treating acute appendicitis, and even the complicated cases. Single port laparoscopic surgery has recently been introduced and it is being increasingly accepted for treating acute appendicitis. The aim of this study is to evaluate the effectiveness of single port laparoscopic appendectomy as compared with that of conventional laparoscopic surgery. METHODS: Eighty-seven patients who underwent laparoscopic appendectomy were enrolled. The clinicopathologic characteristics, the perioperative courses and postoperative pain using the VAS (visual analog scale) were compared between the conventional (n=61) and single port (n=26) groups. RESULTS: There were no significant differences in age (28.2 Vs. 32.4, respectively), gender (29:32 Vs. 13:13, respectively) and BMI (22.3 Vs. 22.0, respectively) between the two groups. An extraperitoneal location of the appendix was found in 10 cases (16.4%) of the conventional group and in 4 cases (15.4%) of the single port group. Statistically, no significant difference was shown in terms of the degree of inflammation of the appendicitis. The average length of the operation was significantly shorter in the single port group compared to that of the conventional group (52.4 Vs. 41.3 minutes, respectively, p<0.05). The VAS at 6 hours after surgery (5.2 Vs. 6.0, respectively) and at the time of discharge (1.9 Vs. 1.9, respectively) showed no differences between the two groups. There was no difference for the postoperative hospital stay (3.8 Vs. 3.1 days, respectively) and the rate of postoperative complications (16.4% Vs. 7.7%, respectively) between the two groups. Wound infection was the most common complication. CONCLUSION: When regarding the minimal scar and invasiveness, single port laparoscopic appendectomy is feasible option for treating acute appendicitis. With accumulation of experiences and the development of instruments, additional studies are needed for the indications and advantages of single port surgery.

Radical Reresection for T2 Gallbladder Cancer Patients Diagnosed following Laparoscopic Cholecystectomy

PURPOSE: Despite advances in imaging techniques, laparoscopic cholecystectomy (LC) gives many advantages to some patients with suspected gallbladder cancer. The aim of this study was to investigate clinicopathological features and to analyze the risk factors of recurrence after radical reresection for T2 gallbladder cancer patients diagnosed following LC. METHODS: From January 2002 to December 2009, the data of 21 consecutive patients for radical reresection for T2 gallbladder cancer were reviewed, retrospectively. The significance of the variables for recurrence was examined by the Kaplan-Meier method and log-rank test followed by multivariate analyses using Cox's proportional hazard model. RESULTS: Of the 21 patients studied, 11 were men and 10 were women. Lymph node metastasis was present in 7 patients (33.4%). The 5-year survival rate and disease-free survival rate in those patients were 75.3% and 67.9%, respectively. In the univariate analysis, the male gender (P=0.0047), poorly differentiated tumor (P=0.0169), presence of lymph node metastasis (P=0.0012), presence of lymphovascular invasion (P=0.0259) and presence of perineural invasion (P=0.0096) were significant factors related to recurrence after radical reresection. In the multivariate analysis, the presence of lymph node metastasis was an independently significant factor (5-year disease free survival rate, 20.9% vs. 83.8% in the absence of lymph node metastasis; P=0.015). CONCLUSION: For patients with T2 gallbladder carcinoma diagnosed following LC, radical reresection is highly recommended and the presence of lymph node metastasis is an unfavorable prognostic factor that calls for additional treatment after radical surgery.

Initial Experience with Laparoscopic Surgery for Treating Upper Gastrointestinal Disease / 대한내시경복강경외과학회지

PURPOSE: Performing laparoscopic surgery for upper gastrointestinal disease has gradually been increasing. The aim of this study is to review the initial experience with laparoscopic surgery for treating upper gastrointestinal diseases. METHODS: We retrospectively studied a total of 76 patients who underwent laparoscopic surgery for upper gastrointestinal disease from April 2003 to December 2008. The clinical features and surgical outcomes were analyzed. RESULTS: The types of upper gastrointestinal diseases that were treated by laparoscopic surgery were early gastric cancer (n=45), advanced gastric cancer (n=6), gastric submucosal tumor (n=14), duodenal ulcer stricture (n=5), duodenal ulcer perforation (n=2), superior mesenteric artery syndrome (n=2), gastroesophageal reflux (n=1) and dysphagia due to parkinsonism (n=1). There were 11 operative morbidities (14.5%), including 1 operative mortality (1.3%). CONCLUSION: Although this study shows the narrow range of indications for performing this laparoscopic procedure and the surgical experience is rather limited, laparoscopic surgery was applied for treating various upper gastrointestinal diseases. Based on this experience, surgeons should make efforts to improve the surgical outcomes.

Is the Yersinia enterocolitica Possible Infectious Agent in Acute Appendicitis?

PURPOSE: With increasing frequency, Yersinia enterocolitica is being recognized as an important bacterial cause of acute gastrointestinal infection with abdominal pain. In addition, the association of Y. enterocolitica infections with acute appendicitis has been suggested. This study was undertaken to ascertain whether Y. enterocolitica is a possible infectious agent in acute appendicitis. METHODS: Between December 2007 and April 2008, 162 patients who underwent appendectomy for presumed appendicitis, enrolled in this prospective study. After surgical excision of appendix, a portion of each specimen was cultured for Y. enterocolitica with highly selective media (Cefsulodin-Irgasan-Novobiocin agar). RESULTS: Pathologically, 150 of the patients had appendicitis and 12 patients had normal appendices. Only one of the 150 patients (0.7%) with appendicitis was found to be culture positive for Y. enterocolitica, while it was not detected from normal appendices. CONCLUSION: The authors were unable to implicate Y. enterocolitica as a major pathogen in acute appendicitis within the Seoul area. However, we thought there to be more need for investigation for association of Y. enterocolitica with acute appendicitis over a broader area and season.

Surgical Treatment for Aortoiliac Occlusions

PURPOSE: To evaluate the efficacy of surgical treatment for multilevel aortoiliac occlusive diseases, we retrospectively analyzed 89 recent cases surgical treatment was used. METHODS: From March 1992 to July 2001, we performed 62 aortobifemoral bypasses and 27 other bypasses as primary procedures. We analyzed surgical indications, combined diseases, cardiac risk assessment, type of occlusion, treatment modalities and cumulative patency rate. RESULTS: In 59 aortobifemoral bypasses, 8 end-to-end and 51 end-to-side proximal anastomoses were performed. Adjuvant PTA, with or without stent before bypass operation, was performed in 13 cases. Types of occlusions were Rutherford type I in 18.0%, type II in 20.2% and type III in 61.8%, respectively. Associated diseases were hypertension, diabetes, cerebrovascular accidents, and myocardial infarction in order of frequency. Mean follow-up duration was 36.4 months. Cumulative patency rate by life table analysis was 77.5%. Leg or foot amputations were performed in 13 cases (14.6%) after bypass operations. Two cases of amputation were performed after 13 simultaneous infrainguinal bypasses, and in 4 cases after staged infrainguinal bypasses. Operative mortality occured in 4 cases (4.5%). CONCLUSION: Aortobifemoral bypass remains one of the most durable and effective arterial reconstructions, for extensive aortoiliac occlusive diseases in young patients with low operative risk. Simultaneous infrainguinal bypass is preferred in patients with poor distal run-off.

Splenorenal Bypass for a Huge Left Renal Aneurysm

Renal artery aneurysms are rare, in less than 1% of consecutive abdominal aortograms. Renal artery aneurysms are bilateral in about 10% of cases. Controversy persists regarding the indications for repair of renal artery aneurysms and optimal method of repair. The authors report a case of left renal artery aneurysm with right renal atrophy in a 37-year-old male patient. This patient has no past medical history including hypertension. On physical examination, a pulsatile mass was palpated in left upper abdomen. Preoperative abdominal CT showed right renal atrophy and 8 cm diameter left renal aneurysm. Abdominal aortogram and left renal angiogram showed huge lobulated outpouching contrast collection at the proximal left renal artery without definite neck and diffuse irregularity at the proximal left renal artery. This patient was treated by splenectomy, thrombectomy, aneurysm resection and end to end splenorenal bypass. No remarkable postoperative complication was observed. The patient was discharged postoperative 12 days.

Adventitial Cystic Disease of the Popliteal Artery: A case report

Adventitial cystic disease of the popliteal artery is a rare disorder that causes localized stenosis or occlusion by compression of the vessel lumen. The disease produces lower extremity claudication, typically in young and middle-aged men. We report a case of the adventitial cystic disease of the popliteal artery in a 55-year-old man with symptom of left calf claudication. Diagnosis was done by ultrasound, angiography, and magnetic resonance imaging. The patient was treated with resection of the diseased popliteal artery followed by interposition of saphenous vein graft. Postoperatively, the symptom and sign resolved completely.

Functional Outcome of Surgical Management for Acute Lower Extremity Ischemia

PURPOSE: Despite simplification of operative techniques, high morbidity and mortality of patients presenting with acute lower extremity ischemia remain a challenge to the vascular surgeon. The purpose of this study is to assess the functional outcome of thromboembolectomy in acute lower extremity ischemia in addition to the technical success. METHOD: A retrospective review was conducted on 52 procedures in 42 patients presenting with acute lower extremity ischemia due to arterial thrombosis or embolism between Jan. 1992 and Feb. 2000, initially underwent thromboembolectomy. After initial thromboembolectomy, we assessed the functional outcome of the salvaged limb according to the recommended scale for gauging changes in clinical status, revised version in 1997. RESULT: There were 35 men and 7 women, the mean age was 64.5 years. Mortality rate was 16.7% and overall amputation rate was 16.7%, major and minor amputation rate were 28.5% and 4.8% respectively. Causes of acute lower extremity ischemia were embolic occlusion (26.9%), native arterial thrombosis (36.5%) and bypass graft thrombosis (36.5%). Underlying diseases were heart disease (48.1%), hypertension (23.1%), cerebrovascular accident (17.3%) and diabetes (11.5%). The sites of native arterial occlusion were aortoiliac (24.2%) and distal to femoral (75.8%). Clinical categories were grade I in 1.9%, IIa in 32.7%, IIb in 61.5% and III in 3.8%. The 1-month limb salvage rate was 61.9%. The functional outcomes of the salvaged limb according to the recommended scale for gauging changes in clinical status, revised version in 1997 were +3 in 30.8%, +2 in 26.9%, +1 in 26.9%, 0 in 0.0%, +1 in 0.0%, +2 in 3.8% and +3 in 11.5%. CONCLUSION: Surgical approach to the management of acute lower extremity ischemia due to thromboembolism can achieve a significant rate of limb salvage. A new scale for gauging changes of clinical status in acute lower extremity ischemia is required to assess the functional outcome of the treatment of acute lower extremity ischemia.

hMLH1/hMSH2 Protein Expression in Sporadic Colorectal Carcinoma and Its Clinicopathological Significance

PURPOSE: DNA replication errors (RERs) in repeated nucleotide sequences (microsatellite instability) is caused by defective mismatch repair (MMR) genes. Ninety percent of colorectal carcinomas in hereditary nonpolyposis colorectal cancer (HNPCC) patients and 10-15% of sporadic colorectal cancers show microsatellite instability. In the majority of colorectal cancers with microsatellite instability, the defective MMR gene is hMLH1 or hMSH2. The author examined immunohistochemical expression of hMLH1 and hMSH2 in 75 cases of colorectal carcinomas excluding HNPCC, based on Amsterdam criteria for investigating clinicopathological characteristics and prognosis in hMLH1/hMSH2 negative cases. METHODS: Formalin fixed, paraffin blocks obtained from tumors of 75 cases of colorectal cancers were stained with two monoclonal antibodies (hMLH1 and hMSH2). The correlation between hMLH1/hMSH2 negativity, and clinicopathological feature and prognosis were statistically analysed. RESULTS: Twelve cases (16.0%) showed hMLH1/hMSH2 negativity. Negative expression of hMLH1/hMSH2 was associated with early onset (under age 50), proximal location, multiplicity, mucinous histologic type and poor differentiation. There was a significant survival advantage in patients with hMLH1/hMSH2 negative colorectal carcinoma. CONCLUSIONS: This study shows that hMLH1/hMSH2 negative colorectal carcinomas have the same clinicopathological characteristics of colorectal carcinomas with microsatellite instability. The immunohistochemical test for hMLH1/hMSH2 protein can be a simple screening method routinely applicable. The result of this test is available for establishing guidelines for management, and an independent prognostic factor for sporadic colorectal cancers.

2 Cases of Metachronous Triple Primary Cancers

Multiple primary cancer for the colon and rectum was reported in numorous literature. Therefore, complete preoperative evaluation of patients presenting with colorectal cancer seems to be essential. In addition, it is fundamental that patients who have been treated for colorectal cancer require careful follow up evaluation. When symptoms and signs of tumor develop in a patient who has been treated for an initial colorectal cancer, the possibility of a localized and curable second, third primary cancer should be considered and evaluated. We report 2 cases of metchronous triple primary cancer with a review of literature.