The Value of Follow-up after Curative Resection for Colorectal Cancer

PURPOSE: This study was aimed at determining whether a regular follow-up of patients with colorectal cancer can lead to improved re-resectability, and which test is useful for detecting a resectable recurrence. METHODS: The medical records of 397 consecutive patients, who underwent a curative resection for colorectal cancer between January 1996 and December 2000, with a mean follow-up of 36 months, were retrospectively analysed. RESULTS: The overall recurrence rate was 19.6%, with 22.5% and 7.8% in the regular and irregular follow-up groups (P=0.002), respectively. There was a significant difference in the asymptomatic recurrence detection rate (68.1 vs. 16.7%; P=0.021), but a curative intent reoperation was possible in 21 (29.1%) of those patients with a cancer recurrence in the regular follow-up group, and in 1 (16.7%) inform the irregular follow-up group, which was not significantly different (P= 0.454). Careful history taking and a physical examination were beneficial in the detection of a resectable recurrence. Serum carcinoembryonic antigen determination and endoscopy were useful for detecting a recurrence (14 cases and 5 cases, respectively), and of these 4 (28.6%) and 5 cases (100%) could be treated with a curative intent reoperation, respectively. Abdominal CT, or MRI, and a chest radiography were also useful for detecting a recurrence (22 cases and 8 cases, respectively), but the curative intent reoperation rates were slightly low (3 cases (13.6%) and 1 case (12.5%), respectively). CONCLUSION: A regular follow-up after a curative resection for colorectal cancer, although facilitating detection of recurrence before symptoms developed, was unlikely to succeed in increasing the rate of a curative reoperation.

Clinical Analysis of Chylous Ascites after Surgery for Gastric Cancer

PURPOSE: Chylous ascites is an accumulation of lymphatic fluid within the peritoneal cavity due to trauma or to an obstruction on the lymphatic system. Postoperative chylous ascites is a rare complication of abdominal surgery. It is frequently reported after retroperitoneal dissections and results in high morbidity and mortality. However, there have been few report of such a complication following a radical gastrectomy. Therefore, we review the clinical analysis and treatment of chylous ascites based on our experience. MATERIALS AND METHODS: From July 1992 to June 2001, we treated 13 cases of chylous ascites after operations for gastric cancer. We reviewed medical charts of those patients retrospectively. RESULTS: The incidence of chylous ascites after operations for gastric cancer was 0.83% (13/1552). The mean time from ingestion of a meal after the operation to the development of symptoms was 2 days (range: 1~6 days). Conservative treatment by fasting, total parenteral nutrition (TPN), and repeated paracentesis was successful in all patients. The mean time from diagnosis to complete resolution was 25 days (range: 2~105 days). CONCLUSION: Chylous ascites should be considered in any patient with a typical milky color of drainage who has recently undergone radical gastrectomy. Treatment with fasting, TPN, and repeated paracentesis usually is successful.

Clinical Analysis of Stercoral Perforation of Colon

PURPOSE: Stercoral perforation of colon is a rare disease with poor prognosis. But according to recent reports, the incidence of stercoral perforation in the colon seemed to have been underestimated. The reason might be the lack of recognition and overlook by surgeons. The purposes of this study were to represent the definition of stercoral perforation, and to help the diagnosis and treatment of stercoral perforation. METHODS: Among the patients who underwent emergency operation for colon perforation at the Department of Surgery, Korea University College of Medicine, from January 1992 to December 2001, 9 patients were diagnosed as stercoral perforation and their medical records were reviewed retrospectively regarding the clinical characteristics, managements and mortality. RESULTS: The age distribution of the patients was from 32 to 76 years. Male to female ratio was 1.3:1. All patients had history of chronic constipation. Six cases (33.3%) had free air, and 5 cases (55.6%) had fecaloma at preoperative simple X-ray. The site of perforation were sigmoid colon (8 cases) and descending colon (1 case). The size of perforation ranged from 1 cm to 6.5 cm (mean: 3.1 2.7 cm). The methods of operation were Hartmann's procedure (8 cases), primary repair and sigmoid loop colostomy (1 case). There were two deaths for sepsis. CONCLUSIONS: The stercoral perforation is not rare as commonly thought. If elderly patients who had history of chronic constipation and symptoms of panperitonitis visit hospital, surgeon should be aware of the possibility of this fatal disease and do early surgical intervention with the aggressive therapy for reducing the mortality.

An Analysis of Complications according to Cartridge Size Following Total Gastrectomy with Roux-en-Y Esophagojejunostomy Using the EEA Stapler

PURPOSE: Anastomotic stricture is one of the most common problems in esophagojejunostomy using an end-to-end anastomosing (EEA) instrument following total gastrectomy. Because anastomotic stricture often develops with small- cartridge EEA, a larger EEA may be used to avoid stricture. The purpose of this retrospective study is to evaluate the difference of complications between patients treated using the EEA25 and ones using EEA28. METHODS: A total of 283 patients underwent curative total gastrectomy and esophagojejunostomy with Roux-en-Y anastomosis, using EEA25 or EEA28, between January 1992 and December 1999. The differences between the EEA25 and EEA28 groups were investigated by comparing them in terms of reflux esophagitis, dysphagia, and stricture. RESULTS: Stricture developed in five patients (13.8%) in the EEA28 group and in 11 patients (4.45%) in the EEA25 group (P<0.05), dysphagia was experienced less frequently in the EEA25 than in the EEA28 group (P<0.05), and no significant differences were evident with regards to reflux esophagitis. CONCLUSION: The choice of a large EEA to avoid anastomotic stricture did not affect the development of dysphagia or stricture. However, a randomized, prospective study should be done to better define the relationship between the size of EEA and the complications of total gastrectomy.

Nodal Staging by Number of Metastatic Lymph Node and Comparison with Nodal Staging of 5th UICC TNM Classification in Gastric Cancer

PURPOSE: The nodal staging of the 5th edition of the Union Internationale Contra la Cancer (UICC) TNM classification in 1997 was changed based on the number of metastatic lymph nodes. We attempted to classify nodal status according to the number of involved lymph nodes and compare with the nodal staging of the 5th UICC TNM classification in order to evaluate the rationality of the new nodal staging system. METHODS: The authors retrospectively analyzed 427 patients with gastric cancer who underwent curative resection from 1993 to 1996 at the Department of Surgery, Korea University College of Medicine. Cumulative survival rates were calculated by the Kaplan-Meier method. The difference between each nodal status was evaluated by the log rank test and the generalized Wilcoxon test. RESULTS: There were statistical differences between 0 and 1 lymph node involved, between 7 and 8, and between 15 and 16. We classified the nodal status into 4 groups according to the number of involved lymph nodes based on the following: group 1 with no lymph node involved, group 2 with 1~7, group 3 with 8~15 and group 4 with more than 15. There was a significant survival difference among the 4 groups with no survival difference between the number of positive lymph nodes in each group. We compare our results with the nodal staging of the UICC TNM classification and found that there were differences between group 2 (1~7 positive lymph nodes) and pN1 of TNM (1~6 positive lymph nodes) and between group 3 (8~15) and pN2 (7~15). CONCLUSION: We were able to classify nodal status into 4 groups according to the number of involved lymph nodes. There was little difference compared with the new nodal staging of the 5th UICC TNM classification, which suggested that the nodal classification of the UICC TNM classification based on the number of metastatic lymph nodes is acceptable. Further analysis of a larger sample size may be necessary.

Clinical Analysis of Biliary Drainage effect on outcome after Pancreaticoduodenectomy / 한국간담췌외과학회지

BACKGROUND/AIMS: Pancreaticoduodenectomy is accompanied by considerable rates of postoperative complications and mortalities. Obstructive jaundice is associated with periampullary lesions. The role of preoperative biliary drainage in patients with biliary obstruction undergoing pancreaticoduodenectomy remains controversial. Some authors show the disadvantages of biliary drainage that increased perioperative infectious complications. We analyzed retrospectively the effect of biliary drainage on pancreaticoduodenectomy and surgical outcome. METHODS: One hundred ten consecutive cases of pancreaticoduodenectomy performed between March 1992 and December 2000 were analyzed. We classified Group A as the patients who performed preoperative biliary drainage and Group B as the patients who did not perform biliary drainage. Multiple preoperative, intraoperative, postoperative variables were examined. Student's T-test, chisquare test or Fisher's Exact test was used for univariate comparison of all variables. RESULTS: Preoperative Biliary drainage was performed in 52 patients (47%) and the remaining 58 patients (53%) did not undergo any form of biliary drainages. The overall morbidity and mortality was 37% and 1.8% each. Total Bilirubin was higher in Group A (13.15 mg/dl) than Group B (4.11 mg/dl) (P=0.000). In Group A complication occurred in 21 patients and 20 patients in Group B (P=0.561). No differences were found between Group A and Group B in the incidence of all complications. More transfusion was needed for Group A (P=0.043). Postoperative hospital stay presented no differences (P=0.375). CONCLUSIONS: Biliary drainage is not required in patients who are planed pancreaticoduodenectomy except that the patient had cholangitis or bleeding tendency due to jaundice and hepatic derangements. The biliary drainage should be reserved for the potential for delay in definitive surgery. And it demands randomized prospective study in the future.

Surgical experiences of Ectopic Liver and Accessory Liver Lobe casese / 한국간담췌외과학회지

PURPOSE: The case of ectopic liver and accessory liver lobe have been rarely reported. A hepatic rudiment appears in the ventral angle between the foregut and the yolk sac; pars hepatica and pars cystica. The close connection between them explains accessory lobe on the Gall bladder surface wall. And the displacement of migration of a portion of the pars hepatica explains the ectopic liver. Difference between ectopic liver and accessory liver lobe can be defined whether the connection with hepatic proper exists or not. But, the definite discrimination of the type is very difficult clinically. Recently, we experienced cases of ectopic liver and accessory liver. CASES: In one patient, 43-year-old woman was referred to our department with left upper quadrant abdominal pain. Abdominal sonogram revealed a mass below the diaphragm attached to the superior pole of the spleen. On the operation, tumor mass was reddish gray colored and measured 10 7 3 cm. There were no direct connections with the liver proper except fibrous tissue, and its blood supply was considered from the left diaphragm. The pathologic result proved hepatocellular carcinoma(HCC). In the other patient, a 68-year-old woman complained right upper quadrant abdominal pain and was diagnosed as chronic cholecystitis on sonogram. During the laparoscopic cholecystectomy, a small bean sized mass, appearing as liver tissue, attached GB body portion was detected. The Mass was measured 1.0 1.0 3.0 cm in size and glistening dark brown colored, smooth surfaced. Streaky stalk connected with liver proper was visible. Pathologic finding confirmed the mass as an accessory liver. Both patients discharged without complications. DISCUSSION: Although the clinical problems are rare in the ectopic liver, it has been reported that ectopic liver is prone to be a cancer and accessory liver can induce symptoms. The larger the size becomes, the more it can be Symptomatic. Surgical treatment should be considered whenever they are diagnosed. More investigations are nedeed to know their clinical importance on the basis of the case accumulation.

Clinical Analysis of a Symptomatic Heterotopic Pancreas

PURPOSE: A heterotopic pancreas is defined as one for which pancreatic tissue is present outside its usual or habitual location and without an anatomic relation either of continuity or of vascularization with the pancreas proper. Most heterotopic pancreases are incidentally encountered during surgery, and on rare occasions, epigastric pain, weight loss, hemorrhage, gastric outlet obstruction, and intussusception have been directly attributable to the presence of a heterotopic pancreas. The purpose of this article is to report the clinical characteristics of the heterotopic pancreas. METHOD: We retrospectively observed 24 patients, who had been pathologically proven to have a heterotopic pancreas, at the Department of Surgery, Korea University Hospital, from Jan. 1990 to Dec. 1998. RESULTS: 16 of the 24 cases were found incidentally during operations due to by other primary diseases; 8 cases were symptomatic. The ratio of males to females was 1.18:1 and most common sites were the stomach and the duodenum (71%). The mean size of the lesion was 1.26 cm, and the sizes in symptomatic cases were larger (mean 1.89 cm) than those in cases where the lesions were found incidentally (mean 0.94 cm). We experienced a case of a ductal adenocarcinoma originating from the heterotopic pancreas in the jejunum of a 73 year old man. CONCLUSION: A heterotopic pancreas should be considered in the differential diagnosis of submucosal tumors, polyps, ulceration, and intestinal tumors, When suspected, an intraoperative frozen section is recommended, and the range and the method of the operation should be decided based on the results of the frozen section.