[A case of gallstone ileus which the cholecystoduodenal fistula closed spontaneously after laparoscopic-assisted simple enterolithotomy].

A 47-year-old woman complaining of diarrhea and vomiting was admitted on the suspicion of gallstone ileus 4 days after onset. Upper gastrointestinal radiography by Gastrografin showed a cholecystoduodenal fistula. Laparoscopic-assisted simple enterolithotomy was performed. The omentum was severely adherent to the gall bladder and fistula, though biliary surgery was not performed. Without second look operation, for cholecystoduodenal fistula closed spontaneously.

Surgical treatment for right pleural effusions caused by pancreaticopleural fistula.

A 56-year-old man with a history of alcohol abuse presented with exertional dyspnea. A chest radiography showed a massive right pleural effusion with sanguineous pleural fluid and an amylase level of 97,188 IU/L. Despite conservative treatment with no oral intake, total parenteral nutrition and repeated thoracentesis, the pleural effusion was persistent and intrathoracic infection was suspected. Surgical intervention was proposed and a preoperative endoscopic retrograde cholangiopancreatography revealed disruption of the mid pancreatic duct and a fistulous tract. A middle segment pancreatectomy was performed for removal of the disrupted portion of the main pancreatic duct and reconstruction of the distal pancreas was completed by end-to-side Rouxen-Y pancreatojejunostomy. The patient had a good postoperative course and was discharged on the 29th postoperative day. He has remained well during the 9 months of follow-up.

Preoperative serum level of CA19-9 predicts recurrence after curative surgery in node-negative colorectal cancer patients.

BACKGROUND/AIMS: We hypothesize that a subset of node-negative colorectal cancer patients exists that is at high risk for recurrence after curative surgery. Preoperative serum levels of sialyl Lewisa (CA19-9), sialyl Lewisx (SLX), sialyl Tn (STN), and carcinoembryonic (CEA) antigens were analyzed for their value in predicting for such a group. METHODOLOGY: One-hundred-forty-five patients with node-negative, T1-4, M0 colorectal cancers were divided into groups of low or high serum antigen levels. Disease-free interval served as the endpoint in evaluating the prognostic strength of each variable. RESULTS: Twenty-seven patients (18.6%) were included in the high group for CA19-9 antigen, 11 (7.6%) for SLX, 13 (9.0%) for STN, and 51 (35.2%) for CEA. The median follow-up was 62.1 months. As compared to those with low levels, patients with elevated CA19-9 had a shorter disease-free interval (P = 0.0026). No significant difference in disease-free interval was noted between low and high groups of SLX, STN, and CEA antigens. Cox regression analysis identified elevated serum CA19-9 level as a predictor for decreased disease-free interval, independent of T-stage or tumor location. CONCLUSIONS: Elevated preoperative serum levels of CA19-9 may serve as a useful marker in identifying patients with node-negative colorectal cancers at high risk for recurrence after surgery.

The use of a mini-laparotomy in total abdominal colectomy for mucosal ulcerative colitis.

BACKGROUND/AIMS: Minimally invasive surgery, with its advantages of early return to normal activity and good cosmetic results, is an important goal in the treatment of patients with mucosal ulcerative colitis. The aim of this study was to compare outcomes utilizing a mini-laparotomy approach to total abdominal colectomy for mucosal ulcerative colitis with those of the conventional approach. METHODOLOGY: Eleven patients scheduled to undergo the first (total abdominal colectomy) of a 2 or 3-stage operation for mucosal ulcerative colitis via a mini-laparotomy between 1999 and 2001 were prospectively studied. The mini-laparotomy described here involves total abdominal colectomy performed through a skin incision shorter than 7 cm. Seven similar patients who underwent conventional laparotomy between 1995 and 1998 served as the control group. RESULTS: The mini-laparotomy approach was accomplished in 9 patients (81.8%). Patient characteristics between cases and controls were similar. Postoperative intervals until standing, walking, flatus, urinary catheter removal, and tolerance of solid diet were significantly shorter in the mini-laparotomy group (P = 0.031, P = 0.023, P = 0.0033, P = 0.0093, and P = 0.023, respectively). CONCLUSIONS: A mini-laparotomy approach to total abdominal colectomy appears feasible and safe in selected patient with mucosal ulcerative colitis and poses an attractive alternative to conventional laparotomy in patients similar to those presented here.

Analysis of tumor morphology in metastatic colorectal cancer: does this classification have any clinical significance?

BACKGROUND: Macroscopic classification of metastatic liver tumors has been recommended to predict patient prognosis. METHODS: We examined the morphological analysis of metastatic colorectal cancer in 64 patients who underwent hepatic resection and the relationship with clinicopathologic factors. To identify the irregularity of the tumor, we calculated three formulas: (1) actual area of representative cut surface of tumor/circular length of tumor margin, (2) actual area of representative cut surface of tumor/elliptic area, defined by the major and minor axes, and (3) deviation of radius of marginal curvature. RESULTS: Following Yasui's macroscopic classification, the values of formulas (1) and (2) in confluent nodules were significantly lower than those in simple nodules ( P < 0.05), while the value of formula (3) in confluent nodules was significantly greater than that in simple nodules ( P< 0.05). Only a lower value of formula (1) (less than 0.19) was significantly associated with postoperative recurrence ( P< 0.05) and a lower value tended to be associated with a shorter disease-free survival after hepatectomy, but not significantly ( P= 0.09). However, most values were not associated with any clinicopathologic factors or postoperative survival. CONCLUSIONS: We conclude that differences in the morphological irregularity of liver tumors in metastatic colorectal cancer do not have clinical significance.

Minilaparotomy approach to terminal ileal Crohn's disease.

The feasibility and safety of a minilaparotomy approach to terminal ileal Crohn's disease have not been fully elucidated. The purpose of this study was to compare early outcomes utilizing this technique as an alternative to conventional approaches. Nine patients with terminal ileal Crohn's disease (but no complicating enteric fistulas) who underwent minilaparotomy between January 1998 and September 2000 were studied prospectively. The minilaparotomy approach entails a complete surgical procedure performed through a skin incision of less than 7 cm. Ten similar patients who underwent conventional laparotomy between January 1995 and December 1997 served as the control group. Age, gender, body weight, height, body mass index, number of prior laparotomies, operating times, operative blood loss, and types of operative procedure were similar for cases and controls. The length of the laparotomy incision in the minilaparotomy approach group was significantly shorter than that in the conventional approach group (median length 6.0 vs. 16.5 cm; p <0.05). Postoperative intervals until initial standing and walking were significantly shorter for minilaparotomy patients than conventional surgery patients (p <0.05 and p <0.05, respectively), whereas postoperative intervals until passing flatus, urinary catheter removal, and tolerance of liquids and solids did not differ for the two groups, nor did the analgesic requirement or postoperative hospital stay. Postoperative complications developed in two conventional-group patients; none was noted with the minilaparotomy approach. Our data suggest that the minilaparotomy approach to terminal ileal Crohn's disease without an enteric fistula is feasible, safe, and less invasive than the conventional approach.

Predictive factors for preoperative serum levels of sialy Lewis(x), sialyl Lewis(a) and sialyl Tn antigens in gastric cancer patients.

Preoperative serum levels of sialyl Lewis(a) (CA19-9), sialyl Lewis(x) (SLX) and sialyl Tn (STN) antigens in 180 patients with gastric cancer were examined to establish predictive factors for serum levels of these antigens compared with carcinoembryonic antigen (CEA). The patients were divided into low and high antigen groups. Multivariate logistic regression analysis revealed the following independent predictive factors for high antigen levels [odds ratio]: liver metastasis for CA19-9 [4.40], SLX [9.90], STN [39.65] and CEA [5.14]; peritoneal dissemination for SLX [4.78] or STN [13.01]; venous invasion for CEA [3.56]; lymph node metastasis for CA19-9 [4.51]. In addition, high CA19-9 levels were independently related to lymph node metastasis in patients with stage I or II tumors. In conclusion, high serum levels of CA19-9, SLX and STN are associated with liver metastasis, while high serum levels of SLX and STN are associated with peritoneal dissemination. In addition, high serum CA19-9 levels may represent an independent predictor for lymph node metastasis.

Difference in prognostic value between sialyl Lewis(a) and sialyl Lewis(x) antigen levels in the preoperative serum of gastric cancer patients.

Sialyl Lewis(a) (CA19-9) and sialyl Lewis(x) antigens (SLX) may play a role in tumor metastasis by serving as functional ligands in the cell adhesion system. The authors examined preoperative serum levels of CA19-9 and SLX in 218 patients who underwent resection for gastric cancer to determine their prognostic value. The patients were divided into two groups, termed the low and high antigen groups, based on a value selected as a diagnostic cutoff. Correlation between the antigen serum levels, various established clinicopathologic factors, and prognosis were studied by univariate and multivariate analysis. The disease-specific interval for high CA19-9 and SLX groups was significantly shorter than that of their respective low groups (p = 0.0024 and p < 0.0001, respectively). Patients with stage III/IV tumors who had high serum SLX levels had shorter disease-specific intervals than those with low serum levels (p = 0.0017). A Cox's regression analysis revealed a high serum SLX level as an independent factor for worse outcome. In addition, logistic regression analysis revealed that a high serum SLX level was an independent predictor for liver metastasis. In conclusion, an elevated preoperative serum SLX level was a predictor for poor outcome after resection for gastric cancer, whereas CA19-9 was not.

Prognostic value of expression of sialosyl-Tn antigen in colorectal carcinoma and transitional mucosa.

We examined the immunohistochemical expression of sialosyl-Tn antigen in the colorectal cancer tissues of 116 patients who underwent curative resection to determine the association between patient prognosis and the expression of sialosyl-Tn in two different tissues: carcinoma and transitional mucosa. Negative or positive expression of sialosyl-Tn in the carcinoma and transitional mucosal tissues were denoted as CA- or CA+ and TM- or TM+, respectively. Patients were classified into one of four groups: CA-/TM-, CA-/TM+, CA+/TM-, and CA+/TM+. CA-/TM- was observed in 13 patients and CA-/TM+, CA+/TM-, or CA+/TM+ was observed in 103 patients. The difference in five-year survival between the CA-/TM- group and all the other groups was statistically significant (P = 0.0457), and multivariate analysis showed that sialosyl-Tn expression in at least one of the two tissues was an independent prognostic factor. We conclude that the evaluation of sialosyl-Tn expression in carcinoma as well as transitional mucosa is useful for predicting survival in colorectal cancer patients.