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Although Hartmann’s procedure (HP) is commonly used as emergency treatment for colorectal disease, the reversal of HP (HR) is infrequently performed. The aims were to evaluate the rate of HR and determine the factors predictive of achieving HR. We retrospectively reviewed the medical records of patients who underwent HP between January 2007 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify which factors were independently associated with HR. In the study period, 437 patients underwent HP, and 127 (29.0%) subsequently underwent HR. Of these, 46 (35.9%) patients experienced post-HR complications. In multivariable analysis, an interval between HP and HR of > 6 months was associated with the only lower rate of post-HR complications. Multivariate analysis showed that HR was less likely in patients aged > 70 years, those with American Society of Anesthesiologists (ASA) class III or IV, elective surgery, those experiencing more than two HP-related complications, and those with a malignancy (an indication for HP). One-third of the patients underwent HR. Age > 70 years, ASA class III or IV, elective surgery, more than two HP-related complications, and malignancy were associated with a non-HR rate.

The aim of this study was to determine the efficacy of oral recombinant methioninase (o-rMETase) on a model of colon cancer growing on the peritoneal surface using a patients-derived orthotopic xenograft (PDOX) nude mouse model. Forty PDOX mouse models with colon cancer growing on the peritoneum were divided into 4 groups of 10 mice each by measuring the tumor size and fluorescence intensity: untreated control; 5-fluorouracil (5-FU) (50 mg/kg, once a week for two weeks, ip) and oxaliplatinum (OXA) (6 mg/kg, once a week for two weeks, ip); o-rMETase (100 units/day, oral 14 consecutive days); combination 5-FU + OXA and o-rMETase. All treatments inhibited tumor growth compared to the untreated control. The combination of 5-FU + OXA plus o-rMETase was significantly more efficacious than the control and each drug alone and was the only treatment that caused tumor regression. The present study is the first demonstrating the efficacy of o-rMETase combination therapy on a PDOX model of peritoneal colon cancer, suggesting potential clinical development of o-rMETase in a recalcitrant cancer.

BACKGROUND/AIM Liver metastasis in colorectal-cancer is a recalcitrant disease. To develop precision individualized therapy of this disease, we developed a patient-derived orthotopic xenograft (PDOX) model of colorectal-cancer liver metastasis. In the present report, we evaluated the efficacy of oral recombinant methioninase (o-rMETase) in combination with 5-fluorouracil (5-FU) and oxaliplatinum (OXA) on the colorectal-cancer liver metastasis PDOX mouse model. MATERIALS AND METHODS Colorectal-cancer liver metastasis PDOX models were randomized into three groups of seven mice. Group 1, untreated control with phosphate buffered saline (PBS); Group 2, treated with 5-FU + OXA; and Group 3, treated with 5-FU + OXA + o-rMETase. RESULTS The colorectal-cancer liver metastasis PDOX model was resistant to 5-FU + OXA (p=0.83 at day 15 of treatment, Group 2). In contrast, the colorectal-cancer liver metastasis PDOX model was arrested by o-rMETase combined with 5-FU + OXA (p

Purpose Surgeons may be uncertain about the optimal timing of appendectomy to decrease complications, especially for complicated appendicitis. The aim of the study was to compare clinical outcomes between early and late surgery for complicated appendicitis. Methods A prospectively maintained database of complicated appendicitis was queried. Elective interval surgery (EIS) group and early surgery (ES) were matched with propensity score and marked with a prefix 'p.' Patient characteristics and surgical outcomes were compared. Results The propensity score-matched EIS group had a lower chance to underwent ileo-cecectomy or right hemicolectomy (1.5% vs. 6.9%, P = 0.031), a tendency of lower rate of postoperative complication (6.9% vs. 13.7%, P = 0.067), a lower rate of wound infection (1.5% vs. 8.4%, P = 0.010), and shorter postoperative hospital stay (3.72 days vs. 5.82 days, P < 0.001) than the propensity score-matched ES group. Multivariate analysis showed that delayed surgery for more than 48 hours or urgent surgery due to failure of EIS and open conversion were independent risk factors for postoperative complications (P = 0.001 and P = 0.025, respectively). In subgroup analysis, high American Society of Anesthesiologists physical status classification and distant abscess or generalized ascites in initial CT increased the risk of failure of EIS. Conclusion EIS can be a useful option for selected adult patients with complicated appendicitis.

We conducted this study to compare the perioperative outcomes of laparoscopic surgery (LS) vs. open surgery (OS) for repairing colonoscopic perforation, and to evaluate the possible predictors of complications. We reviewed the medical records of patients who underwent surgical repair of colonoscopic perforation by LS or OS between January 2005 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify the predictors of postoperative complications. Of the total 99 patients, 40 underwent OS and 59 underwent LS. The postoperative hospital stay and the time to resuming a soft diet were shorter in the LS group than in the OS group (P = 0.017 and 0.026, respectively). The complication rate and Clavien–Dindo classification were not significantly different between the two groups. Multivariable analysis revealed that an American Society of Anesthesiologists score (ASA) ≥ 3 and switching from non-operative management to surgical treatment were independently associated with complications (P = 0.025 and 0.010, respectively). LS may be a safe alternative to OS for repairing colonoscopic perforation with a shorter postoperative hospital stay and time to resuming a soft diet. Patients with an ASA score ≥ 3 and those with changes to their planned treatment should be monitored carefully to minimize their risk of complications.

Purpose Meckel diverticulum (MD), caused by an obliteration defect of the omphalomesenteric duct, is one of the most common congenital anomalies of small intestines. The objective of this study was to review surgical outcomes of MD and evaluate the feasibility of minimally invasive surgery (MIS) in MD. Methods We performed a retrospective analysis of the medical records of patients who underwent diverticulectomy for MD at 6 Hallym University-affiliated hospitals between January 2008 and December 2017. All patients underwent either open surgery or MIS. Patients who underwent MIS were subdivided into laparoscopic only diverticulectomy (LOD) or laparoscopic-assisted diverticulectomy (LAD). Results Of 64 patients, 21 underwent open surgery and 43 underwent MIS. Time to flatus, time to soft food intake, and length of hospital stay were shorter in the MIS group than in the open surgery group (P = 0.047, P = 0.005, and P = 0.015, respectively). Among patients who underwent MIS, the time to flatus and time to soft food intake were longer in the LAD group than in the LOD group (0.3 and 0.9 days, respectively). Multivariate analysis showed that old age and preoperative ileus were independent predictors of complications (P = 0.030 and P = 0.013, respectively). Operation type (open surgery, LOD, or LAD) was not associated with complications. Conclusion The present study showed that MIS is associated with quicker recovery without increasing complications. Therefore, MIS may be a safe alternative to open surgery for MD. An old age and preoperative ileus were associated with a risk of postoperative complications.

Summary Background CT radiation is arguably carcinogenic. Results from single-centre studies, mostly retrospective, have advocated lowering the CT radiation dose for the diagnosis of appendicitis. However, adoption of low-dose CT has been slow. We aimed to assess the effectiveness of low-dose CT compared with standard-dose CT in the diagnosis of appendicitis in adolescents and young adults. Methods We did this pragmatic, multicentre, randomi s ed controlled non-inferiority trial at 20 South Korean teaching hospitals with little experience with low-dose CT. Patients aged 15–44 years with suspected appendicitis were randomly assigned (1:1), via computer-generated random assignments (permuted block sizes of two, four, six, and eight) concealed in sequentially numbered envelopes, to receive low-dose CT (2 mSv) or standard-dose CT (≤8 mSv). Randomisation was stratified by site. Group allocation was concealed from patients, outcome assessors, and adverse event adjudicators; care providers, site pathologists, and data collectors were aware of allocation. The primary endpoint was the negative (unnecessary) appendectomy rate among all appendectomies, with a non-interiority margin of 4·5% for low-dose versus standard-dose CT. Primary analy s is was by modified intention to treat, which included all patients who received an appendectomy in the group to which they were assigned. This trial is registered with ClinicalTrials.gov, number NCT01925014. Findings Between Dec 4, 2013, and Aug 18, 2016, we assigned 1535 patients to the low-dose CT group and 1539 patients to the standard-dose CT group. 22 (3·9%) of 559 patients had a negative appendectomy in the low-dose group versus 16 (2·7%) of 601 patients in the standard-dose group (difference 1·3%, 95% CI −0·8 to 3·3; p=0·0022 for the non-inferiority test). We recorded 43 adverse events in 43 (2·8%) of 1535 patients in the low-dose group and 41 adverse events in 40 (2·6%) of 1539 patients in the standard-dose group. One life-threatening adverse event of anaphylaxis caused by an iodinated contrast material occurred in the low-dose group. Interpretation Radiation dose of appendiceal CT for adolescents and young adults can be reduced to 2 mSv without impairing clinical outcomes. In view of the vast number of appendiceal CT examinations done worldwide, use of low-dose CT could prevent a sizeable number of radiation-associated cancers in the future. Funding Korea Health Industry Development Institute, Seoul National University Bundang Hospital, Dasol Life Science, and Bracco Imaging Korea.

BACKGROUND Surgical orthotopic implantation of human colon cancer tissue to the ceca of mice has been used to mimic behavior of cancer in human patients for the development of precision cancer medicine. However, with the current method of serosal surface implantation (SSI) of pieces of human colon cancer tissue, cancer cells are exposed to the peritoneum, which can artificially increase the rate of peritoneal carcinomatosis (PC) during the disease course. The objective of the present study was to introduce a tumor-sealing method (TSM) and compare it with SSI for the ability to produce clinically-relevant metastases without artificial PC. MATERIALS AND METHODS HCT116 colon cancer cells transfected with green fluorescence protein (GFP) were cultured and then injected into the subcutaneous layer of athymic nude mice. Subcutaneous tumors were allowed to grow sufficiently to supply adequate tumor for orthotopic implantation. For SSI, a 1 mm3-sized tumor fragment was sutured to partially torn serosa of the cecum. For TSM, the blind end of the cecum was folded over the tumor fragment and sealed with sutures. At 20 days after implantation, all mice were opened to visualize PC by intravital fluorescence imaging. At necropsy, distant metastasis was investigated using frozen section of whole blocks of organs. RESULTS At 20 days after implantation, PC rates in the SSI group and the TSM group were 80% (12/15) and 20% (3/15), respectively (p

Selenium seems to be a risk factor for diabetes mellitus (DM) in recent studies, opposite to the previous expectation that it may contribute to prevent DM. The authors aimed to ascertain the relationship between selenium and DM.Data were collected from the National Health and Nutrition Examination Survey conducted from 2011 to 2014. A multivariate logistic regression analysis with adjustment for age, sex, race/ethnicity, hypertension, dyslipidemia and body mass index was conducted to evaluate the odds ratio for DM.The total number of subjects was 19,931. Large proportion of subjects were excluded due to young age (20 years) and missing data. The data of 3406 participants were analyzed, and a total of 604 had DM. In a multivariate logistic regression model, the increase of 10 μg/L in selenium increased the prevalence of DM by 12% (OR: 1.12; 95% CI: 1.06-1.18). Further analysis with 1:1 propensity score matching data with age and sex showed a similar results (OR: 1.08; 95% CI: 1.01-1.15). In addition, the restricted cubic spline regression showed a dose-dependent relationship between selenium level and DM. Subgroup analysis showed a dose-dependent relationship between selenium level and DM regardless of sex or race/ethnicity CONCLUSIONS: This large population study clearly demonstrates a positive association between selenium level and DM. This finding could have implications for nutritional supplementation in clinical settings.

Pancreatic cancer is a highly lethal disease in part due to incomplete tumor resection. Targeting by tumor-specific antibodies conjugated with a fluorescent label can result in selective labeling of cancer in vivo for surgical navigation. In the present study, we describe a patient-derived orthotopic xenograft model of pancreatic cancer that recapitulated the disease on a gross and microscopic level, along with physiologic clinical manifestations. We additionally show that the use of an anti-CEA antibody conjugated to the near-infrared (NIR) fluorescent dye, IRDye800CW, can selectively highlight the pancreatic cancer and its metastases in this model with a tumor-to-background ratio of 3.5 (SEM 0.9). The present results demonstrate the clinical potential of this labeling technique for fluorescence-guided surgery of pancreatic cancer.

Cancer of unknown primary (CUP) is a recalcitrant disease with poor prognosis because it lacks standard first-line therapy. CUP consists of diverse malignancy groups, making personalized precision therapy essential. The present study aimed to identify an effective therapy for a CUP patient using a patient-derived orthotopic xenograft (PDOX) model. This paper reports the usefulness of the PDOX model to precisely identify effective and ineffective chemotherapy and to compare the efficacy of S. typhimurium A1-R with first-line chemotherapy using the CUP PDOX model. The present study is the first to use a CUP PDOX model, which was able to precisely distinguish the chemotherapeutic course. We found that a carboplatinum (CAR)-based regimen was effective for this CUP patient. We also demonstrated that S. typhimurium A1-R was more effective against the CUP tumor than first-line chemotherapy. Our results indicate that S. typhimurium A1-R has clinical potential for CUP, a resistant disease that requires effective therapy.

Cancer of unknown primary (CUP) is a recalcitrant disease with poor prognosis because it lacks standard first-line therapy. CUP consists of diverse malignancy groups, making personalized precision therapy essential. The present study aimed to identify an effective therapy for a CUP patient using a patient-derived orthotopic xenograft (PDOX) model. This paper reports the usefulness of the PDOX model to precisely identify effective and ineffective chemotherapy and to compare the efficacy of S. typhimurium A1-R with first-line chemotherapy using the CUP PDOX model. The present study is the first to use a CUP PDOX model, which was able to precisely distinguish the chemotherapeutic course. We found that a carboplatinum (CAR)-based regimen was effective for this CUP patient. We also demonstrated that S. typhimurium A1-R was more effective against the CUP tumor than first-line chemotherapy. Our results indicate that S. typhimurium A1-R has clinical potential for CUP, a resistant disease that requires effective therapy., Cancer therapeutics: Mouse model reveals best treatments for resistant cancer The genetically-engineered strain of Salmonella A1-R effectively targets human metastatic cancers of unknown primary (CUP) in a mouse model. In up to 5% of advanced cancer diagnosis the primary site of cancer growth cannot be identified. In these cases, prognosis is poor as the most appropriate therapies are determined by the cancer’s tissue of origin. A study led by US researchers Shree Ram Singh, Fritz C. Eilber and Robert M. Hoffman examined the effect of four standard chemotherapeutic drugs and Salmonella A1-R on CUP progression in mice implanted with a lymph node tumor resected from a patient’s neck. To mimic the tumor microenvironment in the patient, the tumor was placed in the corresponding anatomical site in mice. This model showed that only carboplatinum and Salmonella A1-R were able to suppress CUP tumor growth.

In recent years, single-incision laparoscopic appendectomy has been used as an improved form of conventional laparoscopic appendectomy (CLA). We have started to perform gasless laparoscopy-assisted transumbilical appendectomy (GLATUA) in patients with uncomplicated appendicitis. This study aimed to evaluate the feasibility, safety, cosmetic results, and cost-effectiveness of this novel technique of GLATUA.In total, 30 patients with a diagnosis of acute appendicitis without evidence of periappendiceal abcess or perforation and indicated for operation were enrolled in the study. Attempts to operate by the GLATUA technique initially were made in all of the patients. When it was technically difficult to perform appendix extraction via the umbilicus, the procedures were converted to the CLA technique (conversion group). The following factors between the successful group and conversion group were investigated to evaluate feasibility and predictable factors for the success of GLATUA: age, gender, duration from symptom onset to hospital visit, preoperative ileus, preoperative white blood cell count, neutrophil count (%), body mass index, fat infiltration in abdominal computed tomography or ultrasonography, pathologic characteristics of the resected appendix, and postoperative complications.Among the 30 patients, 19 patients underwent operation by the GLATUA technique (63.3%). There were no significant differences between the two groups in terms of demographics, duration from symptom onset to hospital visit, preoperative white blood cell count, neutrophil count (%), and pathologic characteristics of the appendix. Significant differences were observed between the two groups for preoperative ileus in simple abdominal x-ray and fat infiltration in preoperative diagnostic modality. There were no postoperative complications in both groups.GLATUA is a feasible, safe, and cost-effective technique for appendectomy in uncomplicated appendicitis and shows good cosmetic results. It did not increase the rate of complications and represents a possible alternative to the CLA technique in cases without fat infiltration in abdominal tomography or ultrasonography and small bowel ileus in simple abdominal x-ray.

Background and objectives: Single-port laparoscopic appendectomy (SLA) in most previous studies has used intracorporeal excision of the appendix and needed a longer operative time than multi-port laparoscopic appendectomy (MLA), although SLA does have the potential benefit of an almost invisible scar within the umbilicus. Some studies have reported that extracorporeal transumbilical single-incision laparoscopic-assisted appendectomy (TULAA) in children took a considerably reduced operative time compared to MLA. We adopted TULAA in adults, adding routine dissection of the peritoneal attachment of the appendix. The aim was to compare the operative outcomes between TULAA and MLA. Materials and Methods: Between March 2013 and January 2016, 770 patients with acute uncomplicated and complicated appendicitis from 15 to 75 years of age were enrolled retrospectively. The operation was performed as early (EA) and interval appendectomy (IA). Results: Operative time was shorter in the TULAA group than in the MLA group, except for IA. No open conversion occurred in the TULAA group, except one case of ileocecal resection for IA. No intra-abdominal fluid collection was found in the TULAA group. Extended resection (especially partial cecectomy) was performed less frequently in the TULAA group than in the MLA group for IA. Mean postoperative hospital stay was shorter in the TULAA group for uncomplicated appendicitis. When the data of the EA group and the IA group were compared, operative time was significantly shorter in the IA group for both MLA and TULAA. The open conversion rate and the complication rate tended to be lower in the IA group. Confined to IA, the TULAA group tended to have shorter mean initial, postoperative, and total hospital stays. Conclusions: TULAA can be a useful surgical alternative to MLA in adults and young adolescents, because it lacks open conversion and provides both a shorter operative time and a shorter postoperative hospital stay. TULAA is feasible for IA in that it showed a lower rate of extended resection and complications.

Fistula is a representative devastating complication in Crohn's patients due to refractory to conventional therapy and high recurrence. In our phase I clinical trial, adipose tissue-derived stem cells (ASCs) demonstrated their safety and therapeutic potential for healing fistulae associated with Crohn's disease. This study was carried out to evaluate the efficacy and safety of ASCs in patients with Crohn's fistulae. In this phase II study, forty-three patients were treated with ASCs. The amount of ASCs was proportioned to fistula size and fistula tract was filled with ASCs in combination with fibrin glue after intralesional injection of ASCs. Patients without complete closure of fistula at 8 weeks received a second injection of ASCs containing 1.5 times more cells than the first injection. Fistula healing at week 8 after final dose injection and its sustainability for 1-year were evaluated. Healing was defined as a complete closure of external opening without any sign of drainage and inflammation. A modified per-protocol analysis showed that complete fistula healing was observed in 27/33 patients (82%) by 8 weeks after ASC injection. Of 27 patients with fistula healing, 26 patients completed additional observation study for 1-year and 23 patients (88%) sustained complete closure. There were no adverse events related to ASC administration. ASC treatment for patients with Crohn's fistulae was well tolerated, with a favorable therapeutic outcome. Furthermore, complete closure was well sustained. These results strongly suggest that autologous ASC could be a novel treatment option for the Crohn's fistula with high-risk of recurrence.

PURPOSE The purpose of this study was to assess the risk factors for repeated abdominal surgery in Crohn's disease (CD) patients after the first abdominal surgery. Prior studies have tried to identify the risk factors for postoperative recurrence in CD patients, but the results of the studies have been inconsistent. Furthermore, few data on the risk factors for repeated abdominal surgery are available. METHODS Clinical data on CD patients who underwent abdominal surgery from January 2000 to December 2009 were collected from seventeen university hospitals and one colorectal clinic. Data from a total of 708 patients were analyzed to find the risk factors for repeated abdominal surgery in CD patients. The mean follow-up period was 72 months. RESULTS The risk of repeated abdominal surgery was 3 times higher in young patients (below 16 years old) than in older patients (odds ratio [OR], 3.056; 95% confidence interval [CI], 1.021 to 9.150); P = 0.046). Stricturing behavior at diagnosis was also a risk factor for repeated abdominal surgery (OR, 2.438; 95% CI, 1.144 to 5.196; P = 0.021). Among operative indications, only intra-abdominal abscess was associated with repeated abdominal surgery (OR, 2.393; 95% CI, 1.098 to 5.216; P = 0.028). Concerning type of operation, an ileostomy might be a risk factor for repeated abdominal surgery (OR, 11.437; 95% CI, 1.451 to 90.124; P = 0.021). Emergency surgery (OR, 4.994; 95% CI, 2.123 to 11.745; P < 0.001) and delayed diagnosis after surgery (OR, 2.339; 95% CI, 1.147 to 4.771; P = 0.019) also increased the risk of repeated abdominal surgery. CONCLUSION Young age (below 16 years), stricturing behavior, intra-abdominal abscess, emergency surgery, and delayed diagnosis after surgery were identified as possible risk factors for repeated abdominal surgery in CD patients.

Although anterior resection syndrome commonly occurs after anal sphincter-saving surgery, no standard treatment option is currently available.The aim of the present study was to evaluate the clinical effectiveness of biofeedback in patients with anterior resection syndrome after sphincter-saving surgery for rectal cancer.This study was a retrospective review of data collected during the course of treatment.Patients were treated at a teaching hospital (Asan Medical Center) in Seoul, Korea, from January 2003 through December 2008.Patients who received biofeedback therapy for anterior resection syndrome after rectal cancer surgery were included.The Cleveland Clinic Florida fecal incontinence score, number of bowel movements per day, a visual analog scale for assessing patient satisfaction, and anorectal manometry were used to assess outcome of biofeedback treatment.: After biofeedback therapy, significant improvements were observed in fecal incontinence score (P.001), number of bowel movements (P.001), and anorectal manometry data (maximum resting pressure, P = .010; maximum squeeze pressure, P = .006; rectal capacity, P = .003). Compared with patients who started biofeedback treatment less than 18 months after surgery, those who started biofeedback at 18 months or longer after surgery showed greater improvements in fecal incontinence score (P = .032). Only patients with fecal incontinence as the primary symptom showed significant improvements in all variables, including fecal incontinence score, P.001; defecation frequency, P.001; and anorectal manometry (maximum resting pressure, P = .027; maximum squeeze pressure, P = .021; rectal capacity, P = .004). Patients who received radiation therapy in addition to surgery reported a significantly higher satisfaction score than those receiving surgery alone (P = .041).This is a nonrandomized retrospective study. Anorectal manometry was not regularly performed in all patients.Biofeedback therapy produced significant clinical benefits for patients with severe fecal incontinence and may be an effective treatment for patients with anterior resection syndrome after surgery for rectal cancer.

To evaluate the clinical significance of a reduction in serum carcinoembryonic antigen (s-CEA) concentration ratio from before to after preoperative chemoradiotherapy (CRT) in terms of recurrence and prognostic factors in rectal cancer patients.We retrospectively evaluated 333 rectal cancer patients who received preoperative CRT followed by surgery with curative intent between January 2000 and December 2006. Patients were divided into three groups: those with pre-CRT s-CEA≤6 ng/mL (group 1), those with pre-CRT s-CEA6 mg/mL and post-CRT s-CEA≥70% lower than pre-CRT s-CEA (group 2), and those with pre-CRT s-CEA6 mg/mL and post-CRT s-CEA70% lower or higher than pre-CRT s-CEA (group 3).The 5-year disease-free survival rate was similar in group 1 (76.0%) and group 2 (66.0%), but significantly lower in group 3 (39.5%) (p0.001). Multivariate analysis showed that CEA group 3, ypT stage, ypN stage, and type of surgery were independent prognostic factors for disease-free survival.The reduction ratio of pre- to post-CRT s-CEA concentration may be an independent prognostic factor for disease-free survival following preoperative CRT and surgery in rectal cancer patients with initial s-CEA6 ng/mL.

The occurrence of venous thromboembolism (VTE), manifesting as deep vein thrombosis (DVT) or pulmonary embolism (PE), after colorectal cancer surgery in Asian patients remains poorly characterized. The present study was designed to investigate the incidence of symptomatic VTE in Korean colorectal cancer patients following surgery, and to identify the associated risk factors. We retrospectively analyzed data from patients who developed symptomatic VTE after colorectal cancer surgery between 2006 and 2008. Deep vein thrombosis was diagnosed with Doppler ultrasound or contrast venography, and PE was identified with lung ventilation/perfusion scans or chest computed tomography. Thromboprophylaxis, including low-molecular-weight heparin, graduated compression stockings, and intermittent pneumatic compression, was used in patients considered at high risk of VTE. Of the 3,645 patients who underwent colorectal cancer surgery, 31 (0.85%) developed symptomatic VTE. Of those 31 patients, 23 (74.2%) had DVT, 16 (51.6%) had PE, and 8 (25.8%) had both. Two patients died from PE. Univariate analysis showed that a history of VTE, pre-existing cardiovascular disease, respiratory disease, transfusions, postoperative immobilization time, and postoperative complications were associated with VTE (p

The aim of the present study was to compare the influence of preoperative chemoradiotherapy (CRT) with postoperative CRT on the incidence and types of postoperative complications in rectal cancer patients who underwent sphincter-saving resection.We reviewed 285 patients who received preoperative CRT and 418 patients who received postoperative CRT between January 2000 and December 2006.There was no between-group difference in age, gender, or cancer stage. In the pre-CRT group, the mean level of anastomosis from the anal verge was lower (3.5 +/- 1.4 cm vs. 4.3 +/- 1.7 cm, p0.001) and the rate of T4 lesion and temporary diverting ileostomy was higher than in the post-CRT group. Delayed anastomotic leakage and rectovaginal fistulae developed more frequently in the pre-CRT group than in the post-CRT group (3.9% vs. 1.2%, p = 0.020, 6.5% vs. 1.3%, p = 0.027, respectively). Small bowel obstruction (arising from radiation enteritis) requiring surgical intervention was more frequent in the post-CRT group (0% in the pre-CRT group vs. 1.4% in the post-CRT group, p = 0.042). Multivariate analysis identified preoperative CRT as an independent risk factor for fistulous complications (delayed anastomotic leakage, rectovaginal fistula, rectovesical fistula), and postoperative CRT as a risk factor for obstructive complications (anastomotic stricture, small bowel obstruction). The stoma-free rates were significantly lower in the pre-CRT group than in the post-CRT group (5-year stoma-free rates: 92.8% vs. 97.0%, p = 0.008).The overall postoperative complication rates were similar between the pre-CRT and the Post-CRT groups. However, the pattern of postoperative complications seen after sphincter- saving resection differed with reference to the timing of CRT.

Intra-abdominal fistulas occur in one-third of patients with Crohn’s disease (CD). Although they are common, these fistulas may pose difficult problems for the surgeon. We assessed the clinical presentation of intra-abdominal fistulas in patients with CD and compared the clinicopathologic characteristics of CD with and without fistulas. We analyzed consecutive laparotomy cases for 254 patients with CD between 1991 and 2008. Clinicopathologic data were abstracted from patient charts and a prospectively maintained database. Patient variables with and without fistulas were analyzed using the Fisher’s exact test, chi-square test, and Student’s t test. A total of 93 surgical procedures were performed on 83 patients (32.7%) who had at least one intra-abdominal fistula, revealing a total of 122 fistulas. Enteroenteric fistulas were the most common (30.3%), followed by enterocutaneous (23%), enterosigmoid (19.7%), enterocolonic (9.7%), and enterovesical (9.7%). Most cases (95.7%) underwent intestinal resection, with primary anastomosis in 77 of the cases (82.8%). There was no mortality, although 15 (16.1%) patients experienced postoperative complications. In the comparison of 270 cases with and without fistulas, cases with fistulas tended to have more frequent surgeries for perianal fistulas or abscesses (P = 0.001), more frequent intra-abdominal abscesses on CT (P = 0.044), and a higher incidence of combined small bowel and colonic disease (P

Purpose Perianal lesions are common in Crohn disease, but their clinical course is unpredictable. Nevertheless, predicting the clinical course after surgery for perianal Crohn disease (PCD) is important because repeated operations may decrease patient's quality of life. The aim of this study was to predict the risk of reoperation in patients with PCD. Methods From September 1994 to February 2010, 377 patients with PCD were recruited in twelve major tertiary university-affiliated hospitals and two specialized colorectal hospitals in Korea. Data on the patient's demographics, clinical features, and surgical outcomes were analyzed. Results Among 377 patients, 227 patients were ultimately included in the study. Among the 227 patients, 64 patients underwent at least one reoperation. The median period of reoperation following the first perianal surgery was 94 months. Overall 3-year, 5-year, and 10-year cumulative rates of reoperation-free individuals were 68.8%, 61.2%, and 50.5%, respectively. In multivariate analysis (Cox-regression hazard model), reoperation was significantly correlated with an age of onset less than 20 years (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.07-3.48; P = 0.03), history of abdominal surgery (HR, 1.99; 95% CI, 1.08-3.64; P = 0.03), and the type of surgery. Among types of surgery, fistulotomy or fistulectomy was associated with a decreased incidence of reoperation in comparison with incision and drainage (HR, 0.19; 95% CI, 0.09-0.42; P < 0.001). Conclusion Young age of onset and a history of abdominal surgery were associated with a high risk of reoperation for PCD, and the risk of reoperation were relatively low in fistulotomy or fistulectomy procedures.

Robotic surgery is increasingly used for rectal cancer. We compared the short- and long-term outcomes between robotic- and laparoscopic-assisted resection for rectal cancer.A retrospective chart review was performed between 2006 and 2010.Seventeen robotic and 61 laparoscopic surgeries were performed consecutively. Median follow-up time was 58.2 months. No operation was converted to open surgery. No difference was observed between the groups for types of operations, diverting ileostomy rate, operation time, blood loss, and postoperative hospital stay, tumor diameter, distal margin, circumferential margin, tumor stage, differentiation, lymphovascular, or perineural invasion. However, the number of harvested lymph nodes was higher in the robot than that in the laparoscopy group (p = 0.017). Overall morbidity and reoperation rates were similar between the groups. The 5-yr overall and disease-free survival rates of all patients were 82.5% and 81.3%, respectively. The 5-yr overall and disease-free survival rates of the robotic and the laparoscopy groups were 94.1% and 79.7% (p = 0.241), and 94.1% and 77.9% (p = 0.159), respectively.Robot-assisted resection for rectal cancer resulted in harvesting more lymph nodes without increasing morbidity and showed a comparable survival rate, compared with those of laparoscopy.

This study was conducted to evaluate the efficacy and safety of the combination of capecitabine and oral leucovorin (LV) as a third-line chemotherapy for patients with metastatic colorectal cancer (CRC) showing resistance to irinotecan- and oxaliplatin-containing regimens. Patients who showed disease progression while receiving or within 6 months of discontinuing irinotecan- and oxaliplatin-containing regimens received capecitabine 825 mg/m2 in combination with oral LV at a fixed dose of 30 mg, twice a day for 2 weeks followed by a 1-week rest. Twenty-five patients were enrolled from July 2011 to June 2014. Three patients achieved PR, and 11 showed SD. The overall response rate was 12 %, and disease control rate was 56 %. With a median follow-up of 6.8 months, the median time to progression was 2.8 months and the median overall survival was 7.1 months. The most common non-hematologic toxicity was hand-foot syndrome (40 %), followed by mucositis (28 %) and diarrhea (12 %). Grade 3 hand-foot syndrome occurred in two patients (8 %), and grade 3 mucositis in one. Hematologic toxicities were mild, and only one patient developed grade 3 thrombocytopenia. The combination of capecitabine and oral LV showed a modest activity and tolerable toxicity profile in metastatic CRC patients pretreated with irinotecan- and oxaliplatin-containing regimens. Oral LV seems to be able to reduce the usual dose of capecitabine when the two drugs are combined.

A previous phase II clinical trial of adipose-derived stem cell (ASC) therapy for fistulae associated with Crohn's disease, a devastating condition with a high recurrence rate, demonstrated safety and therapeutic potential with a 1-year sustained response. In the present study, 41 of the 43 phase II trial patients were followed for an additional year, regardless of response in the initial year. At 24 months, complete healing was observed in 21 of 26 patients (80.8%) in modified per protocol analysis and 27 of 36 patients (75.0%) in modified intention-to-treat analysis. No adverse events related to ASC administration were observed. Furthermore, complete closure after initial treatment was well-sustained. These results strongly suggest that autologous ASCs may be a novel treatment option for Crohn's fistulae. Significance Long-term follow-up of patients with Crohn's fistula found that one or two doses of autologous adipose-derived stem cell therapy achieved complete closure in 80% of the patients at 12 months. After 24 months, 75% of those patients sustained complete closure, showing sustainable safety and efficacy of the treatment.

Two adult patients with histopathologically proved cavernous lymphangiomas and one adult patient with lymphangiomas of strongly presumed cavernous type by cytologic and computed tomographic findings are reported. On computed tomograms, multiple, aggregated, small, and tiny cysts without a solid portion, along the lymphatic channels are characteristic computed tomographic findings for cavernous lymphangiomas.

Various types of human cancers harbor BRAF somatic mutations, leading researchers to seek molecular targets for BRAF inhibitors. A mutually exclusive relationship has been observed between the BRAF-V600E mutation and K-ras mutations, suggesting that the BRAF-V600E mutation may differ from the other BRAF mutant types. Here, we used microarray analysis to examine differences between the BRAF and K-ras mutant colorectal samples and within the BRAF group (V600E versus non-V600E), in the hope that the identified gene sets could form the basis for new target development. Eleven colorectal cancers (CRCs) with BRAF mutations and nine with K-ras mutations were examined by high-density microarray analysis. We also tested whether other significant genetic or clinical status involved in CRC development, such as APC and TP53 mutations, MSI and TNM-Duke's staging, were related with the observed BRAF- or K-ras associated expression profiles. Unsupervised two-way hierarchical clustering and multidimensional scaling revealed that the differentially expressed genes clustered according to the mutation status of BRAF and K-ras, and that samples with the BRAF-V600E and non-V600E mutants could be distinguished from each other by gene profiling. Examination of TNM-Duke's staging, MSI and mutations in APC and TP53 revealed that these significant mutations could not account for the hierarchical clustering results observed in our study. We herein identified distinct gene expression patterns and gene sets that may form the basis for identification of BRAF-targeting molecules or provide researchers with a better understanding of the molecular pathogenesis underlying RAS-RAF signaling.

Protein S deficiency (PSD) is an inherited or acquired disorder associated with an increased risk of thrombosis. We describe the unusual case of a previously healthy 45-year-old man with PSD. The patient was admitted for work-up of hematochezia and was diagnosed with colorectal cancer. Preoperative evaluation was unremarkable, and he subsequently underwent an uneventful laparoscopic total colectomy. The next day, he complained of chest tightness, and a computed tomography enterography revealed acute thrombosis throughout the entire superior mesenteric vein. Further laboratory evaluation revealed decreased free protein S levels. Polymerase chain reaction and direct sequencing of the PROS1 gene revealed a heterozygous transition (NM_000313.3 c.1907A > G), resulting in an amino acid change (p.Tyr636Cys). Although several case reports have described mesenteric venous thrombosis (MVT) in individuals with PSD, most have just reported decreases in the activity or concentration of protein S. We confirmed a nucleotide alteration of PROS1 associated with PSD. This patient, who had hereditary thrombophilia, may have developed MVT after transient exposure to abdominal surgery. We may need to implement more comprehensive coagulation testing prior to surgery considering the prevalence and possible risk of thromboembolic event.

To investigate the post-failure dynamics of subaerial and subaqueous landslides in various environments, we need a detailed analysis of the geotechnical and rheological behaviour of fine-grained sediments. For fine-grained sediments found in the subaerial and subaqueous environments, rheological research should be conducted as a prelude to understanding flow behaviour and hazard assessment. In this paper, the rheological characteristics of Busan clays from the Nakdong deltaic plain are examined in a shear rate-controlled system. A comparison is made between the Busan clays and low-activity clays in terms of rheometer geometry. Flow curves obtained from the controlled shear rate and the shear stress mode are examined. The viscosity and yield stresses obtained from different geometries, which may produce wall-slip among cylinder, ball-measuring and vane-measuring systems, are highlighted. Based on the relationship between the liquidity index and rheological values (viscosity and yield stress), flow motions are compared. Results show that the differences in mobility are significant when assuming that the flowing materials behave as a Bingham fluid. The runout distance is controlled by the yield stress of fine-grained sediments. Differences in yield stress may be caused by wall roughness and the distance between the ball (vane) and the wall in the rheometer. Under the same geomorphological conditions, the runout distance calculated from vane-measuring systems is much lower than that from ball-measuring and cylinderic systems. These difficulties must be minimized to predict debris flow mobility and to correctly perform hazard risk assessment.

Sclerosing encapsulating peritonitis (SEP) is a rare cause of bowel obstruction that is characterized by the encasement of the small bowel by a thick, whitish, and fibrous membrane. The pathophysiology of SEP is poorly understood and preoperative diagnosis is difficult. Previous reports suggest that SEP may be linked to the chronic use of β-adrenergic blockers. A 46-year-old man with liver cirrhosis and end-stage renal disease on hemodialysis presented with recurrent abdominal pain and borborygmi. He had been taking propranolol to prevent bleeding from gastroesophageal varices for the past 15 years. Abdominal computed tomography showed ileal loops encapsulated by soft tissue with dilatation of the proximal small bowel on the right side of the abdomen. Barium follow-through showed conglomerated distal ileal loops with a cauliflower-like appearance. Explorative laparotomy revealed a thick, fibrous, whitish capsule encapsulating the ileal loops. The covering membrane was dissected and excised, resulting in an improvement in symptoms after surgery. Accordingly, a final diagnosis of SEP was made. Due to the lack of other apparent causes for SEP, we conclude that in this case, the long-term use of propranolol may be associated with the development of SEP.

A chemosensitive single nucleotide polymorphism (SNP) discovery schema is presented that utilizes (i) genome-wide SNP screening, with a human SNP array and an in vitro chemosensitivity assay, in 93 patients with gastric cancer (GC), and (ii) biological utility assessment using cell viability assays of transfected GC cells. Cytotoxicity analysis showed that most of the MKN1 and SNU638 clones transfected with the G allele of Deoxyribonuclease II beta (DNASE2B) rs3738573 were more sensitive to docetaxel than those with the C allele (p≤0.001-0.029) and most of the AGS and SNU638 clones transfected with the T allele of 5-hydroxytryptamine receptor IE (HTRIE) rs3828741 were more sensitive to paclitaxel than those with the C allele (p≤0.001-0.019). Our findings show that the two novel markers, DNASE2B rs3738573 and HTR1E rs3828741, have potential for improving the prediction of chemosensitivity of GC patients.

To determine the accuracy of contrast material-enhanced computed tomographic (CT) colonography for postoperative surveillance in colorectal cancer patients without clinical or laboratory evidence of disease recurrence.The Institutional Review Board approved this HIPAA-compliant study and waived informed consent. Between January 2006 and December 2007, 742 consecutive patients without clinical or laboratory evidence of recurrence following curative-intent colorectal cancer surgery underwent contrast-enhanced CT colonography. Of these, 548 patients who had subsequent colonoscopy and pathologic confirmation of colonic lesions (reference standard) were included in the colonic analysis. All 742 patients were included in the extracolonic analysis. Sensitivity and specificity of CT colonography for nonanastomotic colonic lesions at least 6 mm in size and anastomotic lesions of any size, including performance according to lesion histologic type, were determined. Diagnostic yields of contrast-enhanced CT colonography for colonic cancers and for extracolonic recurrences were obtained.CT colonography depicted all six metachronous cancers and one anastomotic recurrence within the colon in six patients (0.8%; 95% confidence interval [CI]: 0.3%, 1.8%]), for per-patient and per-lesion sensitivities of 100% (95% CIs: 64.3%, 100% and 67.8%, 100%, respectively). All cancer lesions within the colon were amenable to additional curative treatment. CT colonography per-patient and per-lesion sensitivity was 81.8% (95% CI: 60.9%, 93.3%) and 80.8% (95% CI: 64.3%, 97.2%), respectively, for advanced neoplasia and 80.0% (95% CI: 68.6%, 88.1%) and 78.5% (95% CI: 68.3%, 88.7%), respectively, for all adenomatous lesions. Negative predictive values for adenocarcinoma, advanced neoplasia, and all adenomatous lesions were 100%, 99.1%, and 97.0%, respectively. CT colonography specificity was 93.1% (95% CI: 90.4%, 95.2%). Contrast-enhanced CT colonography enabled detection of extracolonic recurrences in an additional 11 patients (1.5%; 95% CI: 0.8%, 2.7%).Contrast-enhanced CT colonography is an accurate and practical surveillance tool following colorectal cancer surgery in patients without clinical or laboratory evidence of recurrence, allowing for simultaneous less-invasive evaluation of both colon and extracolonic organs.http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100385/-/DC1.

This study was performed to determine the efficacy of histone deacetylase inhibitors in gastric cancer, together with other established regimens.The chemosensitivities of 93 gastric cancer patients to established drugs, and three histone deacetylase inhibitors (SAHA, PXD101, and a novel candidate, CG-2) were evaluated using the histoculture drug response assay.Tumor growth inhibition rates were the highest with cisplatin, followed by PXD101, taxol, docetaxel, and TS-1, in descending order. The response rates were 41.9-68.8%, and 37.6-47.3%, respectively, at an inhibition rate cutoff value of 30%. Synergistic activity was evident with most combinations of established drugs and histone deacetylase inhibitors. Diffuse- or mixed-type carcinomas on Lauren classification were closely associated with increased chemosensitivity to TS-1 (p = 0.044). Node-positive and "other than tubular type" tumors on WHO classification were chemosensitive to cisplatin (p = 0.011 and 0.014, respectively). CG-2 chemosensitivity was markedly associated with low preoperative CA724 level (or = 4 U/ml) (p = 0.046).This in vitro chemosensitivity assay validates the comparable chemo-response of gastric cancers to histone deacetylase inhibitors and established drugs, indicating considerable therapeutic efficacy of these agents. Additionally, a number of clinicopathological parameters are significantly associated with specific regimens.

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is a rare disease of unclear origin and pathophysiology. Treatment is symptomatic, with no particular medical therapy except for corticosteroids. We describe a patient with steroid-refractory CMUSE. A 25-year-old woman underwent bowel surgery 4 times because of small-bowel obstruction. She was diagnosed with CMUSE. Despite steroid treatment and immunosuppressive therapy, she continued to complain of recurrent gastrointestinal symptoms and persistent anemia. To avoid short-bowel syndrome in our patient, new medical treatment is necessary for steroid-refractory CMUSE.

We investigated the characteristics of synchronous and metachronous gastric cancer in patients with colorectal cancer. We reviewed 8,680 patients who underwent operations for primary sporadic colorectal cancer from 1989 to 2008. Synchronous gastric cancer was defined as gastric cancer diagnosed within 6 months of a colorectal cancer diagnosis. Gastric cancer diagnosed more than 6 months before or after colorectal cancer was defined as metachronous. The incidences of synchronous and metachronous gastric cancer were 0.93 and 1.4%, respectively (combined 2.4%). The standardized incidence ratio was 1.199 (95% confidence interval [CI] = 1.005–1.420) when the patients with premetachronous gastric cancer were excluded. Patients with synchronous and metachronous gastric cancer were 5 years older on average compared to the control population without gastric cancer. In addition, multivariate analysis revealed an odds ratio (OR) of 3.6 for being male, OR = 2 for positive family history of solid tumors, OR = 2.2 for colonic lesion, and OR = 4 for MSH2 expression loss compared to patients without gastric cancer. Patients with postmetachronous gastric cancer (when compared to synchronous and premetachronous gastric cancer), a preoperative CEA level of less than 6 ng/ml, and a relatively early stage of colorectal cancer had significantly higher overall (p = 0.016, 0.007, and 0.004, respectively) and disease-free survival rates (p = 0.046, 0.003, and 0.004, respectively), only on univariate analysis. Lymphovascular invasion of colorectal cancer and an advanced stage of gastric cancer were independent poor prognostic factors for both overall (p = 0.018) and disease-free survival (p = 0.028). Gastric cancer surveillance is recommended for patients with colorectal cancer, especially when the patient is old and male, has a positive family history of solid tumors, has a colonic lesion, or lacks MSH2 expression.

This study investigated the effects of preoperative chemoradiotherapy (PCRT) and the prognoses of patients with mucinous rectal cancer compared with those with nonmucinous cancer. We retrospectively reviewed the medical records of 368 patients who underwent curative resection after PCRT, between 2000 and 2006, for midrectal to lower-rectal adenocarcinoma. Mucinous cancers were present in 23 patients (6.3%) and nonmucinous cancers in 345. In each patient, clinical stage before chemoradiotherapy was compared with pathologic stage to evaluate the extent of downstaging. Survival and multivariate analyses were performed using clinicopathologic variables. The median follow-up period was 42 months (range, 4–105 months). There was no difference in clinical stage between the groups. Although 58 patients (16.8%) in the nonmucinous group achieved pathologic complete responses (pCR), no mucinous group patient showed such a response. T-downstaging was more frequently observed in the nonmucinous than in the mucinous group (189 vs 7 [54.9% vs 30.4%], P = .03), but N-downstaging was similar in the 2 groups. The 5-year overall survival rate (OS) was significantly lower in the mucinous than in the nonmucinous group (64.8% vs 79.8%, P = .049). Multivariate analysis revealed that mucinous histotype was an independent (negative) prognostic factor for survival (hazard ratio, 2.36; 95% confidence interval, 1.05–5.3; P = .04). Patients with mucinous rectal cancer experienced a lower rate of T-downstaging after PCRT and had a poorer prognosis than did patients with nonmucinous cancer.

Carcinoids are heterogeneous neuroendocrine tumors with malignant potential. The rectum is the third most common location for gastrointestinal carcinoids. We assessed the clinicopathological characteristics of rectal carcinoids. A retrospective study of 203 patients treated for rectal carcinoids at the Asan Medical Center, Seoul, Republic of Korea from 1991 to 2007. The patients were on average 51 (18–83) years old. The male-to-female ratio was 1.48:1. Over half (62.1%) of the patients were asymptomatic. The most frequent symptoms in the symptomatic patients were abdominal pain (11.1%) and hematochezia (10.7%). Local excision was applied to 92.1%, low anterior resection to 4.9%, and biopsy only to 3.0% of total patients. Initially, 4.4% presented with distant metastasis. Distant metastasis rates for tumors ≤1 cm, >1 to ≤2 cm, and >2 cm were 1.7% (3/177), 15.0% (3/20), and 50.0% (3/6), respectively. In the follow-up period, three patients showed recurrences. The size, lymphovascular invasion, perineural invasion, and T and N stages were associated with distant metastasis. The overall 5-year survival rate was 94.0%. The TNM stage and presence of lymphovascular invasion were associated with lower survival. The chance that a rectal carcinoid will develop distant metastases increases as the tumor increases in size, lymphovascular invasion or perineural invasion is present, and T and N stages increase. The TNM stage and presence of lymphovascular invasion were associated with lower survival. Treatment plan should be chosen carefully considering above factors.

To evaluate the feasibility of using computed tomographic (CT) colonography for preoperative examination of the proximal colon after metallic stent placement in patients with acute colon obstruction caused by colorectal cancer.Institutional review board approval was obtained, and patient informed consent was waived. Fifty patients (mean age +/- standard deviation, 58.5 years +/- 11.7), who demonstrated no postprocedural complication after successful placement of self-expandable metallic stents to treat acute colon obstruction caused by cancer, underwent CT colonography 1-43 days (median, 5 days) after stent placement. CT colonography was performed after cathartic preparation by using magnesium citrate (n = 20) or sodium phosphate (n = 3), combined with oral bisacodyl, or by using polyethylene glycol (n = 27). Fecal/fluid tagging was achieved by using 100 mL of meglumine diatrizoate. The colon was distended by means of pressure-monitored CO(2) insufflation. The sensitivity and specificity of CT colonography in evaluating the colon proximal to the stent and CT colonography-related complications were assessed. The 95% confidence intervals (CIs) were calculated for proportional data.Per-lesion and per-patient sensitivities of CT colonography for lesions 6 mm or larger in diameter in the colon proximal to the stent were 85.7% (12 of 14 lesions; 95% CI: 58.8%, 97.2%) and 90% (nine of 10 patients; 95% CI: 57.4%, 99.9%), respectively. CT colonography depicted all synchronous cancers (two lesions) and advanced adenomas (five lesions). Per-patient specificity for lesions 6 mm and larger in the proximal colon was 85.7% (18 of 21 patients; 95% CI: 64.5%, 95.9%). CT colonography did not generate any false diagnosis of synchronous cancer. False-positive findings at CT colonography did not result in a change in surgical plan for any patients. No CT colonography-associated stent dislodgment/migration or colonic perforation occurred in any patient (95% CI: 0%, 6.2%).CT colonography is a safe and useful method for preoperative examination of the proximal colon after metallic stent placement in patients with acute colon obstruction caused by cancer. (c) RSNA, 2010.

Several forms of colonic complications are rarely observed during the clinical course of acute pancreatitis, and potentially fatal in some cases. Colonic lesions associated with acute pancreatitis can be divided into several groups from a pathogenic point of view. Possible pathogenesis includes 1) spread of pancreatic enzymes through the retroperitoneum to mesocolon, causing pericolitis, 2) external inflammatory compression by mesocolic mass secondary to necrosis of fatty tissue, and 3) hypotension due to shock, and thrombosis of mesenteric arteries. These might lead to colonic infarction, fistula formation, perforation, and obstruction during follow-up. We report two cases of colonic obstruction following acute pancreatitis with possible different mechanisms and review Korean cases. One patient developed colonic obstruction due to severe necrotizing pancreatitis, possibly as a result of pericolitis, and the other developed stenosis as a result of ischemic colitis induced by acute pancreatitis. (Korean J Gastroenterol 2009;54:180-185)

연락처: 예병덕, 138-736, 서울시 송파구 풍납동 388-1 울산대학교 의과대학 서울아산병원 내과학교실 Tel: (02) 3010-3181, Fax: (02) 476-0824 E-mail: bdye@amc.seoul.kr Correspondence to: Byong Duk Ye, M.D. Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 388-1, Pungnapdong, Songpa-gu, Seoul 138-736, Korea Tel: +82-2-3010-3181, Fax: +82-2-476-0824 E-mail: bdye@amc.seoul.kr Fig. 1. Simple upright abdominal radiography showed air-fluid levels, dilated small bowel loops and 35 mm-sized radiopaque ovoid lesion (arrow). 장석에 의한 소장 폐쇄

Purpose To perform a Phase I study of preoperative chemoradiation (CRT) with S-1, a novel oral fluoropyrimidine, plus oxaliplatin in patients with locally advanced rectal cancer, to determine the maximum tolerated dose and the recommended dose. Methods and Materials Radiotherapy was delivered to a total of 45 Gy in 25 fractions and followed by a coned-down boost of 5.4 Gy in 3 fractions. Concurrent chemotherapy consisted of a fixed dose of oxaliplatin (50 mg/m 2 /week) on Days 1, 8, 22, and 29 and escalated doses of S-1 on Days 1–14 and 22–35. The initial dose of S-1 was 50 mg/m 2 /day, gradually increasing to 60, 70, and 80 mg/m 2 /day. Surgery was performed within 6 ± 2 weeks. Results Twelve patients were enrolled and tolerated up to Dose Level 4 (3 patients at each dose level) without dose-limiting toxicity. An additional 3 patients were enrolled at Dose Level 4, with 1 experiencing a dose-limiting toxicity of Grade 3 diarrhea. Although maximum tolerated dose was not attained, Dose Level 4 (S-1 80 mg/m 2 /day) was chosen as the recommended dose for further Phase II studies. No Grade 4 toxicity was observed, and Grade 3 toxicities of leukopenia and diarrhea occurred in the same patient (1 of 15, 6.7%). Pathologic complete responses were observed in 2 of 15 patients (13.3%). Conclusions The recommended dose of S-1 was determined to be 80 mg/m 2 /day when combined with oxaliplatin in preoperative CRT, and a Phase II trial is now ongoing.

Extramammary Paget’s disease (EMPD) most commonly occurs in the perineal and genital areas of elderly people. The current treatment of choice is adequate surgical excision. Between 1990 and 2007, 28 patients (27 men and one woman) with EMPD were treated at Asan Medical Center, Seoul, Korea, by wide local excision (WLE) with a 2- to 3-cm normal skin margin. “Carcinoma in situ” (CIS) was defined as confinement of Paget cells to the epithelium, whereas “invasive carcinoma” was defined as infiltration of Paget cells into more than dermal connective tissue. Of the 28 lesions, 21 (75%) were located in the penoscrotal area. Six (21.4%) patients had associated gastrointestinal neoplasms, three with associated gastrointestinal malignancies and four with synchronous colorectal adenomas, including one with both. Surgical procedures included WLE with primary repair in 13 patients (46.4%), WLE with skin graft in 12 (42.9%), WLE with skin graft and Gracilis muscle transposition in two (7.1%), and combined abdominoperineal resection and distal gastrectomy in one (3.6%). Four patients (14.3%) also underwent inguinal lymph node dissection, with three found to have lymph node metastases. Of 11 patients with invasive carcinoma, three (27.3%) had lymph node metastases, compared with none of 17 patients with CIS. Patients with lymph node metastases showed a significantly lower disease-specific survival rate (P = 0.008). Patients with invasive carcinoma tended to have a lower disease-specific survival rate (P = 0.087). EMPD in Korea showed an absolute male predominance and an association with gastrointestinal neoplasms. Lymph node metastasis significantly affected, and depth of invasion tended to affect, disease-specific survival rate.

Endometrial cancer is the second most common cancer in hereditary nonpolyposis colorectal cancer (HNPCC). It has often been overlooked to explore the possibility of HNPCC in endometrial cancer patients. Our study was to investigate how many HNPCC patients existed among endometrial cancer patients. Among patients who underwent hysterectomy for endometrial cancer at Seoul National University Hospital from 1996 to 2004, 113 patients were included, whose family history and clinical data could be obtained and tumor specimens were available for microsatellite instability (MSI) testing and immunohistochemical (IHC) staining of MLH1, MSH2 and MSH6 proteins. There were 4 (3.5%) clinical HNPCC patients fulfilling the Amsterdam criteria II, and 2 (2/4, 50%) of them carried MSH2 germline mutations. There were also 8 (7.1%) suspected HNPCC (s-HNPCC) patients fulfilling the revised criteria for s-HNPCC, and one (1/8, 12.5%) of them revealed MLH1 germline mutation. In 101 patients, who were not clinical HNPCC or s-HNPCC, 11 patients showed both MSI-high and loss of expression of MLH1, MSH2 or MSH6 proteins, and 2 (2/11, 18.2%) of them showed MSH6 germline mutations. In 113 patients with endometrial cancer, we could find 5 (4.4%) HNPCC patients with MMR germline mutation and 2 (1.8%) clinical HNPCC patients without identified MMR gene mutation. Family history was critical in detecting 3 HNPCC patients with MMR germline mutation, and MSI testing with IHC staining for MLH1, MSH2 and MSH6 proteins was needed in the diagnosis of 2 HNPCC patients who were not clinical HNPCC or s-HNPCC, especially for MSH6 germline mutation.