Clinical Usefulness of Preoperative and Postoperative Chest Computed Tomography for Colorectal Cancer

PURPOSE: This research sought to identify the utility value of chest computed tomography (CT) when it comes to the diagnosis of lung metastasis in cases of colorectal cancer. METHODS: From September 2004 to January 2008, 266 patients who were treated for colorectal cancer at Department of Surgery, Hanyang University College of Medicine, were divided into two groups: one that underwent preoperative and postoperative periodical chest CT (periodical inspection group, PIG; May 2006 to January 2008, 135 patients) and one that did not undergo periodical chest CT (non-periodical inspection group, NPIG; September 2004 to April 2006, 131 patients) for comparison. RESULTS: The overall lung metastasis diagnosis rates did not manifest any significant difference. The times to diagnose lung metastasis patients were 6.3 months and 15.7 months for the PIG and the NPIG, respectively (P = 0.022). The size of the metastatic lung nodule was smaller in the PIG than in the NPIG (< 1 cm in 9/9 patients vs. < 1 cm in 6/9 patients in the PIG and the NPIG, respectively; P = 0.02). A solitary lung metastasis was more frequently found in the PIG (5/9 patients) than in the NPIG (1/11 patients) (P = 0.024). During the follow-up period, 100% (2/2 patients) and 60% (3/5 patients) of the patients in the PIG and the NPIG, respectively, with stage III cancer underwent a lung metastasectomy (P = 0.002). CONCLUSION: Chest CT enables early diagnosis with a smaller size and a lower number of lung metastases in patients with colorectal cancer. Moreover, pulmonary the rate of the pulmonary resection for selected patients may be improved. However, the contribution of chest CT to increasing the survival rate must be investigated in a prospective randomized study.

Microsatellite Instability Is Associated with the Clinicopathologic Features of Gastric Cancer in Sporadic Gastric Cancer Patients

PURPOSE: Replication error is an important mechanism in carcinogenesis. The microsatellite instability (MSI-H) of colorectal cancers is associated with the development of multiple cancers. The influence of MSI-H on the development of multiple gastric cancers in sporadic gastric cancer patients has not been defined. This study was performed to reveal the association between the clinicopathologic features and MSI in sporadic gastric cancers. MATERIALS AND METHODS: Between July 2004 and March 2009, the clinicopathologic characteristics, including MSI status, were evaluated in 128 consecutive patients with sporadic gastric cancers. None of the patients had hereditary non-polyposis colorectal cancer of familial gastric cancer. The markers that were recommended by the NCI to determine the MSI status for colorectal cancers were used. RESULTS: MSI-H cancers were found in 10.9% of the patients (14/128). Synchronous gastric cancers were shown in 4 patients (3.1%). Synchronous cancers were found in 2 of 14 patients with MSI-H gastric cancer (14.3%) and 2 of 114 patients with MSS gastric cancer (1.8%; P=0.059, Fisher's exact test). Among the patients with synchronous cancer 50% (2/4) had MSI-H cancer, but 9.7% of the patients (12/124) without synchronous cancer had MSI-H cancer. MSI-H (RR, 24.7; 95% CI, 1.5~398.9; P=0.024) was related with to synchronous gastric cancer, but age, gender, family history, histologic type, location, gross morphology, size, and stage were not related to synchronous gastric cancer. CONCLUSIONS: MSI is associated with the intestinal-type gastric cancer and the presence of multiple gastric cancers in patients with sporadic gastric cancer. Special attention to the presence of synchronous and the development of metachronous multiple cancer in patients with MSI-H gastric cancer is needed.

The Effect of Adjuvant Chemotherapy on Stage IV (T4N1-3M0 and T1-3N3M0) Gastric Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The optimal chemotherapeutic strategy for gastric cancer patients has not been determined, especially with respect to stage and the curability of gastric cancer. The aim of this study was to evaluate the results of adjuvant chemotherapy on stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer after curative gastrectomy between a chemotherapy (CTX) group and non-chemotherapy (non-CTX) group. MATERIALS AND METHODS: Among 1,760 patients who underwent gastric surgery by 1 surgeon in a single institution, 162 stage IV gastric cancer patients with curative gastrectomy were analyzed retrospectively, excluding patients with TanyNanyM1. One hundred twenty-five patients who received different chemotherapeutic regimens were compared to 37 patients who did not receive chemotherapy for reasons of old age or according to their expressed desire. RESULTS: The clinicopathologic factors which showed a clinically significant difference between the two groups were age and histology, which were not associated with patient survival. The CTX group was younger, and had a larger proportion of undifferentiated gastric cancers than the non-CTX group. The mode of treatment failure revealed no significant difference between the CTX and non-CTX groups. The 1, 3, and 5-year disease-free survival and the 1, 3, and 5-year disease-specific survival of the CTX group were 63.9%, 38.4%, and 32.0%, and 85.4%, 52.3%, and 39.6%, respectively, which were more favorable than the non-CTX group (p=0.015 and p=0.001, respectively). Postoperative adjuvant CTX was an independent risk factor for disease-specific survival of stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer patients after curative gastrectomy by multivariate analysis (odds ratio=2.153; 95% confidence interval=1.349-3.435; p=0.001). CONCLUSIONS: Adjuvant CTX may be associated with survival benefit for younger patients with stage IV (T4N1-3M0 and T1-3N3M0) gastric cancer with undifferentiated histology after curative gastrectomy. A randomized controlled trial to reveal the effect of stage-specific adjuvant chemotherapy should be conducted.

Traumatic Rupture of a Mature Cystic Teratoma of the Ovary

Mature cystic teratoma is the most common type of ovarian germ cell tumor. These tumors are usually asymptomatic, though they can cause abdominal pain and abnormal uterine bleeding. The most common complication is ovarian torsion. However, rupture of a mature cystic teratoma is a rare complication. A 73-year-old woman presented to our hospital with abdominal pain and tenderness. She was diagnosed with acute peritonitis secondary to traumatic rupture of a mature cystic teratoma of the ovary. We report the details of this case along with a brief review of the literature.

The Usefulness of Computed Tomography for Patients with Equivocal Acute Appendicitis

PURPOSE: We wanted to determine the usefulness of computed tomography (CT) for patients with clinically-suspected but equivocal acute appendicitis, and we wanted to evaluate the differences of the sensitivity and specificity of CT according to the period of time from onset of the signs and symptoms to the performance of CT. METHODS: A retrospective study was done on 273 patients who visited our hospital for acute abdominal pain from Jan. 2003 to Dec. 2005, and they could not be excluded as suffering from acute appendicitis by their symptoms nor signs. RESULTS: Forty-three (15.8%) of the 273 patients did not undergo operation because their condition was not diagnosed as acute appendicitis and 190 patients were diagnosed as acute appendicitis by CT. The other 40 patients underwent diagnostic laparotomy because acute appendicitis could not be confirmed and any other diagnosis could not be made. The patients were classified into 6 groups according to the period of time from the onset of symptoms and signs to the performance of CT. The sensitivity of CT after 48 hours was statistically significantly increased as compared to performing CT before 48 hours (92.3% vs. 75.8%, respectively; P=0.023). CONCLUSION: Forty-three (15.8%) of the patients with clinically- suspected but equivocal acute appendicitis avoided unnecessary laparotomy by undergoing CT. The sensitivity was increased for diagnosing acute appendicitis by CT when it was performed after 48 hours from the onset of symptoms and signs, but caution may be needed during interpretation because of the false positives (2 patients;4.7%) could due to secondary change of other diseases

A Case of Non-Hodgkin's Lymphoma in Ulcerative Colitis

Malignant intestinal lymphoma complicating ulcerative colitis has been reported. Although the association of colorectal cancer with ulcerative colitis is well described, the association of intestinal lymphoma, ulcerative colitis and prior immunosuppression remains unclear. However, it is important to be aware of the possible risk of lymphoma and carcinoma when patients shows unexpected signs of deterioration or when the clinical course of ulcerative colitis is atypical. Substantial biopsies with colonoscopy are required to make an unequivocal diagnosis in such patients. We report the case of non-Hodgkin's lymphoma in ulcerative colitis with review of the literature.

The Effect of Hyaluronate Membrane on Prevention of Adhesion after Rectal Cancer Surgery: a Prospective Study

PURPOSE: The aim of this study was to evaluate the efficacy of using a Hyaluronate (HA) bioresorbable membrane (SeprafilmTM, Genzyme Corp., Cambridge, MA) to prevent adhesion after rectal cancer surgery. METHODS: We recruited 362 rectal cancer patients who underwent a curative resection between April 2001 and December 2002. We excluded patients with a previous operation history, a stoma procedure, a multivisceral resection, an extended lymphadenectomy, a total colectomy, or a pouch procedure. An adhesive ileus was defined as a symptomatic, radiological intestinal obstruction without evidence of recurrence. RESULTS: We placed the HA membrane under the midline incision in 153 patients. There was no difference between the groups regarding demographic findings and clinicopathological findings, including locations of the tumors, surgery performed, AJCC stage, and adjuvant treatment. While only 1 (0.7%) patient of the HA group experienced an adhesive ileus, 13 (6.2%) cases of adhesion were identified in the control group (P=0.008). Every patient, except 1 in the control group, underwent conservative management. CONCLUSIONS: A Hyaluronate membrane may be effective in preventing an adhesive ileus after rectal cancer surgery. However, a prospective, randomized, double-blind study is needed.

Thymidylate Synthase, Thymidine Phosphorylase, VEGF and p53 Protein Expression in Primary Colorectal Cancer for Predicting Response to 5-fluorouracil-based Chemotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: In the treatment of advanced metastatic colorectal cancer, several new agents, such as irinotecan and oxaliplatin, have been developed, which have improved both disease free and overall survivals. Among these agents, 5-fluorouracil (5-FU) still remains one of the most active agents, and the selection of patients who can benefit from 5-FU-based chemotherapy is still important, as those unlikely to benefit could be spared the harmful side effects. The expression levels of thymidylate synthase (TS), thymidine phosphorylase (TP) and p53 have been known to be associated with the clinical response to 5-FU-based therapy as well as the prognosis, and that of vascular endothelial growth factor (VEGF) is associated with poor survival. MATERIALS AND METHODS: The relationship between the expressions of TS, TP, VEGF and p53 in primary tumors, using immunohistochemistry, and the response of 45 metastatic colorectal cancer patients (M: F=25: 20, median age 59 yrs) to 5-FU-based chemotherapy were evaluated. RESULTS: Thirty-seven patients were treated with 5-FU/ LV/irinotecan (FOLFIRI) and 8 with 5-FU/LV/oxaplatin (FOLFOX). The overall response rate was 28.9% (13/45). When immunohistochemically analyzed with monoclonal antibodies against TS, TP, VEGF and p53, 55.6% of the patients (25/45) were positive for TS, 48.9% (22/45) for TP, 82.2% (37/45) for VEGF, and 80% (36/45) for p53. There was a significant difference in the intensity of TS expression between the clinical responders and non-responders (p=0.036). In terms of the staining pattern of TS expression, diffuse staining was correlated with a poor response (p=0.012) and poor survival (p=0.045). However, there was no correlation between the expressions of TP, VEGF or P53 and the response to chemotherapy. CONCLUSION: These results suggest that the expression of TS in primary colorectal cancer might be an important prognostic factor for chemotherapy response and survival, and might be a useful therapeutic marker for the response of chemotherapy.

Management of Colonic Perforation during Colonoscopic Procedure / 대한소화기내시경학회지

BACKGROUND/AIMS: Colonic perforation appears to be the most dangerous complication during colonoscopy. This study was designed to determine the optimal management for this infrequent accident. METHODS: We reviewed the medical records of 17,510 colonoscopies which were performed during recent one-year period and found eightcolonic perforations (0.05%). RESULTS: Six perforations (0.04%) related to 16,695 diagnostic procedures, whereas two (0.25%) occurred from therapeutic procedures (p=0.05). Operative measures were applied in six (75.0%) patients showing signs of peritonitis. Five patients received primary closure without diversion, and resection with primary anastomosis was performed in one patient who had underlying tuberculous colitis. In addition, one patient was treated conservatively with bowel rest and intravenous antibiotics. Endoscopic clipping was applied in one patient with rectal perforation. Seven patients recovered uneventfully, and one 69-year-old male patient died of cardiogenic shock after the operation. CONCLUSIONS: Although colonic perforation occurs infrequently during colonoscopy, it may sometimes results in a fatal outcome. Primary closure without diversion appears to be appropriate in most cases without comorbid colonic disease.

Colonoscopic Surveillance after Curative Resection for Colorectal Cancer with Synchronous Adenoma / 대한소화기학회지

BACKGROUND/AIMS: Guidelines for current postoperative colonoscopic surveillance are not specified in colorectal cancer (CRC) patients with synchronous adenoma (SA). We performed this retrospective study to determine the postoperative colonoscopic surveillance interval for the CRC patients with SA. METHODS: One hundred and twenty-four CRC patients with SA (SA-group) and the same number of patients without SA (NSA-group) were selected from our database. Two groups were matched by the stage of CRC. Median colonoscopic surveillance period was 55 (12-99) months. The colonoscopic surveillance frequency and interval were similar between the two groups. RESULTS: Mean age was higher and male was more frequent in SA-group than NSA-group (p= 0.0001). The incidence of missed adenoma, advanced missed adenoma and metachronous adenoma (MA) were higher in SA-group (30.8% vs. 5.8% at 1st yr., p=0.0001; 4.4% vs. 0%, p=0.0001; 31.1% vs. 9.1% at 2nd yr., p=0.016) during the first consecutive two years of surveillance. The MA- and advanced-MA-free survival rate were lower in SA-group (24.6% vs. 6.6%, p=0.0001; 4.1% vs. 0%, p=0.02) during three years after surgery. Dysplasia of the SA (p=0.04; OR, 110.3; 95% CI, 1.13-10742.6) and presence of missed adenoma (p=0.036; OR, 43.6; 95% CI, 1.28-1490.1) were risk factors for the advanced MA on a multivariate analysis in SA-group. CONCLUSIONS: Postoperative colonoscopic surveillance at first year after surgery is warranted in CRC patients with SA.

Is Routine Nasogastric Intubation Necessary for Elective Colorectal Surgery?: a Prospective Randomized Controlled Trial

PURPOSE: This study was performed to assess the complications and discomfort of patients with or without a nasogastric tube who underwent elective colorectal surgery and to evaluate the efficacy of the routine practice of employing a nasogastric tube after elective colorectal surgery. METHODS: This study involved a prospective, randomized trial of 100 patients undergoing elective colorectal surgery from February to July 2004. The patients were classified as the nasogastric tube inserted group (NG (+), n=50) and non-inserted group (NG (-), n=50). The inclusion criteria were elective colorectal surgery, age under 70 years and no previous abdominal surgery history. The exclusion criteria were an emergent operation, an overt preoperative bowel obstruction and extensive operations such as pouch surgery and multivisceral resection. RESULTS: The mean age of the subjects was 55 (24~70) years old. There was no difference in terms of age, gender, pathological diagnosis and surgical procedures between the NG (-) and NG (+) groups. A sore throat and nausea was more prevalent in the NG (+) group (P=0.000, P=0.046). The gas passage time was shorter in the NG (-) group than in the NG (+) group (P=0.028). The other variables, such as vomiting, postoperative ileus, postoperative fever, posto-perative atelectasis, postoperative leakage, intraoperativedecompression, stool passage time and the length of the hospital stay revealed no difference between the groups. CONCLUSION: Nasogastric intubation is an uncomfortable procedure for patients and offers no benefit in preventing postoperatve complications. The routine use of a nasogastric tube is not necessary in elective colorectal surgery.

Clinical Usefulness of a PET Scan in the Diagnosis of a Recurrent Colorectal Carcinoma

PURPOSE: The aim of this study was to evaluate the potential efficacy of positron emission tomography using 2- [18F]-fluoro-2-deoxy-D-glucose in detecting recurrent colorectal carcinomas. METHODS: Seventy patients suspected of having recurrent colon cancer were evaluated using PET from January 2001 to March 2003. The PET results were compared with those of computed tomography and clinical examination over 6 months. RESULTS: Among the 70 patients, 17 patients had abnormal CEA levels and no abnormal findings with conventional radiologic methods (group 1), 29 had equivocal findings on computed tomography and other radiologic studies (group 2), and 24 were proven to have recurrent colorectal carcinoma (group 3) respectively. The sensitivity and the specificity of the PET scan, which were proved to be higher then those of CT (93% vs. 72.2%, 88% vs. 48.5%), were 85.7%, and 80%, respectively, in group 1, 86.7%, and 85.7% in group 2 and both 100% in group 3. The interval between diagnosis using PET and conventional studies was 1.9 months. CONCLUSIONS: Positron emission tomography is more sensitive than computed tomography in detecting recurrent colorectal carcinomas. When conventional studies show no abnormal findings except for CEA levels, PET can be a valuable imaging tool in detecting recurrent colorectal cancer and can prevent other unnecessary exploratory procedures.

Should Small Bowel Diverticula be Removed? / 대한소화기학회지

BACKGROUND/AIMS: Small bowel diverticulum is a rare disease that can be found incidentally during a surgical operation. Since reported complication rate is low, uncomplicated small bowel diverticula are generally recommended to be untreated. The aim of this study was to elucidate clinical features of this disease and to determine whether incidental small bowel diverticula should be removed for cure. METHODS: We reviewed the medical records of 80 patients with small bowel diverticular disease who underwent operation at Asan Medical Center between July 1989 and March 2003, retrospectively. RESULTS: Male to female ratio was 61:19, and the mean age was 44 (0-91) years. The most common diverticulum of small bowel is Meckel's diverticulum (63.8%), followed by duodenal diverticulum (15%), jejunal diverticulum (12.5%), and ileal diverticulum (8.7%). Of the 80 cases, 43 (53.7%) were symptomatic, and 37 (46.3%) were incidental. In the symptomatic patients, the most frequent symptom was abdominal pain (58.1%), followed by bleeding (44.2%). As for the treatments, segmental resection (53.7%) was performed more commonly than diverticulectomy (43.8%) in the symptomatic patients. Postoperative complications occurred more commonly in the symptomatic patients (25.6%) than the incidental patients (8.1%). Duodenal diverticula had a high morbidity and mortality rate. CONCLUSIONS: We should consider the diverticular disease of small bowel in patients with unexplained abdominal pain or gastrointestinal bleeding. As most small bowel diverticula, except for duodenal diverticula, are found incidentally and easily removed without postoperative morbidity or mortality, surgical resection appears to be recommended for the purpose of accurate diagnosis and treatment.

Outcome of Curative Resection in Patients with Completely Obstructing Colorectal Cancer

PURPOSE: A large bowel obstruction as a result of primary colorectal cancer has a poor outcome. A retrospective study was designed to verify the recurrence patterns and to determine the prognostic factors after a curative resection in patients with a completely obstructing colorectal cancer. METHODS: Eight hundred patients with stage II and III colorectal adenocarcinomas (37 patients with a complete obstruction and 763 patients without an obstruction) underwent curative surgery between 1989 and 1996 at the Asan Medical Center. The median follow-up period was 55 (3~107) months. RESULTS: Clinicopathologic variables, i.e. sex, serum carcinoembryonic antigen (CEA), Borrmann type, differentiation, and tumor stage in the two groups were similar. Patients with obstructing colorectal cancer were significantly older than those without an obstruction (61+/-14 vs. 56+/-12 years, P=0.02). Rectal cancers were more frequent in the non-obstructing cancers than in the obstructing cancers (P=0.02). The recurrence rate in the two groups was similar (obstructing vs. non-obstructing cancer, 27.0% vs. 28.0%). Ten patients with 12 recurrences were identified in 37 obstructing colorectal cancer patients, three with local recurrences (8.1%) and nine with distant metastasis (24.3%). The 5-year survival rate between the same stages was not different between the two groups (77.8% vs. 85.3% in stage II, 65.1% vs. 60.4% in stage III). Among the various clinicopathologic variables, neural invasion was strongly associated with a poor prognosis in obstructing colorectal cancer on multivariate analysis (P<0.05). CONCLUSION: Because the obstructing cancers and the non-obstructing colorectal cancers had a similar outcome, curative surgery appears to offer the best chance of a cure in stage II and III obstructing colorectal cancer.

Isolated Diaphragmatic Metastasis Originated from Adenocarcinoma of the Colon / Journal of the Korean Cancer Association, 대한암학회지

Isolated diaphragmatic metastasis arising from colorectal cancer has been reported only one case in the literature presently. Here, we presented a new case and discussed the possible pathogenesis and the treatment options. A 42-year-old male patient had received anterior resection for sigmoid colon cancer. Although the increased serum CEA level was detected 20 months after the surgery, metastatic lesion could not be detected by repeated colonoscopy, CT scan, bone scan or PET scan for 35 months. We could detect a suspicious metastatic lesion on the liver by CT scan at 56 month after the surgery. During a second-look operation, we found a solitary metastasis on the diaphragm and removed it along with the 1 cm tumor-free resection margin. Although the prognosis associated with skeletal metastasis is poor, the complete resection of isolated diaphragmatic metastasis and subsequent appropriate adjuvant chemotherapy may achieve a cure the disease provided that other metastatic lesions are absent.

The Postoperative Impact of Co-morbidity in Colorectal Cancer Surgery

PURPOSE: Co-morbidity is the presence of co-existing or additional diseases during the initial diagnosis. It may be used as a prognostic indicator for the postoperative outcomes in most cancers, including colorectal cancers. The impact of respective co-morbidities in colorectal cancer surgeries were evaluated to identify their outcomes regarding complications and hospital stay. METHODS: The medical records of 2,242 colorectal cancer patients, who had had curative operations between Jan. 1997 and Dec. 2001, were reviewed to evaluate the prevalence of co-morbidities. All co-morbidities were adequately evaluated and managed preoperatively. RESULTS: Co-morbidities were observed in 789 out of the 2,242 (35.2%) patients. Hypertension was the most frequent (340, 15.2%), with diabetes (210, 9.4%) and cardiovascular diseases (124, 5.5%) following. Early stages (0~II) were more frequently associated with co-morbidities, compared to late stages (III~IV) (P<0.001). Hypertension and cerebrovascular diseases were significantly associated with postoperative complications (P<0.05). Postoperative complications occurred in 578 out of the 2242 (25.8%) patients: e.g., ileus (10.2%), voiding difficulty (4.4%), wound problems (4.3%), etc. Pulmonary complications occurred more often in patients with cerebrovascular diseases, hypertension, and asthma. Wound complications were observed in patients with hypertension, cerebrovascular diseases, chronic obstructive pulmonary disease, and chronic renal failure (P<0.05). Patients with more than one co-morbidity were closely associated with frequent postoperative co-mplications (P<0.05). However, comorbidities did not seem to affect the duration of the postoperative hospital stay. CONCLUSIONS: Postoperative complications frequently occur in colorectal cancer patients with specific co- morbidities, especially in those with more than one. An adequate management of the co-morbidities preoperatively leads to a good outcome.

Hirschsprung's Disease in Adults

Hirschsprung's disease is a disorder caused by the absence of ganglion cells in the colon and rectum. It has an incidence of 1 in 5000 births, the majority diagnosed and treated in the neonatal period due to symptoms of intestinal obstruction. Persistence of Hirschsprung's disease into adulthood is very rare. In such patients, prolonged periods of constipation are a common problem. For the diagnosis, a colon study and anorectal manometry are performed, and the presence of the disease is confirmed by an excisional biopsy proving the absence of the ganglion cell in Auerbach and Meissner's plexus. Although various surgical procedures have been performed, there is no obvious optimal choice for treatment of Hirschsprung's disease in adolescents and adults. We experienced two cases of Hirschsprung's disease, confirmed by a rectal biopsy, in 20-year patients. Prior to a definitive operation, a sigmoid loop colostomy was performed due to severe dilatation of the left colon and rectum. Six months later, one patient was treated using Duhamel's procedure, and the other by using a proctosigmoidectomy and coloanal anastomosis. No postoperative complications were observed, and the patients had bowel movements three to four times a day. Despite its infrequent incidence, adult Hirschsprung's disease should be suspected in patients who have had lifelong constipation. Several successful surgical treatments have been used for treatment of patients with adult Hirschsprung's disease. In our cases, the functional results of Duhamels' procedure and of a proctosigmoidectomy with coloanal anastomosis were satisfactory.

Clinical Features of Intestinal Obstruction after Colorectal Surgery

PURPOSE: The purposes of this study are to determine the incidence of postoperative ileus after colorectal surgery, to analyze its clinical features, and to identify the risk factors for its development. METHODS: We reviewed the cases of 263 patients with mechanical ileus among 3,237 patients who underwent colorectal surgery in our clinic between June 1989 and December 2000. RESULTS: A total of 263 (8.1%) patients of postoperative ileus were documented, 193 (73.4%) cases occurred during the 1st. year. Postoperative ileus is influenced by the initial site of surgery; the rectum has more impact than the colon (P=0.028). The causes of postoperative ileus were adhesion, recurrence of cancer, and parastomal hernia. Adhesion (81.1%) was the most common cause of ileus, and cancer recurrence (18.0%) was the second. However, in postoperative ileus requiring surgery, cancer recurrence increased with time (2 year: 58.1%). The cases receiving postoperative adjuvant radiation therapy presented a significant increase in the incidence of postoperative ileus (10.3% vs 6.7% P=0.01) and in the requirement for surgical treatment (4.6% vs 2.7%, P=0.04). Patients with a temporary stoma presented a significant increase in the incidence of postoperative ileus than patients with a permanent stoma (P=0.001). The frequency of prior episodes of ileus was the strongest predictor of recurrence. CONCLUSIONS: There is a high risk of adhesion-related problems after colorectal surgery. The risk factors are associated with rectal surgery, postoperative radiation therapy, and a temporary stoma.

Comparative Analysis between Natural Evacuation and Irrigation Technique in Patients with Colostomy

Sixty-three patients with permanent sigmoid colostomy were surveyed to evaluate their satisfaction and complications with the "irrigation technique" and the "atural evacuation" of the colostomy management (irrigation technique; 32 patients, natural evacuation; 31 patients). All patients had colostomy for at least 12 months without disease recurrence. Each patient was interviewed in addition to standard questionnaire. The irrigation was not associated with any major complication including colonic perforation. The irrigation was used younger age group than the natural evacuation (53+/-10 vs. 62+/-12, P=0.01). The frequency of bowel movement was lower in the irrigation than in the natural evacuation (5.1+/-2.5/wk vs. 10.8+/-9.0/wk, P=0.04). Five patients (16%) of the irrigation experienced spontaneous bowel action but only one patient suffered from it. The time spent for managing irrigation was 59+/-13 minutes. Twenty-three patients (74%) of the natural evacuation suffered from one or moreproblems such as expensive apparatus, leakage, skin irritation or odor. Sixteen patients (52%) of the natural evacuation and 2 patients (6%) of the irrigation were restricted in social activity (P=0.0001). Thirteen patients (42%) of the natural evacuation and 1 patient (3%) of the irrigation were dissatisfied with colostomy management (P=0.002). Thus, the irrigation technique seems to be more effective and satisfactory method for managing colostomy without compromising patient's social activity when it is performed in appropriately selected patients.

Adult-to-Adult Living Donor Liver Transplantation

BACKGROUNDS: Living-donor liver transplantation (LDLT) has been established as an efficacious option to resolve the shortage of cadaveric donor organs for pediatric recipients. This surgical innovation has significantly reduced the pretransplantation mortality for children, but the crisis of increasing scarcity of donor organs in our hospital has led us to extend LDLT to adult recipients. However, the extension of LDLT from pediatric recipients to adult recipients has been made only with limited success largely because of the inability of a relatively small-size left-lobe graft to meet the metabolic demands of an adult recipient. It has been postulated that a left-lobe graft smaller than 40% of the recipient's standard liver volume will not result in a successful adult-to-adult LDLT in chronic parenchymal liver disease. METHODS: From February 1997 to October 1997, 10 LDLTs, using 9 extended left-lobe grafts and 1 right-lobe graft, were performed on patients with end-stage parenchymal liver diseases (9 cases of B-hepatitis-induced cirrhosis with or without an associated hepatocellular carcinoma and 1 case of alcoholic cirrhosis) at the Department of Surgery, Asan Medical Center. The ratios of the graft to the standard liver volume of the recipients were in the range of 30% to 55%. RESULTS: All grafts showed immediate function, but delayed normalization of the serum total bilirubin was demonstrated in all recipients receiving left-lobe grafts. There were no mortalities and serious complications in donors. Two recipients died of sepsis 21 days and 40 days after transplantation, and 8 recipients (80%) are alive with good liver function at a median follow-up of 5.1 months (range 2~10 months). CONCLUSIONS: The aim of this article is to report our experience with adult-to-adult LDLT shows that a graft size greater than 30% of the recipient's standard liver volume is able to meet the metabolic demands of adult recipients with chronic parenchymal liver disease and that LDLT might open a new donor pool for adult recipients when the supply of cadaveric organs is severely restricted.