Byung-Kwon Ahn

Acute Abdomen Caused by an Infected Mesenteric Cyst in the Ascending Colon: A Case Report

Mesenteric cysts are rare intra-abdominal tumors. Mesenteric cysts are usually asymptomatic and are incidentally detected during physical or radiological examination. Although uncommon, complications such as infection, bleeding, torsion, rupture and intestinal obstruction cause an acute abdomen. Spontaneous infection is a very rare complication. We present a case of infected mesenteric cysts in the ascending colon, which caused an acute abdomen. A 26-year-old woman was admitted to our hospital with acute abdominal pain. She had a painful mass in the right abdomen on physical examination. Abdominal computed tomography showed a hypodense cystic mass with septation at the mesenteric region of the ascending colon. A laparotomy revealed two cystic tumors at the mesenteric region of the ascending colon. She underwent a right hemicolectomy. The two cysts were filled with a yellowish turbid fluid. The walls of both two cysts were lined with a thin fibrotic membrane without any epithelial cell. They were diagnosed as psuedocysts with E. coli infection. Mesenferic cysts may cause life-threatening complications. Mesenteric cyst, even if it is asymptomatic and was diagnosed incidentally, should be removed completely.

Multiple primary cancers in extracolonic sites with colorectal cancer.

PurposeThe present study was undertaken to clarify the clinical and pathological features of multiple primary cancers, especially those at extracolonic sites, in patients with colorectal cancers.MethodsWe reviewed the records of 2,176 patients who underwent surgery for colorectal cancers in our institute from January 1997 to December 2006. A synchronous multiple primary cancer was defined as extracolonic cancer detected within 6-month interval before and after the detection of colorectal cancer. Any metastasis from colorectal cancers was excluded.ResultsSynchronous multiple primary cancers were identified in 32 patients. The stomach is the most common organ for synchronous multiple primary cancer development in patients with colorectal cancers (0.9%, 20/2,176).ConclusionsGastric cancer is the most common synchronous multiple primary cancers occurring concomitantly with colorectal cancers. Careful preoperative screening is necessary for the detection of multiple primary cancers in extracolonic sites in patients with colorectal cancers.

Sacral Chordoma: Challenging for Resection Margin

See Article on Page 122-131 A chordoma is a rare, bone neoplasm that accounts for 1%-4% of all bone neoplasms [1]. Although it considered to be a low-grade neoplasm with a slow-growing pattern, its clinical course is very aggressive, with a locally-invasive, highly-recurrent character [2]. It has been reported to be predominant in men, and its peak incidence is between 50-60 years of age [3]. It arises from the sacrococcygeal region in approximately 40%-50% of cases, from the base of the skull (spheno-occipital/nasal) in 35%-40% of cases, and from vertebral bodies in 15%-20% of cases [2, 4, 5]. A chordoma usually present clinically with pain as the cardinal symptom. Neurologic symptoms tend to vary based on the location of the lesion. Jeys et al. [6] reviewed 33 patients with a chordoma arising from the sacrococcygeal region. Pain, typically dull and worse with sitting, was the most common presenting symptom in 85% of the patients. Pain commonly developed in the lower back and the sacrum. Other painful regions were the legs, buttocks, and the perianal and perineal regions. The classic symptoms of cauda equine (saddle anesthesia, leg parathesia, motor weakness, bladder dysfunction, bowel dysfunction) occurred in 70% of the patients. Urinary incontinence and outflow obstruction were frequent bladder dysfunction symptoms. The majority of bowel dysfunctions were due to constipation. Unfortunately, these symptoms are nonspecific in nature, and a chordoma has a slow-growing pattern with an insidious onset of symptoms. Therefore, it is often found at the late stages of the disease. Jeys et al. [6] reported that the mean duration of symptoms prior to diagnosis was 120 weeks (2.3 years; range, 0.5-8.0 years). The mean maximum tumor size at resection was 8.3 cm, with a mean volume of 614 cm3. Differential diagnosis is important for the surgical and the postsurgical management of a chordoma. The accurate diagnosis of tumors is of valuable prognostic significance. Fine-needle aspiration biopsy or core-needle biopsy in the case of bony lesions has been suggested to be the most oncologically sound approach to establish a diagnosis before resection, with care to avoid tumor seeding [5, 7]. The excellent capabilities of magnetic resonance imaging and computed tomography allow precise delineation of tumors in terms of volume and anatomic characteristics, and aid in diagnosis [8]. In this study, three of eight patients were misdiagnosed and had undergone primary surgery with an R1 margin at other hospitals. After re-resection, all three cases had recurrences. On the contrary, four patients had been diagnosed with preoperative core-needle biopsy and underwent primary surgery with a R0 resection. One of the four patients had a local recurrence after 18 months. The patient had an initial 12.5-cm × 13.0-cm tumor infiltrating the mesorectum [9]. With early accurate diagnosis, a complete en bloc resection with a R0 resection margin is a key point in the treatment of a chordoma. Rates of local recurrence, as well as survival, appear to depend on the achievement of a R0 resection margin. Tzortzidis et al. [10] reported that aggressive surgical approaches to achieve total resection resulted in long-term control in 50% of the cases. Aggressive surgical resection and reconstruction may require a multidisciplinary team approach.

Thymosin β4 was upregulated in recurred colorectal cancers

Recurrent cancers usually metastasise to other organs and have a very poor prognosis. Recurrence and metastatic spread have been proposed to depend on cancer stem cells, which express CD133.1 The expression of the actin-binding protein, thymosin β4 (Tβ4), has been reported to be elevated in a side population of small cells known as cancer stem cells in the breast cancer cell lines MCF7 and MDA-MB231.2 A recent study has also shown that colorectal cancer cells (CR-CSCs) from different patients that were sorted by CD133 had higher Tβ4 levels than normal colorectal cancer cells. Additionally, a lentiviral strategy to downregulate Tβ4 expression in CR-CSCs lowered the capacity of the cells to grow and migrate in culture, and reduced the tumour size and aggressiveness of CR-CSCs in xenografted mice.3 We have previously reported that Tβ4 levels in metastatic stomach cancers to the ovary were significantly upregulated compared with levels in normal stomachs and primary stomach cancers. Furthermore, Tβ4 expression was colocalised with CD133 expression in primary ovarian carcinomas, metastatic ovarian cancers from stomach cancers, and primary stomach cancers, suggesting that Tβ4 expression is strongly related to CD133 expression and is a characteristic of stem cells or cancer stem cells.4 In the present study, we compared the expression patterns of Tβ4 and CD133 in primary and recurrent colorectal cancer cells from the same patient. We obtained the paraffin-embedded primary and recurrent colorectal cancers of 10 patients. Tβ4 and CD133 expression …

Primary Isolated Extramedullary Plasmacytoma in the Colon

Primary isolated extramedullary plasmacytoma is a rare tumor. Although it commonly involves nasopharynx or upper respiratory tract, only 10% of cases involves the gastrointestinal tract. Stomach and small intestine are the most commonly involved sites in the gastrointestinal tract. Primary isolated extramedullary plasmacytoma of colon is extremely rare. We report a case of 45-year-old man who presented with 1-year history of lower abdominal pain. Colonoscopy showed a colonic stricture about 50 cm from the anal verge. Colonoscopic biopsy showed lymphoid hyperplasia. On computed tomography, enhancing circumferential wall thickening and luminal narrowing with pericolic lymph node enlargement in the transverse colon was identified. Patient underwent extended left hemicolectomy. Histopathologic examination of resected colon identified an isolated primary colonic plasmacytoma of 1.7 cm in diameter with regional lymph node involvement (8/50 positive). To administer adequate treatment, further study about clinical features of primary isolated extramedullary plasmacytoma of colon is necessary.

The Relationship Between the Number of Intersections of Staple Lines and Anastomotic Leakage After the Use of a Double Stapling Technique in Laparoscopic Colorectal Surgery

Purpose: Laparoscopic intracorporeal colorectal anastomosis with double stapling technique is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery. Materials and Methods: In total, 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion and invagination techniques. They were subdivided into 3 groups: 58 patients with no intersection of staple lines (group A), 62 patients with 1 point of intersection (group B) and 8 patients with 2 points of intersection (group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis, and leakage were compared between the 3 groups. Results: Clinical anastomotic leakage was identified in 1 (group C) of 128 patients (0.7%). Overall anastomotic leakage rate was 0% (0/58) in group A, 0% (0/62) in group B, and 12.5% (1/8) in group C (P=0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between the 3 groups in multivariate analysis. Conclusions: The number of intersections of staple lines is associated with anastomotic leakage, and the inversion technique is a useful method for avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.

Volvulus of the Sigmoid Colon Associated With Rectal Cancer: A Case Report.

Sigmoid volvulus is one of the three most common causes of acute colonic obstruction. Predisposing factors include chronic constipation, adhesion from a prior abdominal surgery, and megacolon. However, concomitant presentation of volvulus of the sigmoid colon and rectal cancer is extremely rare. We report a case of a 50-year-old woman with coexisting volvulus of the sigmoid colon and rectal cancer. The patient presented with abdominal distension and pain for 2 days. On computed tomography, the whole colon was dilated with gas and feces. A whirl sign with rotation of the inferior mesenteric vessel was identified. The rectum had irregular wall thickening. Colonoscopy showed a circumscribed, ulcerofungating mass approximately 6 cm from the anal verge. The sigmoid colon was obstructed at a point approximately 25 cm from the anal verge. The mucosa was hyperemic and edematous with the pathognomonic spiral pattern. Endoscopic reduction was not successful. On laparotomy, the sigmoid colon was rotated around its mesentery. It was severely distended with edematous, hyperemic serosa. A tumor of the rectum was identified in the mid-rectum. The patient underwent low anterior resection and protective ileostomy. Pathologic findings confirmed adenocarcinoma of the rectum. The postoperative course was complicated by an ileus, which was managed with conservative treatment.

Hematochezia due to Angiodysplasia of the Appendix

Common causes of lower gastrointestinal bleeding include diverticular disease, vascular disease, inflammatory bowel disease, neoplasms, and hemorrhoids. Lower gastrointestinal bleeding of appendiceal origin is extremely rare. We report a case of lower gastrointestinal bleeding due to angiodysplasia of the appendix. A 72-year-old man presented with hematochezia. Colonoscopy showed active bleeding from the orifice of the appendix. We performed a laparoscopic appendectomy. Microscopically, dilated veins were found at the submucosal layer of the appendix. The patient was discharged uneventfully. Although lower gastrointestinal bleeding of appendiceal origin is very rare, clinicians should consider it during differential diagnosis.

Laparoscopic resection for middle and low rectal cancer.

AIMS: The purpose of this study was to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic resection for middle and low rectal cancers. MATERIALS AND METHODS: From January 2004 to December 2011, review of prospectively collected database revealed a series of 97 laparoscopic resections for middle and low rectal cancer within 10 cm from the anal verge. Five patients with multiple primary cancers were excluded. Operation time, intra-operative blood loss, surgical complications, duration of hospital stay, retrieved lymph nodes, tumour, node, metastasis (TNM) stage and recurrence were retrospectively analysed. RESULTS: Tumours were located within 5 cm of the anal verge in 28 patients (30.4%) and from 5 cm to 10 cm in 64 patients (69.6%). Abdominoperineal resection was performed in 12 patients (13%), and conversion to open surgery was necessary in four patients (4.3%). The mean operation time was 199.7 min (range 105-450 min) and the mean intra-operative blood loss was 169.9 mL (range 20-800 mL). The mean hospital stay was 11.8 days (range 5-45 days) and a mean of 12.2 lymph nodes were retrieved. The incidence of surgical complications was 11.9%, including anastomosis site leakage in five patients (5.4%). There were no mortalities resulting from laparoscopic surgery. The median follow-up period was 28.4 months (range 7-85 months). Recurrence occurred in eight patients (8.7%). CONCLUSIONS: Laparoscopic resection can be applied for middle and low rectal cancers with acceptable surgical and oncological outcomes.

Risk factors for incisional hernia and parastomal hernia after colorectal surgery.

See Article on Page 299-303 Incisional hernias, with an incidence of 9 to 38%, remain one of the most common complications after an incision of the abdominal wall [1-3]. An incisional hernia is defined as a protrusion of intraperitoneal structures through a defect in the anterior abdominal wall fascia [4]. This means that wound healing often fails to occur when multiple predisposing factors, including surgical site infection, malnutrition, diabetes, immunosuppression, and morbid obesity, are present [5]. Incisional hernias are almost universally regarded as technical failures. Technical factors are related to suture material selection, type of fascial closure, ratio of suture to incision length [5]. In spite of many advances, such as new procedures for closing the abdominal wall and new suture materials, the incidence of incisional hernias has not been reduced in recent decades because the developments of incisional hernias is also related to many factors affecting the patients. Surgical site infection is one of the important risk factors for the development of an incisional hernia. Recently, Murray et al. [6] analyzed the incidence of incisional hernias related with surgical site infection in colorectal surgery. They reported that patients with a surgical site infection were 1.9 times more likely to have an incisional hernia than those without a surgical site infection (36.3% vs. 18.8%, P ≤ 0.01). In clean-contaminated and contaminated surgery, such as colorectal surgery, the incidence of surgical site infection has been reported as 3 to 30% [7, 8]. Thus, in colorectal surgery, more effort to prevent surgical site infection is needed. Morbid obesity is another important risk factor for the development of an incisional hernia and a parastomal hernia [9, 10]. Schreinemacher et al. [9] reported that hernias were more prevalent in patients with morbid obesity (body mass index of 30 and higher) and in patients with a temporary stoma wound (25.8% vs. 59.1%). De Raet et al. [10] reported that a waist circumference in excess of 100 cm increased the risk of developing a parastomal hernia (odds ratio, 1.009; 95% confidence interval, 1.002 to 1.016). Other factors, such as anemia, hypoproteinemia, malnutrition, diabetes, immunosuppression, male gender, and old age, are related to surgical wound dehiscence and incisional hernias [11]. Conditions that increase abdominal pressure, such as coughing, vomiting, distention, and ascites, also increase the incidence of incisional hernias. Surgeons have to be aware of poor wound healing conditions to prevent incisional hernias. Perioperative efforts to reduce risk factors and to select proper technical methods of wound closure are essential if the incidence of incisional hernias is to be reduced.