Seung-Bum Ryoo

Management of Appendicitis Presenting with Abscess or Mass

Purpose Management strategy in acute appendicitis patients initially presenting with abscess or mass is surrounded with controversy. This study was performed to identify the outcomes of management for this condition. Methods We retrospectively analyzed prospectively registered 76 patients (male:female = 39:37; mean age, 50.8 years) with appendicitis presenting with abscess or mass over a 9-year period at the Seoul National University Hospital. Patients were divided into three groups (emergency operation group, delayed operation group, and follow-up group), and clinical characteristics and outcomes of treatment were investigated. Results Twenty-eight patients (36.8%) underwent an emergency operation. Of the remaining 48 patients, 20 (41.7%) were initially treated with conservative management through the use of antibiotics only; the other 28 (58.3%) with and additional ultrasound-guided percutaneous drainage of the abscess. Twenty-six (54.2%) patients underwent planned operations after conservative management, and 22 (45.8%) were followed without surgery (median duration, 37.8 month), of which 3 (13%) underwent an appendectomy due to recurrent appendicitis (mean of 56.7 days after initial attack). There were no statistical differences in types of operation performed (appendectomy or ileocecectomy), postoperative complications, and postoperative hospital stay among the patients who underwent emergency operations, delayed operations and operations for recurrence during follow-up. Conclusion Although the recurrence rate was relatively low after conservative management for appendicitis patients presenting with abscess or mass, there was no difference in surgical outcome between the emergent, elective, or recurrent groups. Our results indicate that proper management of appendicitis with abscess or mass can be selected according to surgeons preference.

Favorable surgical treatment outcomes for chronic constipation with features of colonic pseudo-obstruction

AIM To determine long-term outcomes of surgical treatments for patients with constipation and features of colonic pseudo-obstruction. METHODS Consecutive 42 patients who underwent surgery for chronic constipation within the last 13 years were prospectively collected. We identified a subgroup with colonic pseudo-obstruction (CPO) features, with dilatation of the colon proximal to the narrowed transitional zone, in contrast to typical slow-transit constipation (STC), without any dilated colonic segments. The outcomes of surgical treatments for chronic constipation with features of CPO were analyzed and compared with outcomes for STC. RESULTS Of the 42 patients who underwent surgery for constipation, 33 patients had CPO with dilatation of the colon proximal to the narrowed transitional zone. There were 16 males and 17 females with a mean age of 51.2 ± 16.1 years. All had symptoms of chronic intestinal obstruction, including abdominal distension, pain, nausea, or vomiting, and the mean duration of symptoms was 67 mo (range: 6-252 mo). Preoperative defecation frequency was 1.5 ± 0.6 times/wk (range: 1-2 times/wk). Thirty-two patients underwent total colectomy, and one patient underwent diverting transverse colostomy. There was no surgery-related mortality. Postoperative histologic examination showed hypoganglionosis or agangliosis in 23 patients and hypoganglionosis combined with visceral neuropathy or myopathy in 10 patients. In contrast, histology of STC group revealed intestinal neuronal dysplasia type B (n = 6) and visceral myopathy (n = 3). Early postoperative complications developed in six patients with CPO; wound infection (n = 3), paralytic ileus (n = 2), and intraabdominal abscess (n = 1). Defecation frequencies 3 mo after surgery improved to 4.2 ± 3.2 times/d (range: 1-15 times/d). Long-term follow-up (median: 39.7 mo) was available in 32 patients; all patients had improvements in constipation symptoms, but two patients needed intermittent medication for management of diarrhea. All 32 patients had distinct improvements in constipation symptoms (with a mean bowel frequency of 3.3 ± 1.3 times/d), social activities, and body mass index (20.5 kg/m(2) to 22.1 kg/m(2)) and were satisfied with the results of their surgical treatment. In comparison with nine patients who underwent colectomy for STC without colon dilatation, those in the CPO group had a lower incidence of small bowel obstructions (0% vs 55.6%, P < 0.01) and less difficulty with long-distance travel (6.7% vs 66.7%, P = 0.007) on long-term follow-up. CONCLUSION Chronic constipation patients with features of CPO caused by narrowed transitional zone in the left colon had favorable outcomes after total colectomy.

Allogeneic adipose-derived stem cells for the treatment of perianal fistula in Crohn's disease: a pilot clinical trial

Many perianal fistulae in Crohns disease do not respond to conventional surgical and medical management and recurrence rates are high. The study evaluated the safety and feasibility of allogeneic adipose‐derived stem cells for the treatment of perianal fistula in Crohns disease.

Surgical management of colonic diverticular disease: Discrepancy between right- and left-sided diseases

AIM To compare the outcome of the surgical management of left-sided and right-sided diverticular disease. METHODS The medical records of 77 patients who were surgically treated for diverticular disease between 1999 and 2010 in a tertiary referral hospital were retrospectively reviewed. The study population was limited to cases wherein the surgical specimen was confirmed as diverticulosis by pathology. Right-sided diverticula were classified as those arising from the cecum, ascending colon, and transverse colon, and those from the descending colon, sigmoid colon, and rectum were classified as left-sided diverticulosis. To assess the changing trend of occurrence of diverticulosis, data were compared with two previous studies of 51 patients. RESULTS The proportion of left-sided disease cases was significantly increased compared to the results of our previous studies in 1994 and 2001, (27.5% vs 48.1%, P < 0.05). Moreover, no differences in gender, body mass index, multiplicity of the diverticula, fever, or leukocytosis were noted between patients with right-sided and left-sided disease. However, patients with right-sided disease were significantly younger (50.9 year vs 64.0 year, P < 0.01). Furthermore, left-sided disease was significantly associated with a higher incidence of complicated diverticulitis (89.2% vs 57.5%, P < 0.01), combined resection due to extensive inflammation (21.6% vs 5.0%, P < 0.05), operative complications (51.4% vs 27.5%, P < 0.05), and in-hospital mortality (10.8% vs 0%, P < 0.05), along with longer post-operative hospitalization duration (21.3 ± 10.2 d vs 10.6 ± 8.1 d, P < 0.05). CONCLUSION Compared with right-sided diverticular disease, the incidence of left-sided disease in Korea has increased since 2001 and is associated with worse surgical outcomes.

Systemic inflammatory markers as prognostic factors in stage IIA colorectal cancer

The aim of this study was to evaluate systemic inflammatory markers as prognostic factors in patients with stage IIA colorectal cancer.

Colonoscopic Surveillance after Colorectal Cancer Resection: Who Needs More Intensive Follow-Up?

Background/Aims: Although there are guidelines for colonoscopic surveillance after colorectal cancer (CRC) surgery, the data evaluating the effectiveness of these guidelines are limited. We determined the risk factors for metachronous neoplasia (MN) by performing annual colonoscopy examinations after curative resection. Methods: We performed annual colonoscopic surveillance on stage I-III CRC patients after curative resection. We stratified the patients based on the advanced neoplasia risk during the surveillance. Results: Advanced MN detected was in 59 (13.1%) of 451 patients. Overall, the cumulative incidence of advanced MN was 17.3% at 5 years. By the multivariate analysis, the risk factors for advanced MN were male gender, age >65, left-sided index cancer and being in the high-risk group. The cumulative incidence of advanced MN was 38.9% at 5 years in the high-risk group. Among the patients who had advanced MN, secondary advanced MN was detected in 13 patients (22.0%) with a subsequent colonoscopy. The 2-year cumulative incidence of secondary advanced MN was 16.9%. Four (0.88%) patients had metachronous CRC during the surveillance and the interval from the index CRC was a median of 58.5 months. Conclusions: Although the current follow-up guidelines for colonoscopic surveillance after CRC are well established, the high-risk group calls for more meticulous follow-up, which should be continued for a sufficient time.

Complications after ileal pouch-anal anastomosis in Korean patients with ulcerative colitis

AIM To investigate the outcomes of treatments for complications after ileal pouch-anal anastomosis (IPAA) in Korean patients with ulcerative colitis. METHODS Between March 1998 and February 2013, 72 patients (28 male and 44 female, median age 43.0 years ± 14.0 years) underwent total proctocolectomy with IPAA. The study cohort was registered prospectively and analyzed retrospectively. Patient characteristics, medical management histories, operative findings, pathology reports and postoperative clinical courses, including early postoperative and late complications and their treatments, were reviewed from a medical record system. All of the ileal pouches were J-pouch and were performed with either the double-stapling technique (n = 69) or a hand-sewn (n = 3) technique. RESULTS Thirty-one (43.1%) patients had early complications, with 12 (16.7%) patients with complications related to the pouch. Pouch bleeding, pelvic abscesses and anastomosis ruptures were managed conservatively. Patients with pelvic abscesses were treated with surgical drainage. Twenty-seven (38.0%) patients had late complications during the follow-up period (82.5 ± 50.8 mo), with 21 (29.6%) patients with complications related to the pouch. Treatment for pouchitis included antibiotics or anti-inflammatory drugs. Pouch-vaginal fistulas, perianal abscesses or fistulas and anastomosis strictures were treated surgically. Pouch failure developed in two patients (2.8%). Analyses showed that an emergency operation was a significant risk factor for early pouch-related complications compared to elective procedures (55.6% vs 11.1%, P < 0.05). Pouchitis was related to early (35.3%) and the other late pouch-related complications (41.2%) (P < 0.05). The complications did not have an effect on pouch failure nor pouch function. CONCLUSION The complications following IPAA can be treated successfully. Favorable long-term outcomes were achieved with a lower pouch failure rate than reported in Western patients.

The effects of eupatilin (stillen®) on motility of human lower gastrointestinal tracts.

Gastrointestinal motility consists of phasic slow-wave contractions and the migrating motor complex (MMC). Eupatilin (Stillen®) has been widely used to treat gastritis and peptic ulcers, and various cytokines and neuropeptides are thought to be involved, which can affect gastrointestinal motility. We performed a study to identify the effects of eupatilin on lower gastrointestinal motility with electromechanical recordings of smooth muscles in the human ileum and colon. Ileum and colon samples were obtained from patients undergoing bowel resection. The tissues were immediately stored in oxygenated Krebs-Ringers bicarbonate solution, and conventional microelectrode recordings from muscle cells and tension recordings from muscle strips and ileal or colonic segments were performed. Eupatilin was perfused into the tissue chamber, and changes in membrane potentials and contractions were measured. Hyperpolarization of resting membrane potential (RMP) was observed after administration of eupatilin. The amplitude, AUC, and frequency of tension recordings from circular and longitudinal smooth muscle strips and bowel segments of the ileum and colon were significantly decreased after admission of eupatilin. Eupatilin elicited dose-dependent decreases during segmental tension recordings. In conclusion, eupatilin (Stillen®) showed inhibitory effects on the human ileum and colon. We propose that this drug may be useful for treating diseases that increase bowel motility, but further studies are necessary.

Long-term Outcomes and Risk Factors for Reoperation After Surgical Treatment for Gastrointestinal Crohn Disease According to Anti-tumor Necrosis Factor-α Antibody Use: 35 Years of Experience at a Single Institute in Korea

Purpose Crohn disease is characterized by high rates of recurrence and reoperations. However, few studies have investigated long-term surgical outcomes in Asian populations. We investigated risk factors for reoperation, particularly those associated with anti-tumor necrosis factor-α (anti-TNF-α) antibody use, and long-term follow-up results. Methods We reviewed the records of 148 patients (100 males and 48 females) who underwent surgery for gastrointestinal Crohn disease and retrospectively analyzed long-term outcomes and risk factors. Results The mean age at diagnosis was 28.8 years. Thirty-eight patients (25.7%) received monoclonal antibody treatment before reoperation. A small bowel and colon resection was most commonly performed (83 patients, 56.1%). The median follow-up was 149 months, during which 47 patients underwent reoperation. The median interval between the primary and the secondary surgeries was 65 months, with accumulated reoperation rates of 16.5%, 31.8%, and 57.2% after 5, 10, and 15 years, respectively. Obstruction was the most common indication for reoperation (37 patients, 25.0%). In a multivariable analysis, age <17 years at diagnosis (A1) (odds ratio [OR], 2.20; P = 0.023), penetrating behavior (B3) (OR, 4.39; P < 0.001), and no azathioprine use (OR, 2.87; P = 0.003) were associated with reoperation. Anti-TNF-α antibody use did not affect the reoperation rate (P = 0.767). Conclusion We showed a high reoperation rate regardless of treatment with anti-TNF-α antibody, which indicates that recurrent surgery is still needed to cure patients with gastrointestinal Crohn diseases. Younger age at primary operation, penetrating behavior, and no azathioprine use were significant factors associated with reoperation for gastrointestinal Crohn disease.

Surgical Treatment of a Parastomal Hernia

Purpose Parastomal hernia is a major complication of an intestinal stoma. This study was performed to compare the results of various operative methods to treat parastomal hernias. Methods Results of surgical treatment for parastomal hernias (postoperative recurrence, complications and postoperative hospital stays) were surveyed in 39 patients over an 11-year period. The patients enrolled in this study underwent surgery by a single surgeon to exclude surgeon bias. Results Seventeen patients were male, and twenty-two patients were female. The mean age was 65.9 years (range, 36 to 86 years). The stomas were 35 sigmoid-end-colostomies (90%), 2 loop-colostomies (5%), and 2 double-barrel-colostomies. Over half of the hernias developed within two years after initial formation. Stoma relocation was performed in 8 patients, suture repair in 14 patients and mesh repair in 17 patients. Seven patients had recurrence of the hernia, and ten patients suffered from complications. Postoperative complications and recurrence were more frequent in stoma relocation than in suture repair and mesh repair. Emergency operations were performed in four patients (10.3%) with higher incidence of complications but not with increased risk of recurrence. Excluding emergency operations, complications of relocations were not higher than those of mesh repairs. Postoperative hospital stays were shortest in mesh repair patients. Conclusion In this study, mesh repair showed low recurrence and a low complication rate with shorter hospital stay than relocation methods, though these differences were not statistically significant. Further studies, including randomized trials, are necessary if more reliable data on the surgical treatment of parastomal hernias are to be obtained.