BACKGROUND

Gastric outlet obstruction (GOO) results from intrinsic and extrinsic obstruction of the pyloric channel or the duodenum. Here we present a rare case of GOO attributed to dense adhesions between the gallbladder and duodenum secondary to chronic cholecystitis with choledococystoduodenal fistula formation. Previous reports identified elderly females with comorbidities as a predisposing factor; however, our patient was an immunocompetent adult male.

A 43-year-old male with no comorbidities consulted for recurrent epigastric pain, vomiting and weight loss. On contrast enhanced abdominal CT scan, a lamellated cholelithiasis with pneumobilia and an irregular thickening at the proximal duodenum with subsequent GOO was identified. A choledococystoduodenal fistula was considered. Exploratory laparotomy revealed extensive fibrosis and cholecystitis with dense adhesions to surrounding structures. Dissection revealed a gallstone impacted in and adherent to the wall of the gallbladder and a fistula opening into the duodenum. However, there was no definite evidence of impacted gallstone in the duodenum. The dense adhesions secondary to chronic cholecystitis caused duodenal narrowing and subsequent GOO. He eventually underwent antrectomy, pancreatic sparing, total duodenectomy, cholecystectomy, with loop gastrojejunostomy, cholecystojejunostomy and pancreaticojejunostomy. Biopsy specimens taken were negative for malignancy. He was discharged subsequently. However, he was readmitted after five months due to acute abdomen secondary to small bowel rupture, likely from a marginal ulcer.

This case highlights that preoperative and intraoperative differential diagnosis of GOO is a challenge. Chronic calculous cholecystitis through severe inflammation can present as a rare cause of GOO. Optimal treasaFtment plan should take into consideration the underlying etiology of the GOO.

PURPOSE: Preoperative chemoradiation therapy for rectal cancer seems to improve local control, anal sphincter preservation, resectability, and possibly survival in patients. However, there are several adverse effects, too. The aim of this study is to analyze the disadvantages of preoperative chemoradiation for rectal cancer. METHODS: We retrospectively reviewed 139 patients who were treated by using preoperative chemoradiation for an adenocarcinoma of the rectum between January 1995 and December 2004. All patients had fixed or locally advanced lesions, as determined by digital rectal examination. No distant metastasis was proven before preoperative chemoradiation. All of the patiedts received the full scheduled dose of radiation (range, 5,000~5,400 rad). Concurrent intravenous chemotherapy with 5-fluorouracil (425 mg/m2/day) and leucovorin (45 mg/day) was administered continuously on days 1~5 and 29~33. The mean interval between chemoradiation and surgery was 4~6 weeks. After preoperative chemoradiation, 117 patients underwent an operation. We reviewed the side effects of preoperative chemoradiation, postoperative complications, and distant metastases detected during the preoperative period after preoperative chemoradiation and during the operation. RESULTS: The side effects of preoperative chemoradiation were diarrhea (23%), radiation dermatitis (2.2%), fistula (0.7%), sepsis (0.7%), and rectal bleeding (0.7%). Two patients died from sepsis and rectal bleeding. The postoperative complications were bowel obstruction in 9 cases (7.7%), wound seroma in 8 cases (6.8%), wound infection in 5 cases (4.3%), anastomotic leakage in 5 cases (7.1%), rectovaginal fistula in 2 cases (2.8%), an enterocutaneous fistula in 2 cases (1.7%), and a vesicocutaneous fistula in 1 case (0.8%). Distant metastases were detected in 14 patients (10.1%) after preoperative chemoradiation. CONCLUSIONS: Although preoperative chemoradiation can be performed safely, careful management for the side effects of preoperative chemoradiation and for postoperative complications is necessary. We need a more sensitive study method for detecting distant metastasis of rectal cancer, especially during scheduled preoperative chemoradiation.
Adenocarcinoma ; Anal Canal ; Anastomotic Leak ; Dermatitis ; Diarrhea ; Digital Rectal Examination ; Drug Therapy ; Fistula ; Fluorouracil ; Hemorrhage ; Humans ; Intestinal Fistula ; Leucovorin ; Neoplasm Metastasis ; Postoperative Complications ; Preoperative Period ; Rectal Neoplasms* ; Rectovaginal Fistula ; Rectum ; Retrospective Studies ; Sepsis ; Seroma ; Wound Infection ; Wounds and Injuries

No abstract available.
Rectovaginal Fistula*

No abstract available.
Rectovaginal Fistula*

Female ; Humans ; Postoperative Complications ; Rectal Neoplasms ; surgery ; Rectovaginal Fistula ; diagnosis ; etiology ; therapy

PURPOSE: Adjuvant chemotherapy and radiotherapy have been considered effective treatments in advanced rectal cancers. Recently, several studies have reported that preoperative chemoradiation (CRT) may have advantages over postoperative CRT, particularly in reducing local recurrence and preserving the anal sphincter. We studied the short-term efficacy of preoperative CRT for locally advanced rectal cancers. METHODS: Between Jun. 2000 and Aug. 2003, 23 patients were treated with preoperative CRT, followed by surgery (pre-CRT) and 31 patients were treated with chemoradiation postoperatively (post-CRT). We compared these two groups for the incidence and degree of side effects from CRT, postoperative complications, type of surgery, including anal sphincter preservation, and short-term recurrence. RESULTS: The average age and male-to-female ratio of the pre- and the post-CRT groups were 58+/-11, years and 13:10, and 61+/-14 and 14:17, respectively. T downstagings were observed in 17 of 23 (74%) pre-CRT patients. On the RTOG-EORTC scale, the patients who showed hematological, intestinal and dermal side effects in the pre-CRT group and in the post-CRT group were 5, 5, 2 and 5, 2, 4, respectively and the difference was not statistically significant (P=0.41). Anal sphincter preserving surgical procedures were performed 91.3% (21/23) and 83.9% (26/31) of the patients in the pre- and the post-CRT groups, respectively. But this difference was not statistically significant (P=0.4). Postoperative complications in the pre-CRT group were anastomosis site leakages (n=3) and rectovaginal fistula (n=1). In the post-CRT group, complications were two anastomosis site leakages. Four of the 31 post-CRT group patients had recurrences such as locoregional area (n=2), liver (n=1), and lung (n=1) while no patient was observed in pre- CRT group. CONCLUSIONS: Although pre-CRT group showed higher incidence of complications than post-CRT group, these were managed easily and safely. Pre-CRT seems to be an effective modality for treating advanced rectal cancers particularly for preserving anal sphincter. Long-term follow- up data are needed to clarify the effect of pre-CRT.
Anal Canal ; Chemotherapy, Adjuvant ; Humans ; Incidence ; Liver ; Lung ; Postoperative Complications ; Radiotherapy ; Rectal Neoplasms* ; Rectovaginal Fistula ; Recurrence

BACKGROUND: As the incidence of coloanal diseases has been steadily increasing during the past few decades in Korea, we illustrate the necessity of a specialized colorectal clinic for the efficient management of such diseases. METHOD: Outpatients at our colorectal clinic were studied epidemiologically and clinically by retrospective studies between November 1986 to December 1996. RESULTS: During this period, the total number of outpatients were 30,590 of which 24% were new patients. The patient pool consisted of anal diseases (62%), colon diseases (28%) and other diseases (10%). In this study, we found that condyloma, perianal abscesses, anal fistulas were predominant in males compared to females while rectovaginal fistulas, functional bowel diseases, and perianal fissures were predominant in females. There was no sexual bias for rectal cancer. Colorectal diseases occurred in all age groups; however, the peak age was in the fourth or fifth decade where social activity was maximum. There was a variation in age incidence among different disease entities. The range of age for benign conditions such as hemorroids, perianal abscessess and functional bowel diseases were from the third to the fifth decades; however, malignant lesions such as colon cancer were frequently seen in older patients (> 40 years). Condyloma was frequently seen in younger patients (< 20 years). There were no monthly variations in the incidences of colorectal diseases. Yearly variations were not found for colorectal disease, but were found for cancer. Of the cancers, the incidence of rectal cancer was higher than s-colon cancer or colon cancer in year variations. The diagnostic time has been reduced significantly over the past decade. The mean time required for a diagnosis work up in the period from 1984 to 1986 was 9.4 days; the diagnostic time in the period from 1993 to 1996 was 4.7 days. CONCLUSIONS: The incidences of coloanal disease have increased recently in Korea; thus, the demand for an efficient outpatient colorectal clinic has inevitably increased. We concluding that a specialized clinic, such as our colorectal clinic, has become essential for properly managing the exploding number of coloanal patients in Korea.
Abscess ; Bias (Epidemiology) ; Colon ; Colonic Neoplasms ; Diagnosis ; Female ; Humans ; Incidence ; Korea ; Male ; Outpatients* ; Rectal Fistula ; Rectal Neoplasms ; Rectovaginal Fistula ; Retrospective Studies

A clinical study was made of 14 cases of distal rectal cancer treated at the Department of Surgery, St. Mary's Hospital, Catholic University Medical College, from January 1995 to April 1996. The patients were treated in a modified Thomas Jefferson program and received high doses of preoperative radiation followed by a sphincter saving procedure. The results are as follows: 1) There were 5 male patients (35.7%) and 9 female patients(64.3%). There was also a large number of patients in their 50s and 60s. 2) The preoperative pathologic type was a moderately differentiated adenocarcinoma. 3) Rectal bleeding was the most common symptom, followed by tenesmus, constipation, anal pain, and a tarry stool. 4) At diagnosis, the Thomas Jefferson (T.J.) system was used for the clinical stage of the patients. The clinical stage of disease showed a preponderance of T.J. stage I (10 patients), T.J stage II, III, and IV occurred in 2, 1, and 1 patient, respectively. 5) The most common site was 0-3 cm above dentate line (8 patients), followed by 4-6 cm (5 patients) and > 7 cm (1 patient) above the dentate line. 6) The complications after preoperative radiation therapy were diarrhea (3 patients) and perianal dermatitis (5 patients). 7) After preoperative radiation therapy, one case showed pathologic complete remission. 8) The procedure was a Transanal Abdominal TransAnal proctosigmoidectomy and coloanal anastomosis (TATA) in 11 patients, a low anterior resection in 1 patient, an abdominal perineal resection in 1 patient, and a colostomy in 1 patient. 9) The pathologic stage showed a preponderance of Duke's B2 and B1; 5 were B2, 4 were B1, 3 were C2, 1 was D, and 1 was O. 10) The postoperative complications after colostomy repair in TATA were frequent defecation, tenesmus, anal pain at defecation, and rectovaginal fistulas which subsided 3 months after colostomy repair.
Adenocarcinoma ; Colostomy ; Constipation ; Defecation ; Dermatitis ; Diagnosis ; Diarrhea ; Female ; Hemorrhage ; Humans ; Male ; Postoperative Complications ; Rectal Neoplasms* ; Rectovaginal Fistula

PURPOSE: The proportion of sphincter-saving operations for lower rectal cancer is increasing with improved surgical techniques and additional concurrent preoperative chemo-radiation therapy. A defunctioning ileostomy or colostomy is performed after a sphincter-saving operation in the belief that diverting the fecal stream will prevent anastomotic leakage. This study was undertaken to assess all morbidity and combined problems associated with a temporary loop ileostomy. METHODS: A total of 167 patients who had undergone an ileostomy after a proctectomy between July 1997 and May 2007 were enrolled in this study. All patients were analyzed retrospectively, and the enrolled patients were registered in the Colorectal Cancer Database and were followed prospectively. Three patients did not receive an ileostomy take-down operation because of tumor recurrence. RESULTS: Complications of ileostomy formation developed in 20 (11.9%) cases. There were no significant relevant factors influencing the complications of ileostomy formation. Complications related with ileostomy take-down developed in 33 (17.9%) cases. Longer operation time, perioperative transfusion, and postoperative radiotherapy were statistically significant factors related to the complications of ileostomy take-down (P=0.047, P=0.019, P=0.042). After ileostomy take-down, six patients were identified with complications, such as a rectovaginal fistula or an anastomotic stenosis, related with rectal cancer surgery. CONCLUSIONS: The useful ileostomy sometimes carries certain morbidity; therefore, an ileostomy should be performed selectively, and the decision should be made with care. Also, a careful evaluation of the distal part of an ileostomy is necessary before and after an ileostomy take-down.
Anastomotic Leak ; Colorectal Neoplasms ; Colostomy ; Constriction, Pathologic ; Humans ; Ileostomy ; Prospective Studies ; Rectal Neoplasms ; Rectovaginal Fistula ; Recurrence ; Retrospective Studies ; Rivers

PURPOSE: Rectovaginal fistula (RVF) after low anterior resection for rectal cancer is a type of anastomotic leakage. The aim of this study was to find out the difference of leakage, according to RVF presence or absence and to identify the optimal strategy for RVF. METHODS: All female patients who underwent low anterior resection with colorectal anastomosis or coloanal anastomosis (n = 950) were retrospectively analyzed. Patients' demographics and perioperative outcomes were analyzed between the RVF group and leakage without the RVF (nRVF) group. We performed 4 types of procedures—primary repair, diverting stoma, redo coloanal anastomosis (RCA), and conservative procedure—to treat RVF, and calculated the success rates of each type of procedure. RESULTS: The leakage occurred in 47 patients (4.9%). Among them, 18 patients (1.9%) underwent an RVF and 29 (3.0%) underwent nRVF. The RVF group received more perioperative radiotherapy (27.8% vs. 3.4%, P < 0.015) and occurred late onset after surgery (181.3 ± 176.4 days vs. 23.2 ± 53.6 days, P < 0.001) more than did the nRVF group. In multivariate analysis for the risk factor of the RVF group, the RVF group was statistically associated with less than 5 cm of anastomosis more than was the no-leakage group. A total of 35 procedures were performed in 18 patients with RVF for treatment. RCA showed satisfactory success rates (85.7%, n = 6) and, primary repair (transanal or transvaginal) showed acceptable success rate (33.3%, n = 8). CONCLUSION: After low anterior resection for rectal cancer, RVF was strongly correlated with a lower level of primary tumor location. Among the patients who underwent leakages, receipt of perioperative radiotherapy was significantly high in the RVF group than that of the nRVF group. Additionally, this study suggests that RCA might be considered another successful treatment strategy for RVF.
Anastomotic Leak ; Colectomy ; Demography ; Female ; Humans ; Multivariate Analysis ; Radiotherapy ; Rectal Neoplasms ; Rectovaginal Fistula ; Retrospective Studies ; Risk Factors