Pancreatic acinar cell carcinoma (ACC) is a rare neoplasm accounting less than 1% of malignant pancreatic tumors. A 47-year-old male patient visited the emergency room with epigastric pain. Computed tomography or magnetic resonance imaging revealed a 4.7-cm heterogeneously enhanced solid and cystic mass with internal necrosis located in the head of the pancreas. Radiological diagnosis was borderline malignancy such as neuroendocrine tumor or solid pseudopapillary neoplasm. Two months later, the necrotic mass in the pancreas head had grown up to 11 cm, compressing the duodenum, superior mesenteric vein, and proximal transverse colon. Pylorus preserving pancreatoduodenectomy with segmental resection of transverse colon was performed. Histopathological examination revealed that the tumor was pancreatic ACC. The patient recovered without any complication and was doing well without recurrence for 12 months after surgery.

BACKGROUND/AIMS: Magnifying colonoscopy was developed for detailed examination of the surface of colorectal neoplastic lesions. While magnifying colonoscopy is useful for differentiating neoplastic lesions from nonneoplastic ones, for evaluating early colorectal cancers, it still has limits in practice. This study was designed to clarify the usefulness and the limits of magnifying colonoscopy. METHODS: Three hundred and fifty-two lesions, which were observed using magnifying colonoscopy from July to August 1999 and whose histologies were proven, were analyzed according to their pit patterns. The pit patterns are I, normal round pits; II, large starry-shaped pits; IIIs, small round pits; IIIL, large round or rod-shaped pits; IV, branched or gyrus-like pits; and V, irregularly shaped or nonstructural pits. In cases where a pit pattern was hard to read, the pattern was classified as 'D'. RESULTS: The dominant pit pattern for protruded lesions was IIIL, accounting for 44.6%. In diminutive lesions (< or =5 mm), II and IIIL were equally common, 40% of the total for those lesions, respectively. In medium-sized lesions (from 6 to 10 mm), IIIL was the major pit pattern, 45.6% of the total for that type of lesion. In lesions larger than 10 mm, IIIL and IV were the most common pit patterns, each accounting for 26.7% of the total. The overall accuracy ratio of pit pattern diagnoses was 79.5%. The frequency of difficult pit patterns to read was 6.3%. Among them, 77.3% were due to difficulty in interpreting the pit patterns, and 22.7% were due to an inability to clarify the pit pattern because of poor staining. Ninety-one percent of the difficult cases to read involved diminutive lesions, and 86% of those difficult cases involved tubular adenomas. CONCLUSIONS: The 80% accuracy rate for pit pattern diagnosis suggests that magnifying colonoscopy is probably useful, but problems, such as poor staining due to mucus and difficulty with interpretation, still exist.
Adenoma ; Colonoscopy* ; Colorectal Neoplasms ; Diagnosis ; Mucus

PURPOSE: Small-sized carcinoids, less than 1 cm, are easily detected using flexible sigmoidoscopy or total colonoscopy and can be treated by local excision. Recently, there has been many advances in the technique of endoscopic resection. The aim of this study was to determine the endoscopic findings of a rectal carcinoid and to evaluate the effectiveness of endoscopic resection. METHODS: We experienced 22 rectal carcinoids in 21 patients who were treated by endoscopic resection from June 1996 to February 1999. Nineteen cases were followed for an average of 21 months. Follow-up studies consisted of chest P-A, hepatic ultrasonography, and total colonoscopy. RESULTS: The male-to-female ratio was 1.6 to 1. The most common age group was the 4th decade. The tumor was located at the lower rectum in 10 patients, at the upper rectum in 10 patients, and at the rectosigmoid junction in 2 patients. The tumor sizes ranged from 3 to 12 mm in diameter and were smaller than 10 mm in 20 cases (90.1%). Endoscopic finding revealed that the tumors were covered by a normally appearing mucosa in 12 cases, were yellow-discolored polyps in 17 cases, and were sessile-type tumors in 19 cases. The method of treatment was an endoscopic mucosal resection (EMR, 14 cases) or a snare polypectomy (8 cases). Microscopically positive margins were noticed in four cases, two cases of EMR (2/14, 14%) and two cases of snare polypectomy (2/8, 25%). All the patients were alive and clinically free of disease; however, the duration of the follow-up is short. CONCLUSIONS: Endoscopic resection for rectal carcinoid tumors smaller than 1 cm in diameter is a safe, functional, time-saving, and effective treatment. If the tumor suggests a carcinoid, EMR is advised rather than a polypectomy even though the tumor is small. Microscopically positive margins are not absolute indications for further surgery in the treatment of carcinoids smaller than 1 cm in diameter. It is much more important for an endoscopist to be confident that the endoscopic resection is done completely. It is necessary to identify the factors influencing the malignancy potential and to have a longer follow-up.
Carcinoid Tumor* ; Colonoscopy ; Follow-Up Studies ; Humans ; Mucous Membrane ; Polyps ; Rectum ; Sigmoidoscopy ; SNARE Proteins ; Thorax ; Ultrasonography

This study compares the sexual differences among rectal prolapse patients regarding the clinical and the physiologic characteristics with emphasis on males. METHODS: The clinical data, functional status and operative records of 43 patients, who had completed both clinical and functional evaluations were collected in a prospective database and were analyzed according to sex. The functional status of the patients was evaluated by Wexner's constipation score (0~30), Wexner's incontinence score (0~20), anorectal manometry, and pudendal nerve terminal motor latency (PNTML). RESULTS: The incidences of rectal prolapse in males (n=22) and in females (n=21) were similar. The age of onset for males was lower (mean standard deviation, 19.6 19.59 (50% in childhood) vs 52.0 20.75 years; p=0.001) and the duration of symptoms was longer (31.5+/-19.87 vs 12.5+/-14.31 years; p<0.001). Surgery in males was most commonly performed during the sexually active years (51.2+/-16.34 vs 64.5+/-13.19; p=0.006). The incidence of mucosal prolapse in males was higher (10/22 vs 4/17; p=0.065). The incidences and the severities of defecation difficulty in males and females were similar (n=12, mean Wexner score=8.4 vs n=12, mean Wexner score=9.9; p=NS) but, the incidences and the severities of fecal incontinence were lower in males (n=4, mean Wexner score=4.3 vs n=17, mean Wexner score= 14.2; p<0.001). The maximum resting pressure was higher in males (39.2+/-21.46 vs 26.3+/-19.98 mmHg; p=0.049), and the maximum squeezing pressure was better preserved (131.2+/-62.63 vs 67.5+/-37.99 mmHg; p<0.001). No significant difference existed in the PNTML. Female patients underwent abdominal resection rectopexy (n=6), perineal rectosigmoidectomy with lavatoroplasty (n=11), and Delorme's procedure (n=4), but all male patients preferred the perineal approach (rectosigmoidectomy with lavatoroplasty (n=8), Delorme's procedure (n=14)) for fear of sexual dysfunction after the abdominal approach. CONCLUSIONS: These findings suggest that the mechanism for developing rectal prolapse in male and female may be different and that surgical treatment should be tailored to the patient.
Age of Onset ; Constipation ; Defecation ; Fecal Incontinence ; Female ; Humans ; Incidence ; Male* ; Manometry ; Prolapse ; Prospective Studies ; Pudendal Nerve ; Rectal Prolapse*

PURPOSE: Delayed hemorrhage rarely happens after a colonoscopic polypectomy, ranging from 0.2 to 1.8% in frequency. Although its occurrence is unpredictable and it may be serious in some cases, scanty data on its causes, characteristics, and effective management exist in Korea. This study was conducted to provide such data, especially data on the characteristics of delayed hemorrhage and its effective management. METHODS: From 1997 to 1999, one endoscopist at Song-Do Colorectal Hospital performed 5236 polypectomies on 2511 patients. Delayed hemorrhage occurred after 9 of those polypectomies, for a bleeding incidence rate of 0.17% (9/5236). The authors reviewed those 9 incidence of delayed hemorrhage, which involved 9 patients and 9 lesions, with emphasis on the characteristics of the bleeding and the treatment. RESULTS: The mean age of the 9 patients was 50 years, and the male-to-female ratio was 8: 1. The sigmoid colon was involved in 4 of those patients (44.4%), and the right-sided colon was involved in another 4 of those patients. Lesions smaller than 11 mm were either sessile or flat-elevated and accounted for 6 of the 9 lesions (66.7%). The remaning lesions, which were larger than 10 mm, were either pedunculated or semipedunculated. Three (3) of the 9 patients (33.3%) experienced bleeding on day 1, the most common bleeding day. Another 5 patients (55.6%) experienced bleeding during the next 4 days (days 2 to 5). The last patient experienced bleeding on day 9, the latest bleeding day. A snare polypectomy had been performed on 7 of the 9 patients (77.8%), and a hot biopsy had been performed on the other 2 (22.2%). All delayed bleeding was treated by using hemoclips; additional epinephrine injection was used in 55.6% of the cases and an additional detachable snare in 22.2%. Rebleeding was noticed the day following the initial treatment of bleeding in one case and was managed by using hemoclips. CONCLUSIONS: The first 5 days after a colonoscopic polypectomy are crucial, and caution is required during the next 5 days. Thorough knowledge about preventing and managing bleeding is essential.
Biopsy ; Colon ; Colon, Sigmoid ; Epinephrine ; Hemorrhage* ; Humans ; Incidence ; Korea ; SNARE Proteins

The purpose of this study was to determine whether contemporary active surveillance (AS) protocols could sufficiently discriminate significant from indolent tumors in men with low-risk prostate cancer. We retrospectively analyzed 312 patients with low-risk prostate cancer treated with radical prostatectomy. After exclusion of patients with fewer than 10 cores taken at biopsy and those who received neo-adjuvant treatment, 205 subjects satisfied the final inclusion criteria. Five widely accepted AS protocols were employed in this study. A total of 82.0% of the patients met the inclusion criteria of at least one protocol, and 18% did not meet any criteria of published AS protocols. A significant proportion of patients had non-organ-confined disease (8.6% to 10.6%) or a Gleason score of 7 or greater (18.6% to 23.9%) between the different AS criteria. Among patients who did not meet any AS criteria, 32.4% of patients had a pathologically insignificant cancer. Our results indicated a significant adverse pathology in patients who met the contemporary AS protocols. On the other hand, some patients in whom expectant management would be appropriate did not meet any criteria of published AS protocols. None of the clinical or histological criteria reported to date is able to sufficiently discriminate aggressive tumors from indolent ones.
Aged ; Humans ; Kallikreins/blood ; Male ; Middle Aged ; Neoplasm Grading ; Prostate/*pathology ; Prostate-Specific Antigen/blood ; Prostatectomy ; Prostatic Neoplasms/*pathology/surgery ; Retrospective Studies ; Risk Assessment ; Treatment Outcome ; *Watchful Waiting

BACKGROUND: Significant clinical heterogeneity within contemporary risk group is well known, particularly for those with intermediate-risk prostate cancer (IRPCa). Our study aimed to analyze the ability of the Cancer of the Prostate Risk Assessment (CAPRA) score to discern between favorable and non-favorable risk in patients with IRPCa. METHODS: We retrospectively reviewed the data of 203 IRPCa patients who underwent extraperitoneal robot-assisted radical prostatectomy (RARP) performed by a single surgeon. Pathologic favorable IRPCa was defined as a Gleason score ≤ 6 and organ-confined stage at surgical pathology. The CAPRA score was compared with two established criteria for the within-group discrimination ability. RESULTS: Overall, 38 patients (18.7% of the IRPCa cohort) had favorable pathologic features after RARP. The CAPRA score significantly correlated with established criteria I and II and was inversely associated with favorable pathology (all P < 0.001). The area under the receiver operating characteristic curve for the discriminative ability between favorable and non-favorable pathology was 0.679 for the CAPRA score and 0.610 and 0.661 for established criteria I and II, respectively. During a median 37.8 (interquartile range, 24.6–60.2) months of follow-up, 66 patients (32.5%) experienced biochemical recurrence (BCR). Cox regression analysis revealed that the CAPRA score, as a continuous sum score model or 3-group risk model, was an independent predictor of BCR after RARP. CONCLUSION: The within-group discrimination ability of preoperative CAPRA score might help in patient counseling and selecting optimal treatments for those with IRPCa.
Counseling ; Discrimination (Psychology) ; Follow-Up Studies ; Goats ; Humans ; Male ; Neoplasm Grading ; Pathology ; Pathology, Surgical ; Population Characteristics ; Prostate ; Prostate-Specific Antigen ; Prostatectomy ; Prostatic Neoplasms ; Recurrence ; Retrospective Studies ; Risk Assessment ; ROC Curve

Despite the wide application of prostate-specific antigen-based screening leading to a profound stage migration in prostate cancer (PC), a significant percentage of men are still being diagnosed with clinically high-risk disease that requires aggressive treatment. Optimal management in these patients remains challenging, and strong advocates for radical prostatectomy (RP), radiotherapy, androgen deprivation therapy, and, increasingly, a multimodal approach abound. Currently, surgery for high-risk PC is frequently applied. RP offers an attractive opportunity for tumor excision either as a definitive management or as a first step in multimodal therapy. Nevertheless, this approach is still controversial. In this review, we discuss the current evidence for the role of RP in this clinical setting, including surgical considerations and outcomes. The role of robot-assisted RP, which is increasingly utilized in Korea in this clinical scenario, is discussed.
Combined Modality Therapy ; Humans ; Male ; Prostatectomy/*methods ; Prostatic Neoplasms/*surgery/therapy ; Robotic Surgical Procedures/methods ; Treatment Outcome

PURPOSE: The aim of this study was to evaluate and report the new method with a cement augmented screw fixation again to treat the failed intertrochanteric fracture in elderly which were treated with ordinary compression hip screw initially. MATERIALS AND METHODS: From Mar. 1988 to May 2007, 10 patients (mean age 69 years) with the failed intertrochanteric fracture which were treated with initial hip screw, were treated with a cement augmented compression hip screw again. The mean follow-up after surgery was over 18 months. The cause of failure, the period upto the reoperation, the neck-shaft angle after the reoperation, the position of lag screw in the femoral head, and the degree of union at last follow-up were analyzed. The change in the functional hip capacity were evaluated by the classification of Clawson. RESULTS: Causes of failure were superior cutting-out in 6 cases, cortical anchorage failure in 3, and nonunion in one case. The period upto the reoperation was average 7.8 months. Valgus reduction of average 5.7degrees was achieved, and the positions of lag screw were postero-inferior in 6 cases, center in 3, infero-center in one case. We obtained complete union in 9 cases. The functional outcome showed moderate in 6 cases, good in 3 and poor degree in one case. CONCLUSION: Cement augmented compression hip screw treatment will possibly reduce cutting-out of screw and bring more stability in fixation for intertrochanteric fractures in old osteoporotic patients, as well, even in failed cases treated with initial compression hip screw, but proper selection of patients is important.
Aged ; Follow-Up Studies ; Fracture Fixation ; Head ; Hip ; Hip Fractures ; Humans ; Reoperation

Afferent loop obstruction following gastrectomy is a rare but fatal complication. Clinical features of afferent loop obstruction are mainly gastrointestinal symptoms. A 56-year-old female underwent radical total gastrectomy with Roux-en-Y esophagojejunostomy for treatment of advanced gastric cancer. After fourteen months postoperatively, she showed gradual development of edema of both legs. Computed tomography (CT) scan showed disease progression at the jejunojejunostomy site and consequent dilated afferent loop, which resulted in inferior vena cava (IVC) compression. A drainage catheter was placed percutaneously into the afferent loop through the intrahepatic duct and an IVC filter was placed at the suprarenal IVC, and selfexpanding metal stents were inserted into bilateral common iliac veins. With these procedures, sympotms related with afferent loop obstruction and deep vein thrombosis were improved dramatically. The follow-up abdominal CT scan was taken 3 weeks later and revealed the completely decompressed afferent loop and improved IVC patency. Surgical treatment should be considered as the first choice for afferent loop obstruction; however, because it is more immediate and less invasive, non-surgical modalities, such as percutaneous catheter drainage or stent placement, can be effective alternatives for inoperable cases or risky patients who have severe medical comorbidities.
Catheters ; Comorbidity ; Disease Progression ; Drainage ; Edema ; Female ; Follow-Up Studies ; Gastrectomy ; Humans ; Iliac Vein ; Leg ; Middle Aged ; Radiography, Interventional ; Stents ; Stomach Neoplasms ; Tomography, X-Ray Computed ; Vena Cava, Inferior ; Venous Thrombosis*