A 59-year-old man presented with abdominal and left flank pain. The symptom had started 30 days before as an acute nephrolithiasis, which had worsened despite conservative management. The abdomen was slightly distended and tender over the lower abdomen, without signs of generalized peritoneal irritation. A computed tomography (CT) scan showed an abscess in left para-renal space up to the subphrenic space and an unexpected pneumomediastinum. An emergency operation was performed, which showed retroperitoneal diverticulitis perforation of the sigmoid descending junction with abscess formation. A segmental resection of the diseased colon and end-colostomy was performed (Hartmann's procedure). However, the patient's condition progressively deteriorated, and he died of sepsis and multi-organ failure on the 5th postoperative day. Although pneumomediastinum caused by colonic diverticulitis perforation is extremely rare, it could be a life-threatening condition in patients without signs of peritonitis because of delayed diagnosis.
Abdomen ; Abscess ; Colon ; Colon, Sigmoid ; Delayed Diagnosis ; Diverticulitis ; Diverticulitis, Colonic ; Emergencies ; Flank Pain ; Humans ; Mediastinal Emphysema ; Middle Aged ; Nephrolithiasis ; Peritonitis ; Sepsis

Colouterine fistula is an extremely rare condition because the uterus is a thick, muscular organ. Here, we present a case of a colouterine fistula secondary to colonic diverticulitis. An 81-year-old woman was referred to the emergency department with abdominal pain and vaginal discharge. Computed tomography showed a myometrial abscess cavity in the uterus adherent to the thick sigmoid wall. Upon contrast injection via the cervical os for fistulography, we observed spillage of the contrast into the sigmoid colon via the uterine fundus. Inflammatory adhesion of the distal sigmoid colon to the posterior wall of the uterus was found during surgery. The colon was dissected off the uterus. Resection of the sigmoid colon, primary anastomosis, and repair of the fistula tract of the uterus were performed. The postoperative course was uneventful. This case represents an unusual type of diverticulitis complication and illustrates diagnostic procedures and surgical management for a colouterine fistula.
Abdominal Pain ; Abscess ; Colon ; Colon, Sigmoid ; Diverticulitis ; Diverticulitis, Colonic ; Emergencies ; Female ; Fistula ; Humans ; Uterus ; Vaginal Discharge

PURPOSE: Optimal management of colonoscopic perforation (CP) is controversial because early diagnosis and prompt management play critical roles in morbidity and mortality. Herein, we evaluate the outcomes and clinical characteristics of patients with CP according to treatment modality to help establish guidelines for managing CP. METHODS: Our retrospective analysis included 40 CP patients from January 1, 2003, to December 31, 2014. Patients with CP were categorized into 2 groups according to therapeutic modality: operation (surgery) and nonoperation (endo-luminal clip application or conservative treatment) groups. RESULTS: The postoperative morbidity rate was 40%, and no mortalities were noted. The incidence of abdominal pain and tenderness in patients who received only conservative management was significantly lower than in those who underwent surgery (P < 0.001 and P = 0.004, respectively). Patients tended to undergo surgery more often for diagnosis times longer than 24 hours and for diagnostic CPs. The mean hospital stays for the operation and nonoperation groups were 14.6 ± 7.77 and 5.9 ± 1.62 days, respectively (P < 0.001). Compared to the operation group, the nonoperation group began intake of liquid diets significantly earlier after perforation (3.8 ± 1.32 days vs. 5.6 ± 1.25 days, P < 0.001) and used antibiotics for a shorter duration (4.7 ± 1.29 days vs. 8.7 ± 2.23 days, P < 0.001). CONCLUSION: The time of diagnosis and the injury mechanism may be useful indications for conservative management. Nonoperative management, such as endo-luminal clip application, might be beneficial, when feasible, for the treatment of patients with CP.
Abdominal Pain ; Anti-Bacterial Agents ; Colonoscopy ; Diagnosis ; Diet ; Early Diagnosis ; Humans ; Incidence ; Length of Stay ; Mortality ; Retrospective Studies

PURPOSE: An individualized surveillance protocol based on stratified prognostic factors is needed for the early detection of recurrent disease. The aim of this study was to determine both the clinicopathological characteristics for early-recurring colorectal cancer and the impact on survival. METHODS: From January 1996 to September 2000, 1,504 patients with curatively resected colorectal cancer were recruited. The primary goal of this study was to evaluate the time interval until first loco-regional or distant recurrence, and the secondary goal was the last survival status. Early recurrence was defined as recurrence within the first 12 months postoperatively. Clinicopathologic data and preoperative CT records were reviewed. The follow-up period was over 48 months. RESULTS: The 5-year recurrence rate was 25.4%, and 39.5% of these were detected within the first 12 months postoperatively. In the multivariate analysis, the independent prognostic factors for early recurrence were cell differentiation (PD/MUC/SRC), lymphovascular invasion, and absence of adjuvant chemotherapy in stage III and curatively resected colorectal cancer in stage IV. Inaccurate interpretation by a low-quality CT scan resulted in a stage III cancer being understaged preoperatively. The 5-year overall survival rate according to the recurrent time interval was significantly different (early recurrence: 7.4% vs. late recurrence: 23.6%, P<0.05). The resection rate was similar in both groups (early recurrence: 22.7% vs. late recurrence: 27.6%, P=0.392). CONCLUSIONS: Colorectal cancer that recurred within 12 months showed more aggressive biologic behaviors and poor survival. Understaging caused by incomplete preoperative evaluation for disease extension may cause treatment failure.
Cell Differentiation ; Chemotherapy, Adjuvant ; Colorectal Neoplasms ; Follow-Up Studies ; Humans ; Multivariate Analysis ; Recurrence ; Survival Rate ; Treatment Failure

Anorectal trauma associated with retained rectal foreign body is an infrequent clinical problem, but presents a challenge to physicians taking care of patients with this problem. We report a case of rectal foreign body (glass cup) extracted by laparotomy. A 49-year-old male with a history of alcoholism presented to the emergency room four days after inserting a glass cup into his rectum. He complained of vague anal pain and failure to pass flatus or stool for four days. He had attempted to extract the glass cup using various methods (digital, instrumental manipulation, enema), none of which was successful. Computed tomography revealed a glass cup lodged in the rectum, without complication. The patient was brought to the operating room, administered spinal anesthesia, and placed in lithotomy position after failure of extraction in the emergency room. Although the object was palpable, it could not be extracted either manually or by the use of forceps. We decided to perform an emergent laparotomy under general anesthesia. After the abdomen was opened, an attempt was made to milk the object toward the distal rectum. However, this proved to be impossible secondary to severe rectal mucosal edema. The glass cup was eventually extracted through performing a colotomy at the rectosigmoid junction, with primary repair. The patient's postoperative course was uneventful, and he was discharged on the eighth postoperative day.
Abdomen ; Alcoholism ; Anesthesia, General ; Anesthesia, Spinal ; Edema ; Emergencies ; Flatulence ; Foreign Bodies ; Glass ; Humans ; Laparotomy ; Male ; Middle Aged ; Milk ; Operating Rooms ; Rectum ; Surgical Instruments

PURPOSE: The complication after colostomy formation may place undue hardship and emotional trauma on the ostomates. The purpose of this study was to find the effect of preoperative stoma site marking on postoperative stoma related complication. METHODS: We recruited 127 colostomy patients who underwent sigmoid or descending end colostomy, by elective operation. Transverse colostomy, loop colostomy, and emergency operation were excluded in this study. We divided the patients into two groups according to pre-operative stoma site marking by an enterostomal therapist. Postoperative stoma related complications were compared and analysed prospectively using chi-square test and paired t-test. Significance was assigned to a P value of < 0.05. RESULTS: Among 127 patients, 49 were marked preoperatively (marking group) while 78 were not marked (non- marking group). Overall stoma related complications were developed in 32 (25%) cases. Major complications including prolapse, parastomal hernia, stenosis were developed in 10 (8%) cases and minor complications including peristomal dermatitis and wound infection were developed in 22 (17%) cases. Stoma related complications were developed in 7 (14%) cases in the marking group and 25 (32%) cases in the non-marking group (P<0.05). Major complications were developed in 2 (4%) cases in the marking group and 8 (10%) cases in the non-marking group. Minor complications were developed in 5 (10%) cases in the marking group and 17 (22%) cases in the non-marking group. However, the difference in major and minor complications between the groups was not statistically significant. Of minor complications in the non-marking group, 9 (53%) cases due solely to postoperative frequent stool leakage caused by inappropriate location of the stoma. However, in the marking group, postoperative stool leakage was not observed. CONCLUSIONS: Preoperative stoma site marking by an enterostomal therapist may reduce postoperative stoma related complication. All elective procedure that result in stoma formation should be assessed and marked preoperatively.
Colon, Sigmoid ; Colostomy ; Constriction, Pathologic ; Dermatitis ; Emergencies ; Hernia ; Humans ; Prolapse ; Prospective Studies ; Wound Infection

PURPOSE: A retrospective study was performed to provide an overview of changes over time by age, stage, tumor location, and surgical therapy of colorectal cancer over the past 15 years. METHODS: We analyzed the cases 6,314 colorectal cancer patients who underwent surgery at Asan Medical Center between January 1990 and December 2004. The period was divided into three periods: 1990 to 1994, 1995 to 1999, and 2000 to 2004. We analyzed trends over time for stage, resectability, and demographic factors of colorectal cancer over the past 15 years. RESULTS: The mean age of the patients in the periods from 1990 to 1994, from 1995 to 1999, and from 2000 to 2004 were 57.1 (21~89), 57.4 (14~91), and 58.9 (15~91) years, respectively, showing an increasing tendency over time (P<0.001). The male-to-female ratios were 1.2 : 1, 1.3 : 1, and 1.6 : 1, repectively, and this male preponderance has been more marked in recent years (P=0.003). There was no change in tumor location over time. The ratios of early cancer to advanced cancer were 0.06 : 1, 0.09 : 1, and 0.11 : 1, respecfively, showing an increasing tendency over time (P=0.002). The curative resection rate increased over time (P<0.001). The non-curative resection rate was higher and the non-resected rate was lower in the period 2000 to 2004 than in the period 1990 to 1999 (P<0.001). The ratios of the lowest anterior resection to the abdominoperineal resection were 0.06 : 1, 0.49 : 1, and 1.02 : 1, respectively. With decreasing tendency of abdominoperineal resection, the lowest anterior resection rate has increased gradually over time (P<0.001). CONCLUSIONS: Etiologic studies are necessary to understand the male preponderance in colorectal cancer, and multi-center studies should be conducted to understand the changing trend of colorectal cancer in Korea.
Chungcheongnam-do* ; Colorectal Neoplasms* ; Demography ; Humans ; Korea ; Male ; Retrospective Studies

PURPOSE: Anastomotic leakage (AL) is a serious and life-threatening complication following rectal cancer surgery. The impact on long-term oncologic outcome in patients with AL is not clear. The aim of this retrospective study was to evaluate the risk factors of AL and its impact on long-term prognosis after rectal cancer surgery. METHODS: We investigated 1,391 patients who underwent primary resection and anastomosis for rectal cancer between January 1997 and August 2003. Operations were performed as follows: AR (n=164), LAR (n=898), uLAR (n=329). Standard procedures in our clinic were mesorectal excision according to tumor location and autonomic nerve preservation. Median follow-up period was 40.1 months (2~96 months). RESULTS: AL rate was 2.5% (n=35). Gender (male), age (>60 years) and uLAR were independent risk factors in multivariate analysis (HR: 3.03, 95% CI: 1.18~7.22; HR: 2.42, 95% CI: 1.12~7.83; HR: 2.68, 95% CI: 1.08~7.09, respectively). Local recurrence in the AL group was significantly higher than that in the non-AL group (P<0.05), but there was no significant difference in multivariate analysis (P=0.14). Systemic recurrence between both groups was not statistically different. The 5-year overall survival rate was significantly lower in the AL group than in the non-AL group (55.1% vs 74.1%, P<0.05) and the cancer- specific survival rate was lower in the AL group than in the non-AL group (63.0% vs 78.3%, P=0.05). CONCLUSIONS: Age, gender, and anastomotic level were risk factors for AL after rectal cancer surgery and anastomotic leakage was associated with a poor survival.
Anastomotic Leak* ; Autonomic Pathways ; Follow-Up Studies ; Humans ; Multivariate Analysis ; Prognosis ; Rectal Neoplasms* ; Recurrence ; Retrospective Studies ; Risk Factors* ; Survival Rate

PURPOSE: Pneumatosis intestinalis (PI) is increasingly being detected in recent years with the more frequent use of computerized tomography (CT). The present study was performed to evaluate the clinico-radiologic characteristic presentation of PI and to determine the prognostic factors for mortality. METHODS: Fifteen patients who were diagnosed with PI on CT between June 2000 and May 2010 were retrospectively reviewed. Age, sex, location of PI, presence of portal vein gas, time to diagnosis, American Society of Anesthesiologists (ASA) classification, Acute Physiology And Chronic Health Evaluation II (APACHE II), acidosis, shock, and other associated findings were analyzed for their association with outcome. RESULTS: Fifteen patients (7 males and 8 females, average age, 60.3 years) were diagnosed with PI. Mortality rate was 47% (7 patients). The mortality rate in patients with septic shock, APACHE II score (18), acidosis (pH<7.36) were all 100%, 87%, 100%, respectively (P<0.05). Age, sex, location of PI, portal vein gas, time to diagnosis, ASA classification, associated findings did not show statistical difference. CONCLUSION: Shock, APACHE II score (18) and acidosis were associated with high mortality in patients with PI. So, more intensive management and interest are recommended in patients with shock, APACHE II score (18), and acidosis due to PI.
Acidosis ; APACHE ; Female ; Humans ; Male ; Portal Vein ; Retrospective Studies ; Shock ; Shock, Septic

PURPOSE: Colorectal cancer is regarded as preventable with routine checkups. The purpose of this study was to evaluate the usefulness of each test performed during routine checkups and to assess the clinicopathological characteristics of colorectal cancer detected at the Health Promotion Center (HPC). RESULTS: We recruited 120 colorectal cancer patients identified on routine checkup at the HPC. The control group was composed of 3,829 colorectal cancer patients who underwent surgery during the same period. Clinicopathological variables were compared using the chi-square test. RESULTS: The male-to-female ratio was 79:41; the mean age was 57.9 (30~78) years. The incidence of right colon cancer was 16.7%, and that of left colon cancer was 83.7%. Sigmoidoscopy (55.5%), colonoscopy (28.3%), and fecal occult blood tests (FOBT, 10.8%) were used for detecting colorectal cancer. The overall positive rates of FOBT and serum carcinoembryonic antigen (CEA) were 28.3% and 20.8%, respectively, but were higher in advanced colon cancer (49.0% and 31.4%) and right colon cancer (60% and 25%). Early colorectal cancer was more frequent in the study group (54.9%) than in the control group (16.9%, P<0.001). Right colon cancer was significantly associated with advanced colon cancer (80%), and left colon cancer was associated with early colon cancer (62.3%, P=0.001). CONCLUSIONS: Endoscopy, including sigmoidoscopy and colonoscopy, played a crucial role in detecting early colorectal cancer at the HPC. Including endoscopy in basic routine checkup programs should help to increase early detection of colorectal cancer.
Carcinoembryonic Antigen ; Colonic Neoplasms ; Colonoscopy ; Colorectal Neoplasms* ; Endoscopy ; Health Promotion* ; Humans ; Incidence ; Occult Blood ; Sigmoidoscopy