Short-Term Outcomes and Cost-Effectiveness between Long-Course Chemoradiation and Short-Course Radiotherapy for Locally Advanced Rectal Cancer

Purpose@#Long-course chemoradiotherapy (LCRT) has been widely recommended in a majority of rectal cancer patients. Recently, encouraging data on short-course radiotherapy (SCRT) for rectal cancer has emerged. In this study, we aimed to compare these two methods in terms of short-term outcomes and cost analysis under the Korean medical insurance system. @*Materials and Methods@#Sixty-two patients with high-risk rectal cancer, who underwent either SCRT or LCRT followed by total mesorectal excision (TME), were classified into two groups. Twenty-seven patients received 5 Gy×5 with two cycles of XELOX (capecitabine 1000 mg/m 2 and oxaliplatin 130 mg/m 2 every 3 weeks) followed by TME (SCRT group). Thirty-five patients received capecitabine-based LCRT followed by TME (LCRT group). Short-term outcomes and cost estimation were assessed between the two groups. @*Results@#Pathological complete response was achieved in 18.5% and 5.7% of patients in the SCRT and LCRT groups, respectively (p=0.223). The 2-year recurrence-free survival rate did not show significant difference between the two groups (SCRT vs. LCRT:91.9% vs. 76.2%, p=0.394). The average total cost per patient for SCRT was 18% lower for inpatient treatment (SCRT vs. LCRT: $18787 vs. $22203, p<0.001) and 40% lower for outpatient treatment (SCRT vs. LCRT: $11955 vs. $19641, p<0.001) compared to LCRT. SCRT was shown to be the dominant treatment option with fewer recurrences and fewer complications at a lower cost. @*Conclusion@#SCRT was well-tolerated and achieved favorable short-term outcomes. In addition, SCRT showed significant reduction in the total cost of care and distinguished cost-effectiveness compared to LCRT.

Single‑port versus multiport robotic total mesorectal excision for rectal cancer: initial experiences by case‑matched analysis of short‑term outcomes

Purpose@#The da Vinci single-port (SP) system has been used in various surgical fields, including colorectal surgery.However, limited experience has been reported on its safety and feasibility. This study aims to evaluate the short-term outcomes of SP robotic surgery for the treatment of rectal cancer compared with multiport (MP) robotic surgery. @*Methods@#Rectal cancer patients who underwent curative resection in 2020 were reviewed. A total of 43 patients underwent robotic total mesorectal excision (TME), of which 26 (13 in each group, SPTME vs. MPTME) were included in the case-matched cohort for analysis. Intraoperative and postoperative outcomes and pathological results were compared between the 2 groups. @*Results@#Median tumor height was similar between the 2 groups (SPTME vs. MPTME : 5.9 cm [range, 2.2–9.6 cm] vs. 6.7 cm [range, 3.4–10.0 cm], P = 0.578). Preoperative chemoradiotherapy was equally performed (38.5%). The median estimated blood loss was less (20.0 mL [range, 5.0–20.0 mL] vs. 30.0 mL [range, 20.0–30.0 mL], P = 0.020) and the median hospital stay was shorter (7 days [range, 6–8 days] vs. 8 days [range, 7–9 days], P = 0.055) in the SPTME group. Postoperative complications did not differ (SPTME vs. MPTME : 7.7% vs. 23.1%, P = 0.587). One patient in the SPTME group and 3 in the MPTME group experienced anastomotic leakage. @*Conclusion@#SP robotic TME showed perioperative outcomes similar to MP robotic TME. The SP robotic system can be considered a surgical option for the treatment of rectal cancer. Further prospective randomized trials with larger cohorts are required.

Efficacy of air leak test in detection of anastomotic leaks after rectal excision: a retrospective case-controlled study

Purpose@#Although its efficacy is uncertain, an intraoperative air leak test (ALT) is commonly used to detect mechanical defects following bowel anastomosis. This study aimed to evaluate the efficacy of ALT to detect anastomotic leakage (AL) following rectal excision. @*Methods@#We reviewed our database for patients with rectal cancers who had undergone curative surgery between January 2012 and January 2018. Patients were grouped according to whether or not an ALT was performed. Propensity score analyses were performed to compare outcomes for groups in a 1:1 case-matched cohort. @*Results@#In total, 1,191 patients underwent rectal excision; 438 (219 in each group) formed the case-matched cohort for analysis. The protective stoma rate was 16.0% and 14.6% in the ALT and the no-ALT groups, respectively (P = 0.791). In the ALT group, 2 patients (0.9%) showed a positive result and were treated with rectal tube drainage, resulting in no leakage.There was no significant difference in postoperative AL rate between the groups (ALT group: 4.6% vs. no-ALT group: 4.1%, P > 0.999). @*Conclusion@#ALT played a minimal role in detecting AL following rectal excision. Further studies are warranted to validate our results and clarify whether AL can be prevented with ALT or alternative methods.

Minimally invasive surgery for colorectal cancer, a look back to look forward: a personal history

While laparoscopic colonoscopy was reported by several surgeons in the early 1990s, laparoscopic colorectal surgery has been attempted sporadically since 1992 in Korea. Then, in 2000, the Korean Laparoscopic Colorectal Surgery Study Group was established. Didactic lectures, videos, and live surgery by the early pioneers of this group inspired and helped many surgeons initiate the laparoscopic approach to the treatment of colorectal disease. As a result, the penetration rate of minimally invasive colorectal cancer surgery nationwide is increasing to 80% in 2018. As a witness on this journey, I would like to share my personal minimally invasive colorectal cancer surgery history and perspectives on future surgery in this field.

Optimal strategies of rectovaginal fistula after rectal cancer surgery

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.

Clinical Implications of Lymph Node Metastasis in Colorectal Cancer: Current Status and Future Perspectives

Lymph node metastasis is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with colorectal cancer. Lymph node status based on examination of a resected specimen is a key element of the current staging system and is also a crucial factor to determine use of adjuvant chemotherapy after surgical resection. However, the current tumor-node-metastasis (TNM) staging system only incorporates the number of metastatic lymph nodes in the N category. Numerous attempts have been made to supplement this simplified N staging including lymph node ratio, distribution of metastatic lymph nodes, tumor deposits, or extracapsular invasion. In addition, several attempts have been made to identify more specific prognostic factors in resected colorectal specimens than lymph node status. In this review, we will discuss controversies in lymph node staging and factors that may influence survival beyond lymph node status.

Tissue factor expression is associated with recurrence in patients with non-metastatic colorectal cancer

PURPOSE: Previous studies have addressed the role of the hypercoagulable state in the pathogenesis of cancer progression and metastasis. In this study, we investigated the association between coagulation factors, including tissue factor (TF) expression, platelet count, and fibrinogen level, and disease recurrence in patients with non-metastatic colorectal cancer.METHODS: Patients who underwent curative resection for stage II or III colorectal cancer between 2000 and 2007 were included in this study. Data from a prospectively maintained database were retrospectively reviewed. TF expression was determined by immunohistochemistry using an anti-TF monoclonal antibody. The Kaplan-Meier method was used to estimate 5-year disease-free survival.RESULTS: TF was highly expressed in 257 of 297 patients (86.5%). TF expression was not significantly associated with the platelet counts (P=0.180) or fibrinogen level (P=0.281). The 5-year disease-free survival rate was lower in patients with high TF expression than in patients with low TF expression (72.3% vs. 83.9%, P=0.074). In Cox hazard analysis, high TF expression was an independent risk factor for tumor recurrence (hazard ratio [HR] 2.446; 95% confidence interval [CI], 1.054–5.674; P=0.037). Undifferentiated histologic type (HR, 2.911; 95% CI, 1.308–6.481; P=0.009), venous invasion (HR, 2.784; 95% CI, 1.431–5.417; P=0.003), and lymph node metastasis (HR, 2.497; 95% CI, 1.499–4.158; P < 0.001), were also significantly associated with disease recurrence.CONCLUSION: TF expression is associated with a recurrence in patients with non-metastatic colorectal cancer. However, further studies are required to clarify the underlying mechanisms relating TF expression with oncologic outcomes and its potential role as a therapeutic target.

A novel robotic right colectomy for colon cancer via the suprapubic approach using the da Vinci Xi system: initial clinical experience

PURPOSE: We developed a technique of totally-robotic right colectomy with D3 lymphadenectomy and intracorporeal anastomosis via a suprapubic transverse linear port. This article aimed to introduce our novel robotic surgical technique and assess the short-term outcomes in a series of five patients. METHODS: All colectomies were performed using the da Vinci Xi system. Four robot trocars were placed transversely in the supra pubic area. Totally-robotic right colectomy was performed, including colonic mobilization, D3 lymphadenectomy, and intra corporeal stapled functional anastomosis. The 2 middle suprapubic trocar incisions were then extended to retrieve the specimen. RESULTS: Five robotic right colectomies via the suprapubic approach were performed between August 2015 and February 2016. The mean operation time was 183 ± 29.37 minutes, and the mean estimated blood loss was 27 ± 9.75 mL. The time to clear liquid intake was 3 days in all patients, and the mean length of stay after surgery was 6.2 ± 0.55 days. No patient required conversion to conventional laparoscopic surgery. There were no perioperative complications. According to the pathology report, the mean number of harvested lymph nodes was 36.6 ± 4.45. Four patients were stage III, and 1 patient was stage II according to the 7th edition of the American Joint Committee on Cancer system. CONCLUSION: Totally-robotic right colectomy via the suprapubic approach can be performed successfully in selected patients. Further comparative studies are required to verify the clinical advantages of our technique over conventional robotic surgery.

Long-term outcomes after Natural Orifice Specimen Extraction versus conventional laparoscopy-assisted surgery for rectal cancer: a matched case-control study

PURPOSE: The aim of this study was to compare the long-term outcomes of total laparoscopic surgery with Natural Orifice Specimen Extraction (NOSE) with those for conventional laparoscopy (CL)-assisted surgery for treating rectal cancers. METHODS: We reviewed the prospectively collected records of 844 patients (163 NOSE and 681 CL) who underwent curative surgery for mid- or upper rectal cancers from January 2006 to November 2012. We applied propensity score analyses and compared oncological outcomes for the NOSE and CL groups in a 1:1 matched cohort. RESULTS: After propensity score matching, each group included 138 patients; the NOSE and CL groups did not differ significantly in terms of baseline clinical characteristics. The median follow-up was 57.7 months (interquartile range, 42.4–82.5 months). The combined 5-year local recurrence rate for all tumor stages was 4.1% (95% confidence interval [CI], 0.9%–7.4%) in the NOSE group and 3.0% (95% CI, 0%–6.3%) in the CL group (P = 0.355). The combined 5-year disease-free survival rates for all stages were 89.3% (95% CI, 84.3%–94.3%) in the NOSE group and 87.3% (95% CI, 81.8%–92.9%) in the CL group (P = 0.639). The postoperative mean fecal incontinence scores at 6, 12, and 24 months were similar between the 2 groups. CONCLUSION: In our experience, NOSE for mid- and upper rectal cancer had acceptable long-term oncologic outcomes comparable to those of conventional minimal invasive surgery and seems to be a safe alternative to reduce access trauma.

Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis

PURPOSE: Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients. METHODS: Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up. RESULTS: A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444). CONCLUSION: In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.

Simultaneous integrated boost intensity-modulated radiotherapy versus 3-dimensional conformal radiotherapy in preoperative concurrent chemoradiotherapy for locally advanced rectal cancer

PURPOSE: To evaluate the feasibility of simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) for preoperative concurrent chemoradiotherapy (PCRT) in locally advanced rectal cancer (LARC), by comparing with 3-dimensional conformal radiotherapy (3D-CRT). MATERIALS AND METHODS: Patients who were treated with PCRT for LARC from 2015 January to 2016 December were retrospectively enrolled. Total doses of 45 Gy to 50.4 Gy with 3D-CRT or SIB-IMRT were administered concomitantly with 5-fluorouracil plus leucovorin or capecitabine. Surgery was performed 8 weeks after PCRT. Between PCRT and surgery, one cycle of additional chemotherapy was administered. Pathologic tumor responses were compared between SIB-IMRT and 3D-CRT groups. Acute gastrointestinal, genitourinary, hematologic, and skin toxicities were compared between the two groups based on the RTOG toxicity criteria. RESULTS: SIB-IMRT was used in 53 patients, and 3D-CRT in 41 patients. After PCRT, no significant differences were noted in tumor responses, pathologic complete response (9% vs. 7%; p = 1.000), pathologic tumor regression Grade 3 or higher (85% vs. 71%; p = 0.096), and R0 resection (87% vs. 85%; p = 0.843). Grade 2 genitourinary toxicities were significantly lesser in the SIB-IMRT group (8% vs. 24%; p = 0.023), but gastrointestinal toxicities were not different across the two groups. CONCLUSION: SIB-IMRT showed lower GU toxicity and similar tumor responses when compared with 3D-CRT in PCRT for LARC.

Simultaneous integrated boost intensity-modulated radiotherapy versus 3-dimensional conformal radiotherapy in preoperative concurrent chemoradiotherapy for locally advanced rectal cancer

PURPOSE: To evaluate the feasibility of simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) for preoperative concurrent chemoradiotherapy (PCRT) in locally advanced rectal cancer (LARC), by comparing with 3-dimensional conformal radiotherapy (3D-CRT). MATERIALS AND METHODS: Patients who were treated with PCRT for LARC from 2015 January to 2016 December were retrospectively enrolled. Total doses of 45 Gy to 50.4 Gy with 3D-CRT or SIB-IMRT were administered concomitantly with 5-fluorouracil plus leucovorin or capecitabine. Surgery was performed 8 weeks after PCRT. Between PCRT and surgery, one cycle of additional chemotherapy was administered. Pathologic tumor responses were compared between SIB-IMRT and 3D-CRT groups. Acute gastrointestinal, genitourinary, hematologic, and skin toxicities were compared between the two groups based on the RTOG toxicity criteria. RESULTS: SIB-IMRT was used in 53 patients, and 3D-CRT in 41 patients. After PCRT, no significant differences were noted in tumor responses, pathologic complete response (9% vs. 7%; p = 1.000), pathologic tumor regression Grade 3 or higher (85% vs. 71%; p = 0.096), and R0 resection (87% vs. 85%; p = 0.843). Grade 2 genitourinary toxicities were significantly lesser in the SIB-IMRT group (8% vs. 24%; p = 0.023), but gastrointestinal toxicities were not different across the two groups. CONCLUSION: SIB-IMRT showed lower GU toxicity and similar tumor responses when compared with 3D-CRT in PCRT for LARC.

A Survival Analysis of Gastric or Colorectal Cancer Patients Treated With Surgery: Comparison of Capital and a Non-capital City / 예방의학회지

OBJECTIVES: The objective of the present study was to compare prognosis of patients with gastric or colorectal cancer according to places where they received surgeries. METHODS: The cancer patients underwent surgeries in sampled hospitals located in Daegu were matched 1:1 to the patients who visited sampled hospitals in Seoul using propensity score method. After the occurrences of death were examined, Kaplan-Meier method was used for survival analysis and the log-rank test was performed to compare the survival curves. RESULTS: A total of six out of 291 gastric cancer patients who had surgeries in Daegu died (2.1%) and ten deaths (3.4%) occurred from patients went Seoul hospitals. Out of 84 gastric cancer patients who had chemotherapy after surgeries in Daegu, 13 (15.5%) patients died while 18 (21.4%) deaths occurred among patients underwent surgeries in Seoul. Six deaths (6.9%) out of 87 colorectal cancer patients who had surgeries in Daegu were reported. Five patients (5.7%) died among the patients underwent surgeries in Seoul. Among the colorectal cancer patients with chemotherapy after surgeries, 13 patients (12.4%) who visited hospitals in Daegu and 14 (13.3%) patients who used medical centers in Seoul died. There were no significant differences according to places where patients used medical services. CONCLUSIONS: The result of this study is expected to be used as basic data for policy making to resolve centralization problem of cancer patients and to help patients to make rational choices in selection of medical centers.

Family Avoidance of Communication about Cancer: A Dyadic Examination / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study aimed to examine the following questions: to what extent do patients and caregivers perceive their family members to be avoidant of communication regarding patient's cancer, and to what extent do these perceptions interrelate; and how do such perceptions influence their own and each other's communication behaviors, communication outcome, mental health, and quality of life. MATERIALS AND METHODS: A national survey was performed with 990 patient-caregiver dyads (participation rate, 76.2%). To examine the dyadic interaction, we developed linked patient and family member questionnaires, including the Family Avoidance of Communication about Cancer (FACC) scale. RESULTS: The mean scores (standard deviations) of patient- and caregiver-perceived FACC were low at 10.9 (15.5) and 15.5 (17.5), respectively (p < 0.001), and concordance was low, a well (Spearman's rho, 0.23). Patient-perceived FACC was associated with lower levels of disclosure and behaviors of holding back communication, as well as lower levels of mental health outcome and quality of life. The same was true for caregivers (all p < 0.05). Patient-perceived FACC was associated with caregiver holding back, caregiver's depression level, and caregiver quality of life (all p < 0.05). Both patient- and caregiver-perceived FACC were independently associated with communication difficulty within the family. CONCLUSION: Future research would benefit from the measurement of FACC from both patients and caregivers, and promote family intervention to enhance openness to communication, which would be helpful for improving mental health and quality of life for both patients and caregivers.

Laparoscopic para-aortic lymph node dissection for patients with primary colorectal cancer and clinically suspected para-aortic lymph nodes

PURPOSE: Treatment of patients with para-aortic lymph node metastasis from colorectal cancer is controversial. The goal of this study was to investigate the technical feasibility of laparoscopic intrarenal para-aortic lymph node dissection in patients with colorectal cancer and clinically suspected para-aortic lymph node dissection. METHODS: The inclusion criteria for the laparoscopic approach were patients with infrarenal para-aortic lymph node metastasis from colorectal cancer. Patients who had any other distant metastatic lesion or metachronous para-aortic lymph node metastasis were excluded from this study. Perioperative outcomes and survival outcomes were analyzed. RESULTS: Between November 2004 and October 2013, 40 patients underwent laparoscopic para-aortic lymph node dissection. The mean operating time was 192.3 +/- 68.8 minutes (range, 100-400 minutes) and the mean estimated blood loss was 65.6 +/- 52.6 mL (range, 20-210 mL). No patient required open conversion. The postoperative complication rate was 15.0%. Sixteen patients (40.0%) had pathologically positive lymph nodes. In patients with metastatic para-aortic lymph nodes, the 3-year overall survival rate and disease-free survival rate were 65.7% and 40.2%, respectively. CONCLUSION: The results of our study suggest that a laparoscopic approach for patients with colorectal cancer with metastatic para-aortic lymph nodes can be a reasonable option for selected patients.

Clinical Significance of Substaging and HER2 Expression in Papillary Nonmuscle Invasive Urothelial Cancers of the Urinary Bladder

The study aimed to verify the prognostic utility, therapeutic application and clinical benefits of tumor substaging and HER2 status in papillary non-muscle invasive bladder cancer (NMIBC). Select NMIBC transurethral resection specimens from 141 patients were used to construct tissue microarrays for assessing the substaging, HER2 protein expression by immunohistochemistry (HER2-IHC) and gene amplification by dual-color silver in situ hybridization (HER2-SISH). Substages were identified by the differing depth of tumor invasion (pTa / pT1a / pT1b / pT1c). HER2 protein expression was semiquantitatively analyzed and grouped into negative (score 0, 1+) and positive (score 2+, 3+). Other clinicopathological variables were also investigated. For NMIBC, HER2-IHC and HER2-SISH showed positive results in 6/141 (4.3%) and 4/141 (2.8%) respectively, which correlated well with tumor substaging. In multivariate analysis, substaging, HER2-IHC, and HER2-SISH were found to be independent predictors of progression-free survival (P < 0.001, P < 0.001, P = 0.031). HER2-IHC was the sole independent predictor of recurrent free survival in NMIBC (P = 0.017). It is suggested that tumor substaging and HER2 status are independent predictive markers for tumor progression or recurrence, and thus could be included in diagnostic and therapeutic management for NMIBC.

Can intravenous patient-controlled analgesia be omitted in patients undergoing laparoscopic surgery for colorectal cancer?

PURPOSE: Opioid-based intravenous patient-controlled analgesia (IV-PCA) is a popular method of postoperative analgesia, but many patients suffer from PCA-related complications. We hypothesized that PCA was not essential in patients undergoing major abdominal surgery by minimal invasive approach. METHODS: Between February 2013 and August 2013, 297 patients undergoing laparoscopic surgery for colorectal cancer were included in this retrospective comparative study. The PCA group received conventional opioid-based PCA postoperatively, and the non-PCA group received intravenous anti-inflammatory drugs (Tramadol) as necessary. Patients reported their postoperative pain using a subjective visual analogue scale (VAS). The PCA-related adverse effects and frequency of rescue analgesia were evaluated, and the recovery rates were measured. RESULTS: Patients in the PCA group experienced less postoperative pain on days 4 and 5 after surgery than those in the non-PCA group (mean [SD] VAS: day 4, 6.2 [0.3] vs. 7.0 [0.3], P = 0.010; and day 5, 5.1 [0.2] vs. 5.5 [0.2], P = 0.030, respectively). Fewer patients in the non-PCA group required additional parenteral analgesia (41 of 93 patients vs. 53 of 75 patients, respectively), and none in the non-PCA group required rescue PCA postoperatively. The incidence of postoperative nausea and vomiting was significantly higher in the non-PCA group than in the PCA group (P < 0.001). The mean (range) length of hospital stay was shorter in the non-PCA group (7.9 [6-10] days vs. 8.7 [7-16] days, respectively, P = 0.03). CONCLUSION: Our Results suggest that IV-PCA may not be necessary in selected patients those who underwent minimal invasive surgery for colorectal cancer.

Comparison of Surgical Skills in Laparoscopic and Robotic Tasks Between Experienced Surgeons and Novices in Laparoscopic Surgery: An Experimental Study

PURPOSE: Robotic surgery is known to provide an improved technical ability as compared to laparoscopic surgery. We aimed to compare the efficiency of surgical skills by performing the same experimental tasks using both laparoscopic and robotic systems in an attempt to determine if a robotic system has an advantage over laparoscopic system. METHODS: Twenty participants without any robotic experience, 10 laparoscopic novices (LN: medical students) and 10 laparoscopically-experienced surgeons (LE: surgical trainees and fellows), performed 3 laparoscopic and robotic training-box-based tasks. This entire set of tasks was performed twice. RESULTS: Compared with LN, LEs showed significantly better performances in all laparoscopic tasks and in robotic task 3 during the 2 trials. Within the LN group, better performances were shown in all robotic tasks compared with the same laparoscopic tasks. However, in the LE group, compared with the same laparoscopic tasks, significantly better performance was seen only in robotic task 1. When we compared the 2 sets of trials, in the second trial, LN showed better performances in laparoscopic task 2 and robotic task 3; LE showed significantly better performance only in robotic task 3. CONCLUSION: Robotic surgery had better performance than laparoscopic surgery in all tasks during the two trials. However, these results were more noticeable for LN. These results suggest that robotic surgery can be easily learned without laparoscopic experience because of its technical advantages. However, further experimental trials are needed to investigate the advantages of robotic surgery in more detail.

Predictive factors and the prognosis of recurrence of colorectal cancer within 2 years after curative resection

PURPOSE: Because predicting recurrence intervals and patterns would allow for appropriate therapeutic strategies, we evaluated the clinical and pathological characteristics of early and late recurrences of colorectal cancer. METHODS: Patients who developed recurrence after undergoing curative resection for colorectal cancer stage I-III between January 2000 and May 2006 were identified. Early recurrence was defined as recurrence within 2 years after primary surgery of colorectal cancer. Analyses were performed to compare the clinicopathological characteristics and overall survival rate between the early and late recurrence groups. RESULTS: One hundred fifty-eight patients experienced early recurrence and 64 had late recurrence. Multivariate analysis revealed that the postoperative elevation of carbohydrate antigen 19-9 (CA 19-9), venous invasion, and N stage correlated with the recurrence interval. The liver was the most common site of early recurrence (40.5%), whereas late recurrence was more common locally (28.1%), or in the lung (32.8%). The 5-year overall survival rates for early and late recurrence were significantly different (34.7% vs. 78.8%; P < 0.001). Survival rates after the surgical resection of recurrent lesions were not different between the two groups. CONCLUSION: Early recurrence within 2 years after surgery was associated with poor survival outcomes after colorectal cancer recurrence. An elevated postoperative CA 19-9 level, venous invasion, and advanced N stage were found to be significant risk factors for early recurrence of colorectal cancer.

Characteristic Phenotypes in Korean Crohn's Disease Patients Who Underwent Intestinal Surgery for the Treatment

There are no previous large scale studies which have evaluated the phenotypes and clinical characteristics of Korean Crohn's disease patients who underwent intestinal resection. The purpose of this multicenter retrospective cohort study was to evaluate the clinical characteristics of Korean Crohn's disease patients who underwent intestinal resection during the study period. A total of 686 patients were enrolled in this study. The study period was over a 20-yr period (1990-2009). The patients were divided into the first-10-yr group and the second-10-yr group. The phenotypes and clinical characteristics were compared between the groups. The most common site of the disease was the ileal area (37.8%) and stricturing behavior was observed in 38.3% patients. The most common type of surgery was segmental resection of the small bowel (30.6%). These phenotypes showed a similar pattern in both the first and second study period groups and did not show any significant differences between the groups. The number of registered patients increased continuously. The phenotypes of Korean Crohn's disease patients who underwent intestinal resection are different compared with previously reported clinical characteristics of general Crohn's disease patients.