Preoperative Chemoradiation Therapy in the Management of Locally Advanced Rectal Cancer

PURPOSE: Surgery is the standard care in the treatment of rectal cancer. However, after surgery alone, local recurrence and distant metastasis remain high for locally advanced rectal cancer. Preoperative chemoradiation therapy (pre-CRT) has been thought to be effective for increasing resectability and decreasing the rate of local recurrence for locally advanced rectal cancer. This study was designed to assess the efficacy of preoperative concurrent chemoradiation therapy in the management of locally advanced rectal cancer. METHODS: Between July 1999 and December 2003, 29 patients had locally advanced rectal cancer (uT3/ T4, uN1 by endorectal ultrasonography) or were ineligible to undergo sphincter-preserving surgery. All patients were treated with pre-CRT, followed by surgery in 25 patients. Patients were treated with radiation therapy with a total dose of 45~50.4 Gy to the surgical bed and pelvic lymph- node area for 5.5 weeks. We analyzed the degree of toxicity and the therapeutic resopnse from CRT, the type of surgery, including sphincter-saving procedures, and the mid- term outcome. RESULTS: Of the 29 patients who received pre-CRT, a radical resection was possible in 25 patients. A low anterior resection and an ultra-low anterior resection- coloanal anastomosis were performed in 13 (52%) and 7 (28%) cases, respectively. Sphincter-preserving surgery was performed in 80% of the patients. The postoperative pathological response rates of CRT were 25% complete remission, 45% partial remission, 30% no response. Postoperative complications and toxicity from CRT were acceptable. The duration of median follow-up was 24 months (9~62 months). Recurrence was seen in 6 cases. Distant recurrence alone was seen in 5 patients (19.2%) and distant and local recurrences were seen in only one patient (4%). The 3-year overall survival rate was 72.4%, and 3-year disease-free survival rate was 59.5%. CONCLUSION: Our data suggested that preoperative concurrent CRT therapy for locally advanced rectal cancer is safe and tolerable. These data showed a high local control rate and a high 3-year survival rate. Preoperative CRT was an effective modality for sphincter preservation in selected patients who would have required an abdominoperineal resection. Additional studies with larger numbers of patients and long-term follow up are warranted to confirm our results. In addition, more effective chemotherapeutic regimens are needed to decrease distant metastasis.

The Effect of Reoperation on the Patency Rate of Arteriovenous Fistula for Hemodialysis

PURPOSE: We designed this study to find out the risk factors affecting the patency rate after creation of an arteriovenous fistula (AVF) for hemodialysis. METHODS: Between March 1997 and December 2001, a total of 397 AVF operations in 314 patients were performed by a single surgeon using the same surgical technique and principles. One hundred and forty cases (35.3%) were reoperations due to previous AVF failure. Artificial vessels (=PTFE, polytetrafluoroethylene) were used for the AVF in 39 cases (9.8%). The sex, age, diabetes mellitus, previous operation history and type of dialysis center were considered as a possible risk factors affecting the patency rate. RESULTS: After a mean follow-up of 18.3 months, there were 63 cases of patient death, 15 of kidney transplantation, and 104 of AVF failure identified. The overall patency rates of 1, 2 and 3 year were 76.2, 70.9, and 66.9%, respectively. From the multivariate analysis, the previous operation history was the only significant factor affecting the patency rate of AVF (P=0.001, odd ratio=2.58). Although the diabetic patient (odd ratio=1.43) and artificial vessel groups (odd ratio=1.678) showed high odd ratios, these factors were not statistically significant (P>0.05). From the univariate analysis, the reoperation cases also showed a significantly inferior patency rate compared to the first operation cases (1 year patency rate was 65.2% and 83.7%, P=0.001). However, the diabetes and types of vessel showed no significant differences in patency rates. CONCLUSION: A reoperation of an AVF creation was the most significant risk factor affecting the patency rate after its original creation. The first attempt AVF creations showed-favorable patency rates. To improve the overall patency rate of an AVF creation, a more delicate preoperative study and accurate surgical technique will be required at the time of the first AVF operation.