Impact of the COVID-19 pandemic on the outcomes of laparoscopic appendectomy for acute appendicitis

Purpose@#This retrospective study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the time interval from symptom onset to surgery and on the operative outcomes of laparoscopic appendectomy for patients with acute appendicitis. @*Methods@#Between October 2018 and July 2021, laparoscopic appendectomy was performed in 502 patients with acute appendicitis admitted to Hallym University Chuncheon Sacred Heart Hospital in Chuncheon, Korea. We compared demographic data, serum levels of inflammatory markers, time to event of appendicitis, and operative outcomes between the pre-COVID-19 and post-COVID-19 pandemic groups. @*Results@#Laparoscopic appendectomy was performed in 271 patients in the pre-COVID-19 group and in 231 patients in the post-COVID-19 group. There were no differences in baseline characteristics, serum inflammatory marker levels, or the proportions of complicated appendicitis between the groups (25.1%, pre-COVID-19 vs. 31.6%, post-COVID-19; P = 0.106).The time intervals between symptom onset and hospital arrival (24.42 hours vs. 23.59 hours, P = 0.743) and between hospital arrival and the start of surgery (10.12 hours vs. 9.04 hours, P = 0.246) did not increase post-COVID-19. The overall 30-day postoperative complication rate did not differ significantly between the groups (9.6% vs. 10.8%, P = 0.650), and the severity of 30-day postoperative complications was also similar in both groups (P = 0.447). @*Conclusion@#This study demonstrates that hospitalization and surgeries were not delayed in patients with acute appendicitis and that the operative outcomes of laparoscopic appendectomy did not worsen despite the COVID-19 pandemic.

Laparoscopic Hartmann’s Reversal: Application of a Single-Port Approach Through the Colostomy Site

Purpose@#Recently, laparoscopic reversal of Hartmann’s colostomy was performed with favorable outcomes by many surgeons. We partially applied the concepts of single-port laparoscopic procedure through the colostomy site to remove intraperitoneal adhesion during initial step of the laparoscopic Hartmann’s reversal. This study aimed to evaluate the feasibility and safety of the laparoscopic reversal of Hartmann’s colostomy with the application of single-port laparoscopic techniques through the colostomy site. @*Methods@#From October 2008 to November 2018, the laparoscopic Hartmann’s reversal was attempted in 20 patients. After colostomy take-downs, the single-port device was installed at the colostomy site and the single-port laparoscopic procedure was performed to remove intraperitoneal adhesions to provide space for additional trocars. After additional trocars were inserted, the descending colon and rectal stump were mobilized, and the colorectal anastomosis was completed. We retrospectively reviewed the medical records and analyzed the data to identify the perioperative complication rates as the primary outcome. @*Results@#Of the 20 patients, 3 patients (15.0%) had open conversions due to severe adhesions. Intraoperative small bowel injuries occurred in 2 patients (10.0%) and these were repaired through the colostomy site. Postoperative complications developed in 4 patients (20.0%) and were managed with medical treatments or wound closures under local anesthesia. @*Conclusion@#The single-port laparoscopic procedure through the colostomy site is sufficiently safe in order to complete the Hartmann’s reversal. We recommend that the colostomy site should be used as the access route into the abdominal cavity for the Hartmann’s reversal.

Laparoscopic Adhesiolysis for Small Bowel Obstruction: Effective Alternatives or Immoderate Challenge?

Laparoscopic lysis for intraperitoneal adhesion should be performed only in selective patients with small bowel obstruction by experienced surgeons. Current evidence is insufficient to postulate that laparoscopic surgery is safe and effective alternative treatment option for small bowel obstruction.

Clinical outcomes of minimally invasive surgery for Meckel diverticulum: a multicenter study

Purpose@#Meckel diverticulum (MD), caused by an obliteration defect of the omphalomesenteric duct, is one of the most common congenital anomalies of small intestines. The objective of this study was to review surgical outcomes of MD and evaluate the feasibility of minimally invasive surgery (MIS) in MD. @*Methods@#We performed a retrospective analysis of the medical records of patients who underwent diverticulectomy for MD at 6 Hallym University-affiliated hospitals between January 2008 and December 2017. All patients underwent either open surgery or MIS. Patients who underwent MIS were subdivided into laparoscopic only diverticulectomy (LOD) or laparoscopic-assisted diverticulectomy (LAD). @*Results@#Of 64 patients, 21 underwent open surgery and 43 underwent MIS. Time to flatus, time to soft food intake, and length of hospital stay were shorter in the MIS group than in the open surgery group (P = 0.047, P = 0.005, and P = 0.015, respectively). Among patients who underwent MIS, the time to flatus and time to soft food intake were longer in the LAD group than in the LOD group (0.3 and 0.9 days, respectively). Multivariate analysis showed that old age and preoperative ileus were independent predictors of complications (P = 0.030 and P = 0.013, respectively). Operation type (open surgery, LOD, or LAD) was not associated with complications. @*Conclusion@#The present study showed that MIS is associated with quicker recovery without increasing complications.Therefore, MIS may be a safe alternative to open surgery for MD. An old age and preoperative ileus were associated with a risk of postoperative complications.

Impact of Adjuvant Therapy Type on Survival in Stage II/III Rectal Cancer Without Preoperative Chemoradiation: A Korean Multicenter Retrospective Study

PURPOSE: This study compared the oncologic impact of postoperative chemotherapy and chemoradiotherapy on patients with rectal cancer without preoperative chemoradiation. METHODS: This retrospective study analyzed 713 patients with a mean follow-up of 58 months who had undergone radical resection for stage II/III rectal cancer without preoperative treatment in nine hospitals from January 2004 to December 2009. The study population was categorized a chemotherapy group (CG, n = 460) and a chemoradiotherapy group (CRG, n = 253). Five-year overall survival (OS) and disease-free survival (DFS) were analyzed, and independent factors predicting survival were identified. RESULTS: The patients in the CRG were significantly younger (P < 0.001) and had greater incidences of low rectal cancer (P < 0.001) and stage III disease (P < 0.001). Five-year OS (P = 0.024) and DFS (P = 0.012) were significantly higher in the CG for stage II disease; however, they were not significantly different for stage III disease. In the multivariate analysis, independent predictive factors were male sex, low rectal cancer and stage III disease for OS and male sex, abdominoperineal resection, stage III disease and tumor-positive circumferential margin for DFS. However, adjuvant therapy type did not independently affect OS (hazard ratio [HR], 1.243; 95% confidence interval [CI], 0.794–1.945; P = 0.341) and DFS (HR, 1.091; 95% CI, 0.810–1.470; P = 0.566). CONCLUSION: Adjuvant therapy type did not affect survival of stage II/III rectal cancer patients without neoadjuvant chemoradiotherapy. These results suggest that adjuvant therapy can be chosen based on the patient’s condition and the policies of the surgeons and hospital facilities.

Safety and Feasibility of Laparoscopic Surgery for Small Bowel Obstruction

PURPOSE: Laparoscopic adhesiolysis is increasingly used to treat patients with small bowel obstruction (SBO), however, its safety of laparoscopic surgery(LS) with bowel resection in SBO is unclear. The purpose of the present study was to compare the perioperative outcomes of LS with those of open surgery (OS) for SBO and to evaluate the risk factors of 30-day postoperative morbidity and recurrence. METHODS: We retrospectively reviewed medical records of patients who had been diagnosed with SBO and underwent surgery at four Hallym-University-affiliated hospitals between January 2013 and December 2016. The rates of 30-day postoperative complications and recurrence were compared between groups using univariate and multivariate analysis. Propensity score matching was performed to compare the outcome. RESULTS: A total of 117 patients with SBO were included in the present study, of which 86 underwent OS and 31 underwent LS. Time to water intake, time to soft diet, and postoperative hospital stay were significantly shorter in the LS group (p=0.002, 0.003, and 0.027, respectively). The complication (p=0.249) and recurrence rate (p=0.679) were similar between the two group. Propensity score matching analysis demonstrated that laparoscopic surgery showed quicker recovery and similar complication and recurrence rate. In multivariate analysis, LS was not associated with either complications (p=0.806) or recurrence (p=0.956). CONCLUSION: LS is associated with several perioperative advantages for the treatment of SBO without affecting the risk of 30-day postoperative complications or recurrence. Therefore LS can be a safe and feasible option for treating SBO.

Mechanical Bowel Preparation and Prophylactic Antibiotic Administration in Colorectal Surgery: A Survey of the Current Status in Korea

PURPOSE: The usefulness of mechanical bowel preparation (MBP) in colon surgery was recently challenged by many multicenter clinical trials and meta-analyses. The objectives of this study were to investigate current national opinions about MBP and prophylactic antibiotics (PA) and to provide preliminary data for developing future Korean guidelines for MBP and PA administration in colorectal surgery. METHODS: A questionnaire was mailed to 129 colorectal specialists. The questionnaires addressed the characteristics of the hospital, the MBP methods, and the uses of oral and intravenous antibiotics. RESULTS: A total of 73 questionnaires (56.6%) were returned. First, in regard to MBP methods, most surgeons (97.3%) used MBP for a mean of 1.36 days. Most surgeons (98.6%) implemented whole bowel irrigation and used polyethylene glycol (83.3%). Oral antibiotic use was indicated in over half (52.1%) of the responses, the average number of preoperative doses was three, and the mean time of administration was 24.2 hours prior to the operation. Finally, the majority of responders stated that they used intravenous antibiotics (95.9%). The responses demonstrated that second-generation cephalosporin-based regimens were most commonly prescribed, and 75% of the surgeons administered these regimens until three days after the operation. CONCLUSION: The results indicate that most surgeons used MBP and intravenous antibiotics and that half of them administered oral PA in colorectal surgery preparations. The study recommends that the current Korean guidelines should be adapted to adequately reflect the medical status in Korea, to consider the medical environment of the various hospitals, and to establish more accurate and relevant guidelines.

Laparoscopic Colorectal Surgery Is Safe for Elderly Patients over the Age of 70 / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic surgery is used in elderly patients to maximize the benefits of improved postoperative recovery but this supposition lacks proper evidence. The aims of this study were to assess the safety and feasibility of laparoscopic colorectal surgery in elderly patients (group A, age > or =70 years, n=77) by a comparison with those in younger patients (group B, age 200 minutes), ICU stay and rectal surgery. CONCLUSION: Laparoscopic colorectal surgery in elderly patients is safe and does not compromise the postoperative outcomes despite the comorbid conditions of the elderly patients.

Risk Factors of Peritoneal Recurrence after Curative Resection of Colorectal Cancer

PURPOSE: Peritoneal recurrence after curative resection of colorectal cancer has been considered to be a lethal condition and to be suitable for palliative chemotherapy. Recently, aggressive approaches such as cytoreductive surgery and perioperative intraperitoneal chemotherapy were introduced for peritoneal malignancies to improve survival. The aim of this study is to identify the risk factors of peritoneal recurrence after curative resection of colorectal cancer and to determine the indication of early postoperative intraperitoneal chemotherapy (EPIC). METHODS: From January 1997 to December 2007, a total of 2,320 patients' records with curative resection for colorectal cancer were collected through the prospective colorectal cancer registry protocol in Kyungpook National University Hospital, Korea. Of those, a total of 1,929 patients were included for analysis of the relationship between perioperative clinicopathologic variables and peritoneal recurrence. RESULTS: The study group was composed of 1,086 men and 843 women with a mean age of 61.1. In multivariate analysis, preoperative level of serum CA19-9>37 U/ml (odd ratio [OR] 3.217; 95% confidence interval [95% CI] 1.525~6.788), right colon cancer (OR 2.524; 95% CI 1.158~5.502), pT4 tumor (OR 2.131; 95% CI 1.009~4.502) and positive apical lymph node (OR 3.045; 95% CI 1.023~9.066) were independent risk factors of peritoneal recurrence after curative resection of colorectal cancer. CONCLUSION: In colorectal cancer patients with increased preoperative serum levels of CA19-9, right-sided location, serosal exposure or invasion of adjacent organ, and positive apical lymph node, more scrupulous surveillance for peritoneal recurrence was necessary during the postoperative follow-up period. In selective patients with risk factors of peritoneal recurrence, more aggressive strategies for management, such as EPIC, were able to be considered under the acceptable general condition and life-expectancy.

Anastomosis Protection with Mallecot in Low Rectal Anastomosis

PURPOSE: Anastomotic leakage following surgery is one of the most significant causes of morbidity and mortality. Therefore, prevention of anastomotic leakage is crucial for safe rectal surgery. The aim of this study is to determine the effect of Mallecot(R) insertion on the prevention of anastomotic leakage after low rectal anastomosis. METHODS: From January 2002 to December 2006, 264 rectal cancer surgeries were performed in one center and by one surgeon. Among them, 110 cases whose anastomosis was located below 6 cm from the anal verge were collected and reviewed retrospectively. We made a diverting stoma on 6 out of 20 patients with high risk of anastomotic leakage, and inserted Mallecot(R) on the remaining 14 patients transanally. Removal of Mallecot(R) was done at the 7th postoperative day after a digital rectal examination to identify the completeness of anastomosis had been performed. RESULTS: Totally, anastomotic leakage occurred in 8 of 110 patients (73%). Among the 90 patients without any preventive measures, 7 incidents of anastomotic leakage were observed; on the other hand, 1 of 14 patients with Mallecot(R) insertion suffered anastomotic leakage. In two of the patients with leakage, including 1 in the Mallecot(R) group, the leakage was resolved via percutaneous drainage; in the other 6 patients were reoperated. CONCLUSIONS: The importance of preventing an anastomotic leakage after low rectal surgery cannot be overemphasized to reduce morbidity and to improve the prognosis. In addition, Mallecot(R) insertion may be an alternative method for diverting stoma formation.

Clinical significance of age for premenopausal women with primary breast cancer / 한국유방암학회지

PURPOSE: Breast carcinoma in young patients has been reported to present with more aggressive biologic characteristics and to behave poorer compared with the disease in older patients. However, the association between the age and the prognosis in premenopausal patients has rarely been reported on. This study aimed to reveal the clinicopathologic characteristics and prognostic significance of young age (age35 years (the younger premenopausal group) and 853 patients were aged >35 years (the older premenopausal group). The clinicopathologic characteristics and treatment outcomes were compared between the younger and older groups. RESULTS: Compared to the older premenopausal group, the younger group showed earlier menarche (15.2+/-19 years old versus 16.0+/-1.7 years old, respectively, p<0.001), larger tumor (3.7+/-2.1cm versus 3.2+/-2.0cm, respectively, p=0.002), more metastatic axillary lymph nodes (3.8+/-7.0 versus 2.4+/-5.7, respectively, p=0.001), more advanced TNM stage (p=0.015), a lower PR positive rate (47.7% versus 59.9%, respectively, p=0.011), and a higher P53 positive rate (71.7% versus 54.9%, respectively, p=0.034). The recurrence rate for the younger group was 26% as compared with 14.4% for the older group. The overall 5-year and 10-year survival rates of younger group were 79.3% and 68.5%, respectively and these of older group were 91.1% and 84.3%, respectively. CONCLUSION: In premenopausal women with breast cancer, patients with an age< or =35 years have a greater chance of having an endocrine non-responsive tumor, and they are more likely present with larger tumor, more metastatic axillary lymph nodes and a more advanced TMN stage. These results show that younger premenopausal patients have a worse prognosis than older premenopausal patients.