The Effect of Anastomotic Leakage on the Incidence and Severity of Low Anterior Resection Syndrome in Patients Undergoing Proctectomy: A Propensity Score Matching Analysis

Purpose@#Proctectomy for the treatment of rectal cancer results in inevitable changes to bowel habits. Symptoms such as fecal incontinence, constipation, and tenesmus are collectively referred to as low anterior resection syndrome (LARS). Among the several risk factors that cause LARS, anastomotic leakage (AL) is a strong risk factor for permanent stoma formation. Therefore, the purpose of this study was to investigate the relationship between the severity of LARS and AL in patients with rectal cancer based on the LARS score and the Memorial Sloan Kettering Cancer Center (MSKCC) defecation symptom questionnaires. @*Methods@#We retrospectively analyzed patients who underwent low anterior resection for rectal cancer since January 2010. Patients who completed the questionnaire were classified into the AL group and control group based on medical and imaging records. Major LARS and MSKCC scores were analyzed as primary endpoints. @*Results@#Among the 179 patients included in this study, 37 were classified into the AL group. After propensity score matching, there were significant differences in the ratio of major LARS and MSKCC scores of the control group and AL group (ratio of major LARS: 11.1% and 37.8%, P<0.001; MSKCC score: 67.29±10.4 and 56.49±7.2, respectively, P<0.001). Univariate and multivariate analyses revealed that AL was an independent factor for major LARS occurrence and MSKCC score. @*Conclusion@#This study showed that AL was a significant factor in the occurrence of major LARS and defecation symptoms after proctectomy.

Effect of pelvic drain displacement on anastomotic leakage-related morbidity after rectal cancer surgery

Purpose@#Drain insertion after proctectomy is common in clinical practice, although the effectiveness of drains has been questioned. However, drains are commonly displaced after surgery. We hypothesized that drain displacement is associated with clinical outcomes and aimed to assess differences in clinical outcomes, such as overall morbidity, including anastomotic leakage (AL), reintervention rates, length of hospital stay, and mortality rates, between patients who experienced displaced drains and those who did not. @*Methods@#Rectal cancer patients who underwent proctectomy at a single institution between January 2015 and December 2020 were retrospectively reviewed. Clinical characteristics were compared between patients who experienced displaced drains and those who did not. The primary endpoint was the occurrence of reintervention in patients with AL. The secondary endpoints were overall morbidity rates, AL rates, length of hospital stay, and mortality within 30 days. @*Results@#Among 248 patients who underwent proctectomy, 93 (37.5%) experienced displaced drains. A higher proportion of patients who experienced displaced drains required reintervention due to AL than those who did not experience displaced drains (odds ratio, 3.61; 95% confidential interval, 1.20–10.93; p = 0.016). However, no significant difference was found in the overall morbidity rate, mortality, and length of hospital stay between the groups. @*Conclusion@#Drain displacement does not worsen outcomes such as overall morbidity rate, mortality, and length of hospital stay after proctectomy but is associated with an increase in the need for reintervention in patients with AL.

Effect of pelvic drain displacement on anastomotic leakage-related morbidity after rectal cancer surgery

Purpose@#Drain insertion after proctectomy is common in clinical practice, although the effectiveness of drains has been questioned. However, drains are commonly displaced after surgery. We hypothesized that drain displacement is associated with clinical outcomes and aimed to assess differences in clinical outcomes, such as overall morbidity, including anastomotic leakage (AL), reintervention rates, length of hospital stay, and mortality rates, between patients who experienced displaced drains and those who did not. @*Methods@#Rectal cancer patients who underwent proctectomy at a single institution between January 2015 and December 2020 were retrospectively reviewed. Clinical characteristics were compared between patients who experienced displaced drains and those who did not. The primary endpoint was the occurrence of reintervention in patients with AL. The secondary endpoints were overall morbidity rates, AL rates, length of hospital stay, and mortality within 30 days. @*Results@#Among 248 patients who underwent proctectomy, 93 (37.5%) experienced displaced drains. A higher proportion of patients who experienced displaced drains required reintervention due to AL than those who did not experience displaced drains (odds ratio, 3.61; 95% confidential interval, 1.20–10.93; p = 0.016). However, no significant difference was found in the overall morbidity rate, mortality, and length of hospital stay between the groups. @*Conclusion@#Drain displacement does not worsen outcomes such as overall morbidity rate, mortality, and length of hospital stay after proctectomy but is associated with an increase in the need for reintervention in patients with AL.

The Usefulness of a 180° Rotatable Monitor for an Assistant to Overcome the Hand-Eye Discordance in Laparoscopic Colorectal Surgery

Purpose@#Hand-eye discordance during laparoscopic colon surgery is an obstacle to the assistant. We evaluated the usefulness of a 180° rotatable laparoscopic monitor for the colorectal surgery assistant to overcome hand-eye discordance. @*Methods@#Twenty-six residents of the department of surgery (novice group, n=13; experienced group, n=13) participated in this study. They performed grasping a ring and transferring it to standing bars on a laparoscopic training kit under the conventional view and a 180° rotated monitor view. We defined successful performance when this procedure was completed in 3 minutes. @*Results@#The number of successful performance was higher under the 180° rotated monitor view than under the conventional view monitor (6.88±2.79 vs. 0.92±0.80, p<0.01). Under the 180° rotated monitor view, the experienced group had a higher number of successful performances than the novice group (8.31±2.59 vs. 5.46±2.26, p=0.009). However, no statistically significant difference was found between the two groups under the conventional view (1.23±0.93 vs. 0.62±0.51, p=0.091). @*Conclusion@#This study shows the usefulness of a 180° rotated monitor view to overcome hand-eye discordance, which adversely affects the laparoscopic performance of the colorectal surgery assistant.

Abdominopelvic Actinomycosis Mimicking Peritoneal Carcinomatosis: A Case Report

Actinomycosis is a rare chronic bacterial infection primarily caused by Actinomyces israelii. A 47-year-old woman presented to our clinic with a 1-week history of lower abdominal pain. Preoperative imaging studies revealed multiple peritoneal and pelvic masses suggestive of malignancy. The primary tumor could not be identified despite further endoscopic and gynecological evaluation. On exploration for tissue confirmation, excisional biopsies from multiple masses were performed because complete excision was not possible. Histopathological examination confirmed actinomycosis with multiple abscesses, and the patient was treated with antibiotics. We present a case of disseminated peritoneal actinomycosis that mimicked malignant peritoneal carcinomatosis on imaging studies.

Abdominopelvic Actinomycosis Mimicking Peritoneal Carcinomatosis: A Case Report

Actinomycosis is a rare chronic bacterial infection primarily caused by Actinomyces israelii. A 47-year-old woman presented to our clinic with a 1-week history of lower abdominal pain. Preoperative imaging studies revealed multiple peritoneal and pelvic masses suggestive of malignancy. The primary tumor could not be identified despite further endoscopic and gynecological evaluation. On exploration for tissue confirmation, excisional biopsies from multiple masses were performed because complete excision was not possible. Histopathological examination confirmed actinomycosis with multiple abscesses, and the patient was treated with antibiotics. We present a case of disseminated peritoneal actinomycosis that mimicked malignant peritoneal carcinomatosis on imaging studies.

Clinical value of an adenosine triphosphate-based chemotherapy response assay in resectable stage III colorectal cancer

PURPOSE: ATP-based chemotherapy response assay (ATP-CRA) is a well-documented and validated technology that can individualize chemotherapy. This study was undertaken to assess the usefulness of ATP-CRA in advanced colorectal cancer (CRC) patients receiving adjuvant chemotherapy. METHODS: A total of 136 patients with curative resection between January 2006 and April 2014 were evaluated using ATP-CRA. Patients received either the FOLFOX or Mayo clinic regimen chemotherapy following assay results. The sensitive-group (S-group) was defined as a drug-producing ≥ 40% reduction in ATP, and the resistant-group (R-group) as an ATP reduction of < 40%. These 2 groups were further subdivided to produce 4 subgroups: the FOLFOX sensitive subgroup (the FS subgroup [n = 65]), the Mayo sensitive subgroup (the MS subgroup [n = 40]), the FOLFOX resistant subgroup (the FR subgroup [n = 10]), and the Mayo resistant subgroup (the MR subgroup [n = 21]). Clinical responses and survival results were compared for both treatment regimens. RESULTS: The FS and MS subgroups showed a better disease-free survival rate (29% vs. 40%, 35% vs. 47.6%) and overall survival rate (92.3% vs. 80.0%, 87.5% vs. 76.2%) than FR and MR subgroups. The FS and MS subgroups showed a longer time to relapse (20.2 months vs. 9.5 months, 17.6 months vs. 16.4 months) than the FR and MR subgroups. CONCLUSION: ATP-CRA tailored-chemotherapy has the potential to provide a survival benefit in resectable advanced CRC.

Prognostic Impact of Microsatellite Instability in Colorectal Cancer Presenting With Mucinous, Signet-Ring, and Poorly Differentiated Cells

PURPOSE: Mucinous cells (MUCs), signet-ring cells (SRCs), and poorly differentiated cells (PDCs) are uncommon histologic types and have been associated with advanced tumor stage and poor prognosis. However, MUCs, SRCs, and PDCs are commonly observed in cancers with high microsatellite instability (MSI), which have favorable outcomes compared with cancers with microsatellite stability (MSS). The purpose of this study was to evaluate the prognostic impact of high-MSI in patients with sporadic colorectal cancer presenting with MUCs, SRCs, and/or PDCs. METHODS: Between January 2006 and December 2012, 176 with proven microsatellite status who also presented with MUCs, SRCs, and PDCs were selected for this study and were divided into 2 groups, high-MSI and MSS; their outcomes were analyzed. RESULTS: Of the 176 patients, 56 and 120, respectively, had high-MSI and MSS cancers. High-MSI cancers had larger tumors, proximal tumor location, and a lower TNM stage. The recurrence rate was lower in the high-MSI group (13.7% vs. 35.4%, P = 0.006). Common patterns of distant metastasis for MUC, SRC, PDC cancers were peritoneal spread (46.9%) and hematogenous metastasis (46.4%). The 5-year CSS rates were 88.2% and 61.2% for patients with high-MSI and MSS cancers, respectively (P < 0.0001). In the multivariate analysis, except for stage-IV cancer, MSI status was an independent risk factor for cancer-specific survival (MSS: hazard ratio, 4.34; 95% confidence interval, 1.68-11.21). CONCLUSION: In patients with colorectal cancer presenting with MUCs, SRCs, and/or PDCs, those with high-MSI cancers had better outcomes.

Comparative Study of Postoperative Complications in Patients With and Without an Obstruction Who Had Left-Sided Colorectal Cancer and Underwent a Single-Stage Operation After Mechanical Bowel Preparation

PURPOSE: The purpose of this study is to compare postoperative complications for single-stage surgery after mechanical bowel preparation in patients who experienced obstruction and those who did not. METHODS: From 2000 to 2011, 1,224 patients underwent a single-stage operation for left colorectal cancer after bowel preparation. Nonobstruction (NOB) and obstruction (OB) colorectal cancer patients were 1,053 (86.0%) and 171 (14.0%), respectively. Postoperative morbidity and mortality were compared between groups. RESULTS: The OB group had poor preoperative conditions (age, white blood cell, hemoglobin, albumin level, and advanced tumor stage) compared with the NOB group (P < 0.05). Mean on-table lavage time for the OB group was 17.5 minutes (range, 14-60 minutes). Mean operation time for the OB group was statistically longer than that of the NOB group (OB: 210 minutes; range, 120-480 minutes vs. NOB: 180 minutes; range, 60-420 minutes; P < 0.001). Overall morbidity was similar between groups (NOB: 19.7% vs. OB: 23.4%, P = 0.259). Major morbidity was more common in the OB group than in the NOB group, but the difference was without significance (OB: 11.7% vs. NOB: 7.6%, P = 0.070). Postoperative death occurred in 16 patients (1.3%), and death in the OB group (n = 7) was significantly higher than it was in the NOB group (n = 9) (4.1% vs. 0.9%, P = 0.001). Twelve patients had surgical complications, which were the leading cause of postoperative death: postoperative bleeding in five patients and leakage in seven patients. CONCLUSION: Postoperative morbidity for a single-stage operation for obstructive left colorectal cancer is comparable to that for NOB, regardless of poor conditions of the patient.

Effectiveness of Sodium Picosulfate/Magnesium Citrate (PICO) for Colonoscopy Preparation

PURPOSE: Bowel preparation with sodium phosphate was recently prohibited by the U.S. Food and Drug Administration. Polyethylene glycol (PEG) is safe and effective; however, it is difficult to drink. To identify an easy bowel preparation method for colonoscopy, we evaluated three different bowel preparation regimens regarding their efficacy and patient satisfaction. METHODS: In this randomized, comparative study, 892 patients who visited a secondary referral hospital for a colonoscopy between November 2012 and February 2013 were enrolled. Three regimens were evaluated: three packets of sodium picosulfate/magnesium citrate (PICO, group A), two packets of PICO with 1 L of PEG (PICO + PEG 1 L, group B), and two packets of PICO with 2 L of PEG (PICO + PEG 2 L, group C). A questionnaire survey regarding the patients' preference for the bowel preparation regimen and satisfaction was conducted before the colonoscopies. The quality of bowel cleansing was scored by the colonoscopists who used the Aronchick scoring scale and the Ottawa scale. RESULTS: The patients' satisfaction rate regarding the regimens were 72% in group A, 64% in group B, and 45.9% in group C. Nausea and abdominal bloating caused by the regimens were more frequent in group C than in group A or group B (P < 0.01). Group C showed the lowest preference rate compared to the other groups (P < 0.01). Group C showed better right colon cleansing efficacy than group A or group B. CONCLUSION: Group A exhibited a better result than group B or group C in patient satisfaction and preference. In the cleansing quality, no difference was noted between groups A and C.

Clinicopathologic Features and Clinical Outcomes of Desmoplastic Small Round Cell Tumors in Abdomen

Desmoplastic small round cell tumor (DSRCT) is a rare malignant tumor that occurs mainly in the abdominal cavity and has a tendency to occur in young males. But it occurs in other primary sites including the central nerve system, lung, kidney and soft tissue like bone. Major symptoms include abdominal palpable mass, abdominal pain and distention. Useful studies for diagnosis are radiographic study including computerized tomogram and percutaneous pathologic study. DSRCT is an aggressive malignant neoplasm and its prognosis is poor. The overall survival at three years is about 30%. This report describes 5 cases of DSRCT since 2002. The median age of patients was 35 years. All patients are men that presented abdominal pain and abdominal mass. 3 patients underwent surgical resection of tumor and 4 patients received chemotherapy. The survival time of 2 expired patients was 39 and 28 months, individually. And the follow-up period of survival patients is 23~31 months.

Diagnostic Usefulness of Routinely Performed Preoperative Chest Computed Tomography for Colorectal Cancer

PURPOSE: The most common site of metastases in colorectal cancer (CRC) is the liver, and the second common site is the lung (10-20%). Preoperative staging for CRC is very important. The aim of this study was to assess the usefulness of chest computed tomography (CT) for preoperative staging in CRC. METHODS: From January 2006 to December 2007, a total of 597 patients with colorectal cancer underwent surgery at our hospital. One hundred fifty of those patients had received chest CT preoperatively. We analyzed the chest radiologic findings from chest x-ray (CXR), abdominal CT, and chest CT. RESULTS: The detection rate of abnormal lung findings was higher in chest CT than in the other chest radiologic findings (chest PA: 10 [6.6%]; abdominal CT: 19 [12.7%]; chest CT: 48 [32.0%]). On the chest CT, 19 of the 150 (12.7%) patients that had received a chest CT preoperatively were initially suspected of having malignant lesions. Besides two primary lung malignancies (solitary nodules), metastatic lesions were revealed in 5 (3.3%), 11 (7.3%), and 17 (11.3%) patients on CXR, abdominal CT, and chest CT, respectively. Eleven (64.7%) of the patients having metastatic chest CT lesions were also identified on lower lung fields by abdominal CT. Seven also had other metastatic foci (liver and paraaortic LN). Initially, stage IV was identified in 37 (24.7%) and 40 (26.7%) patients in abdominal CT and chest CT, respectively. After one year, 11 of the 150 (7.3%) patients who had received a chest CT had been diagnosed with pulmonary metastasis. CONCLUSION: Chest computed tomography is the most sensitive method for the diagnosis of pulmonary metastases. However, if the interpretations of abdominal CT and individualized diagnostic methods are accurate, the demand for unnecessary preoperative work-up may be reduced.

The Usefulness of FDG-PET/CT for the Prediction of Regional Lymph Node Metastases in Colorectal Cancer

PURPOSE: Proper preoperative staging is important in planning optimal therapy for individual patients and improving outcome. There is no ideal imaging methods for accurate colorectal cancer staging. The purpose of our study was to determine the usefulness of fluorodeoxyglucose positron emission tomography (FDG-PET)/computed tomography (CT) for the status of regional lymph node metastasis in colorectal cancer. METHODS: Two hundred forty six surgically resected colorectal cancers were retrospectively reviewed from Jan 2007 to Jul 2009. All patients underwent abdominal CT and FDG-PET/CT preoperatively. RESULTS: There were 129 males (52.4%) and the mean age was 62 (range: 25~88 years). Tumor location was the colon in 148 (59.7%) patients, and the rectum in 98 (40.3%) patients. Pathological stages were I: 43 (17.5%), II: 78 (31.7%), III: 81 (32.9%), IV: 44 (17.9%). Regional lymph node metastasis by pathological examination was 118 (48%) patients. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of regional lymph node staging were 66.4%, 66.7%, 64.8%, 68.3%, and 67%, respectively, with the FDG-PET/CT, and 57.1%, 71.3%, 64.8%, 64.3%, and 65%, respectively, with whole abdominal CT. The difference in the accuracy of nodal staging between the two modalities was not significant. CONCLUSION: The diagnostic accuracy of FDG-PET/CT for the assessment of regional lymph node metastasis in colorectal cancer was relatively low, and similar to that of abdominal CT. Therefore, further study will be needed to determine the clinical usefulness of preoperative FDG-PET/CT in colorectal cancer.

A Case of Solitary Rectal Diverticulum Presenting with a Retrorectal Mass

Colonic diverticula are common whereas but rectal diverticula are very rare, with only sporadic reports in the literature since 1911. Most patients with rectal diverticula are diagnosed incidentally, inflammatory processes may have developed at the time of the diagnosis. We report the case of a 42-year-old woman presenting with a retrorectal mass that was detected incidentally. She was suspected of having a rectal diverticulum by transrectal ultrasonography and magnetic resonance imaging. However, the colonoscopic findings were unremarkable. A rectal diverticulum was confirmed intraoperatively, and a transanal diverticulectomy was performed.

Intraoperative Radiotherapy for Locally Advanced Rectal Cancer

PURPOSE: Although intraoperative radiotherapy (IORT) is known to be a method that can reduce local recurrence in locally advanced colorectal cancer, it is not widely used. The aim of this study was to report our experience with IORT for locally advanced rectal cancer. METHODS: From 1991 to 1994, nine patients with locally advanced rectal cancer received IORT. External beam radiotherapy was given postoperatively in five patients and preoperatively in three. Seven patients received chemotherapy. IORT was done with 6-MeV or 9-MeV electrons, and 12 Gy was irradiated at the tumor bed. The median follow-up period was 84 months (range, 15 to 208 months). RESULTS: The median age of patients was 51 years (range, 42 to 73 years). All patients had advanced clinical T-stage (cT3/4) cancer. The overall and the disease-free survival rates were 66.7% and 66.7% at 5 years, respectively. One patient developed a local recurrence near the anastomosis site, which was out of the IORT field. Four patients died before the last follow-up; three from distant metastasis and one from secondary primary cancer. Adverse effects related to IORT did not occur. CONCLUSION: Although the number of patients was small in this study, IORT is thought to be safe and effective in reducing local recurrence in locally advanced rectal cancer. However, the role of IORT should be refined in the era of preoperative radio-chemotherapy followed by total mesorectal excision.

Primary Rectal Malignant Melanoma with Rapid Progression after Complete Resection / 대한소화기학회지

No abstract available.

Transanal Small Bowel Eviceration due to Traumatic Rectal Perforation

Transanal small bowel evisceration by rectal perforation is a very rare presentation. It occurs spontaneously or in association with trauma. We experienced a 20-year-old female patient who had transanal evisceration of the small bowel due to blunt trauma. Operative findings showed traumatic rectal perforation and gangrenous change of the eviscerated small bowel due to tearing of the small bowel mesentery. Segmental resection of gangrenous small bowel with immediate anastomosis and Hartmann's procedure of rectal perforation were performed. After 9 months, reduction of sigmoid colostomy and colorectal anastomosis were performed. We report this rare case with a review of the literature.

The Prognostic Impact of Obstructed Colorectal Cancer

PURPOSE: An obstructed colorectal cancer (OB) has a poorer survival than a non-obstructed cancer (NOB). This study examined the prognostic impact of bowel obstruction on colorectal cancer. METHODS: From December 1999 to December 2005, patients undergoing single stage operation for OB were examined prospectively. OB (n= 193) was compared with a NOB (n=444) used in a primary tumor resection during the same period. 637 colorectal cancers were examined in this study. RESULTS: The overall operative mortality was 21 (3.3%) and the postoperative mortality was significantly higher in the OB (OB: 16, 8.3%) group than in the NOB (NOB: 5, 1.1%) group. The proportion of OB was higher in the left-colon (52.8%) than in the right colon (16.0%) and rectum (31.1%, P<0.001). However, OB was associated with an older age (P=0.013). The proportion of advanced tumor stage was higher in OB (II: 35.8%, III: 39.5%, IV: 24.7%) than in NOB (II: 53.2%, III: 35.8%, IV: 11.0%, P<0.001). The 5-year cancer-related survival for OB was worse than NOB (OB: 77.3%, NOB: 57.8%, P<0.05). However, in the cases of a colorectal cancer performed curative resection (stage II and III), the survival for OB was not worse than NOB: stage II (OB: 82.8%, NOB: 92.2%, P=0.24), stage III (OB: 65.2%, NOB: 56.9%, P=0.43). CONCLUSIONS: OB has older and more advanced disease characteristics. However, if an oncologically curative resection is performed, the survival for OB is similar to that of a NOB.

IMA-origin Lymph Node Metastasis in Left Colon Cancer

PURPOSE: Although an extended colon resection with high ligation of the inferior mesenteric artery (IMA) generally has been recommended as curative surgery for advanced left colon cancer (LCC), it shows little or no survival advantage over segmental resection with low ligation of IMA. The present study is to determine the risk factors associated with IMA-origin lymph-node (LN) metastasis and to clarify the implication of IMA-origin LN metastasis. METHODS: We examined the clinicopathological results of 200 cases of LCC. LN dissection was performed as follows: D2 en-bloc resection of the primary tumor, IMA-origin LN dissection, and paraaortic LN dissection. RESULTS: The incidence of IMA-origin LN metastasis of LCC was 4.5% (9 cases), and all cases involved sigmoid colon cancer. The independent risk factors of IMA-origin LN metastasis were four or more regional LN metastases (hazard ratio: 16.51, 95% confidence interval: 1.60~164.12) and a preoperative CEA level of greater than 6 ng/ml of (hazards ratio: 6.63, 95% confidence interval: 1.06~41.32). The incidence of IMA-origin LN metastasis among stage IIIC patients was 26.7%. Five of the 9 (55.6%) cases of IMA-origin LN metastasis had a concomitant paraaortic LN metastasis. CONCLUSIONS: The incidence of IMA-origin LN metastasis among patients with LCC was low; however, IMA-origin LN metastasis should be considered as a systemic metastasis.

Cecal Cancer with Xanthogranulomatous Inflammation

Xanthogranulomatous inflammation is a chronic inflammatory condition characterized by aggregation of lipid-laden foamy macrophages (xanthoma cells). This disease entity is well- recognized in the kidney and gallbladder. However, involvement of the colon is extremely rare. Radiologically, xanthogranulomatous inflammation could be misinterpreted as a locally invasive cancerous lesion. Indeed, coexisting malignancy has been reported in xanthogranulomatous inflammation. In this case report, a woman complained of fever and right lower quadrant abdominal pain for a period of 5 days. A huge mass lesion with severe pericolic infiltration was found on abdominal CT scan. Right hemicolectomy was performed along with removal of the adjacent soft tissue and right ovary and fallopian tube. Pathology examination demonstrated xanthogranulomatous inflammation coexisting with cecal cancer (T3N0M0).