A Comparison of the Oncologic Results after Laparoscopic Abdominoperineal Resection and Ultra-low Anterior Resection with Hand-sewn Coloanal Anastomosis for Treating Distal Rectal Cancer / 대한내시경복강경외과학회지

PURPOSE: Abdominoperineal resection (APR) has been regarded as the standard procedure for the treatment of distal rectal cancer since Miles first described it in 1908. But because of the better understanding of the patterns of spreading tumor, the pelvic physiology, the development of stapling devices and introduction of total mesorectal excision (TME), the rate of sphincter preserving surgery has been increasing. The aim of this study is to compare the oncologic outcomes after laparoscopic APR and ultra-low anterior resection with handsewn coloanal anastomosis (CAA) for treating distal rectal cancer. METHODS: Between January 2003 and October 2007, 95 patients who were followed up for more than 2 years after curative laparoscopic APR or CAA for distal rectal cancer were included in this study. The clinical characteristics, pathologic findings, postoperative complications and oncologic results were retrospectively analyzed. RESULTS: There were 31 APRs and 64 CAAs. The median follow-up period was 43 (5~79) months. The mean distance between the lower margin of the tumor and the anal verge was 2.1+/-1.2 cm in APR and 3.7+/-1.4 cm in CAA (p<0.001). There were 2 (6.5%) local recurrences and 8 (25.8%) systemic recurrences after APR and 3 (4.7%) local recurrences and 10 (15.6%) systemic recurrences after CAA, respectively (p=0.641, p=0.161). The 3-year disease-specific survival rate was 86.7% in APR and 93.5% in CAA (p=0.407). The 3-year disease free survival rate was 73.7% in APR and 80.1% in CAA (p=0.161) but there were no significant differences in the oncologic results according to the stages between the two groups. CONCLUSION: The operative procedures are changing toward sphincter preservation. Laparoscopic ultra-low anterior resection and hand-sewn coloanal anastomosis is oncologically as safe as laparoscopic APR for treating lower rectal cancer. However, APR should be considered the standard treatment for distal rectal cancer when it invades the anal sphincter or the levator ani.

The Long-term Results and Causes of Death after Abdominal Aortic Aneurysm Repair

PURPOSE: The purpose of this study was to analyze the causes of late death and the long-term survival of patients following abdominal aortic aneurysm (AAA) repair. METHODS: From 1993 to 2005, 146 (98 intact and 48 ruptured) consecutive AAA patients underwent open repair. The perioperative data was supplemented with a retrospective review of the medical records and the use of the database of the National Statistical Office to calculate the survival rates and the causes of death. RESULTS: There was one operative death (1%) in the intact AAA group and 12 (25%) in the ruptured AAA group. After exclusion of the operative deaths, the survival rates of the intact AAA patients were 94.5% at 1 year, 77.0% at 5 years and 33.2% at 10 years; these findings demonstrated a significant longer survival for the intact AAA patients than for patients with ruptured AAA (86.1% at 1 year, 56.7% at 5 years and 0% at 10 years, respectively). The causes of late death included cardiovascular disease in 52.8% (coronary artery disease in 22.6%, cerebrovascular disease in 20.8%, other arterial aneurysms in 5.7% and graft-related death in 3.8%), malignancies in 11.3% and pulmonary disease in 11.3%. The multivariate analysis showed that the long-term survival rates were influenced by the rupture status, the history of cerebrovascular disease and hypertension. CONCLUSION: This study showed that the long-term survival after intact AAA repair was better than that for ruptured AAA repair even if we exclude the operative deaths. The most common cause of late death was cardiovascular disease. Our findings suggest that the patients with preoperative cerebrovascular disease and hypertension require additional care.

Comparative Evaluation of Immune Responses after Laparoscopic and Open Surgery in Patients with Colorectal Cancer

PURPOSE: The laparoscopic approach is thought to reduce postoperative immunologic and metabolic effects after surgery compared to the open approach. This study was designed to compare the systemic immune and metabolic responses after laparoscopic and open surgery in patients with colorectal cancer. METHODS: Forty-four patients with colorectal cancer were prospectively assigned to undergo either a laparoscopic (n=22) or open (n=22) approach. The postoperative immune and metabolic responses were assessed by measuring the serum level of the relative proportion of lymphocytes, the T-cell count, the natural killer cell (NK-cell) count, the human leukocyte antigen-DR (HLA-DR) expression on monocytes, the interleukin-6 (IL-6), and the C-reactive protein (CRP) at specific time intervals. RESULTS: Both approaches resulted in a significant decrease in lymphocyte count, T-cell count, NK-cell count, and HLA-DR expression on monocytes at 2, 24, and 72 hours postoperatively. However, the decrease in HLA-DR expression on monocytes was more significant in open surgery at 2 hour postoperatively (mean level, laparoscopic: 90.9% vs. open: 83.1%, P<0.001). Significant rises in IL-6 and CRP were demonstrated within 72 hour postoperatively in both groups. However, no significant difference between the two groups was seen. CONCLUSIONS: Although both laparoscopic and open surgery in patients with colorectal cancer evoked an alteration of the systemic inflammatory and immune response, our data showed that a HLA-DR expression on monocytes may be less compromised after laparoscopic approach for an immediate postoperative period. However, clearer evidence from large-scaled prospective randomized trials are needed.

Heterotopic Mesenteric Ossification Following Intraabdominal Surgery

Heterotopic mesenteric ossification is a very uncommon disorder that is characterized by new bone formation in the mesentery, which does not normally undergo ossification. A 52-year-old female experienced a small bowel obstruction 12 days after a segmental resection of the small bowel following a trauma. A laparotomy was performed 16 days after the initial operation, and a 2 cm hard mass was detected in the small bowel mesentery, with severe fibrous adhesions around the mass, involving the jejunum, which required resection. Postoperatively, the patient developed an intraabdominal abscess, followed by intestinal fistulation. The patient gradually recovered by conservative management, and left hospital 70 days after the first operation. Microscopic examination of the mass showed well oriented trabeculae of the osseous tissue, osteoid formation, with fine calcification and osteoblastic activity, but there was no formation of mature lamellar bone or clear evidence of the "zone phenomenon" that is classically described in heterotopic ossification. These findings appeared consistent with an early stage of heterotopic ossification. The etiology and pathogenesis are unknown; the heterotopic mesenteric ossification was thought to be associated with the trauma (intraabdominal surgery). The previous literature on heterotopic mesenteric ossification is reviewed, and a new case reported.

Heterotopic Mesenteric Ossification Following Intraabdominal Surgery

Heterotopic mesenteric ossification is a very uncommon disorder that is characterized by new bone formation in the mesentery, which does not normally undergo ossification. A 52-year-old female experienced a small bowel obstruction 12 days after a segmental resection of the small bowel following a trauma. A laparotomy was performed 16 days after the initial operation, and a 2 cm hard mass was detected in the small bowel mesentery, with severe fibrous adhesions around the mass, involving the jejunum, which required resection. Postoperatively, the patient developed an intraabdominal abscess, followed by intestinal fistulation. The patient gradually recovered by conservative management, and left hospital 70 days after the first operation. Microscopic examination of the mass showed well oriented trabeculae of the osseous tissue, osteoid formation, with fine calcification and osteoblastic activity, but there was no formation of mature lamellar bone or clear evidence of the "zone phenomenon" that is classically described in heterotopic ossification. These findings appeared consistent with an early stage of heterotopic ossification. The etiology and pathogenesis are unknown; the heterotopic mesenteric ossification was thought to be associated with the trauma (intraabdominal surgery). The previous literature on heterotopic mesenteric ossification is reviewed, and a new case reported.