Coring-out fistulectomy for perianal cryptoglandular fistula: a retrospective cohort study on 20 years of experience at a single center

Purpose@#Cryptoglandular fistula is one of the common anal diseases requiring surgical treatment. Various surgical techniques have been introduced; however, there is no known standard technique. Coring-out fistulectomy is a surgical technique that accurately resects only the fistula tract. However, only a few cases of this procedure have been reported.We aimed to analyze the surgical outcomes of coring-out fistulectomy for cryptoglandular anal fistulas. @*Methods@#We retrospectively reviewed the medical records of patients who underwent coring-out fistulectomy for a cryptoglandular fistula between 1999 and 2019. Primary outcomes were the treatment success rate (recurrence and healing rates) and incidence of fecal incontinence. @*Results@#A total of 184 patients were included in our study. The average age of the patients was 44 years (range, 16–75 years), and 88.0% were male. Twenty-four (13.0%), 13 (7.1%), and 68 patients (37.0%) underwent operation for recurrent fistula, multiple tracts, and complex type fistula, respectively. The healing rate was 92.4%, and recurrence occurred in 15 of 170 healed patients (8.8%). Thus, the treatment success rate was 84.2%. There was no fecal incontinence except in 1 patient who had preoperative fecal incontinence because of cauda equine syndrome. In multivariable analysis of the factors affecting the treatment success rate, the complex fistula (odds ratio [OR], 14.2; 95% confidence interval [CI], 4.7– 43.0; P < 0.001) and undetected internal opening during the operation (OR, 4.0; 95% CI, 1.4–11.6; P = 0.012) were significant factors. @*Conclusion@#Coring-out fistulectomy is a simple and feasible technique for sphincter-preserving anal fistula surgery.

Retroperitoneal sarcomas: Outcomes of repeated resections

Purpose@#Retroperitoneal sarcomas (RPS) are rare malignant tumors arising from mesenchymal cells. The objective of this study was to review the treatment experiences and to identify prognostic factors for overall survival (OS) after primary resection and subsequent reoperations for recurrences. @*Methods@#The medical records of patients who underwent resection for RPS at our institution between June 2002 and December 2016 were retrospectively reviewed. Univariate and multivariable Cox proportional hazards modeling was used to assess the prognostic factors for OS. @*Results@#A total of 48 patients were enrolled. On multivariable analysis in primary resection group, the FNCLCC (Fédération Nationale des Centres de Lutte Contre le Cancer) grade was a significant prognostic factor for OS (P=0.006). The patients who received chemotherapy after primary resection were significantly associated with poor prognosis (P=0.009). The 5-year OS rate after primary resection (n=48) were 58.1% and the 5-year cumulative reoperation rate after primary resection was 62.5%. After second resection for recurrence after primary resection (n=23), the 5-year OS rate was 64.3%. There was a tendency towards decreased surgery-free survival rate as the number of repeated resections for recurrent RPS increased. In the subset of patients (n=16) who underwent more than 3 repeated resections at our institute, the 5-year OS rate was 75.0%, indicating that repeated resections are not associated with worse outcome. @*Conclusion@#Only low tumor grade was an independent favorable prognostic factor for OS. Although the prognosis for RPS remains poor, repeated resections for recurrence are not associated with poor prognosis. Aggressive surgical strategies for recurred RPS patients are warranted.

Preoperative Colonoscopic Tattooing Using a Direct Injection Method with Indocyanine Green for Localization of Colorectal Tumors: An Efficacy and Safety Comparison Study

Purpose@#Endoscopic tattooing is used to mark colorectal lesions for subsequent surgery. As a tattooing agent, India ink has been widely used but is not currently available in Korea. Indocyanine green (ICG) can be applied as an alternative agent. However, studies on colonoscopic tattooing by the direct injection of indocyanine green are lacking. This study aimed to compare the efficacy and safety between an ICG direct injection method and an India ink saline test injection method. @*Methods@#A total of 227 patients who underwent preoperative endoscopic tattooing for colorectal neoplasm (149 patients in the ICG direct injection group and 78 patients in the India ink saline test injection group) were included in the study. The efficacy of the two methods was compared by visualization and safety was compared by evaluating the perioperative tattooing complications. @*Results@#The visualization of lesions in the ICG group was not different from that of the India ink group (p=0.42, 96.0% vs 98.7%, respectively). Only one patient in the ICG group had abdominal pain related to tattooing, but no complications developed in the India ink group. @*Conclusion@#Considering the good visualization and low complication rate, the direct injection of ICG can be used as an alternative tattooing method.

Preoperative Colonoscopic Tattooing Using a Direct Injection Method with Indocyanine Green for Localization of Colorectal Tumors: An Efficacy and Safety Comparison Study

Purpose@#Endoscopic tattooing is used to mark colorectal lesions for subsequent surgery. As a tattooing agent, India ink has been widely used but is not currently available in Korea. Indocyanine green (ICG) can be applied as an alternative agent. However, studies on colonoscopic tattooing by the direct injection of indocyanine green are lacking. This study aimed to compare the efficacy and safety between an ICG direct injection method and an India ink saline test injection method. @*Methods@#A total of 227 patients who underwent preoperative endoscopic tattooing for colorectal neoplasm (149 patients in the ICG direct injection group and 78 patients in the India ink saline test injection group) were included in the study. The efficacy of the two methods was compared by visualization and safety was compared by evaluating the perioperative tattooing complications. @*Results@#The visualization of lesions in the ICG group was not different from that of the India ink group (p=0.42, 96.0% vs 98.7%, respectively). Only one patient in the ICG group had abdominal pain related to tattooing, but no complications developed in the India ink group. @*Conclusion@#Considering the good visualization and low complication rate, the direct injection of ICG can be used as an alternative tattooing method.

Retroperitoneal sarcomas: Outcomes of repeated resections

Purpose@#Retroperitoneal sarcomas (RPS) are rare malignant tumors arising from mesenchymal cells. The objective of this study was to review the treatment experiences and to identify prognostic factors for overall survival (OS) after primary resection and subsequent reoperations for recurrences. @*Methods@#The medical records of patients who underwent resection for RPS at our institution between June 2002 and December 2016 were retrospectively reviewed. Univariate and multivariable Cox proportional hazards modeling was used to assess the prognostic factors for OS. @*Results@#A total of 48 patients were enrolled. On multivariable analysis in primary resection group, the FNCLCC (Fédération Nationale des Centres de Lutte Contre le Cancer) grade was a significant prognostic factor for OS (P=0.006). The patients who received chemotherapy after primary resection were significantly associated with poor prognosis (P=0.009). The 5-year OS rate after primary resection (n=48) were 58.1% and the 5-year cumulative reoperation rate after primary resection was 62.5%. After second resection for recurrence after primary resection (n=23), the 5-year OS rate was 64.3%. There was a tendency towards decreased surgery-free survival rate as the number of repeated resections for recurrent RPS increased. In the subset of patients (n=16) who underwent more than 3 repeated resections at our institute, the 5-year OS rate was 75.0%, indicating that repeated resections are not associated with worse outcome. @*Conclusion@#Only low tumor grade was an independent favorable prognostic factor for OS. Although the prognosis for RPS remains poor, repeated resections for recurrence are not associated with poor prognosis. Aggressive surgical strategies for recurred RPS patients are warranted.

Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences

PURPOSE: Rectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures. METHODS: Between 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted. RESULTS: The median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058). CONCLUSION: Radiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.

Significance of lymph node metastasis in the survival of stage IV colorectal cancer by hematogenous metastasis

PURPOSE: Although lymph node (LN) metastasis is an important prognostic marker of colorectal cancer (CRC), the effect of LN metastasis on the survival of stage IV CRC is debated yet. METHODS: LN status and survivals as well as clinicopathological features of synchronous stage IV CRC patients, operated for 8 years, were analyzed. Patients with hematogenous metastases were included only but those with peritoneal seeding or preoperative adjuvant therapy were not included. RESULTS: Total 850 patients were enrolled and 77 (9.1%) were without LN metastases (N0M1). N0M1 patients were older and have favorable pathological features including lower CEA than patients with LN metastasis (N + M1). The pathologically poor features accumulated with N stage progression within N + M1. N0M1 had better 5-year overall survival (OS) and disease free survival than N + M1. And 5-year OS's within N + M1 group were stratified and different according to N stage progression, although the effect of N stage progression is different according to curative resection or not. When compared with stage III, 5-year OS of N0M1 with curative resection was comparable to that of anyTN2aM0 and was better than anyTN2bM1. CONCLUSION: LN metastasis is a significant prognostic factor in stage IV by hematogenous metastasis, too. N stage progression accumulates pathologically poor prognostic factors. However, the effect on survival of each N stage progression differs depending on curative resection or not of the hematogenous metastases.

Comparison of post-surgery follow-up methods in patients aged 80 years or older with non-metastatic colorectal cancer

PURPOSE: Studies investigating the appropriate post-surgery follow-up method for elderly patients with colorectal cancer are limited. Thus, the purpose of this study was to compare survival rates between two follow-up methods in patients aged 80 years or older who underwent surgery for colorectal cancer.METHODS: Between January 1, 2002 and December 31, 2010, 165 patients aged 80 years or older underwent curative resection for non-metastatic colorectal cancer at the Department of Surgery, Seoul National University Hospital. Sixty-six of these patients were excluded due to the lack of follow-up, while the remaining 99 were included in our study. These 99 patients were divided into the following two groups depending on their post-surgery follow-up method. Patients who underwent follow-up on a regular basis, which was defined as once every six months to one year, with carcinoembryonic antigen (CEA) and computed tomography (CT) comprised the Regular group, and those who received follow-up with CEA alone or underwent CT procedures once every two years or more comprised the Minimal group. Overall survival was analyzed with the log-rank test and Cox regression analysis.RESULTS: Of the 99 patients, 62 were in Regular group and 37 were in Minimal group. There was no difference in overall survival rate between the two post-surgery follow-up methods (regular group vs. minimal group: 51.6% vs. 50.9% [5-year overall survival rate], P=0.819). Additionally, no significant differences was detected between the groups following multivariate analysis (harzard ratio=0.907; 95% confidence interval=0.460–1.788, P=0.777).CONCLUSION: A significant survival gain was not observed between Regular and Minimal group. To draw a more definite conclusion, a multi-center randomized research study should be conducted.

Outcomes after local excision for rectal neuroendocrine tumor

PURPOSE: Neuroendocrine tumor is a rare tumor in the rectum, but incidence has been increasing. Local excision is an option for treatment of small tumors, and transanal excision or endoscopic resection can be undergone. But indications for local excision have not been established yet. This study was to compare the long-term oncologic outcomes between transanal excision and endoscopic resection for rectal neuroendocrine tumor.METHODS: Patients diagnosed and treated with rectal neuroendocrine tumor from 2000 to 2015 were collected prospectively, and medical records were analyzed retrospectively.RESULTS: Forty patients were included, mean age was 50.20±13.35 years (male:female=23:17). Transanal excision and endoscopic resection were performed in 28 (70%) and 12 (30%) patients, respectively. Mean tumor size was 0.63±0.37 cm, and tumor location was 5.45±1.89 cm from anal verge. Tumor location was more distal rectum in transanal excision (5.04±1.73 cm vs. 6.42±1.98 cm, P=0.049). Pathologic T stage was T1 in all patients. Most of the patients (90%) showed tumor grade 1. After median 24 months (range, 0–86 months) follow-up, one patient (2.5%) experienced local recurrence. The patient underwent further transanal excision. There was no mortality after local excision.CONCLUSION: Local excision is a safe and effective treatment for small-sized neuroendocrine tumors in rectum.

Surgical treatment for high-grade pseudomyxoma peritonei originated from appendix: Analysis of clinical outcomes of repeated debulking surgery

PURPOSE: To evaluate the effect of repeated debulking surgery for high-grade pseudomyxoma peritonei (PMP) originating from the appendix.METHODS: Between January 1998 and December 2014, fifty patients, who underwent debulking surgery for high-grade PMP originating from the appendix, were obtained from a prospectively collected database and retrospectively analyzed. Two groups according to the number of operations were divided and analyzed.RESULTS: A total of 118 operations were performed. Thirty-one patients received more than two operations. The median interval between operations was 18.2 months (range, 2–170 months). Complications developed after 26 operations (22.0%), including ileus (n=10), intra-abdominal fluid collection (n=7), surgical site infection (n=5), and others. There were two mortalities within 30 days after operation. Between two groups of patients who received one operation only and patients who received more than two operations, transfusion, diversion operation, and postoperative complication rate showed statistically significant differences. Two groups of patients had no differences in overall survival rates.CONCLUSION: Our results indicate that the number of operations does not affect the survival rate of high-grade appendiceal PMP, in which repeated debulking surgery is vital to relieve symptoms of the tumor burden.

Long-term Oncologic Outcomes of Obesity after Laparoscopic Surgery for Colorectal Cancer in Asian Patients

PURPOSE: The adverse effects of obesity on short-term surgical outcomes after laparoscopic colorectal surgery have been reported. However, the influence of obesity on long-term oncological outcomes after laparoscopic surgery in Asian patients has not been well understood. The aim of this study was to evaluate the effect of obesity on long-term oncologic outcomes in patients who underwent laparoscopic surgery for colorectal cancer. METHODS: Overall, 424 consecutive patients who underwent laparoscopic resection for colorectal cancer between January 2005 and July 2012 were included in this retrospective study. Patients were classified as non-obese (body mass index [BMI] <25.0 kg/m²) and obese (BMI ≥25.0 kg/m²) according to the categories proposed by the International Obesity Task Force. A survival analysis was performed using clinicopathologic characteristics, including obesity. RESULTS: Of the 424 patients, 325 (76.7%) were classified as non-obese and 99 (23.3%) as obese. The clinicopathologic characteristics of the obese and non-obese groups were similar, except that there were more underlying comorbidities, a lower frequency of smoking, and fewer tumors in rectum in the obese group. Results of the multivariate analysis showed that older age, elevated serum carcinoembryonic antigen, high-grade histology, advanced tumor stage, and perineural invasion were associated with poorer disease-free survival and overall survival. Obesity was not significantly associated with disease-free survival (hazard ratio [HR], 1.196; 95% confidence interval [CI], 0.686~2.086; p=0.528) or overall survival (HR, 1.156; 95% CI, 0.584~2.289; p=0.677). CONCLUSION: Laparoscopic surgery for colorectal cancer seems to be safe and feasible for obese patients in terms of long-term oncologic outcomes.

Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study

PURPOSE: This study prospectively investigated the effects of biofeedback therapy on objective anorectal function and subjective bowel function in patients after sphincter-saving surgery for rectal cancer. METHODS: Sixteen patients who underwent an ileostomy were randomized into two groups, one receiving conservative management with the Kegel maneuver and the other receiving active biofeedback before ileostomy closure. Among them, 12 patients (mean age, 57.5 years; range, 38 to 69 years; 6 patients in each group) completed the study. Conservative management included lifestyle modifications, Kegel exercises, and medication. Patients were evaluated at baseline and at 1, 3, 6, and 12 months after ileostomy closure by using anal manometry, modified Wexner Incontinence Scores (WISs), and fecal incontinence quality of life (FI-QoL) scores. RESULTS: Before the ileostomy closure, the groups did not differ in baseline clinical characteristics or resting manometric parameters. After 12 months of follow-up, the biofeedback group demonstrated a statistically significant improvement in the mean maximum squeezing pressure (from 146.3 to 178.9, P = 0.002). However, no beneficial effect on the WIS was noted for biofeedback compared to conservative management alone. Overall, the FI-QoL scores were increased significantly in both groups after ileostomy closure (P = 0.006), but did not differ significantly between the two groups. CONCLUSION: Although the biofeedback therapy group demonstrated a statistically significant improvement in the maximum squeezing pressure, significant improvements in the WISs and the FI-QoL scores over time were noted in both groups. The study was terminated early because no therapeutic benefit of biofeedback had been demonstrated.

Erratum: Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study

In this article, the sixth author's affiliation was misprinted unintentionally.