Predictive factors and the prognosis of recurrence of colorectal cancer within 2 years after curative resection.

PURPOSE: Because predicting recurrence intervals and patterns would allow for appropriate therapeutic strategies, we evaluated the clinical and pathological characteristics of early and late recurrences of colorectal cancer. METHODS: Patients who developed recurrence after undergoing curative resection for colorectal cancer stage I-III between January 2000 and May 2006 were identified. Early recurrence was defined as recurrence within 2 years after primary surgery of colorectal cancer. Analyses were performed to compare the clinicopathological characteristics and overall survival rate between the early and late recurrence groups. RESULTS: One hundred fifty-eight patients experienced early recurrence and 64 had late recurrence. Multivariate analysis revealed that the postoperative elevation of carbohydrate antigen 19-9 (CA 19-9), venous invasion, and N stage correlated with the recurrence interval. The liver was the most common site of early recurrence (40.5%), whereas late recurrence was more common locally (28.1%), or in the lung (32.8%). The 5-year overall survival rates for early and late recurrence were significantly different (34.7% vs. 78.8%; P < 0.001). Survival rates after the surgical resection of recurrent lesions were not different between the two groups. CONCLUSION: Early recurrence within 2 years after surgery was associated with poor survival outcomes after colorectal cancer recurrence. An elevated postoperative CA 19-9 level, venous invasion, and advanced N stage were found to be significant risk factors for early recurrence of colorectal cancer.

Transvaginal specimen extraction versus conventional minilaparotomy after laparoscopic anterior resection for colorectal cancer: mid-term results of a case-matched study.

BACKGROUND: Although the vagina is considered a viable route during laparoscopic surgery, a number of concerns have led to a need to demonstrate the safety of a transvaginal approach in colorectal surgery. However, the data for transvaginal access in left-sided colorectal cancer are extremely limited, and no study has compared the clinical outcomes with a conventional laparoscopic procedure. OBJECTIVE: We compared the clinical outcomes of totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) with those of the conventional laparoscopic approach with minilaparotomy (LAP) for anastomosis construction and specimen retrieval in left-sided colorectal cancer. METHODS: Fifty-eight patients underwent TVSE between October 2006 and July 2011 and were matched by age, surgery date, tumor location, and tumor stage with patients who underwent conventional LAP for left-sided colorectal cancer. RESULTS: Operative time was significantly longer in the TVSE group (149.3 ± 39.8 vs. 131.9 ± 41.4 min; p = 0.023). Patients in the TVSE group experienced less pain (pain score 4.9 ± 1.6 vs. 5.8 ± 1.9; p = 0.008), shorter time to passage of flatus (2.2 ± 1.1 vs. 2.7 ± 1.2 days; p = 0.026), and higher satisfaction with the cosmetic results (cosmetic score 8.0 ± 1.4 vs. 6.3 ± 1.5; p = 0.001). More endolinear staplers for rectal transection were used in the LAP group (1.2 ± 0.5 vs. 1.1 ± 0.2; p = 0.021). Overall morbidities were similar in both groups; however, three wound infections only occurred in the LAP group. After a median follow-up of 34.4 (range 11-60) months, no transvaginal access-site recurrence occurred. The 3-year disease-free survival was similar between groups (91.5 vs. 90.8%; p = 0.746). CONCLUSIONS: Transvaginal access after totally laparoscopic anterior resection is safe and feasible for left-sided colorectal cancer in selected patients with better short-term outcomes.

Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy for patients with colorectal cancer peritoneal carcinomatosis: initial results from a single center.

BACKGROUND: In recent decades, a combination of cytoreductive surgery and intraperitoneal chemotherapy has yielded improvements in the survival of patients with peritoneal carcinomatosis. Laparoscopic cytoreductive surgery and intraperitoneal chemotherapy comprise a challenging and rarely reported surgical procedure. METHODS: Between November 2004 and February 2010, 29 patients underwent cytoreductive surgery and early postoperative intraperitoneal chemotherapy for peritoneal carcinomatosis secondary to colorectal cancer. Of the 29 patients, 15 underwent laparoscopic surgery and 14 underwent open surgery. RESULTS: The patient characteristics did not differ significantly between the two groups. Synchronous peritoneal carcinomatosis with a primary tumor was more common in the laparoscopic group, and the Gilly stage of peritoneal carcinomatosis was found more frequently in the open group. Complication rate and hospital stay were less in the laparoscopic group. However, the outcomes for the patients undergoing the combined treatment were similar between the two groups with respect to completeness of cytoreduction, operation morbidity, and overall survival. The laparoscopic group had a cytoreduction completeness of 86.7 % and an operative morbidity of 13.3 %. Operative mortality occurred for one patient after open surgery. CONCLUSIONS: Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy can be performed safely for selected patients with peritoneal carcinomatosis from colorectal cancer to a limited extent. Further studies with longer follow-up periods and larger numbers of patients are warranted to confirm the study findings.

Urinary and erectile function in men after total mesorectal excision by laparoscopic or robot-assisted methods for the treatment of rectal cancer: a case-matched comparison.

BACKGROUND: Urinary and sexual dysfunction are recognized complications of rectal cancer surgery in men. This study compared robot-assisted total mesorectal excision (RTME) and laparoscopic total mesorectal excision (LTME) with regard to these functional outcomes. METHODS: A series of 32 men who underwent RTME between February 1, 2009 and December 31, 2010 were matched 1:1 with patients who underwent LTME. The matching criteria were age, body mass index, tumor distance from the anal verge, neoadjuvant chemoradiation therapy, and tumor stage. Urinary and erectile function were evaluated using the International Prostatic Symptom Score (IPSS) and the five-item version of the International Index of Erectile Function (IIEF-5) scale. Data were collected from the two groups at baseline and at 3, 6, and 12 months after surgery and compared. RESULTS: The mean IPSS score did not differ between the two groups at baseline at any point of measurement. The mean baseline IIEF-5 score was similar between the two groups and was decreased at 3 months. The mean IIEF-5 score was significantly higher in the RTME group at 6 months than in the LTME group (14.1 ± 6.1 vs. 9.4 ± 6.6; p = 0.024). The interval decrease in IIEF-5 scores was significantly higher in the LTME group than in the RTME group at 6 months (4.9 ± 4.5 vs. 9.2 ± 4.7; p = 0.030). CONCLUSIONS: The men in the RTME group experienced earlier restoration of erectile function than did those in the LTME group. Bladder function was similar during the 12 months after RTME or LTME.

Robotic-assisted transabdominal intersphincteric resection: a technique involving a completely abdominal approach and coloanal anastomosis.

BACKGROUND: As the use of a surgical robot allows for improved dexterity and visual field, we successfully conducted transabdominal intersphincteric resection (ISR) and perineal coloanal anastomosis for a very low lying rectal cancer. The aim of this study was to evaluate the technical feasibility of this procedure. MATERIALS AND METHODS: Eight patients underwent robotic-assisted transabdominal ISR with coloanal anastomosis for low rectal cancers. The surgical procedures included 5 steps: colonic mobilization with ligation of inferior mesenteric vessels, total mesorectal excision, intersphincteric dissection with rectal transection, specimen retrieval, and coloanal anastomosis. RESULTS: The median operation time was 210 minutes, and the median estimated blood loss was 40.0 mL. The hypogastric nerve and pelvic nerve plexus was preserved in all patients. No intraoperative-related or robotic system-related morbidities were observed. In all patients, R0 resection was achieved, and the quality of the total mesorectal excision was optimal. CONCLUSIONS: Robotic transabdominal ISR is a safe operation with an expectation of future advances in pathologic quality and functional preservation. Additional work in a larger series of patients is necessary to refine this technique and to establish its efficacy.

Short-term clinical outcome of robot-assisted intersphincteric resection for low rectal cancer: a retrospective comparison with conventional laparoscopy.

BACKGROUND: A robotic system (da Vinci(®) Surgical System, Intuitive Surgical Inc., Sunnyvale, CA, USA) has technical advantages over conventional laparoscopic surgery because it increases the precision and accuracy of anatomical dissection. The present study aimed to compare the short-term outcomes between robot-assisted intersphincteric resection (ISR) and laparoscopic ISR for distal rectal cancer. METHODS: Patients who underwent robot- or laparoscopy-assisted ISR for rectal cancer between March 2008 and July 2011 were included in this retrospective comparative study. Perioperative and postoperative data, including complications and early functional outcomes, were analyzed between the two groups. Functional outcomes were evaluated using the Wexner scoring system, the International Prostate Symptom Score, and the 5-item version of the International Index of Erectile Function. RESULTS: A total of 40 patients underwent robot-assisted and 40 underwent laparoscopic ISR. The mean operative time was significantly longer in the robotic group than in the laparoscopic group (235.5 vs. 185.4 min; p < 0.001). Transabdominal ISR, in which intersphincteric dissection is completed in the pelvic cavity, was performed more with robotic assistance than with laparoscopic surgery (8 vs. 2 cases; p = 0.043). No difference was observed between groups regarding postoperative morbidity and pathological outcomes. The robot-assisted group showed a trend toward less postoperative blood loss and early recovery of functional outcomes. CONCLUSION: Robot-assisted surgery was safe and effective for ISR of distal rectal cancer and showed surgical outcomes similar to those of the latest laparoscopic ISR. The favorable results of the robot-assisted ISR included reduced adaptation time, alleviated difficulty of perineal phase, and early recovery of functional outcomes in this analysis of short-term clinical outcomes.

Early postoperative and long-term oncological outcomes of laparoscopic treatment for patients with familial adenomatous polyposis.

PURPOSE: We evaluated the short- and long-term outcomes of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (TPC/IPAA) for treatment of familial adenomatous polyposis (FAP). Also, we assessed the oncologic outcomes in FAP patients with coexisting malignancy. METHODS: From August 1999 to September 2010, 43 FAP patients with or without coexisting malignancy underwent TPC/IPAA by a laparoscopic-assisted or hand-assisted laparoscopic surgery. RESULTS: The median age was 33 years (range, 18 to 58 years) at the time of operation. IPAA was performed by a hand-sewn method in 21 patients (48.8%). The median operative time was 300 minutes (range, 135 to 610 minutes), which reached a plateau after 22 operations. Early postoperative complications within 30 days occurred in 7 patients (16.3%) and long-term morbidity occurred in 15 patients (34.9%) including 6 (14.0%) with desmoid tumors and 3 (7.0%) who required operative treatment. Twenty-two patients (51.2%) were diagnosed with coexisting colorectal malignancy. The median follow-up was 58.5 months (range, 7.9 to 97.8 months). There was only 1 case of local recurrence in the pelvic cavity. No cases of adenocarcinoma at the residual rectal mucosa developed. 5-year disease-free survival rate for 22 patients who had coexisting malignancy was 86.5% and 5-year overall survival rate was 92.6%. Three patients died from pulmonary or hepatic metastasis. CONCLUSION: Laparoscopic TPC/IPAA in patients with FAP is feasible and offers favorable postoperative outcomes. It also delivered acceptable oncological outcomes in patients with coexisting malignancy. Therefore, laparoscopic TPC/IPAA may be a favorable treatment option for FAP.

Influence of surgical manipulation and surgical modality on the molecular detection of circulating tumor cells from colorectal cancer.

PURPOSE: The aim of this study was to evaluate the relationship between the detection of circulating tumor cell molecular markers from localized colorectal cancer and the time-course of a surgical manipulation or surgical modality. METHODS: From January 2010 to June 2010, samples from the peripheral blood and the inferior mesenteric vein were collected from 42 patients with cancer of the sigmoid colon or rectum. Pre-operative, intra-operative (both pre-mobilization and post-mobilization), and post-operative samples were collected. We examined carcinoembryonic antigen (CEA) mRNA and cytokeratin-20 (CK20) mRNA by real-time reverse-transcriptase polymerase chain reaction. Changes in mRNA detection rates were analyzed according to the time of blood sample collection, the surgical modality, and patient clinicopathological features. RESULTS: mRNA expression rates before surgical resection did not differ between blood samples from the peripheral and inferior mesenteric veins. The detection rate for CEA and CK20 mRNA showed a tendency to increase after operative mobilization of the cancer-bearing bowel segment. Furthermore, the cumulative detection rates for CEA and CK20 mRNA increased significantly over the course of surgery (pre-mobilization vs. post-mobilization). The cumulative detection rate decreased significantly after surgical resection compared with the pre-operative rates. However, no significant difference was observed in the detection rates between different surgical modalities (laparoscopy vs. open surgery). CONCLUSION: The results of this study suggest that surgical manipulation has a negative influence on the dissemination of circulating tumor cells during operations on localized colorectal cancer. However, the type of surgical technique did not affect circulating tumor cells.

Single-incision Laparoscopic Surgery for Appendiceal Mucoceles: Safety and Feasibility in a Series of 16 Consecutive Cases.

PURPOSE: The aim of this study was to evaluate the technical feasibility, safety, and oncological outcomes of transumbilical single-incision laparoscopic surgery in patients with an uncomplicated appendiceal mucocele. METHODS: A review of a prospectively collected database at the Kyungpook National University Hospital from January 2006 to September 2010 revealed that a series of 16 consecutive patients underwent single-incision laparoscopic surgery (SILS) for an appendiceal mucocele. Data regarding patient demographics, operating time, conversion, surgical morbidity, lateral lymph node status, and mid-term oncologic result were analyzed. RESULTS: The reported series consisted of 7 women (50%) and 9 men with a mean age of 61.6 years (range, 41 to 88 years). The mean operative time was 66.8 minutes (range, 33 to 150 minutes). Perioperative mortality and morbidity were 0% and 6.2%, respectively. Recovery after the procedure was rapid, and the mean hospital stay was 6.8 days (range, 3 to 22 days). Pathology revealed 12 lesions compatible with a mucinous cystadenoma and four others compatible with benign cystic tumors. All surgical margins were clear. In one case, an extra port had to be placed, and another case required conversion from SILS to a standard open laparotomy immediately after identification of the tumor because of a micro-perforation with focal mucin collection. With a median follow-up of 28.7 months, no re-admission or tumor recurrence, such as pseudomyxoma peritonei, was noted in 14 patients. CONCLUSION: A single-port laparoscopic mucocelectomy should be safe and feasible and has the advantage of being a minimally invasive approach. Prospective controlled studies comparing SILS and conventional open surgery, with long-term follow-up evaluation, are needed to confirm the author's initial experience.

Abdominal aortic aneurysm repair in patient with a renal allograft: a case report.

Renal transplant recipients requiring aortic reconstruction due to abdominal aortic aneurysm (AAA) pose a unique clinical problem. The concern during surgery is causing ischemic injury to the renal allograft. A variety of strategies for protection of the renal allograft during AAA intervention have been described including a temporary shunt, cold renal perfusion, extracorporeal bypass, general hypothermia, and endovascular stent-grafting. In addition, some investigators have reported no remarkable complications of the renal allograft without any specific measures. We treated a case of AAA in a patient with a renal allograft using a temporary aortofemoral shunt with good result. Since this technique is safe and effective, it should be considered in similar patients with AAA and previously placed renal allografts.