Bong-Hyeon Kye

Tumor budding as a risk factor of lymph node metastasis in submucosal invasive T1 colorectal carcinoma: a retrospective study

BackgroundThis study was designed to identify risk factors for lymph node metastasis of early stage colorectal cancer, which was confirmed to a carcinoma that invaded the submucosa after radical resection.MethodsIn total, 55 patients revealing submucosal invasive colorectal carcinoma on pathology who underwent curative radical resection at the Department of Surgery, St. Vincent’s Hospital, The Catholic University of Korea from January 2007 to September 2010 were evaluated retrospectively. Tumor size, depth of submucosal invasion, histologic grade, lymphovascular invasion, tumor budding, and microacinar structure were reviewed by a single pathologist. Student t-test for continuous variables and Chi-square test for categorical variables were used for comparing the clinicopathological features between two groups (whether lymph node involvement existed or not). Continuous variables are expressed as the mean ± standard error while statistical significance is accepted at P < 0.05.ResultsThe mean age of 55 patients (34 males and 21 females) was 61.2 ± 9.6 years (range, 43–83). Histologically, eight (14.5%) patients had metastatic lymph node. In the univariate analysis, tumor budding (P = 0.047) was the only factor that was significantly associated with lymph node metastasis. Also, the tumor budding had a sensitivity of 83.3%, a specificity of 60.5%, and a negative predictive value of 0.958 for lymph node metastasis in submucosal invasive T1 colorectal cancer.ConclusionsThe tumor budding seems to have a high sensitivity (83.3%), acceptable specificity (60.5%), and a high negative predictive value (0.958). A close examination of pathologic finding including tumor budding should be performed in order to manage early CRC properly.

Treatment of Right Colonic Diverticulitis: The Role of Nonoperative Treatment

Purpose The purpose of this study is to evaluate the value of nonoperative treatment for right-sided colonic diverticulitis. Methods One hundred fifty-eight patients with right-sided colonic diverticulitis were evaluated. Clinical history, physical and radiologic findings, and treatments were reviewed retrospectively. Also, additional episodes and treatment modalities were checked. Results Our patients were classified according to treatment modality; 135 patients (85.4%) underwent conservative treatment, including antibiotics and bowel rest, and 23 patients (14.6%) underwent surgery. The mean follow-up length was 37.3 months, and 17 patients (17.5%) underwent recurrent right-sided colonic diverticulitis. Based on treatment modality, including surgery and antibiotics, no significant differences in the clinical features and the recurrence rates were noted between the two groups. Conclusion Conservative management with bowel rest and antibiotics could be considered as a safe and effective option for treating right-sided colonic diverticulitis. This treatment option for right-sided colonic diverticulitis, even if the disease is complicated, may be the treatment of choice.

Overview of radiation therapy for treating rectal cancer.

A major outcome of importance for rectal cancer is local control. Parallel to improvements in surgical technique, adjuvant therapy regimens have been tested in clinical trials in an effort to reduce the local recurrence rate. Nowadays, the local recurrence rate has been reduced because of both good surgical techniques and the addition of radiotherapy. Based on recent reports in the literature, preoperative chemoradiotherapy is now considered the standard of care for patients with stages II and III rectal cancer. Also, short-course radiotherapy appears to provide effective local control and the same overall survival as more long-course chemoradiotherapy schedules and, therefore, may be an appropriate choice in some situations. Capecitabine is an acceptable alternative to infusion fluorouracil in those patients who are able to manage the responsibilities inherent in self-administered, oral chemotherapy. However, concurrent administration of oxaliplatin and radiotherapy is not recommended at this time. Radiation therapy has long been considered an important adjunct in the treatment of rectal cancer. Although no prospective data exist for several issues, we hope that in the near future, patients with rectal cancer can be treated by using the best combination of surgery, radiation therapy, and chemotherapy in near future.

Learning Curves in Laparoscopic Right-Sided Colon Cancer Surgery: A Comparison of First-Generation Colorectal Surgeon to Advance Laparoscopically Trained Surgeon

BACKGROUND We aimed to evaluate the learning curve (LC) for laparoscopic right-sided colon cancer surgery (LRCCS) by comparing the results between two surgeons (first-generation colorectal surgeon versus laparoscopically trained surgeon). METHODS The study was a retrospective analysis that evaluated 117 consecutive LRCCSs performed by two surgeons, the first-generation surgeon (Surgeon A) and laparoscopically trained surgeon (Surgeon B), from April 1995 to August 2006. Patients were divided into two groups; patients included in groups I and II received LRCCSs from surgeons A and B, respectively. RESULTS The moving average method revealed that the operation times of surgeons A and B began to shorten after the 9th case. The cumulative sum (CUSUM) analysis of group I data showed that the 24th case was the peak point of conversion. The 35th case was the peak for intraoperative complications, and the 17th case was the peak for postoperative complications. There was only one case of conversion in group II. The peak points for inadequate lymph node dissection were the 37th case in group I and the 8th case in group II. The CUSUM analysis for surgeons A and B showed that the 18th case and the 8th case, respectively, were the overall peak points in the failure of LRCCS. CONCLUSIONS We suggest that careful observation of a laparoscopic procedure, such as acting as the scope operator for a certain amount of time, may help in shortening the LC of the actual procedure.

Clinicopathological features of retrorectal tumors in adults: 9 years of experience in a single institution.

Purpose Primary tumors of the retrorectal space in adults are very rare. Most of them are benign masses, but malignant masses are reported on occasion. This study aimed to investigate the clinicopathological features of retrorectal tumors. Methods The medical records of fifteen patients who underwent surgical resection of a retrorectal tumor from March 2002 to April 2010 in our hospital were reviewed retrospectively. Results Out of 15 patients, thirteen were females and two males. About 1.7 patients were diagnosed with retrorectal tumor annually in our hospital. The incidence is one per 1,500 surgeries performed under general anesthesia. An anterior approach was performed in eight patients and a posterior approach with excision of the coccyx in five patients. Combined approach was performed in two patients. Four patients (three in abdominal approach and one in combined approach) underwent laparoscopic resection. The mean size of tumors was 6.2 ± 2.9 cm. Mature teratoma (four) and neurilemmoma (four) were the most common tumors. Except for one case of chondrosarcoma, fourteen tumors were confirmed to be of benign nature in histologic examination. Patients who underwent a transabdominal approach with laparoscopic surgery had no postoperative complication and had a tendency to experience earlier recovery than those with open surgery. Conclusion Surgical resection of a retrorectal tumor is recommended to relieve pressure symptoms and to confirm the diagnosis. A laparoscopic approach may offer excellent visualization of the deep structures in the retrorectal space, reduce surgical trauma, and be helpful for early postoperative recovery.

Delorme's Procedure for Complete Rectal Prolapse: Does It Still Have It's Own Role?

Purpose Although there are more than a hundred techniques, including the transabdominal and the perineal approaches, for the repair of the rectal prolapsed, none of them is perfect. The best repair should be chosen not only to correct the prolapse but also to restore defecatory function and to improve fecal incontinence throughout the patients lifetime. The aim of this retrospective review is to evaluate clinical outcomes of the Delormes procedure for the management of the complete rectal prolapse. Methods A total of 19 patients (13 females and 6 males) with complete rectal prolapses were treated by using the Delormes procedure in St. Vincents Hospital, The Catholic University of Korea, from February 1997 to February 2007. Postoperative anal incontinence was evaluated using the Cleveland Clinic Incontinence Score. Results All 19 patients had incontinence to liquid stool, solid stool, and/or flatus preoperatively. Three (15.8%) patients reported recurrence of the rectal prolapse (at 6, 18, 29 months, respectively, after the operation). Information on postoperative incontinence was available for 16 of the 19 patients. Twelve of the 16 patients (75%) reported improved continence (5 [31.3%] were improved and 7 [43.7%] completely recovered from incontinence) while 4 patients had unchanged incontinence symptoms. One (6.3%) patient who did not have constipation preoperatively developed constipation after the operation. Conclusion The Delormes procedure is associated with a marked improvement in anal continence, relatively low recurrence rates, and low incidence of postoperative constipation. This allows us to conclude that this procedure still has its own role in selected patients.

Laparoscopic Surgery for Transverse Colon Cancer: Short- and Long-Term Outcomes in Comparison with Conventional Open Surgery

BACKGROUND Published studies on laparoscopic surgery for transverse colon cancer are scarce. More studies are necessary to evaluate the feasibility, safety, and long-term oncologic outcomes of laparoscopic surgery for transverse colon cancer. SUBJECTS AND METHODS From April 1996 to December 2010, 102 consecutive patients with stage II or III disease who had undergone curative resection for transverse colon cancer were enrolled. Seventy-nine patients underwent laparoscopy-assisted colectomy (LAC), whereas 23 patients underwent conventional open colectomy (OC). Short- and long-term outcomes of the two groups were compared. RESULTS The OC group had a larger tumor size (7.6 ± 3.4 cm versus 5.2 ± 2.3 cm, P = .004) and more retrieved lymph nodes (26.4 ± 11.6 versus 17.5 ± 9.4, P = .002), without differences in resection margins. In the LAC group, return to diet was faster (4.5 ± 1.2 days versus 5.4 ± 1.8 days, P = .013), and postoperative hospital stay was shorter (12.1 ± 4.2 days versus 15.9 ± 4.8 days, P = .000). There were no differences in occurrence of intra- or postoperative complications. There were no statistically significant differences in overall survival rate (OS) or disease-free survival rate (DFS) between the two groups (5-year OS, 90.4% versus 90.5%, P = .670; 5-year DFS, 84.2% versus 90.7%, P = .463). CONCLUSIONS Laparoscopic surgery for transverse colon cancer has better short-term outcomes compared with open surgery, with acceptable long-term outcomes. As in colorectal cancer of other sites, laparoscopic surgery can be a feasible alternative to conventional surgery for transverse colon cancer.

Laparoscopic splenectomy: 3 ports are enough.

With advanced technologies and accumulating experience, a new consensus concerning the least invasive laparoscopic splenectomy should be addressed. We retrospectively analyzed 41 consecutive patients who underwent laparoscopic splenectomy from 1994 to 2007. We divided our patients into 3 groups according to the number of trocars used: group 1 (n=11, 5 trocars), group 2 (n=21, 4 trocars), and group 3 (n=9, 3 trocars). In each group, postural change was made for the operation: supine for group 1, semilateral for group 2, and true lateral for group 3. Except for the shorter operation time for group 3 compared with group 1 and group 2 (P<0.001), there were no differences in perioperative parameters. Considering the least invasive nature of laparoscopic operations, 3-port splenectomy seems to be very promising in this context. Additionally, proper modification of patients posture is an essential part of the least invasive ever 3-port laparoscopic splenectomy.

How much colonic redundancy could be obtained by splenic flexure mobilization in laparoscopic anterior or low anterior resection

Background and Objectives: Splenic flexure mobilization (SFM) is performed to ensure a tension free anastomosis with an adequate resection margin in laparoscopic anterior resection (AR) or low anterior resection (LAR). This retrospective study was performed to determine the amount of colonic redundancy that can be expected by SFM. Methods: Retrospective review of medical record for a total of 203 patients who underwent SFM during laparoscopic AR or LAR for the treatment of sigmoid colon or rectal cancer was performed. Results: The obtained redundancy of the colon by SFM was 27.81 ± 7.29 cm from the sacral promontory. The redundancy of the colon by SFM with high ligation of the inferior mesenteric vein (IMV) (29.54 ± 7.17 cm from the sacral promontory) was greater than that with low ligation of the IMV (24.94 ± 6.07 cm from the sacral promontory, P < 0.0001). It took about 9.82% of the total operation time to perform SFM. There was no intraoperative complication during SFM. Conclusions: SFM during laparoscopic AR or LAR is a safe and feasible option. Based on the result of this study, one can gain about 27.81 cm redundancy of the colon by SFM.

Long-term oncologic outcomes of laparoscopic surgery for splenic flexure colon cancer are comparable to conventional open surgery

Purpose Few studies about laparoscopic surgery for splenic flexure colon cancer have been published. This study aims to compare the short- and long-term outcomes of laparoscopic surgery for splenic flexure colon cancer with those of conventional open surgery. Methods From January 2004 to December 2010, 51 consecutive patients who underwent curative resection for stages I–III splenic flexure colon cancer were enrolled. Thirty-three patients underwent laparoscopy-assisted colectomy, while 18 patients underwent conventional open colectomy. Short- and long-term outcomes of the 2 groups were compared. Results There were no differences in baseline characteristics, intra- and postoperative complications. The laparoscopy group showed longer operation time (median [interquartile range, IQR]: 295.0 [255.0–362.5] minutes vs. 180.0 [168.8–206.3] minutes, P < 0.001). In the laparoscopy group, return of bowel function was faster (median [IQR]: 3 [2–4] vs. 4 [3–5], P = 0.007) and postoperative hospital stay was shorter (median [IQR]: 9 [8–11] vs. 10.5 [9–19], P = 0.026). There were no statistically significant differences in overall survival rate (84.3% vs. 76.0%, P = 0.560) or disease-free survival rate (93.8% vs. 74.5%, P = 0.078) between the 2 groups. Conclusion Laparoscopic surgery for splenic flexure colon cancer has better short-term outcomes than open surgery, as well as acceptable long-term outcomes. Laparoscopic surgery can be a safe and feasible alternative to conventional open surgery for splenic flexure colon cancer.