Chang Hwan Cho

Comparative study of resection and radiofrequency ablation in the treatment of solitary colorectal liver metastases

BACKGROUND We compared outcomes in patients with solitary colorectal liver metastases treated by either hepatic resection (HR) or radiofrequency ablation (RFA). METHODS A retrospective analysis from a prospective database was performed on 67 consecutive patients with solitary colorectal liver metastases treated by either HR or RFA. RESULTS Forty-two patients underwent HR and 25 patients underwent RFA. The 5-year overall and local recurrence-free survival rates after HR (50.1% and 89.7%, respectively) were higher than after RFA (25.5% and 69.7%, respectively) (P = .0263 and .028, respectively). In small tumors less than 3 cm (n = 38), the 5-year survival rates between HR and RFA were similar, including overall (56.1% vs 55.4%, P = .451) and local recurrence-free (95.7% vs 85.6%, P = .304) survival rates. On multivariate analysis, tumor size, metastases treatment, and primary node status were significant prognostic factors. CONCLUSIONS HR had better outcomes than RFA for recurrence and survival after treatment of solitary colorectal liver metastases. However, in tumors smaller than 3 cm, RFA can be recommended as an alternative treatment to patients who are not candidates for surgery because the liver metastases is poorly located anatomically, the functional hepatic reserve after a resection would be insufficient, the patients comorbidity inhibits a major surgery, or extrahepatic metastases are present.

Oncologic outcomes after neoadjuvant chemoradiation followed by curative resection with tumor-specific mesorectal excision for fixed locally advanced rectal cancer: Impact of postirradiated pathologic downstaging on local recurrence and survival

Objective:The purpose of this study was to determine the oncologic outcomes and clinical factors affecting survival in patients who underwent neoadjuvant chemoradiotherapy following tumor specific mesorectal excision for locally advanced, fixed rectal cancer. Summary Background Data:Neoadjuvant chemoradiation therapy has resulted in significant tumor downstaging, which enhances curative resection and subsequently improves local disease control for rectal cancer. However, oncologic outcomes, according to clinical factors, have not yet been fully understood in locally advanced and fixed rectal cancer. Methods:A total of 114 patients who had undergone neoadjuvant chemoradiation for advanced rectal cancer (T3 or T4 and node positive) were investigated retrospectively. Chemotherapy was administered intravenously with 5-FU and leucovorin during weeks 1 and 5 of radiotherapy. The total radiation dose was 5040 cGY in 25 fractions delivered over 5 weeks. Tumor-specific mesorectal excision was done 4 to 6 weeks after the completion of neoadjuvant chemoradiation. Survival and recurrence rates, according to the pathologic stage, were evaluated. Moreover, factors affecting survival were investigated. Results:The 5-year survival rates according to pathologic stage were: 100% in pathologic complete remission (n = 10), 80% in stage I (n = 23), 56.8% in stage II (n = 34), and 42.3% in stage III (n = 47) (P = 0.0000). Local, systemic, and combined recurrence rates were 11.4%, 22.8%, and 3.5%, respectively. Multivariate analysis showed that the pathologic N stage and operation method were the independent factors affecting survival rate. Conclusion:Pathologic complete remission showed excellent oncologic outcomes, and the pathologic N stage was the most important factor for oncologic outcomes.

Intestinal endometriosis mimicking carcinoma of rectum and sigmoid colon: a report of five cases

Among women with intestinal endometriosis, the sigmoid colon and rectum are the most commonly involved areas. Sometimes, the differential diagnosis of colorectal endometriosis from carcinoma of the colon and rectum is difficult due to similar colonoscopic and radiologic findings. From October 2002 to September 2007, we performed five operations with curative intent for rectal and sigmoid colon cancer that revealed intestinal endometriosis. Colonoscopic and radiologic findings were suggestive of carcinoma of rectum and sigmoid colon, such as rectal cancer, sigmoid colon cancer and gastrointestinal stromal tumor (GIST). Anterior resection was performed in two patients, low anterior resection was performed in one patient and laparoscopic low anterior resection was done in two patients. We suggest to consider also intestinal endometriosis in reproductive women presenting with gastrointestinal symptoms and an intestinal mass of unknown origin.

Gastrointestinal stromal tumor of the rectum: an analysis of seven cases.

PurposeGastrointestinal stromal tumors (GISTs) rarely originate in the rectum. We investigated the clinicopathologic characteristics of rectal GISTs.MethodsWe analyzed the medical records of seven patients who underwent surgery for GIST of the rectum between 1998 and 2003.ResultsThere were two men and five women with a median age of 55 years (range, 41–72 years) at the time of diagnosis. The median follow-up period was 23 months (range, 7–75 months). The chief symptoms were hematochezia, constipation, and anal pain. All patients underwent curative resection; in the form of abdominoperineal resection in five patients, transanal excision in one, and Hartmanns operation with prostatectomy in one. The median tumor size was 6.6 cm (range, 1–12 cm). Four patients received adjuvant radiation therapy. Local recurrence developed in two patients; 54 months and 23 months after surgery, respectively.ConclusionThe common symptoms of rectal GIST were the same as those of other rectal tumors. Curative surgical resection should be done, but further studies are necessary to investigate better adjuvant treatment strategies for patients with rectal GISTs

Robotic total mesorectal excision for the treatment of rectal cancer.

Robotic techniques have been developed to facilitate endoscopic surgery and to overcome its disadvantages. Thus, we performed robotic total mesorectal excison (TME) in a patient with rectal cancer, using the da Vinci® Surgical System. To our knowledge, this is the first robotic low anterior resection, based on standard TME principles, with pelvic autonomic nerve preservation. In conclusion, this robotic system is an excellent instrument for performing the standard TME procedure in rectal cancer patients.

Clinical Impact of Tumor Regression Grade after Preoperative Chemoradiation for Locally Advanced Rectal Cancer: Subset Analyses in Lymph Node Negative Patients

Background We investigated the prognostic significance of tumor regression grade (TRG) after preoperative chemoradiation therapy (preop-CRT) for locally advanced rectal cancer especially in the patients without lymph node metastasis. Methods One-hundred seventy-eight patients who had cT3/4 tumors were given 5,040 cGy preoperative radiation with 5-fluorouracil/leucovorin chemotherapy. A total mesorectal excision was performed 4-6 weeks after preop-CRT. TRG was defined as follows: grade 1 as no cancer cells remaining; grade 2 as cancer cells outgrown by fibrosis; grade 3 as a minimal presence or absence of regression. The prognostic significance of TRG in comparison with histopathologic staging was analyzed. Results Seventeen patients (9.6%) showed TRG1. TRG was found to be significantly associated with cancer-specific survival (CSS; P = 0.001) and local recurrence (P = 0.039) in the univariate study, but not in the multivariate analysis. The ypN stage was the strongest prognostic factor in the multivariate analysis. Subgroup analysis revealed TRG to be an independent prognostic factor for the CSS of ypN0 patients (P = 0.031). TRG had a stronger impact on the CSS of ypN (-) patients (P = 0.002) than on that of ypN (+) patients (P = 0.521). In ypT2N0 and ypT3N0, CSS was better for TRG2 than for TRG3 (P = 0.041, P = 0.048), and in ypN (-) and TRG2 tumors, CSS was better for ypT1-2 than for ypT3-4 (P = 0.034). Conclusion TRG was found to be the strongest prognostic factor in patients without lymph node metastasis (ypN0), and different survival was observed according to TRG among patients with a specific histopathologic stage. Thus, TRG may provide an accurate prediction of prognosis and may be used for f tailoring treatment for patients without lymph node metastasis.

Hand-Sewn Coloanal Anastomosis for Distal Rectal Cancer: Long-Term Clinical Outcomes

As the oncologic safety of coloanal anastomosis (CAA) has been proved by many other authors, the incidence of CAA following ultralow anterior resection has increased. The purpose of this study is to evaluate the functional outcome and complications of patients who underwent ultralow anterior resection and CAA for distal rectal cancer. Fifty-seven patients underwent CAA following ultralow anterior resection between July 1997 and November 2003. Forty-four patients, who were followed up more than 6 months after diverting ileostomy closure, were evaluated for recurrence, complications, and functional outcomes. The mean follow-up period was 36.3 ±22.8 months (range, 8–83 months). The complications were multiple fistula (n = 3), fistula with anal stenosis (n = 1), local recurrence with anal stenosis (n =1), and anal stenosis (n =7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements were observed more than six times per day in 16 patients. Overall recurrence occurred in six patients (13.6%). The 5-year survival rate was 85.3%, and the disease-free 5-year survival rate was 73.3%. Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, and tolerable function, complications and poor functional outcomes of CAA do occur. Therefore, the choice of this method should be considered carefully.

Clear cell adenocarcinoma of the sigmoid colon.

Dear Editor, Clear cell adenocarcinoma generally develops in the kidney, ovaries, extra-ovarian endometriosis, uterine cervix, upper vagina or lower genital tract. Although pathological examinations and immunohistochemistry techniques have improved over the years, this tumor type has rarely been diagnosed in the colon. Therefore, isolated clear cell adenocarcinoma of the colon is considered to be a rare malignancy. In 1964, Hellstrom et al. described a case of a sigmoid colon adenocarcinoma composed of clear tumor cells, which resembled the physaliferous (clear) cells of chordomal tumors. Since this original description, nine other cases of clear cell adenocarcinoma of the large intestine have been reported despite the rarity of this tumor type. Most of the reported primary clear cell colonic adenocarcinomas were found exclusively in the left colon and generally in elderly men. This is in agreement with our presented case in which we found a clear cell colonic adenocarcinoma on the left side of an elderly man. A previously healthy 62-year-old man was admitted to our surgical department because of abdominal discomfort and intermittent melena for a duration of 6 months. A colonoscopy showed three descending colonic polyps and fungating masses approximately 2 cm in size that were below the level of polyps in the sigmoid colon. Endoscopic mucosal resections were performed on the three polyps and endoscopic biopsy was only applied to the fungating mass. The resected polyp specimens revealed hyperplastic polyps, tubular adenoma and chronic non-specific inflammation, respectively. Biopsy specimens of the fungating mass revealed intramucosal carcinomatous change resembled clear cell adenocarcinoma. No abnormal findings were noted in the liver, gallbladder or kidney and we found no evidence of pathologic lymphadenopathy. A low anterior resection was performed by using the double stapling method. Gross findings of the resected specimen showed a 1.2×1.5 cm-sized polypoid firm, solid mass. The histological examination showed a clear cell adenocarcinoma in the tubular adenoma. A clear cell adenocarcinoma had invaded the muscularis mucosa. Lymph node metastases were not found in eight regional lymph nodes and lymphovascular invasion was not identified. The tubules of the tubular adenoma of the colonic polyps were partly lined by clear cells. The clear cells were uniformly clear and grew in both acinar and papillary configurations. Both columnar and polygonal shapes were observed and the clear cytoplasm contained small, apparently unstructured vacuoles. The nuclei included one or more prominent Int J Colorectal Dis (2007) 22:1543–1544 DOI 10.1007/s00384-006-0257-8

Simultaneous robotic total mesorectal excision and total abdominal hysterectomy for rectal cancer and uterine myoma

Dear editor, The Intuitive Surgical® da Vinci surgicalTM system (Intuitive Surgical®, Sunnyvale, CA) was specifically developed to compensate the technical limitations of laparoscopic instruments such as two-dimensional visions, misaligned hands and instruments, limited dexterity of instruments inside patient, and fixed instrument tips. The da VinciTM system provides a stable camera platform, three-dimensional imaging, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling, and instruments with multiple degrees of freedom. However, until now, world experience with robotic colorectal cancer surgery and total abdominal hysterectomy (TAH) has been limited, and there are no previous reports on simultaneous robotic total mesorectal excision (TME) and TAH. Therefore, we present our experience with simultaneous robotic TME and robotic TAH in a patient with rectal cancer and uterine myoma. A 46-year-old woman was referred for further evaluation and management of rectal mass. The patient had no other medical or surgical history. With rigid sigmoidscopy, a mass was detected 10 cm from the anal verge. Colonoscopy noted a fungating mass (1.0×1.0 cm) at the rectum with normal findings at other site. Endoscopic mucosal resection was performed. The pathology shown was moderately differentiated adenocarcinoma with submucosa and lymphovascular invasion. The preoperative abdomino-pelvic computed tomography scan showed no visualized mucosal lesion, lymphadenopathy, or distant metastasis. However, multiple uterine myomas were detected. The determined treatment was curative low anterior resection (LAR) and TAH using the da Vinci surgicalTM system. Standard mechanical bowel preparation was performed 24 h before the operation, and pneumatic compression stocking was applied 1 h before the operation. For robotic hysterectomy, the patient was placed in a low dorsal and steep Trendelenburg position. An 18F-Foley catheter was used for bladder drainage. A RUMI uterine manipulator was placed with a Koh colpotomy ring and a vaginal balloon pneumo-occluder (Cooper Surgical, Trumball, CT). CO2 insufflation was begun with a trocar and continued to a pressure of 12 mmHg. After pneumoperitoneum was obtained, four ports were placed. A 12-mm disposable trocar was inserted at the umbilical level to host the camera. Two 8-mm trocars were introduced in each lower quadrant of the abdomen, lateral to the epigastric arteries, and 2–3 cm below the umbilical level. A fourth assistant port (10 mm) was placed at mid-distance between the umbilicus and the left robotic arm. After the ports were in place, a surgical cart was positioned between the patient’s legs behind the second assistant. Three robotic arms were docked to the trocars. Int J Colorectal Dis (2008) 32:207-208 DOI 10.1007/s00384-007-0300-4

Asymptomatic Tubular Duplication of the Transverse Colon in an Adult

Colonic duplication is a rare congenital anomaly of the alimentary tract. In most cases, symptomatic duplications of the colon are recognized and treated by childhood. It is uncommon for these lesions to be detected in the adulthood since they present with vague symptoms if at all. We experienced a case of asymptomatic tubular duplication of the transverse colon in a 40-year-old female. Barium enema revealed a tubular duplication of the transverse colon. The duplicated segment arose from the mid ascending colon and incorporated just proximal to the splenic flexure, running parallel to the transverse colon and communicating with it at both ends. Colonoscopy demonstrated a normal colonic mucosa in the duplicated segment. The diameter of its lumen gradually narrowed proximally and the colonoscope could not be passed through the proximal opening of the segment. The patient did not need any treatment. Duplications of the alimentary tract can be found at any age. The possibility of congenital lesions in the adult population should not be overlooked.