Seong Kyu Baek

Robotic surgery: colon and rectum.

Although robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, the role of robotics in colorectal surgery is still largely undefined and different with respect to its application in abdominal versus pelvic surgery. This review aims to elucidate current developments in colorectal robotic surgery.In colon surgery, robotic techniques are associated with longer operative times and higher costs compared with laparoscopic surgery. However, robotics provides a stable camera platform and articulated instruments that are not subject to human tremors. Because of these advantages, robotic systems can play a role in complex procedures such as the dissection of lymph nodes around major vessels. In addition robot-assisted hand-sewn intracorporeal anastomoses can be easily performed by the surgeon, without a substantial need for a competent assistant. At present, although the short-term outcomes and oncological adequacy of robotic colon resection have been observed to be acceptable, the long-term outcomes of robotic colon resection remain unknown.In rectal surgery, robotic-assisted surgery for rectal cancer can be carried out safely and in accordance with current oncological principles. However, to date, the impact of robotic rectal surgery on the long-term oncological outcomes of minimally invasive total mesorectal excision remains undetermined. Robotic total mesorectal excision may allow for better preservation of urinary and sexual functions, and robotic surgery may attenuate the learning curve for laparoscopic rectal resection. However, a major drawback to robotic rectal surgery is the high cost involved.Large-scale prospective randomized clinical trials such as the international randomized trial ROLARR are required to establish the benefits of robotic rectal surgery.

An essential microRNA maturing microprocessor complex component DGCR8 is up-regulated in colorectal carcinomas

MicroRNAs (miRNAs) regulate gene expression through degradation and/or translational repression of target mRNAs. Dysregulations in the miRNA machinery may be involved in carcinogenesis of colorectal cancer (CRC). The purpose of the current study was to evaluate the DiGeorge syndrome critical region gene 8 (DGCR8) and argonaute 2 (AGO2) mRNA expression in CRC and to evaluate the value of clinical parameters on their expression. We investigated the mRNA expressions of DGCR8 and AGO2 in 60 CRC tissues and adjacent histologically non-neoplastic tissues by using quantitative real-time PCR. Our study revealed that the mRNA expression level of DGCR8 is up-regulated in CRC. However, AGO2 mRNA expression was not significantly altered in CRC tissues. Neither DGCR8 nor AGO2 mRNA expression level was not associated with any clinical parameters, including age, tumor stage, CEA titer, and BMI in CRC cases. However, the mRNA expression levels of DGCR8 and AGO2 were positively correlated to each other. This study demonstrated for the first time that the DGCR8 mRNA expression level was up-regulated in CRC, suggesting its important role in pathobiology of colorectal carcinogenesis.

Risk Factors for the Development of Clostridium difficile -associated Colitis after Colorectal Cancer Surgery

Purpose Clostridium difficile (C. difficile)-associated colitis, a known complication of colon and rectal surgery, can increase perioperative morbidity and mortality, leading to increased hospital stay and costs. Several contributing factors, including advanced age, mechanical bowel preparation, and antibiotics, have been implicated in this condition. The purpose of this study was to determine the clinical features of and factors responsible for C. difficile-associated colitis after colorectal cancer surgery. Methods The medical records of patients who had undergone elective resection for colorectal cancer from January 2008 to April 2010 were reviewed. Cases that involved procedures such as transanal excision, stoma creation, or emergency operation were excluded from the analysis. Results Resection with primary anastomosis was performed in 219 patients with colorectal cancer. The rate of postoperative C. difficile-associated colitis was 6.8% in the entire study population. Preoperative metallic stent insertion (P = 0.017) and aged sixty and older (≥ 60, P = 0.025) were identified as risk factors for postoperative C. difficile-associated colitis. There were no significant differences in variables such as preoperative oral non-absorbable antibiotics, site of operation, operation procedure, and duration of prophylactic antibiotics. Conclusion Among the potential causative factors of postoperative C. difficile-associated colitis, preoperative metallic stent insertion and aged sixty and older were identified as risk factors on the basis of our data. Strategies to prevent C. difficile infection should be carried out in patients who have undergone preoperative insertion of a metallic stent and are aged sixty and older years.

Reduced-port robotic anterior resection for left-sided colon cancer using the Da Vinci single-site(®) platform.

Single‐Site® port plus one conventional robotic port, a reduced‐port robotic surgery (RPRS) for left‐sided colorectal cancer, can enable lymphovascular dissection using the Endowrist® function; this allows safe rectal transection through an additional port and maintains the cosmetic advantage of single‐incision laparoscopic surgery.

Perforated appendicitis caused by foreign body ingestion.

Most ingested foreign bodies pass through the gastrointestinal tract without any incident. However, foreign bodies lodged in the appendix can cause an inflammatory reaction with or without perforation. Here, we present a case of a 54-year-old woman with perforated appendicitis who consumed wild game containing a shot pellet. Five months before admission, she had eaten the meat of a pheasant that had been shot with a shotgun. Abdominal computed tomography confirmed the diagnosis of perforated appendicitis with abscess due to a foreign body. Subsequently, a laparoscopic appendectomy was performed. Follow-up radiographs obtained after the surgery did not identify the foreign body. Histolopathologic examination confirmed appendiceal perforation with focal inflammation secondary to a foreign body.

Robotic Anterior Resection for Sigmoid Colon Cancer Using Reduced Port Access.

245 Diseases of the Colon & ReCtum Volume 59: 3 (2016) Recently, 2 new advancements, single-port laparoscopic surgery (sPls) and a robotic surgical system, have been integrated into modern colorectal surgical practice. the potential advantages of sPls include improved cosmetic outcomes, reduced postoperative incisional pain, fewer incisional hernias and organ injuries, and fewer wound complications. however, sPls for left-sided colon cancer is a challenging procedure even in the hands of a skilled laparoscopic colorectal surgeon because of difficulties in creating instrument triangulation and using endostaplers in the pelvic cavity with sufficient distal margins from the single port at the umbilicus. Robotic single-port access was designed especially to overcome the limitations of sPls, and it has been used to perform cholecystectomies, gynecological surgeries, and urological procedures. this platform can easily create instrument triangulation while minimizing external robotic arm collisions because the robotic instruments are crossed at the port site but are reassigned by the software to fit the corresponding hand of the surgeon on the robotic console. however, it has not been widely applied to colorectal diseases because of the lack of wrist articulation, limited range of motion of the semirigid robotic instruments, limited variety of instruments available for the robotic single-port platform, difficulty in using endostaplers in the pelvic cavity, and lack of a second retraction that is required for colorectal surgery. Robotic reduced-port access in left-sided colorectal cancer surgery can enable lymph node dissection around the inferior mesenteric artery with autonomic nerve preservation by using wrist articulation. this allows safe distal bowel transection through the additional port and maintains the cosmetic advantages of sPls. this technique can be a viable option until a more advanced robotic platform specifically designed for sPls is developed (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/a211).

Influence of old age on the postoperative outcomes of obstructive colorectal cancer surgery after the insertion of a stent

Purpose In some patients more than 70 years of age with obstructive colorectal cancer, their concerns about the postoperative complications lead them to refuse surgery after the insertion of a stent. This study aimed to compare the postoperative outcomes between obstructive colorectal cancer patients aged less than 70 years and those aged 70 years and more who underwent surgery after the insertion of a colonoscopic stent. Methods Patients with obstructive colorectal cancer who underwent surgery after the insertion of a colonoscopic stent between March 2004 and March 2014 were reviewed retrospectively by using medical records. The patients were divided into two groups: 22 patients were aged less than 70 years (group A) and 30 patients were aged more than 70 years (group B). Results Although no significant difference in comorbidity was noted between the two groups, the American Society of Anesthesiologists (ASA) score was higher in group B. There was no significant difference in cancer location, stage, or the time from the insertion of the stent to operation. The perioperative results including operation time, blood loss, and length of stay were not significantly different between the groups. The postoperative complications were also not significantly different. Conclusion The surgical outcomes of elderly patients were similar to those of younger patients, despite higher ASA scores. These results indicate that surgery can be performed safely in elderly patients with obstructive colorectal cancer after the insertion of a stent.

Oncologic outcomes of early adjuvant chemotherapy initiation in patients with stage III colon cancer

Purpose Although adjuvant chemotherapy reduces the risk of disease recurrence in stage III colon cancer patients, published guidelines do not specify when it should be initiated. This study aimed to assess the effect of adjuvant chemotherapy initiation time on disease recurrence and survival in stage III colon cancer patients undergoing curative surgical resection. Methods The medical records of stage III colon cancer patients undergoing curative resection between February 2004 and December 2009 were reviewed. Results Of the 133 enrolled patients, 27 (20.3%) began adjuvant chemotherapy within 3 weeks of surgery, whereas 106 (79.7%) did after 3 weeks following surgery. Patients receiving chemotherapy within 3 weeks of surgery were less likely to experience recurrences than those beginning treatment later (11.1% vs. 33%, P = 0.018). The mean disease-free survival of patients receiving adjuvant therapy earlier was 54.6 months, whereas that of patients with later treatment was 43.5 months (P = 0.014). However, no significant differences in overall survival were observed between the 2 groups. Conclusion Adjuvant chemotherapy should be initiated as soon as a patients clinical condition allows. Patients with stage III colon cancer may benefit from adjuvant chemotherapy initiated within 3 weeks of surgery.

Endoscopic management of delayed perforation of the rectum caused by a peritoneal dialysis catheter.

Bowel perforation caused by a peritoneal dialysis (PD) catheter is an uncommon complication. It occurs mostly at the time of insertion of a catheter. Delayed perforation of the bowel by a PD catheter can also occur, but is even more uncommon. The ideal management of perforation of the colon by a PD catheter remains to be established because of its very low incidence. Definite surgery is the usual treatment. Here, we report on a 50-year-old male patient who presented with severe watery diarrhea owing to delayed rectal perforation caused by a PD catheter. A computed tomography scan revealed that the catheter tip was inside the lumen of the rectum. This was further confirmed by colonoscopy after bowel preparation. The PD catheter was removed via the original abdominal incision and the rectal perforation was closed using 3 endoscopic clips. The patient made an uneventful recovery.

Impact of Adjuvant Therapy Type on Survival in Stage II/III Rectal Cancer Without Preoperative Chemoradiation: A Korean Multicenter Retrospective Study

Purpose This study compared the oncologic impact of postoperative chemotherapy and chemoradiotherapy on patients with rectal cancer without preoperative chemoradiation. Methods This retrospective study analyzed 713 patients with a mean follow-up of 58 months who had undergone radical resection for stage II/III rectal cancer without preoperative treatment in nine hospitals from January 2004 to December 2009. The study population was categorized a chemotherapy group (CG, n = 460) and a chemoradiotherapy group (CRG, n = 253). Five-year overall survival (OS) and disease-free survival (DFS) were analyzed, and independent factors predicting survival were identified. Results The patients in the CRG were significantly younger (P < 0.001) and had greater incidences of low rectal cancer (P < 0.001) and stage III disease (P < 0.001). Five-year OS (P = 0.024) and DFS (P = 0.012) were significantly higher in the CG for stage II disease; however, they were not significantly different for stage III disease. In the multivariate analysis, independent predictive factors were male sex, low rectal cancer and stage III disease for OS and male sex, abdominoperineal resection, stage III disease and tumor-positive circumferential margin for DFS. However, adjuvant therapy type did not independently affect OS (hazard ratio [HR], 1.243; 95% confidence interval [CI], 0.794–1.945; P = 0.341) and DFS (HR, 1.091; 95% CI, 0.810–1.470; P = 0.566). Conclusion Adjuvant therapy type did not affect survival of stage II/III rectal cancer patients without neoadjuvant chemoradiotherapy. These results suggest that adjuvant therapy can be chosen based on the patient’s condition and the policies of the surgeons and hospital facilities.