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.
Rectal neoplasms; Radiatiotherapy; Chemoradiotherapy
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.
laparoscopic anterior resection; laparoscopic low anterior resection; splenic flexure mobilization
Inflammatory myofibroblastic (IMF) tumor is a rare solid tumor that often affects children. IMF tumors occur primarily in the lung, but the tumor may affect any organ system with protean manifestations. A 22-year-old woman was evaluated for palpable low abdominal mass that had been increasing in size since two months prior. Abdominal computed tomography showed a lobulated, heterogeneous contrast enhancing soft tissue mass, 6.5 × 5.7 cm in size in the ileal mesentery. At surgery, the mass originated from the greater omentum laying in the pelvic cavity and was completely excised without tumor spillage. Histologically, the mass was a spindle cell lesion with severe atypism and some mitosis. Immunohistochemistry for anaplastic lymphoma kinase-1 revealed that the lesion was an IMF tumor. Because of its local invasiveness and its tendency to recur, this tumor can be confused with a soft tissue sarcoma. Increasing physician awareness of this entity should facilitate recognition of its clinical characteristics and laboratory findings.
Inflammatory myofibroblastic tumor; Spindle cell tumor; ALK-1; Omental mass
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 patient's lifetime. The aim of this retrospective review is to evaluate clinical outcomes of the Delorme's procedure for the management of the complete rectal prolapse.
A total of 19 patients (13 females and 6 males) with complete rectal prolapses were treated by using the Delorme's procedure in St. Vincent's Hospital, The Catholic University of Korea, from February 1997 to February 2007. Postoperative anal incontinence was evaluated using the Cleveland Clinic Incontinence Score.
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.
The Delorme's 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.
Incontinence; Delorme's procedure; Rectal prolapse
Rectal burns caused by hot water enema have been reported only occasionally and the majority of them were treated in a conservative manner. Although intractable rectal stricture caused by rectal burn is rare, it may be treated by endoscopic intervention or surgery. A 52-year-old woman who had used various methods of enema to treat her chronic constipation eventually undertook a hot water enema herself. After that, anal pain and constipation became aggravated prompting her to visit our clinic. Although various nonoperative treatments including endoscopic stenting were performed, her obstructive symptom did not improve and endoscopic findings had not changed. Hence, we performed a laparoscopic proctosigmoidectomy and transanal coloanal anastomosis with ileal diversion to treat the disease, and as a result, her obstructive symptom improved well. Corrective surgery such as resection of involved segment with anastomosis may be beneficial in relieving obstructive symptoms of an intractable rectal stricture caused by hot water enema.
Hot water enema; Rectal burn; Rectal stricture; Constipation
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.
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.
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.
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.
Retrorectal tumor; Anterior approach; Posterior approach; Combined approach; Laparoscopy
The purpose of this study is to evaluate the value of nonoperative treatment for right-sided colonic diverticulitis.
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.
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.
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.
Diverticulitis; Colonic diverticulitis; Drug therapy
The physiology of the anorectal region is very complex, and it is only recently that detailed investigations have given us a better understanding of its function. The methods that are used for the evaluation of anorectal physiology include anorectal manometry, defecography, continence tests, electromyography of the anal sphincter and the pelvic floor, and nerve stimulation tests. These techniques furnish a clearer picture of the mechanisms of anorectal disease and demonstrate pathophysiologic abnormalities in patients with disorders of the anorectal region. Therefore, therapeutic recommendations for anorectal disease can be made best when the anatomy and the physiology of the anorectal region are understood.
Anorectal physiology; Anorectal physiologic test; Biofeedback therapy
The incidence of complications after colonoscopy is very low. The complications after colonoscopy that are of clinical concern are bleeding and perforation. The present study was conducted to determine the clinical outcomes and the risk factors of a colostomy or a colectomy after colonoscopic colon perforation.
From March 2009 to December 2012, the records of all patients who were treated for colorectal perforation after colonoscopy were reviewed retrospectively. The following parameters were evaluated: age, sex, purpose of colonoscopy, management of the colonic perforation, and interval from colonoscopy to the diagnosis of a colonic perforation. A retrospective analysis was performed to determine the risk factors associated with major surgery for the treatment of a colon perforation after colonoscopy.
A total 27 patients were included in the present study. The mean age was 62 years, and 16 were males. The purpose of colonoscopy was diagnostic in 18 patients. The most common perforation site was the sigmoid colon. Colonic perforation was diagnosed during colonoscopy in 14 patients, just after colonoscopy in 5 patients, and 24 hours or more after colonoscopy in 8 patients. For the treatment of colonic perforation, endoscopic clipping was performed in 3 patients, primary closure in 15 patients, colon resection in 2 patients, Hartmann's procedures in 4 patients, and diverting colostomy in 3 patients. If the diagnosis of perforation after colonoscopy was delayed for more than 24 hours, the need for major treatment was increased significantly.
Although a colonic perforation after colonoscopy is rare, if the morbidity and the mortality associated with the colonic perforation are to be reduced, prompt diagnosis and management are very important.
Intestinal perforation; Colonoscopy
Neoadjuvant chemoradiation therapy followed by curative surgery has gained acceptance as the therapy of choice in locally advanced rectal cancer. However, deterioration of anorectal function after long-course neoadjuvant chemoradiation therapy combined with surgery for rectal cancer is poorly defined. The aim of this study was to evaluate the physiological and clinical change of anorectal function after neoadjuvant chemoradiation therapy for rectal cancer.
We analyzed 30 patients on whom preoperative anorectal manometry data were available both before and after chemoradiation from October 2010 to September 2011. All patients underwent long-course neoadjuvant chemoradiation therapy. We compared manometric parameters between before and after neoadjuvant chemoradiation therapy.
Of 30 patients, 20 were males and 10 females. The mean age was 64.9 ± 9.9 years (range, 48-82). Before nCRT, the rectal compliance was higher in patients with ulceroinfiltrative type (P = 0.035) and greater involvement of luminal circumference (P = 0.017). However, there was the tendency of increased rectal sensory threshold for desire to defecate when the patient had decreased circumferential ratio of the tumor (P = 0.099), down-graded T stage (P = 0.016), or reduced tumor volume (P = 0.063) after neoadjuvant chemoradiation.
Neoadjuvant chemoradiation therapy did not significantly impair overall sphincter function before radical operation. The relationship between tumor response of chemoradiation and sensory threshold for desire to defecate may suggest that neoadjuvant chemoradiation may be helpful for defecatory function as well as local disease control, at least in the short-term period after the radiation in locally advanced rectal cancer patients.
Anorectal function; Neoadjuvant chemoradiation; Manometry; Rectal cancer
Primary mesenteric carcinoid tumor is very rare, although secondary mesenteric involvement is common, reported as 40% to 80%. And distant metastasis rate reported as 80% to 90%, when the size is larger than 2 cm. We present a case of very rare primary mesenteric carcinoid tumor showing benign character though large size. The patient visited St. Vincent's Hospital, The Catholic University of Korea with increasing palpable abdominal mass. At laparotomy, a well encapsulated mass arising from the mesentery near the ligament of Treitz was found without any adjacent organ invasion or distant metastasis. The mass was measured as 8.2 × 7.3 cm and histopathologically benign character. At 11 months of follow up, the patient was recurrence free.
Carcinoid tumor; Mesentery; Neoplasms
This 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.
In 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.
The 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.
The 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.
Lymph node metastasis; T1 colorectal cancer; Tumor budding
This retrospective study compared the clinicopathological results among three groups divided by time sequence to evaluate the impact of introducing laparoscopic surgery on long-term oncological outcomes for right-sided colon cancer.
From April 1986 to December 2006, 200 patients who underwent elective surgery with stage II and III right-sided colon cancer were analyzed. The period for group I referred back to the time when laparoscopic approach had not yet been introduced. The period for group II was designated as the time when first laparoscopic approach for right colectomy was carried out until we overcame its learning curve. The period for group III was the period after overcoming this learning curve.
When groups I and II, and groups II and III were compared, overall survival (OS) did not differ significantly whereas disease-free survival (DFS) in groups I and III were statistically higher than in group II (P = 0.042 and P = 0.050). In group III, laparoscopic surgery had a tendency to provide better long-term OS ( P = 0.2036) and DFS ( P = 0.2356) than open surgery. Also, the incidence of local recurrence in group III (2.6%) was significantly lower than that in groups II (7.4%) and I (12.1%) ( P = 0.013).
Institutions should standardize their techniques and then provide fellowship training for newcomers of laparoscopic colon cancer surgery. This technique once mastered will become the gold standard approach to colon surgery as it is both safe and feasible considering the oncological and technical aspects.
Laparoscopic surgery; Learning curve; Long-term outcome; Right sided colon cancer
The lung is the second most common site of metastasis from colorectal cancer. Of all patients who undergo a curative resection for colorectal cancer, 10% to 15% will develop lung metastasis. As a hepatic resection of colorectal liver metastases results in improved survival, many reports have suggested that a pulmonary resection of a colorectal lung metastasis would also improve survival. The aim of this study was to analyze the postoperative outcomes of and the prognostic factors for a surgical resection of a lung metastasis.
Between August 1997 and March 2006, 27 patients underwent surgical resections for colorectal lung metastases at Seoul St. Mary's hospital. A retrospective review of patients' characteristics and various tumor factors was performed.
The mean interval between colorectal resection and lung metastasis was 24.0 ± 15.1 months. The overall 3- and 5-year survival rates were 76.5% and 22.2%, respectively. The mean follow-up after pulmonary resection was 39.5 ± 21.6 months (range, 3.3 to 115 months). Except for the existence of hilar-lymph-node metastasis (P < 0.001), no risk factors that we studied were statistically significant. Two patients had hilar-lymph-node metastasis. They survived for only for 3.3- and 11.6-months, respectively.
In our study, we found that a pulmonary resection for metastases from colorectal cancer may improve survival in selected patients.
Colorectal neoplasms; Neoplasm metastasis; Lung
Fluorouracil (5-FU) and leucovorin combination therapy have shown synergistic or additive effect against advanced colorectal cancer, but the frequency of mucositis and diarrhea is increased. Most previous studies have used high dose leucovorin (300~500 mg/m2). However, some studies of oxaliplatin and 5-FU with low-dose or high-dose leucovorin in Korea have shown similar response rates. Therefore, we studied the necessity of leucovorin and evaluated the objective tumor response rates and toxicities of a regimen of oxaliplatin and 5-FU without leucovorin every 2 weeks in metastatic colorectal cancer patients.
Materials and Methods
Twenty-four patients with metastatic colorectal cancer were enrolled between January 2002 and March 2003. Patients received 85 mg/m2 of oxaliplatin on day 1, a bolus 5-FU 400 mg/m2 on day 1 and a continuous 5-FU infusion at 600 mg/m2/ 22 hours days 1 and 2, every 2 weeks.
Of the 24 patients treated, 17 patients received previous 5FU with leucovorin and/or other chemotherapy. Three patients could not be evaluated. Five partial responses were observed with overall response rate of 21% (n=24). Of the previous chemotherapy group (n=17), 4 partial responses were observed with response rate of 24%. Median overall survival was 18 months (range 4~32 months) and median progression free survival was 4 months (range 2~6 months). This regimen was well tolerated and only 1 grade 3 anemia was observed.
Oxaliplatin/5-FU combination therapy without leucovorin achieved a relatively high response rate even in patients resistant to the previous 5-FU chemotherapy, and toxicity was minimal.
Oxaliplatin; 5-Flurouracil; Colorectal neoplasms
Intravascular papillary endothelial hyperplasia (Masson's hemangioma) is a disease characterized by exuberant endothelial proliferation within the lumen of medium-sized veins. In 1923, Masson regarded this disease as a neoplasm inducing endothelial proliferation, however, now it is considered to be a reactive vascular proliferation following traumatic vascular stasis. The lesion has a propensity to occur in the head, neck, fingers, and trunk. Occurrence within the abdominal cavity is known to be very rare, and especially in the liver, there has been no reported case up to date. The authors have experienced intravascular papillary endothelial hyperplasia of the liver in a 69-yr-old woman, and report the case with a review of the literature.
Intravascular Papillary Endothelial Hyperplasia; Hemangioma; Liver