Laparoscopic Resection of Presacral Tumor: A New Approach in the Era of the Minimally Invasive Surgery

Presacral tumors are rare; however, once diagnosed, surgical resection is recommended even in asymptomatic patients as there is potential risk for growth or malignant transformation. Many different types of surgical approaches to resect presacral tumors have been reported including posterior, anterior, and combined abdominosacral approaches. With introduction of the minimally invasive approach, laparoscopic or robotic approaches to resect presacral tumors are reported increasingly. We report a case of successful anterior laparoscopic resection for a presacral mass that was incidentally diagnosed during management of pancreatitis.

Postoperative Outcomes of Stoma Takedown: Results of Long-term Follow-up

PURPOSE

Stoma takedown is a frequently performed procedure with considerable postoperative morbidities. Various skin closure techniques have been introduced to reduce surgical site infections. The aim of this study was to assess postoperative outcomes after stoma takedown during a long-term follow-up period.

METHODS

Between October 2006 and December 2015, 84 consecutive patients underwent a colostomy or ileostomy takedown at our institution. Baseline characteristics and perioperative outcomes were analyzed through retrospective reviews of medical records.

RESULTS

The proportion of male patients was 60.7%, and the mean age of the patients was 59.0 years. The overall complication rate was 28.6%, with the most common complication being prolonged ileus, followed by incisional hernia, anastomotic leakage, surgical site infection, anastomotic stenosis, and entero-cutaneous fistula. The mean follow-up period was 64.3 months. The univariate analysis revealed no risk factors related to overall complications or prolonged ileus.

CONCLUSION

The postoperative clinical course and long-term outcomes following stoma takedown were acceptable. Stoma takedown is a procedure that can be performed safely.

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.

Does circumferential tumor location affect the circumferential resection margin status in mid and low rectal cancer?

BACKGROUND/OBJECTIVE

The purpose of this study was to assess the impact of circumferential tumor location on circumferential resection margin (CRM) status and the depth of tumor invasion in mid and low rectal cancer.

METHODS

We retrospectively analyzed whole-mount slides of 58 patients who underwent total mesorectal excision for mid and low rectal cancer. The rate of tumor-positive CRM was compared according to the circumferential tumor location. In 31 patients, morphometric analyses of whole-mount specimens were performed to measure the depth of tumor invasion according to circumferential tumor location.

RESULTS

Among 58 patients, 50% of tumors were anterior tumor and 50% were nonanterior. A tumor-positive CRM was more observed frequently in anterior tumors than in nonanterior tumors (41.1% vs. 10.3%, p = 0.007). In a multivariate analysis, anterior tumor was the only independent risk factor for a positive CRM (odds ratio 4.725, 95% confidence interval 1.102-20.261, p = 0.037). In a morphometric analysis of 31 patients, the depth of tumor invasion from the muscularis mucosa was greater (11.9 mm vs. 6.6 mm, p = 0.028) in those with anterior tumors.

CONCLUSION

Anterior tumors are associated with a higher risk of tumor-positive CRM and tend to exhibit deeper invasion in mid and low rectal cancer.

Influence of Shorter Duration of Prophylactic Antibiotic Use on the Incidence of Surgical Site Infection Following Colorectal Cancer Surgery

Purpose

This study aimed to identify the risk factors for surgical site infections (SSIs) in patients undergoing colorectal cancer surgery and to determine whether significantly different SSI rates existed between the short prophylactic antibiotic use group (within 24 hours) and the long prophylactic antibiotic use group (beyond 24 hours).

Methods

The medical records of 327 patients who underwent colorectal resection due to colorectal cancer from January 2010 to May 2014 at a single center were retrospectively reviewed, and their characteristics as well as the surgical factors known to be risk factors for SSIs, were identified.

Results

Among the 327 patients, 45 patients (13.8%) developed SSIs. The patients were divided into two groups according to the duration of antibiotic use: group S (within 24 hours) and group L (beyond 24 hours). Of the 327 patients, 114 (34.9%) were in group S, and 213 (65.1%) were in group L. Twelve patients (10.5%) in group S developed SSIs while 33 patients (15.5%) in group L developed SSIs (P = 0.242). History of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were independent risk factors for SSIs.

Conclusion

This study shows that discontinuation of prophylactic antibiotics within 24 hours after colorectal surgery has no significant influence on the incidence of SSIs. This study also showed that history of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were associated with increased SSI rates.

Surgical management of enterocutaneous fistula

Enterocutaneous (EC) fistula is an abnormal connection between the gastrointestinal (GI) tract and skin. The majority of EC fistulas result from surgery. About one third of fistulas close spontaneously with medical treatment and radiologic interventions. Surgical treatment should be reserved for use after sufficient time has passed from the previous laparotomy to allow lysis of the fibrous adhesion using full nutritional and medical treatment and until a complete understanding of the anatomy of the fistula has been achieved. The successful management of GI fistula requires a multi-disciplinary team approach including a gastroenterologist, interventional radiologist, enterostomal therapist, dietician, social worker and surgeons. With this coordinated approach, EC fistula can be controlled with acceptable morbidity and mortality.

Septic thrombophlebitis of the porto-mesenteric veins as a complication of acute appendicitis

Pylephlebitis, a rare complication of acute appendicitis, is defined as thrombophlebitis of the portal venous system. Pylephlebitis usually occurs due to secondary infection in the region drained into the portal system. We report a case of pylephlebitis caused by acute appendicitis. The patient was transferred from a private clinic 1 wk after appendectomy with the chief complaints of high fever and abdominal pain. He was diagnosed with pylephlebitis of the portal vein and superior mesenteric vein by CT-scan. The patient was treated with antibiotics and anticoagulation therapy, and discharged on the 25th day and follow-up CT scan showed a cavernous transformation of portal thrombosis.

[TNM staging, molecular staging and prognostic factors of rectal cancer]

Pathologic evaluation of the resected specimen is a critical component when managing the patients with rectal cancer, from initial diagnosis through definitive treatment. The best estimation of prognosis in rectal cancer is related to the anatomic extent of disease determined by pathology. Although a large number of staging system has been developed for rectal cancer over the years, use of TNM staging system of the AJCC (American Joint Committee on Cancer) and the UICC (International Union Against Cancer) are gaining popularity among the colorectal surgeons. Multiple genetic alterations are the prerequisite for carcinogenesis including rectal cancer. Although numerous molecular markers are investigated in relation to prognosis or response to therapy of rectal cancer, those molecular markers could not provide sufficient evidence for the incorporation of available prognostic biomarkers into clinical practice. In this article, the evolution of staging system of rectal cancer and its prognostic relevance are reviewed comprehensively.