-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Anastomotic leakage is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate the modified double-stapling technique (MDST), as an alternative for conventional double-stapling technique (DST), and whether it could reduce the anastomotic leakage rate in laparoscopic anterior resection (Lapa-AR). STUDY DESIGN: Between March 2009 and October 2010, a total of 189 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectosigmoid colon were divided into the MDST group (n = 95) and the DST group (n = 94) according to the anastomotic technique. Data were analyzed retrospectively. Morbidity and anastomotic leakage rate were compared between the two groups. RESULTS: Patient demographics, preoperative comorbidity, tumor size, stage, and operative details were comparable between the two groups. There was no difference in operation time between the two groups. The overall complication rate was significantly lower in the MDST group than in the DST group (3.2 vs. 10.6 %, p = 0.042), including anastomotic leakage rate (0 vs.4.6 %, p = 0.029). The anastomotic technique was the only factor associated with anastomotic leakage in univariate analysis. CONCLUSIONS: Our comparative study demonstrates MDST to have better short-term outcome in reducing anastomotic leakage compared with DST. This technique could be an alternative approach to maximize the patients' benefit in laparoscopic anterior resection.
Journal of Gastrointestinal Surgery 01/2013; · 2.83 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Purpose: Circumferential resection margin (CRM) involvement is a well-known predictor for poor prognosis in rectal cancer. However, the significance is controversial in some studies. Accordingly, this study attempted to examine the prognostic impact of CRM involvement in stage III rectal cancer. Materials and Methods: Between January 1990 and December 2007, a total of 449 patients who underwent curative resection followed by complete adjuvant chemoradiotherapy for stage III rectal cancer located within 12 cm from the anal verge were selected. Patients were divided into a CRM-positive group (n=79, 17.6%) and a CRM-negative group (n=370, 82.4%). Results: With a median follow-up of 56.6 months, recurrent disease was seen in 53.2 and 43.5% of the CRM-positive and CRM-negative group, respectively. CRM involvement was an independent prognostic factor for 5-year systemic recurrence-free survival (HR: 1.5, CI: 1.0-2.2, p=0.017). However, no significant difference was observed for local recurrence rate between the two groups (13.0 and 13.5%, respectively, p=0.677). Conclusion: In this study, local recurrence rate did not differ according to CRM involvement status in stage III rectal cancer patients, although CRM involvement was shown to be an independent poor prognostic factor. Accordingly, validation of the results of this study by further large prospective randomized trials is warranted.
Yonsei medical journal 01/2013; 54(1):131-8. · 0.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE:: The objective of this study was to clarify the impact of robotic surgery (RS) in the management of mid and low rectal cancer in comparison with open surgery (OS) and laparoscopic surgery (LS). BACKGROUND:: The benefits of RS in the treatment of rectal cancer have not yet been clearly described. METHODS:: Using propensity scores for adjustment of sex, age, body mass index, tumor stage, and tumor height, a well-balanced cohort with 165 patients in each group, was created by matching each patient who underwent RS as the study group with one who underwent OS or LS as the control group (RS:OS = 1:1, RS:LS = 1:1 match). Pathological results, morbidity, perioperative recovery, and short-term oncological results were compared between the 3 groups. RESULTS:: In RS and LS, the time to first flatus and resumed soft diet and length of hospital stay were significantly shortened compared with OS. Robotic surgery showed better recovery outcomes than LS with regard to time to resumed soft diet and length of hospital stay. The visual analog scale was significantly lower in the RS than in the OS and LS from postoperative days 1 to 5. The voiding problem and circumferential resection margin involvement rate were significantly lower in the RS group than in the OS group. No significant difference in 2-year disease-free survival was observed among the 3 groups. CONCLUSIONS:: Robotic surgery may be an effective tool in the effort to maximize the advantages of minimally invasive surgery in the management of mid to low rectal cancer.
Annals of surgery 10/2012; · 7.90 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Purpose. Compression anastomoses may represent an improvement over traditional hand-sewn or stapled techniques. This prospective exploratory study aimed to assess the efficacy and complication rates in patients undergoing anterior resection (AR) or low anterior resection (LAR) anastomosed with a novel end-to-end compression anastomosis ring, the ColonRing. Methods. In all, 20 patients (13 male) undergoing AR or LAR were enrolled to be anastomosed using the NiTi Shape Memory End-to-End Compression Anastomosis Ring (NiTi Medical Technologies Ltd, Netanya, Israel). Demographic, intraoperative, and postoperative data were collected. Results. Patients underwent AR (11/20) or LAR using laparoscopy (75%), robotic (10%) surgery, or an open laparotomy (15%) approach, with a median anastomotic level of 14.5 cm (range, 4-25 cm). Defunctioning loop ileostomies were formed in 6 patients for low anastomoses. Surgeons rated the ColonRing device as either easy or very easy to use. One patient developed an anastomotic leakage in the early postoperative period; there were no late postoperative complications. Mean time to passage of first flatus and commencement of oral fluids was 2.5 days and 3.2 days, respectively. Average hospital stay was 12.6 days (range, 8-23 days). Finally, the device was expelled on average 15.3 days postoperatively without difficulty. Conclusions. This is the first study reporting results in a significant number of LAR patients and the first reported experience from South Korea; it shows that the compression technique is surgically feasible, easy to use, and without significant complication rates. A large randomized controlled trial is warranted to investigate the benefits of the ColonRing over traditional stapling techniques.
Surgical Innovation 06/2012; · 2.13 Impact Factor
-
International Journal of Colorectal Disease 04/2012; 25(3):411-413. · 2.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Rectal cancer surgery using a minimally invasive technique has been regarded as a challenging procedure. Since the introduction
of the robotic surgical system into the operating theater, totally robotic rectal surgery has been attempted with several
techniques. Abdomino-perineal resection might be a more reliable indication for totally robotic surgery than low anterior
resection. Because the range of dissection is confined to the pelvic cavity and mobilization of the sigmoid colon, problems
during totally robotic surgery can be minimized. With our technique, totally robotic surgery can be performed successfully.
Technical advantages of the current robotic system can be reflected in patient benefits after totally robotic abdomino-perineal
resection.
KeywordsRobotic surgery–Rectal cancer–Abdomino-perineal resection
Journal of Robotic Surgery 04/2012; 5(1):43-46.
-
[show abstract]
[hide abstract]
ABSTRACT: Bladeless trocar decreases accidental injuries and incisional hernia; further a closure of fascial defect is considered to be unnecessary if a 12-mm bladeless trocar is used at nonmidline. We present a case of bowel herniation after using 12-mm bladeless trocar in robotic colorectal surgery. A 67-year-old woman had rectal cancer and underwent a robot-assisted low anterior resection. The facial defect after using 12-mm bladeless trocar was closed with the routine procedure. On postoperative day 7, her hernia of the trocar site was diagnosed by an abdominal computed tomography. The herniation was reduced with laparoscopic surgery. In conclusion, a trocar site hernia can occur after using a 12-mm bladeless trocar in robotic surgery.
Surgical laparoscopy, endoscopy & percutaneous techniques 02/2012; 22(1):e34-6. · 1.23 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The aim of this study was to evaluate the impact of visceral fat obesity (VFO) on early surgical and oncologic outcomes of laparoscopic total mesorectal excision (LTME) for rectal cancer.
Between June 2003 and June 2009, a total of 142 patients who had undergone LTME were included. Patients were divided into the obese group (OG) and the non-obese group (NOG) according to BMI and visceral fat area (VFA). Obesity was defined by BMI ≥25 kg/m² or VFA ≥130 cm².
There were 37 (26.0%) and 29 (20.4%) obese patients according to BMI and VFA, respectively. The OG, defined by both VFA and BMI, had a significantly longer operative time. The VFO group experienced more frequent conversion to laparotomy (17.2% vs. 5.0%; P = 0.047) and significantly higher blood loss during surgery (205.8 ± 257.0 mL vs. 102.5 ± 219.9 mL; P = 0.031), whereas there was no significant difference when defined by BMI. Time to first flatus was significantly longer in the VFO group compared with the NOG (mean 3.5 days vs. 2.7 days; P = 0.046), whereas it was not significantly different when classified by BMI. Regarding oncologic parameters, the VFO group had a significantly higher number of patients from whom less than 12 total lymph nodes were retrieved (65.5% vs. 34.5%; P = 0.002); however, there was no difference between the two groups defined by BMI.
VFO is proven to be a more reliable predictive factor than BMI in estimating early surgical outcomes for patients who underwent LTME. VFO is associated with fewer numbers of retrieved lymph nodes.
International Journal of Colorectal Disease 11/2011; 27(4):497-505. · 2.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The robotic system has been adopted as the new modality for minimally invasive surgery for rectal cancer. However, analysis of risk factors for complications after robotic rectal cancer surgery (RRS) has been limited. This study aimed to identify the risk factors for complications after RRS.
The records of 389 consecutive patients who underwent RRS between June 2006 and October 2010 were retrieved from our prospectively collected database.
The overall complication rate was 19%. The most common complication was anastomotic leakage (7.0%), followed by voiding difficulty, intrapelvic abscess, and ileus/obstruction. Multivariate analysis revealed the following as risk factors for postoperative complications: male gender, history of previous abdominal surgery, and lower tumor level (hazard ratio [HR] = 1.8, 95% confidence interval [CI] = 1.0-3.1, p = 0.041; HR = 2.3; 95% CI = 1.2-4.6, p = 0.012; and HR = 1.9, 95% CI = 1.1-3.3, p = 0.020, respectively). With regard to pelvic septic complications, lower tumor level, large tumor size, and preoperative chemoradiation remained variables that retained their statistical significance in multivariate analysis (HR = 2.6, 95% CI = 1.1-6.1, p = 0.029; HR = 2.7, 95% CI = 1.1-6.1, p = 0.017; HR = 2.9, 95% CI = 1.3-6.5, p = 0.007, respectively). The rate of postoperative complications was not influenced by the difference in laparoscopic surgery experience or the technique of robotic surgery.
Surgeons should be more cautious with these patient factors to optimize the benefits of robotic rectal resection.
World Journal of Surgery 09/2011; 35(11):2555-62. · 2.36 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Coloanal anastomosis (CAA)/intersphincteric resection (ISR) is a promising method of sphincter-preserving surgery for very low rectal cancer. Recently, a robotic system has been attempted in CAA/ISR. By means of a robotic system, an excellent stereoscopic view may be obtained with high illumination, and adequate traction and countertraction can be easily performed in a narrow pelvis using the Endowrist function. During robotic CAA/ISR, although the robotic system is necessary to perform pelvic dissection that comes before the perianal approach, the huge robotic arms located in the low abdominal region could interfere with comfortable perianal dissection for the surgeon. Therefore, the robotic system has to be withdrawn and then set up again above the patient's abdomen, which is time-consuming. Moreover, this process also makes it difficult to maintain the aseptic circumstance of the robotic system. To address this problem, it is necessary to change the sequence of the procedure.
Patients with low rectal adenocarcinoma located within 6 cm above the anal verge were recruited and underwent robotic CAA/ISR. We performed the perianal approach first before docking the robotic system. In the transanal approach, manual dissection started at the level of the dentate line (for cases of CAA) or intersphincteric groove (for cases of ISR). The mucosa was stripped from the starting point to just above the levators. Robotic dissection was followed while maintaining pneumoperitoneum via packed gauzes in the anus. The surgical principles included high ligation of inferior mesenteric vessels and total mesorectal excision. Splenic flexure mobilization was selectively performed when the end of the remaining sigmoid colon could not reach the anal canal after the routine mobilization of the left colon side. After completion of total mesorectal excision, further dissection continued to the pelvic floor (Fig. 1). The puborectalis muscle sling was laterally exposed, and the anococcygeal ligament was noted on the posterior side of the anal canal. Intersphincteric dissection through the puborectalis ended at the intra-anal canal. Finally, the dissection plane could meet the perianal dissection plane. At this point, we could identify the gauze, which was packed via the perianal approach before beginning robotic dissection. The muscular rectal wall was divided by a cautery at the level of the puborectalis muscle by robotic arms. While performing the CAA/ISR, secure and meticulous dissection through the pelvic floor is important for oncological safety, which could be easily performed with the aid of robotic ergonomic Endowrist function and a magnified three-dimensional view even in a narrow pelvic cavity. Specimen extraction was done through the anus or additional minilaparotomy skin incision. In some cases, a planned ileostomy site was used as the minilaparotomy incision. For patients with bulky and heavy mesorectum, it is difficult and even dangerous to extract the specimen via the anus, which could induce traction injuries to the marginal vessels. Hand-sewn coloanal anastomosis was performed after removing the robotic cart from the operation field. The entire operative procedure is shown in the video. Early surgical outcomes, morbidity, and short-term follow-up data were extracted from a prospectively collected database.
Robotic CAA/ISR for low rectal cancer was performed on 47 patients between August 2007 and December 2010. Forty-one patients underwent robotic CAA, and six patients underwent robotic ISR. There were 28 male and 19 female patients. The median age was 58 (range 32-86) years. The median body mass index was 23.3 (range 14.6-28.0) kg/m(2). Five patients (10.6%) had a history of abdominal surgery. According to American Society of Anesthesiology disease classification, 35 patients (74.5%) were class I, and 12 (25.5%) patients class II. The median distance between adenocarcinoma and the anal verge was 4 (range 1-6) cm. Preoperative chemoradiotherapy was provided to 19 patients (40.4%). There was no conversion to laparoscopic or open procedure. Operation time for robotic CAA/ISR was 360.9 ± 128.5 (mean ± standard deviation) min. For specimen retrieval, transanal extraction was performed in 23 cases (49%) and minilaparotomy was created for 24 cases (51%), including three cases of planned ileostomy site. Protective ileostomy was performed for 37 patients (78.7%). Blood loss was 158.0 ± 236.5 ml. The disease stage of the patients was as follows: stage 0, n = 1; stage I, n = 20; stage II, n = 5; stage III, n = 12; and pathologic complete response, n = 9. Tumor size was 2.7 ± 1.5 cm. The distal resection margin was 1.0 ± 1.2 cm. The circumferential resection margins were positive in 3 patients (6.4%). The number of retrieved lymph nodes was 9.8 ± 5.8. The first postoperative bowel movement was observed on day 2 (range, days 1-5). The median diet consumption began on day 3 (range, days 2-21). The median hospital stay was 9 (range 5-30) days. There were 10 complications in the early postoperative period (21.3%): 3 anastomotic leakages (6.4%), 1 wound infection (2.1%), 5 pelvic abscesses (10.6%), and 1 postoperative ileus (2.1%). During the short-term follow-up periods (median 21.3 months, range 3.5-40.7 months), one local recurrence, three distal metastases, and one combined recurrence were observed. Two-year disease-free survival rate was 83.7%.
Robotic CAA/ISR can be performed with good technical efficiency and acceptable morbidity. Further randomized, controlled studies assessing long-term survival, pelvic autonomic nerve function, and bowel function are needed before robotic CAA/ISR becomes widely accepted. Changing the sequence of the procedure, and thus performing the perianal approach before robotic dissection, may be a feasible method to avoid interference of the robotic system in the surgeon's moves using nonrobotic instruments while performing robotic CAA/ISR.
Annals of Surgical Oncology 08/2011; 19(1):154-5. · 4.17 Impact Factor
-
Annals of Surgical Oncology 07/2011; · 4.17 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Surgery is the standard treatment for a primary gastrointestinal stromal tumor (GIST); however, surgical resection is often not curative, particularly for large GISTs. In the past decade, with imatinib mesylate (IM), management strategies for GISTs have evolved significantly, and now IM is the standard care for patients with locally advanced, recurrent or metastatic GISTs. Adjuvant therapy with imatinib was recently approved for use, and preoperative imatinib is an emerging treatment option for patients who require cytoreductive therapy. IM neoadjuvant therapy for primary GISTs has been reported, but there is no consensus on the dose of the drug, the duration of treatment and the optimal time of surgery. These are critical because drug resistance or tumor progression can develop with a prolonged treatment. This report describes two cases of large rectal malignant GISTs, for which a abdominoperineal resection was initially anticipated. The two patients received IM preoperative treatment; we followed-up with CT or magnetic resonance imaging to access the response. After 9 months of treatment, a multi-disciplinary consensus that maximal benefit from imatinib had been achieved was reached. We determined the best time for surgical intervention and successfully performed sphincter-preserving surgery before resistance to imatinib or tumor progression occurred. We believe that a multidisciplinary team approach, considerating the optimal duration of therapy and the timing of surgery, is required to optimize treatment outcome.
Journal of the Korean Society of Coloproctology 06/2011; 27(3):147-52.
-
[show abstract]
[hide abstract]
ABSTRACT: The aims of this study are to identify the natural course of inferior mesenteric artery (IMA) lymph node metastasis, and to evaluate the prognostic impact of IMA lymph node metastasis in the sigmoid colon and rectal cancer.
From our prospectively collected database, a total of 625 patients who underwent resection with curative intent for stage III adenocarcinoma of the sigmoid colon and rectal cancer between June 1995 and June 2007 were selected. Patients were divided into the IMA-positive group (n = 33) and the IMA-negative group (n = 592) according to IMA lymph node metastasis status. Clinicopathological features, recurrence patterns, and 5-year disease-free survival rates were compared between the two groups.
Following curative resection, 5-year disease-free survival rate was 31.9% in the IMA-positive group and 69.4% in the IMA-negative group (p < 0.001). Cox regression analysis revealed that rectal cancer, pathologic stage, and presence of IMA lymph node metastasis were independently associated with disease-free survival. Systemic recurrence rate was significantly higher in the IMA-positive group than in the IMA-negative group (48.5 vs. 20.8%, respectively, p = 0.001). Para-aortic nodal recurrence showed significant association with presence of IMA lymph node metastasis on multivariate analysis (hazard ratio 11.8; 95% confidence interval 2.7-52.2, p = 0.001).
Presence of IMA lymph node metastasis should be considered as a predictive factor for high systemic recurrence, and should be treated and followed up with caution for para-aortic nodal recurrence.
Annals of Surgical Oncology 03/2011; 18(3):704-10. · 4.17 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to investigate the prognostic impact of the lymph node ratio (LNR) in ypN-positive rectal cancer patients who received preoperative chemoradiation (preop-CRT).
A total of 75 patients diagnosed as node-positive after undergoing preop-CRT followed by curative resection were enrolled. Patients were categorized into two groups based on their median LNR, 0.143.
The median metastatic and retrieved lymph node numbers were 2.0 (range: 1-79) and 18.0 (range: 5-80). Abdominoperineal resection, circumferential resection margin involvement and higher LNR were proven to be independent adverse prognostic factors affecting survival in the multivariate analysis including LNR as a covariate. Of the 47 patients with ypN1, 35 (74.5%) showed a lower LNR (N1G1) and 12 (25.5%) showed a higher LNR (N1G2). The N1G1 group showed better overall survival than the N1G2 group (P = 0.018). There was no difference between the survival rates of the N1G2 group and the ypN2 group (P = 0.987).
LNR is an independent prognostic factor after preop-CRT for rectal cancer. LNR showed better prognosis stratification than the ypN stage. Therefore, LNR should be considered as an additional prognostic factor in node-positive rectal cancer after preop-CRT.
Journal of Surgical Oncology 03/2011; 104(1):53-8. · 2.10 Impact Factor
-
Annals of Surgical Oncology 01/2011; · 4.17 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Total mesorectal excision (TME) has gained worldwide acceptance as a standard surgical technique in the treatment of rectal cancer. Ever since laparoscopic surgery was first applied to TME for rectal cancer, with increasing penetration rates, especially in Asia, an unstable camera platform, the limited mobility of straight laparoscopic instruments, the two-dimensional imaging, and a poor ergonomic position for surgeons have been regarded as limitations. Robotic technology was developed in an attempt to reduce the limitations of laparoscopic surgery. The robotic system has many advantages, including a more ergonomic position, stable camera platform and stereoscopic view, as well as elimination of tremor and subsequent improved dexterity. Current comparison data between robotic and laparoscopic rectal cancer surgery show similar intraoperative results and morbidity, postoperative recovery, and short-term oncologic outcomes. Potential benefits of a robotic system include reduction of surgeon's fatigue during surgery, improved performance and safety for intracorporeal suture, reduction of postoperative complications, sharper and more meticulous dissection, and completion of autonomic nerve preservation techniques. However, the higher cost for a robotic system still remains an obstacle to wide application, and many socioeconomic issues remain to be solved in the future. In addition, we need more concrete evidence regarding the merits for both patients and surgeons, as well as the merits compared to conventional laparoscopic techniques. Therefore, we need large-scale prospective randomized clinical trials to prove the potential benefits of robot TME for the treatment of rectal cancer.
Journal of the Korean Society of Coloproctology 12/2010; 26(6):377-87.
-
Hyuk Hur, Jeonghyun Kang,
Nam Kyu Kim,
Byung Soh Min,
Kang Young Lee,
Sang Joon Shin,
Ki Chang Keum,
Junjeong Choi,
Hoguen Kim,
Sung Ho Choi,
Mi-Young Lee
[show abstract]
[hide abstract]
ABSTRACT: This study aims to correlate thymidylate synthase (TS) gene polymorphisms with the tumor response to preoperative 5-fluorouracil (5-FU)-based chemoradiation therapy (CRT) in patients with rectal cancer.
Forty-four patients with rectal cancer treated with 5-FU-based preoperative CRT were prospectively enrolled in this study. Thymidylate synthase expression and TS gene polymorphisms were evaluated in tumor obtained before preoperative CRT and were correlated with the pathologic response, as assessed by histopathologic staging (pTNM) and tumor regression grade.
Patients exhibited 2R/3R and 3R/3R tandem repeat polymorphisms in the TS gene. With regard to TS expression in these genotypes, 2R/3RC and 3RC/3RC were defined as the low-expression group and 2R/3RG, 3RC/3RG, and 3RG/3RG as the high-expression group. There was no significant correlation between TS expression and tumor response. There was no significant difference in the tumor response between patients homozygous for 3R/3R and patients heterozygous for 2R/3R. However, 13 of 14 patients in the low-expression group with a G>C single-nucleotide polymorphism (SNP) (2R/3RC [n = 5] or 3RC/3RC [n = 9]) exhibited a significantly greater tumor downstaging rate, as compared with only 12 of 30 patients in the high-expression group without the SNP (2R/3RG [n = 10], 3RC/3RG [n = 9], or 3RG/3RG [n = 11]) (p = 0.001). The nodal downstaging rate was also significantly greater in this low-expression group, as compared with the high-expression group (12 of 14 vs. 14 of 30, p = 0.014). However, there was no significant difference in the tumor regression grade between these groups.
This study suggests that SNPs within the TS enhancer region affect the tumor response to preoperative 5-FU-based CRT in rectal cancer.
International journal of radiation oncology, biology, physics 10/2010; 81(3):669-76. · 4.59 Impact Factor
-
International Journal of Colorectal Disease 08/2009; 25(3):411-3. · 2.38 Impact Factor
