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Minimal invasive surgery for mid and low rectal cancer after neoadjuvant long-course chemoradiotherapy (LCRT) can be challenging. The aim of our study was to compare outcomes of laparoscopic and robotic resections in mid and low rectal cancers after LCRT. Between Jan 2006 and Dec 2010, all patients who underwent robotic or laparoscopic resections for mid and low rectal cancers after LCRT were identified from a prospective database. These patients received treatment (5FU-based chemotherapy, 50.4 Gy radiotherapy), as they were T3 or T4 and/or node + ve. Patients in the two groups were compared with respect to demographics, clinical safety, and oncological outcomes. One hundred thirty-eight patients underwent rectal cancer resection after LCRT, either robotic (n = 74) or laparoscopic (n = 64). The patients in both groups were comparable in terms of demographics, distance of tumor from anal verge, and type of procedures. There were four (6.3 %) conversions in laparoscopic group and one (1.4 %) in the robotic group (p = 0.183). The morbidity rates in the laparoscopic and robotic group were 26.6 % and 16.2 %, respectively (p = 0.137). With a median follow up of 3 years, the local recurrence in the laparoscopic and robotic group was four (6.3 %) and two (2.7 %), respectively (p = 0.420). The 3-year overall survival rate for laparoscopic and robotic group was 92.1 and 90.0 %, respectively (p = 0.803). The 3-year disease-free survival was also comparable, 78.8 % (laparoscopic) versus 77.7 % (robotic) (p = 0.390). With a median follow up of 3 years, robotic surgery for mid and low rectal cancer was associated with oncological outcomes comparable to laparoscopic surgery.

Purpose: The aim of this study is to describe our initial experience and assess the feasibility and safety of robotic and laparoscopic lateral pelvic node dissection (LPND) in advanced rectal cancer. Methods: Between November 2007 and November 2012, extended minimally invasive surgery for LPND was performed in 21 selected patients with advanced rectal cancer, including 11 patients who underwent robotic LPND and 10 who underwent laparoscopic LPND. Extended lymphadenectomy was performed when LPN metastasis was suspected on preoperative magnetic resonance imaging even after chemoradiation. Results: All 21 procedures were technically successful without the need for conversion to open surgery. The median operation time was 396 minutes (range, 170?581 minutes) and estimated blood loss was 200 mL (range, 50?700 mL). The median length of stay was 10 days (range, 5?24 days) and time to removal of the urinary catheter was 3 days (range, 1?21 days). The median total number of lymph nodes harvested was 24 (range, 8?43), and total number of lateral pelvic lymph nodes was 7 (range, 2?23). Six patients (28.6%) developed postoperative complications; three with an anastomotic leakages, two with ileus and one patient with chyle leakage. Two patients (9.5%) developed urinary incontinence. There was no mortality within 30 days. During a median follow-up of 14 months, two patients developed lung metastasis and there was no local recurrence. Conclusion: Robotic and laparoscopic LPND is technically feasible and safe. Minimally invasive techniques for LPND in selected patients can be an acceptable alternative to an open LPND.

This study aimed to compare voiding and male sexual dysfunction between open and laparoscopic rectal cancer surgery.Ninety-seven patients (62 male and 35 female) who underwent open (n = 41) or laparoscopic (n = 56) surgery for rectal cancer were prospectively enrolled. Urine flowmetry, the international prostate symptom score, and the international index of erectile function were assessed preoperatively and postoperatively.Voiding function score increased 1 month after surgery (open: 9.3 ± 4.6 to 14.0 ± 8.2, laparoscopic: 8.3 ± 5.3 to 12.3 ± 5.2; P = 0.002 and P 0.001). The score was even higher in both groups after 6 months, but the increases were not statistically significant (open: 9.9 ± 4.5, laparoscopic: 9.2 ± 5.6; P = 0.546 and P = 0.280). Male patients who underwent open surgery (n = 22) experienced declining sexual function until 12 months post surgery (before: 55.2 ± 9.8, 12 months: 48.7 ± 15.9, P = 0.031). In laparoscopic group (n = 28), sexual function decreased until 6 months after surgery, but rose again by 12 months (before: 55.4 ± 9.0, 12 months: 52.2 ± 11.7, P = 0.134).Voiding dysfunction recovered after 6 months following both open and laparoscopic surgery. Male sexual function recovered more quickly in laparoscopic group and returned to preoperative levels after 12 months.

Subsidence after anterior cervical reconstruction using a titanium mesh cage (TMC) has been a matter of debate. The authors investigated and analyzed subsidence and its effect on clinical and radiologic parameters after cervical reconstruction using a TMC for degenerative cervical disease. Thirty consecutive patients with degenerative cervical spine disorders underwent anterior cervical corpectomy followed by reconstruction with TMC. Twenty-four patients underwent a single-level corpectomy, and six patients underwent a two-level corpectomy. Clinical outcomes were assessed using a Visual Analogue Scale (VAS), the Japanese Orthopedic Association (JOA) score and the Neck Disability Index (NDI). Fusion status, anterior and posterior subsidence of the TMC, segmental angle (SA) and cervical sagittal angle (CSA) were assessed by lateral and flexion-extension radiographs of the neck. The mean follow-up period was 27.6 months (range, 24 to 49 months). The VAS, NDI and JOA scores were all significantly improved at the last follow-up. No instances of radiolucency or motion-related pseudoarthrosis were detected on radiographic analysis, yielding a fusion rate of 100%. Subsidence occurred in 28 of 30 patients (93.3%). The average anterior subsidence of the cage was 1.4 ± 0.9 mm, and the average posterior subsidence was 2.9 ± 1.2 mm. The SA and CSA at the final follow-up were significantly increased toward a lordotic angle. Anterior cervical reconstruction using TMC and plating in patients with cervical degenerative disease provides good clinical and radiologic outcomes. Cage subsidence occurred frequently, especially at the posterior part of the cage. Despite the prominent posterior subsidence of the TMC, SA and CSA were improved on final follow-up radiographs, suggesting that posterior subsidence may contribute to cervical lordosis.

This study aimed to examine the effects of a postsurgical, inpatient exercise program on postoperative recovery in operable colon cancer patients We conducted the randomized controlled trial with two arms: postoperative exercise vs. usual care. Patients with stages I–III colon cancer who underwent colectomy between January and December 2011 from the Colorectal Cancer Clinic, were recruited for the study. Subjects in the intervention group participated in the postoperative inpatient exercise program consisted of twice daily exercise, including stretching, core, balance, and low-intensity resistance exercises. The usual care group was not prescribed a structured exercise program. The primary endpoint was the length of hospital stay. Secondary endpoints were time to flatus, time to first liquid diet, anthropometric measurements, and physical function measurements. A total of 31 (86.1 %) patients completed the trial, with adherence to exercise interventions at 84.5 %. The mean length of hospital stay was 7.82 ± 1.07 days in the exercise group compared with 9.86 ± 2.66 days in usual care (mean difference, 2.03 days; 95 % confidence interval (CI), −3.47 to −0.60 days; p = 0.005) in per-protocol analysis. The mean time to flatus was 52.18 ± 21.55 h in the exercise group compared with 71.86 ± 29.2 h in the usual care group (mean difference, 19.69 h; 95 % CI, −38.33 to −1.04 h; p = 0.036). Low-to-moderate-intensity postsurgical exercise reduces length of hospital stay and improves bowel motility after colectomy procedure in patients with stages I–III colon cancer.

The aim of this study is to investigate if retrieval of 12 lymph nodes (LNs) is sufficient to avoid stage migration as well as to evaluate the prognostic impact of insufficient LN retrieval in different treatment settings of rectal cancer, particularly in the case of preoperative chemoradiotherapy (pCRT). The data of all patients with biopsy proven rectal adenocarcinoma who underwent curative surgery between January 2005 and December 2012 were analyzed. Univariate and multivariate analyses for oncologic outcomes were performed in LN metastasis or no LN metastasis (LN−) group. Subgroup analyses were performed according to whether a patient had received pCRT. A total of 1825 patients were enrolled into the study. The maximal Chi-square method revealed the minimum number of harvested LNs required to be 12. Univariate and multivariate analyses found LNs ≥ 12 to be an independent prognostic factor for both overall survival (OS) (hazard ratio [HR] = 0.5, 95% confidence intervals [CIs]: 0.3–0.8; P = 0.002) and disease-free survival (DFS) (HR = 0.6, 95% CI: 0.4–0.7; P

Single-incision laparoscopic surgery is cosmetically beneficial, but technically challenging. In this study, the learning curve (LC) for single-incision laparoscopic right hemicolectomy (SILRC), incorporating complete mesocolic excision to resect right-sided colon cancer, was investigated through multidimensional techniques. Between December 2009 and May 2015, 64 patients each underwent SILRC of right-sided colon cancer at Severance Hospital, performed in all instances by the same surgeon. Moving average and cumulative sum control chart (CUSUM) were used for LC analyses retrospectively. Surgical failure was defined as conversion to conventional laparoscopic surgery, postsurgical morbidity within 30 days, harvested lymph node count

760 Background: Clinical benefit of adjuvant chemotherapy (AC) is still controversial in locally advanced rectal cancer (LARC) after neoadjuvant chemoradiation therapy (CRT) followed by total mesorectal excision (TME). We aim to explore the role of adjuvant chemotherapy with fluoropyrimidine for ypT0-3N0 patients. Methods: Patients with ypT0-3N0 rectal cancer after neoadjuvant CRT and TME were included using retrospective cohort of Yonsei Cancer Center. Patients were categorized according to receipt of adjuvant chemotherapy (AC vs. no AC). Disease free survival (DFS) and overall survival (OS) between treatment groups were compared using all patients’ cohort (APC) and propensity score-matched patients’ cohort (PSMPC). Results: total of 339 patients were evaluated. Of all, 87 patients (25.7%) did not receive AC. There was no difference in DFS between two groups [hazard ratio (HR) = 1.079, p-value = 0.782 in APC; HR = 1.22, p-value in PSMPC]. Also there was no difference in OS between two groups (HR = 1.140, p-value 0.717 in APC; HR = 1.366, p-value 0.472 in PSMPC). Advanced T stage and positive resection margin were associated with inferior DFS and OS by multivariate analysis. In subgroup analysis by baseline characteristics, we could not find any group with benefit of adjuvant chemotherapy. Conclusions: AC did not improve DFS and OS of patients with ypT0-3N0 rectal cancer after neoadjuvant CRT followed by TME. The role of AC in LARC with ypT0-3N0 after preoperative CRT should be evaluated in prospective randomized trials with larger sample size.

Purpose Rectal cancer patients achieving pCR are known to have an excellent prognosis, yet no widely accepted consensus on risk stratification and post-operative management (e.g., adjuvant therapy) has been established. This study aimed to identify magnetic resonance imaging (MRI) high-risk factors for tumor relapse in pathological complete remission (pCR) achieved by rectal cancer patients who have undergone neoadjuvant concurrent chemoradiation therapy (CRT) and curative resection. Materials and methods We analyzed 88 (male/female = 55/33, median age, 59.5 years [range 34-78]) pCR-proven rectal cancer patients who had undergone pre-CRT MRI, CRT, post-CRT MRI and curative surgery between July 2005 and December 2012. Patients were observed for post-operative tumor relapse. We analyzed the pre/post-CRT MRIs for parameters including mrT stage, mesorectal fascia (mrMRF) status, tumor volume, tumor regression grade (mrTRG), nodal status (mrN), and extramural vessel invasion (mrEMVI). We performed univariate analysis and Kaplan-Meier survival analysis. Results Post-operative tumor relapse occurred in seven patients (8.0%, n = 7/88) between 5.7 and 50.7 (median 16.8) months. No significant relevance was observed between tumor volume, volume reduction rate, mrTRG, mrT, or mrN status. Meanwhile, positive mrMRF (Ppre-CRT = 0.018, Ppre/post-CRT = 0.006) and mrEMVI (Ppre-CRT = 0.026, Ppre-/post-CRT = 0.008) were associated with higher incidence of post-operative tumor relapse. Kaplan-Meier survival analysis revealed a higher risk of tumor relapse in patients with positive mrMRF (Ppre-CRT = 0.029, Ppre-/post-CRT = 0.009) or mrEMVI (Ppre-CRT = 0.024, Ppre-/post-CRT = 0.003). Conclusion Positive mrMRF and mrEMVI status was associated with a higher risk of post-operative tumor relapse of pCR achieved by rectal cancer patients, and therefore, can be applied for risk stratification and to individualize treatment plans.

Malignant glioma cells invading surrounding normal brain are inoperable and resistant to radio- and chemotherapy, and eventually lead to tumor regrowth. Identification of genes related to motility is important for understanding the molecular biological behavior of invasive gliomas. According to our previous studies, Metallothionein 1E (MT1E) was identified to enhance migration of human malignant glioma cells. The purpose of this study was to confirm that MT1E could modulate glioma invasion in vivo. Firstly we established 2 cell lines; MTS23, overexpressed by MT1E complementary DNA construct and pV12 as control. The expression of matrix metalloproteinases (MMP)-2, -9 and a disintegrin and metalloproteinase 17 were increased in MTS23 compared with pV12. Furthermore it was confirmed that MT1E could modulate MMPs secretion and translocation of NFkB p50 and B-cell lymphoma-3 through small interfering ribonucleic acid knocked U87MG cells. Then MTS23 and pV12 were injected into intracranial region of 5 week old male nude mouse. After 4 weeks, for brain tissues of these two groups, histological analysis, and immunohistochemical stain of MMP-2, 9 and Nestin were performed. As results, the group injected with MTS23 showed irregular margin and tumor cells infiltrating the surrounding normal brain, while that of pV12 (control) had round and clear margin. And regrowth of tumor cells in MTS23 group was observed in another site apart from tumor cell inoculation. MT1E could enhance tumor proliferation and invasion of malignant glioma through regulation of activation and expression of MMPs.

Purpose This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR. Methods Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts. Results Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]). Conclusion The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.

A rectal carcinoma, including primary an adenosquamous and a squamous cell carcinoma (SCC), is a very rare disease, accounting for 0.025% to 0.20% of all large-bowel malignant tumors. Because SCCs have a higher mortality than adenosquamous carcinomas, determining whether the primary rectal cancer exhibits an adenomatous component or a squamous component is important. While differentiating between these 2 components, especially in poorly differentiated rectal cancer, is difficult, specific immunohistochemical stains enable accurate diagnoses. Here, we report the use of immunohistochemical stains to distinguish between the adenomatous and the squamous components in 2 patients with low rectal cancer, a 58-year-old man and a 73-year-old woman, who were initially diagnosed using the histopathologic results for a poorly differentiated carcinoma. These data suggest that using these immunohistochemical stains will help to accurately diagnose the type of rectal cancer, especially for poorly differentiated carcinomas, and will provide important information to determine the proper treatment for the patient.

The close association between mucinous histology and microsatellite instability (MSI) may have hindered the evaluation of prognostic significance of mucinous histology. The aim of this retrospective study was to investigate whether mucinous histology was associated with a worse prognosis, independent of MSI status, compared to nonmucinous histology in patients with stage III colon cancer.This study enrolled 394 consecutive patients with stage III colorectal cancer treated with adjuvant FOLFOX after curative resection (R0). Clinicopathological information was retrospectively reviewed. Tumors were analyzed for MSI by polymerase chain reaction to determine MSI status. Kaplan-Meier method, log-rank test, and Cox proportional hazard regression models were used.The estimated rate of 3-year disease-free survival (DFS) in patients with nonmucinous adenocarcinoma (NMA 79.2 %) was significantly greater than that in patients with mucinous adenocarcinoma (MA) and adenocarcinoma with mucinous component (MC) (56.9 %; log-rank, P = 0.002). In univariate analysis, histology (NMA vs. MA/MC), American Joint Committee on Cancer stage (IIIA, IIIB, and IIIC), and lymphovascular invasion (present vs. absent) were significantly associated with DFS. In multivariate analysis, mucinous histology (MA/MC) was associated with decreased DFS in all patients (hazard ratio 1.82, 95 % confidence interval 1.03-3.23, P = 0.0403). In patients with MA/MC, no difference in DFS was observed between MSI and microsatellite stability (log-rank, P = 0.732).Mucinous histology is an independent poor prognostic factor for DFS in patients with stage III colon cancer after adjuvant FOLFOX chemotherapy.

Robotic surgery is increasingly used in the field of rectal cancer surgery. This study aimed to compare the short- and long-term outcomes between robotic and laparoscopic ultralow anterior resection (uLAR) and coloanal anastomosis (CAA). Between January 2007 and December 2010, a retrospective chart review was performed for all patients with low rectal cancer who underwent curative uLAR and CAA with or without intersphincteric resection using either a robotic or a laparoscopic approach. The study excluded patients with tumors invading the levator ani or external sphincter, patients with T4 cancers invading the prostate or vagina, and patients for whom an open approach was used. Patients’ short- and long-term outcomes were evaluated. This study enrolled 84 consecutive patients (47 in the robotic group and 37 in the laparoscopic group). The patient characteristics and operative data did not differ significantly between the groups except for the rate of conversion to open surgery (robot, 2.1 % vs laparoscopy, 16.2 %; p = 0.02). The postoperative outcomes also were similar in the two groups, but the hospital stay was shorter in the robotic group than in the laparoscopic group (robot, 9 days vs laparoscopy, 11 days; p = 0.011). No postoperative mortality occurred. The median follow-up period was 31.5 months. No difference was shown in local recurrence, 3-year overall survival, or disease-free survival between the two groups. Robotic uLAR and CAA with or without ISR is a safe and feasible surgical approach with a lower conversion rate, a shorter hospital stay, and similar oncologic outcomes compared with a laparoscopic approach. Further prospective and case–control cohort studies with longer follow-up periods are required.

This study aimed to describe clinical outcomes of rectal carcinoids according to the 7th American Joint Council on Cancer (AJCC) TNM staging system.We retrospectively reviewed 122 patients who were treated for rectal carcinoids between 1995 and 2010.Among 122 patients, 81.2% (n = 99) were classified as stage I, 4.9% (n = 6) as stage II, 11.5% (n = 14) as stage III, and 2.5% (n = 3) as stage IV. Lymph node (LN) metastasis rates for pT1a, 1b, 2, and 3 stages were 1.2% (1/85), 16.7% (3/18), 0% (0/4) and 84.6% (11/13), respectively. The 5-year overall survival (OS) rate was 88.4%. The 5-year OS rates were estimated to be 100%, 80%, 51.4% and 0% for stage I, II, III, and IV, respectively (P0.001). The 5-year disease-free survival (DFS) rate was 82.3%. The 5-year DFS rates were estimated to be 97.7%, 62.5%, 17.1%, and 0% for stages I, II, III, and IV, respectively (P0.001).Using the new TNM stage, we confirmed a prognostic difference in LN metastasis rates, OS, and DFS for rectal carcinoids. In clinical practice, the new TNM stage can be very useful for predicting prognosis.

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).The benefits of RS in the treatment of rectal cancer have not yet been clearly described.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.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.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.

Purpose: The optimal time between neoadjuvant chemoradiotherapy (CRT) and surgery for rectal cancer has been debated. This study evaluated the influence of this interval on oncological outcomes. Methods: We compared postoperative complications, pathological downstaging, disease recurrence, and survival in patients with locally advanced rectal cancer who underwent surgical resection ＜8 weeks (group A, n = 105) to those who had surgery ≥8 weeks (group B, n = 48) after neoadjuvant CRT. Results: Of 153 patients, 117 (76.5%) were male and 36 (23.5%) were female. Mean age was 57.8 years (range, 28 to 79 years). There was no difference in the rate of sphincter preserving surgery between the two groups (group A, 82.7% vs. group B, 77.6%; P = 0.509). The longer interval group had decreased postoperative complications, although statistical significance was not reached (group A, 28.8% vs. group B, 14.3%; P = 0.068). A total of 111 (group A, 75 [71.4%] and group B, 36 [75%]) patients were downstaged and 26 (group A, 17 [16.2%] and group B, 9 [18%]) achieved pathological complete response (pCR). There was no significant difference in the pCR rate (P = 0.817). The longer interval group experienced significant improvement in the nodal (N) downstaging rate (group A, 46.7% vs. group B, 66.7%; P = 0.024). The local recurrence (P = 0.279), distant recurrence (P = 0.427), disease-free survival (P = 0.967), and overall survival (P = 0.825) rates were not significantly different. Conclusion: It is worth delaying surgical resection for 8 weeks or more after completion of CRT as it is safe and is associated with higher nodal downstaging rates.

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). 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. 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. 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.

Robot-assisted surgery is a new and emerging surgical procedure for rectal cancer patients. However, there is a lack of information regarding oncologic outcomes for this procedure. We aimed to evaluate oncologic and perioperative clinicopathologic outcomes of surgical resection using robotic instruments for rectal cancer. Data from rectal cancer patients (n = 370) diagnosed with stage I–IV disease sited below 15 cm from the anal verge who underwent robot-assisted tumor-specific mesorectal excision consecutively from June 2006 to December 2010 were evaluated. Clinicopathologic and follow-up data were recorded prospectively and analyzed retrospectively. Perioperative clinicopathologic outcomes, postoperative complications, 3-year overall survival rate, and 3-year disease-free survival rate were analyzed. All patients underwent robot-assisted tumor-specific mesorectal excision. Of all postoperative pathologic stages, 15 (4.1 %) were stage 0 (pathologic complete remission), 126 (34.1 %) stage I, 95 (25.7 %) stage II, 118 (31.9 %) stage III, and 16 (4.3 %) stage IV. The 3-year overall survival rate was 93.1 % (pathologic complete remission = 100 %, stage I = 99.2 %, stage II = 97.1 %, stage III = 90.1 %, and stage IV = 48.4 %). The 3-year disease-free survival rate was 79.2 % (pathologic complete remission = 100 %, stage I = 93.7 %, stage II = 79.8 %, stage III = 69.6 %, and stage IV = 0.0 %). The 3-year cumulative local recurrence rate was 3.6 % (n = 10). The circumferential resection margin positive rate was 5.7 % (n = 21). Local recurrence developed in one patient and systemic recurrence developed in five patients. The total number of patients with postoperative complications was 86 (23.2 %). These data show the feasibility and safety of robot-assisted tumor-specific mesorectal excision for rectal cancer in terms of oncologic outcomes.

The aim of this study was to evaluate factors affecting the difficulty of laparoscopic total mesorectal excision (L-TME), focusing on the pelvic anatomy.Seventy-four patients who underwent L-TME were prospectively enrolled. Tumor and patient factors, including magnetic resonance imaging-based pelvic measurements (obstetric conjugate, sacral length, sacral depth, interspinous distance, and intertuberous distance), were analyzed with respect to pelvic dissection time. Variable significantly correlated with pelvic dissection time in linear regression were considered risk factors which we defined as lower or upper quartile of each significant variable. Patients were categorized into 3 groups: easy group, no risk factors; moderate group, 1 to 2 risk factors; and difficult group, ≥ 3 risk factors.Multivariate analysis showed that long sacral length, shallow sacral angle, narrow intertuberous diameter, and large tumor size were significantly associated with longer pelvic dissection time (P=0.018, P0.001, P=0.034, P=0.032, respectively). The cutoff values of the upper quartile were 11.5 cm and 4.5 cm for sacral length and tumor size, and cutoff values of the lower quartile were 3.0 cm and 8.9 cm for sacral depth and intertuberous diameter. Logistic regression analysis showed that difficult group significantly contributed to intraoperative complication (95% confidence interval: 1.364-122.313, P=0.026) but not postoperative complication.Having a narrow, deep pelvis and a large tumor were not found to adversely affect postoperative outcomes. However, in terms of operation time and intraoperative difficulty, anatomical factors should be taken into consideration when planning L-TME.

PURPOSE Laparoscopic colectomy has clinical benefits such as short hospital stay, less postoperative pain, and early return of bowel function. However, objective evidence of its immunologic and oncologic benefits is scarce. We compared functional recovery after open versus laparoscopic sigmoidectomy and investigated the effect of open versus laparoscopic surgery on acute inflammation as well as tumor stimulation. MATERIALS AND METHODS A total of 57 patients who were diagnosed with sigmoid colon cancer were randomized for elective conventional or laparoscopically assisted sigmoidectomy. Serum samples were obtained preoperatively and on postoperative day 1. C-reactive protein (CRP) and interleukin-6 (IL-6) were measured as inflammation markers, and vascular endothelial growth factor (VEGF) and insulin-like growth factor binding protein-3 (IGFBP-3) were used as tumor stimulation factors. Clinical parameters and serum markers were compared. RESULTS Postoperative hospital stay (p=0.031), the first day of gas out (p=0.016), and the first day of soft diet (p

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.

Background Although self-expandable metal stent (SEMS) insertion has been shown to be an effective therapy for palliation of obstruction from colorectal malignancy, the clinical efficacy of SEMS insertion in the palliation of colorectal obstruction from an extracolonic malignancy (ECM) has not been extensively evaluated. Objective The aim of this study was to evaluate the clinical outcomes and complications of SEMSs compared with those of emergency surgery for relief of colorectal obstruction in patients with advanced gastric cancer (AGC). Design Retrospective study. Patients From January 2000 to December 2009, patients with AGC who were treated with SEMSs (N = 111) or emergency surgery (N = 69) for palliation of malignant colorectal obstruction were included. Intervention SEMS insertion or surgery. Results Although acute complications and stoma formations were lower in the SEMS group than in the surgery group, the clinical efficacy of SEMSs was inferior to emergency surgery (technical success, 73.9% vs 94.2%, P = .001; clinical success, 54.1% vs 75.4%, P = .005). SEMS-related complications occurred in 64.5%, including reobstruction (36.8%), stent migration (10.5%), perforation (13.2%), and bleeding (3.9%). The median duration of patency was not statistically different between the patients who underwent SEMS insertion and those who underwent emergency surgery (117 days vs 183 days, P = .105). Patients with fewer than 2 obstructive sites or less than 2 years to obstructive symptom onset after diagnosis of AGC showed better clinical outcomes after endoscopic stenting. Limitations Retrospective and single-center study. Conclusions SEMS insertion seems to be less effective than emergency surgery for the palliation of colorectal obstruction in patients with AGC. Further study is necessary to define those patients with ECM who may benefit from SEMS insertion.

Background: Although the vertebral artery injuries (VAI) associated with cervical spine trauma are usually clinically occult, they may cause fatal ischemic damage to the brain stem and cerebellum. Methods: We performed a prospective study using computed tomographic angiography (CTA) to determine the frequency of VAI associated with cervical spine injuries and investigate the clinical and radiological characteristics. Between January 2005 and August 2007, 99 consecutive patients with cervical spine fractures and/or dislocations were prospectively evaluated for patency of the VA, using the CTA, at the time of injury. Results: Complete disruption of blood flow through the VA was demonstrated in seven patients with unilateral occlusion (7.1%). There were four men and three women with a mean age of 43 (range, 33-55 years). Unilateral occlusion of the right vertebral artery occurred in four patients and of the left in three. Regarding the cervical injury type, two cases were cervical burst fractures (C6 and C7), two had C4-5 fracture/dislocations, two had a unilateral transverse foraminal fracture, and one had dens type III fracture. All patients presented with good patency of the contralateral VA. None of the patients developed secondary neurological deterioration due to vertebrobasilar ischemia during the follow-up period with a mean duration of 23 months. Conclusions: VAI should be suspected in patients with cervical trauma that have cervical spine fractures and/or dislocations or transverse foramen fractures. CTA was useful as a rapid diagnostic method for ruling out VAI after cervical spine trauma.

This study aims to evaluate the efficacy of (18)F-FDG PET in assessing tumor response after preoperative chemoradiation therapy (CRT) for rectal cancer.Maximum standardized uptake value (SUV) was measured for 37 patients who underwent (18)F-FDG PET before and 4 weeks after completion of preoperative CRT. Pre-SUV, post-SUV, the difference between pre- and post-SUV (ΔSUV), and reduction rate (RR) were correlated with tumor response.A lower mean post-SUV and a higher mean RR were shown in good tumor response (T-downstaging(+) and tumor regression grade 1, 2). Considering pathologic complete response (pCR), the mean post-SUV and the mean RR were significantly different between pCR (+) patients (N = 13) and pCR (-) patients (N = 24) (2.7 vs. 4.8, P 0.001, 73.9% vs. 58.7%, P = 0.009). With a 3.35 cut-off value for the post-SUV by receiver operating characteristic analysis, 84.6% sensitivity, 79.2% specificity, and 81.2% overall accuracy were obtained for discriminating between pCR (+) and pCR (-) (area under the curve = 0.885, P 0.001).(18)F-FDG PET is potentially useful as a method for assessing tumor response after preoperative CRT for rectal cancer. Post-SUV and RR were significantly associated with pathological treatment response, especially in pCR.

The benefit of adjuvant radiotherapy in patients with stage IIA (T3N0) rectal cancer following total mesorectal excision (TME) is controversial. We evaluated the effect of adjuvant chemoradiotherapy (CRT) versus chemotherapy (CT) alone on the local recurrence and survival of patients with stage IIA rectal cancer after TME.Between 1996 and 2004, patients with stage IIA rectal cancer who received adjuvant CT (n = 29) or CRT (n = 122) following TME were enrolled. Oncologic outcomes were compared between groups, and risk factors for local recurrence and overall survival rates were analyzed.The median follow-up period was 78 months. No significant differences were observed in the 5-year local recurrence (3.4% versus 9.0%; P = 0.348) or 5-year overall survival rates (86.2% versus 80.3%; P = 0.924) between CT and CRT. However, involvement of the circumferential resection margin and age60 years were associated with adverse oncologic outcomes.Additional postoperative radiotherapy did not alter local recurrence or survival after TME in patients with stage IIA rectal cancer. Postoperative radiation may be an overtreatment as an adjuvant therapy in patients with stage IIA rectal cancer if they had no other risk factors. However, randomized controlled trials are warranted to confirm this suggestion.

AIM To evaluate whether the incorporation of a novice first assistant into a laparoscopic team affects operative outcomes after laparoscopic sigmoidectomy for sigmoid colon cancer. METHODS Sixty-five patients who underwent laparoscopic sigmoidectomy were prospectively enrolled in this study between March 2008 and October 2008. One surgeon with a novice first assistant during the study period carried out all operations. Outcomes of this population were compared with those of 50 patients (control group) that underwent laparoscopic sigmoidectomy between March 2007 and February 2008 by the same surgeon with an experienced first assistant. The 65 patients operated upon with the involvement of the novice (the patients group) were allocated to 2 groups by case number, that is, to an early group (case numbers 1 to 10) and to a late group (case numbers 11 to 65). RESULTS Mean operative times were 233+/-50 minutes in the control group, 305+/-113 minutes in the early group, and 226+/-58 minutes in the late group (P=0.04). Multiple regression analysis showed that in the early group, body mass index and tumor diameter significantly contributed to operative time. The incidences of intraoperative and postoperative complications were not significantly different in the early, late, and control groups. CONCLUSIONS The incorporation of a novice first assistant into a laparoscopic team was not found to affect operative outcomes adversely. However, in terms of operative time, novice assistants probably need experience of around 10 cases before they can be viewed as fully competent surgical team members during laparoscopic sigmoidectomy.

Surgery for thoracic disc herniations is still challenging, and the disc excision via a posterior laminectomy is considered risky. A variety of dorsolateral and ventral approaches have been developed. However, the lateral extracavitary and transthoracic approach require extensive surgical exposure. Therefore, we adopted a posterior transdural approach for direct visualization without entry into the thoracic cavity. Three cases that illustrate this procedure are reported here with the preoperative findings, radiological findings and surgical techniques used. After the laminectomy, at the involved level, the dorsal dura was opened with a longitudinal paramedian incision. The cerebrospinal fluid was drained to gain more operating space. After sectioning of the dentate ligaments, gentle retraction was applied to the spinal cord. Between the rootlets above and below, the ventral dural bulging was clearly observed. A small paramedian dural incision was made over the disc space and the protruded disc fragment was removed. Neurological symptoms were improved, and no surgery-related complication was encountered. The posterior transdural approach may offer an alternative surgical option for selected patients with thoracic paracentral soft discs, while limiting the morbidity associated with the exposure.

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.

Purpose 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. Methods and Materials 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. Results 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. Conclusions This study suggests that SNPs within the TS enhancer region affect the tumor response to preoperative 5-FU–based CRT in rectal cancer.

Pedunculated extra-luminal leiomyoma is a rare solid tumor. We present a case of a 20-year-old Caucasian woman with a painful pedunculated extraluminal mass located on the bladder dome and associated with dysuria. She underwent robot-assisted laparoscopic resection, and the histological findings confirmed a leiomyoma.

Self-expanding metallic stents (SEMS) have been used as a bridge to surgery in patients with obstruction by colorectal cancer, but the oncologic safety of this technique has not yet been established. The aim of the present study was to compare the outcomes of bridge to surgery after SEMS insertion and nonobstructing elective surgery.Between October 1999 and July 2007, 35 patients who had left-sided colon malignancy obstruction and underwent surgical resection after SEMS insertion (group A) were matched to 350 patients who underwent elective surgery for nonobstructing left-sided colon cancer based on stage II, III, and IV malignancies according to the 2001 American Joint Committee on Cancer (group B). Group B was randomly extracted from the colorectal database of our institute. The two groups were compared for clinicopathologic variables, complications, and survival rate.There were no significant differences in clinicopathologic variables between group A and group B. However, the stoma formation rate was statistically different between the two groups (p = 0.003). Self-expanding metallic stent insertion had an adverse effect on the 5-year overall survival rate (A vs. B, 38.4% vs. 65.6%, respectively; p = 0.025) and the 5-year disease-free survival rate (A vs. B, 48.3% vs. 75.5%, respectively; p = 0.024).These data show that insertion of SEMS as a bridge to surgery in the management of left-sided colon cancer obstruction is possibly associated with adverse oncologic outcomes compared with nonobstructing elective surgery, but it is unclear what magnitude of this effect is related to the underlying obstruction rather than to the SEMS.

Over the past several years, preoperative chemoradiotherapy (CRT) has contributed remarkably to make more sphincter-preserving procedure (SPP) possible for lower rectal cancer. The aim of this study was to compare the outcomes between abdominoperineal resection (APR) and SPP after preoperative CRT in patients with locally advanced lower rectal cancer.A retrospective investigation was conducted with a total of 122 patients who underwent radical surgery combined with preoperative CRT for locally advanced lower rectal cancer. Of these, 50 patients underwent APR and 72 received SPP. Surgery was performed 6-8 weeks after completion of preoperative CRT. Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated.Circumferential resection margin (CRM) involvement (P = 0.037) and postoperative complication rate (P = 0.032) were significantly different between APR and SPP. Patients who underwent APR had a higher 5-year local recurrence (22.0% vs. 11.5%, P = 0.028) and lower 5-year cancer-specific survival (52.9% vs. 71.1%, P = 0.03) rate than those who underwent SPP. Pathologic N stage was the most critical predictor for local recurrence and survival.Our study shows that APR following preoperative CRT exhibited more adverse oncologic outcomes compared with SPP. This result may be due to higher rates of CRM involvement in APR even with preoperative CRT. We suggest that sharp perineal dissection and wider cylindrical excision at the level of the anorectal junction are required to avoid CRM involvement and improve oncologic outcomes in patients who undergo APR following preoperative CRT.

Purpose The aim of this study was to determine the correlation between tumor volume changes assessed by three-dimensional (3D) magnetic resonance (MR) volumetry and the histopathologic tumor response in rectal cancer patients undergoing preoperative chemoradiation therapy (CRT). Methods and Materials A total of 84 patients who underwent preoperative CRT followed by radical surgery were prospectively enrolled in the study. The post-treatment tumor volume and tumor volume reduction ratio (% decrease ratio), as shown by 3D MR volumetry, were compared with the histopathologic response, as shown by T and N downstaging and the tumor regression grade (TRG). Results There were no significant differences in the post-treatment tumor volume and the volume reduction ratio shown by 3D MR volumetry with respect to T and N downstaging and the tumor regression grade. In a multivariate analysis, the tumor volume reduction ratio was not significantly associated with T and N downstaging. The volume reduction ratio (>75%, p = 0.01) and the pretreatment carcinoembryonic antigen level (≤3 ng/ml, p = 0.01), but not the post-treatment volume shown by 3D MR (≤ 5ml), were, however, significantly associated with an increased pathologic complete response rate. Conclusion More than 75% of the tumor volume reduction ratios were significantly associated with a high pathologic complete response rate. Therefore, limited treatment options such as local excision or simple observation might be considered after preoperative CRT in this patient population.

✓Disc herniations of the upper lumbar spine (L1–2 and L2–3) have a frequency of 1 to 2% of all disc herniations. During posterior discectomy after laminectomy, significant manipulation of the exiting nerve root is unavoidable because of the narrow lamina and the difficulty in mobilizing the nerve root. The authors adopted a transdural approach in patients with calcified central disc herniation at the L1–2 level to reduce the risk of nerve root injury. Four patients suffering from radiating pain together with back pain were treated using the transdural approach. Pre-operative neuroimaging studies revealed severe central disc herniation with calcification at the L1–2 level. After laminectomy or laminotomy, the incised dura mater was tacked, and the cauda equina rootlets were gently retracted. An intentional durotomy was performed over its maximal bulging of the ventral dura. After meticulous dissection of dense adhesions between the disc herniation and the dural sac, adequate decompression with removal of calcified disc fragments and osteophytes was accomplished. Clinical symptoms improved in all patients. Postoperative permanent cerebrospinal fluid leakage and pseudomeningocele were not observed, and no patient had a progressive lumbar deformity at an average follow-up of 53 months. Transient mild motor weakness and sensory change were observed in two patients postoperatively; however, these symptoms resolved completely within 1 week. The posterior transdural approach offers an alternative in central calcified upper lumbar disc herniation when root retraction is dangerous.

Preoperative chemoradiation therapy (CRT) is the standard treatment for patients with locally advanced rectal cancer (LARC) and can improve local control and survival outcomes. However, the responses of individual tumors to CRT are not uniform and vary widely, from complete response to disease progression. Patients with resistant tumors can be exposed to irradiation and chemotherapy that are both expensive and at times toxic without benefit. In contrast, about 60% of tumors show tumor regression and T and N down-staging. Furthermore, a pathologic complete response (pCR), which is characterized by sterilization of all tumor cells, leads to an excellent prognosis and is observed in approximately 10-30% of cases. This variety in tumor response has lead to an increased need to develop a model predictive of responses to CRT in order to identify patients who will benefit from this multimodal treatment. Endoscopy, magnetic resonance imaging, positron emission tomography, serum carcinoembryonic antigen, and molecular biomarkers analyzed using immunohistochemistry and gene expression profiling are the most commonly used predictive models in preoperative CRT. Such modalities guide clinicians in choosing the best possible treatment options and the extent of surgery for each individual patient. However, there are still controversies regarding study outcomes, and a nomogram of combined models of future trends is needed to better predict patient response. The aim of this article was to review currently available tools for predicting tumor response after preoperative CRT in rectal cancer and to explore their applicability in clinical practice for tailored treatment.

Purpose Single-port plus one-port, reduced-port laparoscopic surgery (RPLS) may decrease collisions between laparoscopic instruments and the camera in a narrow, bony, pelvic cavity while maintaining the cosmetic advantages of single-incision laparoscopic surgery. The aim of this study is to describe our initial experience with and to assess the feasibility and safety of RPLS for tumor-specific mesorectal excisions (TSMEs) in patients with colorectal cancer. Methods Between May 2010 and August 2012, RPLS for TSME was performed in 20 patients with colorectal cancer. A single port with four channels through an umbilical incision and an additional port in the right lower quadrant were used for RPLS. Results The median operation time was 231 minutes (range, 160-347 minutes), and the estimated blood loss was 100 mL (range, 50-500 mL). We transected the rectum with one laparoscopic stapler in 17 cases (85%). The median time to soft diet was 4 days (range, 3-6 days), and the length of hospital stay was 7 days (range, 5-45 days). The median total number of lymph nodes harvested was 16 (range, 7-36), and circumferential resection margin involvement was found in 1 case (5%). Seven patients (35%) developed postoperative complications, and no mortalities occurred within 30 days. During the median follow-up period of 20 months (range, 12-40 months), liver metastasis occurred in 1 patient 10 months after surgery, and local recurrence was nonexistent. Conclusion RPLS for TSME in patients with colorectal cancer is technically feasible and safe without compromising oncologic safety. However, further studies comparing RPLS with a conventional, laparoscopic low-anterior resection are needed to prove the advantages of the RPLS procedure.

Four consecutive cases of a colonic stricture following a da Vinci robot-assisted ultra-low anterior resection (LAR) with coloanal anastomosis and diverting ileostomy for the treatment of rectal cancer are reported. The colonic strictures developed after early proximal colonic ischemia without anastomotic site leakage or disruption. All patients were treated with preoperative chemoradiation therapy. During the postoperative recovery period, patients developed colonic ischemia, presenting with a high, spiking fever, but without any symptoms of peritonitis. Patients were treated with conservative management (antibiotic therapy) and discharged after two weeks when in good condition. Several months after discharge, all four patients developed a long-segment colonic stricture from the anastomosis site to the distal colon. Management of the colon strictures, including the anastomotic site, involved colonic dilation with a Hegar dilator in an outpatient clinic for several months. The ileostomies in three patients could not be closed.

Anorectal malignant melanoma (AMM) is a very rare and aggressive disease. The purpose of this article is to review the clinical features of AMM, to understand treatment options, and optimal therapy by reviewing pertinent literature. Traditionally an abdominoperineal resection (APR) sacrificing the anal sphincter has been performed for radical resection of cancer, but recently, wide excision of AMM is attempted since quality of life after surgery is an important issue. Some authors reported that there was no difference in five-year survival between the patient who underwent an APR and wide excision. The goal of both APR and wide excision was to improve survival with R0 resection. Adjuvant chemoradiation therapy can be performed to achieve an R0 resection. AMM shows very poor prognosis. At this time, research on AMM is insufficient to suggest a treatment guideline. Thus, treatment options, and a therapeutic method should be selected carefully.

Purpose Laparoscopic resection for transverse colon cancer is a technically challenging procedure that has been excluded from various large randomized controlled trials of which the long-term outcomes still need to be verified. The purpose of this study was to evaluate long-term oncologic outcomes for transverse colon cancer patients undergoing laparoscopic colectomy (LAC) or open colectomy (OC). Methods This retrospective review included patients with transverse colon cancer who received a colectomy between January 2006 and December 2010. Short-term and five-year oncologic outcomes were compared between these groups. Results A total of 131 patients were analyzed in the final study (LAC, 84 patients; OC, 47 patients). There were no significant differences in age, gender, body mass index, tumor location, operative procedure, or blood loss between groups, but the mean operative time in LAC was significantly longer (LAC, 246.8 minutes vs. OC, 213.8 minutes; P = 0.03). Hospital stay was much shorter for LAC than OC (9.1 days vs. 14.5 days, P < 0.01). Postoperative complication rates were not statistically different between the two groups. In terms of long-term oncologic data, the 5-year disease-free survival and overall survival were not statistically different between both groups, and subgroup analysis according to cancer stage also revealed no differences. Conclusion LAC for transverse colon cancer is feasible and safe with comparable short- and long-term outcomes.