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Background: Colorectal cancer is one of the most common cancers worldwide. Colorectal cancer that has recurred and metastasized to other organs also has a very poor prognosis. According to recent studies, the long interspersed element-1 (LINE-1) retrotransposon open reading frame (ORF) is located in the intron of the c-Met proto-oncogene, which is involved in cancer progression and metastasis, and regulates its expression. However, no study has compared the expression patterns of LINE-1 ORF1 and c-Met, which are closely related to cancer progression and metastasis, and their correlation in primary and recurrent cancers.Methods: In the present study, we compared the expression patterns of LINE-1 ORF1 and c-Met in both primary and recurrent colorectal cancer tissues from 10 patients. Expression patterns and correlations between LINE-1 ORF1 and c-Met proto-oncogene proteins were analyzed by immunofluorescence staining using both LINE-1 ORF1 and c-Met antibodies.Results: The expression patterns of LINE-1 ORF1 and c-Met showed significant individual differences, and the expression of both proteins was correlated in all colorectal cancer patients. However, the expression levels of LINE-1 ORF1 and c-Met were not significantly different between primary and recurrent colorectal cancers. Conclusions: The protein expression levels of LINE-1 ORF1 and c-Met were correlated, but did not change significantly in cases of recurrent colorectal cancer in the same patient.

Background/Aims Early diagnosis of peritoneal metastases in patients with colorectal cancer (CRC) can influence patient prognosis. The aim of this study was to identify the clinical significance of carcinoembryonic antigen (CEA) in peritoneal fluid detected during operation in stage I-III CRC patients. Methods Between April 2009 and April 2015, we reviewed medical records from a total of 60 stage I-III CRC patients who had peritoneal fluid collected during operation. Patients who had positive cytology in the assessment of peritoneal fluid were excluded. We evaluated the values of CEA in peritoneal fluid (pCEA) to predict the long-term outcomes of these patients using Kaplan-Meier curves and Cox regression models. Results The median follow-up duration was 37 months (interquartile range, 21-50 months). On receiver operating characteristic analysis, pCEA had the largest area under the curve (0.793; 95% confidence interval, 0.635-0.950; P=0.001) with an optimal cutoff value of 26.84 (sensitivity, 80.0%; specificity, 76.6%) for predicting recurrence. The recurrence rate was 8.1% in patients with low pCEA (

Purpose Laparoscopic intracorporeal colorectal anastomosis with double stapling technique is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery. Materials and methods In total, 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion and invagination techniques. They were subdivided into 3 groups: 58 patients with no intersection of staple lines (group A), 62 patients with 1 point of intersection (group B) and 8 patients with 2 points of intersection (group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis, and leakage were compared between the 3 groups. Results Clinical anastomotic leakage was identified in 1 (group C) of 128 patients (0.7%). Overall anastomotic leakage rate was 0% (0/58) in group A, 0% (0/62) in group B, and 12.5% (1/8) in group C (P=0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between the 3 groups in multivariate analysis. Conclusions The number of intersections of staple lines is associated with anastomotic leakage, and the inversion technique is a useful method for avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.

Objectives The purpose of this study is to evaluate feasibility and safety of simultaneous laparoscopy-assisted resection for synchronous colorectal and gastric cancer. Methods From January 2001 to December 2013, a total of 29 patients underwent simultaneous resection for synchronous colorectal and gastric cancers. Medical records were reviewed, retrospectively. Results Eight patients (5 male) underwent laparoscopy-assisted resection (LAP group) and twenty one patients (17 male) underwent open surgery (Open group). In the both group, the mean age (65.2 vs. 63.7 years, p =0.481), body mass index (22.6 vs. 22.3, p = 0.896) was comparable, respectively. In LAP group, laparoscopy-assisted distal gastrectomy was performed for all eight patients. In Open group, subtotal gastrectomy with billroth I gastroduodenostomy was most common procedure (66.7%). The operation time, blood loss volume was similar between the two groups. Gas out was earlier (3.0 vs. 4.6 days p = 0.106), postoperative hospital stay was shorter (12.0 vs. 18.3 days, p = 0.245) in LAP group. The postoperative complications were an ileus, a wound seroma and a bile leakage in LAP group, pneumonia (10.0%), wound bleeding (5.0%) and leakage (5.0%) in Open group. Conclusions The simultaneous laparoscopy-assisted resection for synchronous colorectal cancer and gastric cancer is a feasible and safe procedure.

With advancement of minimal invasive surgery, a simultaneous laparoscopy-assisted resection for colorectal cancer and metastasis has become feasible. Hence, we report three cases of simultaneous laparoscopic surgery for colorectal cancer with liver or lung metastasis. In the first case, laparoscopic right hemicolectomy and left lateral segmentectomy of liver was performed for ascending colon cancer and liver metastasis. In the second case, laparoscopic right hemicolectomy and wedge resection of right lower lung was performed for cecal cancer and lung metastasis. In the third case, laparoscopic right hemicolectomy and wedge resection of left lower lung was performed for ascending colon cancer and lung metastasis. In the first two cases, patients quickly returned to normal activity. In the third case, postoperative bleeding was observed, but spontaneously stopped. There was no postoperative mortality. Simultaneous laparoscopic surgery represents a feasible option for colorectal cancer with metastases on the other organs.

Common causes of lower gastrointestinal bleeding include diverticular disease, vascular disease, inflammatory bowel disease, neoplasms, and hemorrhoids. Lower gastrointestinal bleeding of appendiceal origin is extremely rare. We report a case of lower gastrointestinal bleeding due to angiodysplasia of the appendix. A 72-year-old man presented with hematochezia. Colonoscopy showed active bleeding from the orifice of the appendix. We performed a laparoscopic appendectomy. Microscopically, dilated veins were found at the submucosal layer of the appendix. The patient was discharged uneventfully. Although lower gastrointestinal bleeding of appendiceal origin is very rare, clinicians should consider it during differential diagnosis.

Single-incision laparoscopic surgery (SILS) has become popular due to the advantage of minimizing surgical. We report on two cases of simultaneous appendectomy and cholecystectomy using a single-incision laparoscopic technique. The patients were 49- and 50-year old females diagnosed with acute appendicitis with concomitant cholelithiasis. Body mass indices of the patients were 22.3 and 26.0. A 3 cm abdominal incision was made via the umbilicus, and a single port platform was created using a small wound retractor (ALEXIS ® wound retractor S, Applied Medical, Santa Margarita, CA, USA) and a surgical glove. Cholecystectomy was performed first, followed by the appendectomy. The operation times were 165 and 280 minutes, and blood loss was 50 and 150 ㏄, respectively. The postoperative hospital stays were five and seven days, and one patient had a wound seroma as a surgical complication. W e believe that SILS for simultaneous appendectomy and cholecystectomy is a feasible and safe minimally invasive procedure.

Sigmoid volvulus is one of the three most common causes of acute colonic obstruction. Predisposing factors include chronic constipation, adhesion from a prior abdominal surgery, and megacolon. However, concomitant presentation of volvulus of the sigmoid colon and rectal cancer is extremely rare. We report a case of a 50-year-old woman with coexisting volvulus of the sigmoid colon and rectal cancer. The patient presented with abdominal distension and pain for 2 days. On computed tomography, the whole colon was dilated with gas and feces. A whirl sign with rotation of the inferior mesenteric vessel was identified. The rectum had irregular wall thickening. Colonoscopy showed a circumscribed, ulcerofungating mass approximately 6 cm from the anal verge. The sigmoid colon was obstructed at a point approximately 25 cm from the anal verge. The mucosa was hyperemic and edematous with the pathognomonic spiral pattern. Endoscopic reduction was not successful. On laparotomy, the sigmoid colon was rotated around its mesentery. It was severely distended with edematous, hyperemic serosa. A tumor of the rectum was identified in the mid-rectum. The patient underwent low anterior resection and protective ileostomy. Pathologic findings confirmed adenocarcinoma of the rectum. The postoperative course was complicated by an ileus, which was managed with conservative treatment.

Objectives To reduce the risk of postoperative infectious complications and anastomotic leakage in colorectal surgery, preoperative mechanical bowel preparation (MBP) is performed routinely. The aim of this study was to evaluate the safety of primary anastomosis in elective colorectal surgery without MBP. Methods From Jan. 2005 to Dec. 2006, three hundred and seventy-nine patients of elective colorectal surgery with primary anastomosis were performed with MBP in 352 cases (Prep group) and without MBP in 24 cases (Non-prep group). For preoperative MBP, 4 liters of polyethylene glycol solution was administered. Postoperative infectious complications and other morbidity were reviewed with medical records and prospectively collected data. Results Demographic, clinical and treatment characteristics did not differ significantly between the two groups. The overall rate of abdominal infectious complications (wound infection, anastomotic leak) was 2.9 % in the Prep group and 9 % in the Non-prep group (P > 0.05). Anastomotic leak occurred in nine patients (2.6%) in the Prep group and one (4.5%) in the Non-prep group. Conclusions The incidence of infectious complications after elective colorectal surgery without MBP did not differ significantly compare to that with MBP. However, prospective, randomized clinical trial is needed to assess the safety of primary anastomosis in elective colorectal surgery without MBP.

Purpose : The aim of this study is to figure out the clinicopathologic factors associated with recurrence in colorectal cancers with four or more lymph node metastasis (N2 stage). Material and Method: From 2004, Jan to 2006, Dec, a total of 675 patients with colorectal adenocarcinoma were underwent surgery in our hospital. One hundred thirty patients with N2 stage were selected for retrospective review with medical records. Clinicopatholotic factors, such as sex, age, preoperative CEA, tumor location, tumor size, tumor differentiation, T-stage, were studied. Results : Of the 130 patients, eighty-seven patients were underwent radical surgery for colorectal adenocarcinoma. Mean age was 60.6 (34-86 years). Tumors were located in the colon, 25 patients and the rectum 62 patients. Mean tumor size was 5.8 (2.0-19 cm). With TNM classification, T2, T3, T4 were 1, 80, 6 patients, respectively. Mean number of retrieved lymph node was 21.1 (7-110). Mean follow-up period was 30.5 (5-48 months). Recurrence was identified in 34 patients (39.1%). According to tumor differentiation, recurrence rate was 36.8% of well and moderate differentiation, 54.5% of poor differentiation (p=0.327). Recurrence rate was 37.5% in T3 stage, and 66.7% in T4 stage (p=0.267). Conclusions : Recurrence rate was not different significantly according to clinicopathologic factors in colorectal adenocarcinoma with N2 stage after radical surgery. Further study is necessary to identify the risk factor for recurrence in colorectal adenocarcinoma with N2 stage.

Presacral tumors are rare with neurogenic tumors being even rarer with only The purpose of this study is to review our experience of simultaneous laparoscopic resection for synchronous pulmonary metastases of colorectal cancers. The four cases of video-assisted thoracoscopic surgery (VATS) for synchronous pulmonary metastases were performed. For colorectal cancers, open colectomy (Open group) was performed in 2 patients and laparoscopic colectomy (LAP group) in 2 patients. In the Open group, low anterior resection was performed for colorectal cancer in two patients. In LAP group, right hemicolectomy was performed in two patients. Operation time was 245, 320 min in Open group and 295, 315 min in LAP group. Blood loss was 200, 350 cc in Open group and 300, 800 cc in LAP group. Postoperative complication was a pulmonary edema in Open group and a wound bleeding in LAP group. There was no postoperative mortality. Simultaneous laparoscopic resection for synchronous pulmonary metastases is a feasible option for minimal invasive treatment of colorectal cancer.

Thymosin (TB-4) has been reported to play a key role in tumor growth, metastasis and angiogenesis. In addition, TB-4 induced the expression of vascular endothelial growth factor (VEGF) and stabilized the hypoxia-inducible factor (HIF)- in melanoma cells. Although the importance of thymosin in angiogenesis and metastasis has been proven, there are few studies that show the expression patterns of TB-4, VEGF and HIF-. This study was conducted to analyze the relationship among these proteins in various tumors. Using tissue microarray analysis, we investigated the expression patterns of TB-4, VEGF and HIF- in various tumors to identify the expression patterns and relationships of these proteins in certain tumors. TB-4 was highly expressed in osteosarcoma, colon adenocarcinoma, esophageal squamous cell carcinoma, kidney and urinary bladder transitional carcinoma, lung cancer, and liver cancer. HIF- was highly expressed in nasal cavity inverted papilloma, lung cancer, and esophageal squamous cell carcinoma. The expression patterns of TB-4 and HIF- were almost similar and co-localized. VEGF expression was high in the blood vessels in tumors, but usually not high in the tumors themselves. VEGF was moderately expressed in stomach cancer, liver angiosarcoma, gall bladder adenocarcinoma, and uterus endometrial adenocarcinoma. The expression patterns of VEGF shows similarities in certain tumors including stomach cancer, osteosarcoma, liposarcoma, lung cancer, liver cancer, gall bladder adenocarcinoma, esophageal squamous cell carcinoma, stomach cancer, colorectal carcinoma and renal cell carcinoma. These results suggest that the expression patterns of TB-4, HIF- and VEGF were co-localized and related to tumorigenesis and angiogenesis of certain tumors.

Background: Adjuvant chemotherapy is a crucial part of treatment for patients with locally advanced colon cancer. This study was conducted to investigate the actual practice in the use of adjuvant chemotherapy for patients with high-risk stage II or stage III colon cancer in South Korea. Methods: This was a 24-month open-label, prospective, observational study conducted at 12 centers across South Korea. Patients with high-risk stage II and stage III colon cancer receiving adjuvant chemotherapy after curative surgery were included, and data were collected at baseline, third, and sixth month. Results: A total of 246 patients were included in the analyses. Of five available regimens (FOLFOX, CAPOX, 5-FU/LV, capecitabine, and UFT/LV), FOLFOX was most commonly used (82.5%). Investigators indicated the “efficacy” as the major cause for selecting FOLFOX or CAPOX. For 5-FU/LV, capecitabine, or UFT/LV, the “safety” or “patient's characteristics (age, comorbidity, and stage)” was one of the most important selecting factors. Patients receiving 5-FU/LV, capecitabine, or UFT/LV had older age, worse PS and lower disease stage (stage II) than patients receiving FOLFOX or CAPOX. Hematologic toxicities were the most common cause of dose adjustment and treatment delay. Conclusions: In South Korea, FOLFOX was the most commonly used regimen for adjuvant chemotherapy and its efficacy was the main cause for selecting this regimen. Patients receiving 5-FU/LV, capecitabine, or UFT/LV had older age, worse PS and lower disease stage (stage II) than patients receiving FOLFOX or CAPOX.

Recurrent cancers usually metastasise to other organs and have a very poor prognosis. Recurrence and metastatic spread have been proposed to depend on cancer stem cells, which express CD133.1 The expression of the actin-binding protein, thymosin β4 (Tβ4), has been reported to be elevated in a side population of small cells known as cancer stem cells in the breast cancer cell lines MCF7 and MDA-MB231.2 A recent study has also shown that colorectal cancer cells (CR-CSCs) from different patients that were sorted by CD133 had higher Tβ4 levels than normal colorectal cancer cells. Additionally, a lentiviral strategy to downregulate Tβ4 expression in CR-CSCs lowered the capacity of the cells to grow and migrate in culture, and reduced the tumour size and aggressiveness of CR-CSCs in xenografted mice.3 We have previously reported that Tβ4 levels in metastatic stomach cancers to the ovary were significantly upregulated compared with levels in normal stomachs and primary stomach cancers. Furthermore, Tβ4 expression was colocalised with CD133 expression in primary ovarian carcinomas, metastatic ovarian cancers from stomach cancers, and primary stomach cancers, suggesting that Tβ4 expression is strongly related to CD133 expression and is a characteristic of stem cells or cancer stem cells.4 In the present study, we compared the expression patterns of Tβ4 and CD133 in primary and recurrent colorectal cancer cells from the same patient. We obtained the paraffin-embedded primary and recurrent colorectal cancers of 10 patients. Tβ4 and CD133 expression …

Aims: Recently, BRAF mutation testing has been introduced as a marker in differentiating Lynch syndrome from sporadic colorectal cancers or in predicting colorectal cancers with worse prognosis. Individuals with hereditary predisposition to cancer development are at an increased risk of developing multiple primary cancers. The purpose of this study is to identify mutation in the BRAF gene in multiple primary cancers with colorectal cancer and stomach cancer. Methods: BRAF mutation was analysed in 45 patients with colorectal cancer and stomach cancer, synchronously or metachronously. Results: Mean age was 64.07 years (range: 47–83 years). For the colorectal cancer, tumors were located at the sigmoid colon in eight patients (17.8%) and at the rectum in 22 patients (48.9%). Twenty-three patients (51.1%) had synchronous cancer. Four patients (8.9%) had family members with cancer. BRAF mutation was identified in three patients (6.7%). All three of these patients had metachronous cancers. The colorectal cancers were located in the sigmoid colon (1 patient) and the rectum (2 patients). Conclusions: BRAF mutation rate was low in the multiple primary cancer with colorectal cancer and stomach cancer. With only BRAF gene study, it was not possible to identify any correlation with family history of colorectal cancer. Further study means considering other genes – MSI, MSH2, MLH1, MSH6.

Primary isolated extramedullary plasmacytoma is a rare tumor. Although it commonly involves nasopharynx or upper respiratory tract, only 10% of cases involves the gastrointestinal tract. Stomach and small intestine are the most commonly involved sites in the gastrointestinal tract. Primary isolated extramedullary plasmacytoma of colon is extremely rare. We report a case of 45-year-old man who presented with 1-year history of lower abdominal pain. Colonoscopy showed a colonic stricture about 50 cm from the anal verge. Colonoscopic biopsy showed lymphoid hyperplasia. On computed tomography, enhancing circumferential wall thickening and luminal narrowing with pericolic lymph node enlargement in the transverse colon was identified. Patient underwent extended left hemicolectomy. Histopathologic examination of resected colon identified an isolated primary colonic plasmacytoma of 1.7 cm in diameter with regional lymph node involvement (8/50 positive). To administer adequate treatment, further study about clinical features of primary isolated extramedullary plasmacytoma of colon is necessary.

The present study was undertaken to clarify the clinical and pathological features of multiple primary cancers, especially those at extracolonic sites, in patients with colorectal cancers.We reviewed the records of 2,176 patients who underwent surgery for colorectal cancers in our institute from January 1997 to December 2006. A synchronous multiple primary cancer was defined as extracolonic cancer detected within 6-month interval before and after the detection of colorectal cancer. Any metastasis from colorectal cancers was excluded.Synchronous multiple primary cancers were identified in 32 patients. The stomach is the most common organ for synchronous multiple primary cancer development in patients with colorectal cancers (0.9%, 20/2,176).Gastric cancer is the most common synchronous multiple primary cancers occurring concomitantly with colorectal cancers. Careful preoperative screening is necessary for the detection of multiple primary cancers in extracolonic sites in patients with colorectal cancers.

Bevacizumab is a monoclonal antibody that targets vascular endothelial growth factor (VEGF), and it has shown promise as a clinical agent against metastatic colorectal cancer, and particularly in combination with chemotherapy. Bowel perforation is a known risk that's associated with bevacizumab use, but the etiology is unknown. Here we report on two cases of metastatic colorectal cancer in which the patients suffered from intestinal perforation after chemotherapy with bevacizumab. For the first case, a 47 year-old man had rectal cancer with concurrent liver and lung metastasis. He underwent chemotherapy with 5-fluorouracil, irinotecan and bevacizumab. Fever and abdominal pain developed seven days later, and rectal perforation was identified upon exploration 13 days later. For the second case, a 48 year-old woman had sigmoid colon cancer with peritoneal and ovary metastases. After seven days of chemotherapy with 5-fluorouracil, oxaliplatin and bevacizumab, exploratory surgery revealed a perforation at the ileum.

Although multiple primary colorectal cancer has been recognized as a significant clinical entity, its clinical and pathological features and its prognosis are still controversial. The purpose of this study was to clarify clinical and pathological features of multiple primary colorectal cancer.Among 1669 patients who underwent surgery for primary colorectal cancer from January 1997 to June 2005, 26 patients (1.6%) with multiple primary colorectal cancer were identified. We reviewed clinical characteristics including diagnostic interval, lesions, operating methods, and TNM stage, and we defined the index lesion as the most advanced lesion among the synchronous lesions. For the purposes of the study, the colon and rectum were classified into three segments. The right-side colon included the appendix, cecum, ascending colon, hepatic flexure, and transverse colon, and the left-side colon included the splenic flexure, descending colon, and sigmoid colon.Of the 26 patients with multiple primary colorectal cancers, nineteen patients were male and seven patients were female, with a mean age of 61.5 years. Nineteen patients had synchronous colorectal cancers and seven patients had metachronous colorectal cancers. In the metachronous cases, the mean diagnostic interval was 36.8 months. The site of the first lesion in metachronous colorectal cancers was the right colon in five cases (71.4%) and the left colon in two cases (28.6%), and the site of the second lesion was the rectum in six cases (55.5%), the right colon in three cases (33.3%), and the left colon in one case. The TNM stage of the second lesions in the metachronous colorectal cancers was stage II in four cases (57.1%), stage III in one case (14.3%), and stage IV in one case (14.3%). For the synchronous colorectal cancers, the operation methods were single-segment resection combined with endoscopic mucosal resection in five cases (26.3%), single-segment resection alone in six cases, two-segment resection in six cases, and total colectomy in two cases.In metachronous colorectal cancers, the secondary lesions were later-stage cancer. Therefore, careful postoperative follow-up is necessary for patients who have undergone surgery for colorectal cancers. Further study of therapeutic modalities is important for synchronous colorectal cancers.

Background/Aims: Laparoscopic surgery has been proven to be an effective alternative to open surgery in patients with colon cancer. However, data on laparoscopic surgery in patients with rectal cancer are insufficient. The aim of this study was to compare the long-term outcomes of laparoscopic and open surgery in patients with rectal cancer. Methods: A total of 307 patients with rectal cancer who were treated by open and laparoscopic curative resection at Kosin University Gospel Hospital (Busan, Korea) between January 2002 and December 2011 were reviewed retrospectively. Results: Regarding treatment, 176 patients underwent an open procedure and 131 patients underwent a laparoscopic procedure. The local recurrence rate after laparoscopic resection was 2.3%, compared with 5.7% after open resection (p=0.088). Distant metastases occurred in 6.9% of the laparoscopic surgery group, compared with 24.4% in the open surgery group (p＜0.001). In univariate analysis, age (≥75 years vs. ≤60 years), preoperative staging, surgical approach (open vs. laparoscopic), elevated initial CEA level, elevated follow-up CEA level, number of positive lymph nodes, and postoperative chemotherapy affected overall survival and disease free survival. However, in multivariate analysis, the surgical approach apparently did not affect long-term oncologic outcome. Conclusions: In this study, long-term outcomes after laparoscopic surgery for rectal cancer were not inferior to those after open surgery. Therefore, laparoscopic surgery would be an alternative operative tool to open resection for rectal cancer, although further investigation is needed. (Korean J Gastroenterol 2015;65:273-282)

This paper presents an approach to developing Real-time Dependable Systems (RDSs) based on a real-time object model. A system development process can be divided into two phases, that is, Specification Phase and Construction Phase. In the Specification Phase, especially for an RDS, system requirements are decomposed into a group of Real-Time Objects (RTOs) and appropriate objects are identified by means of a decomposition scheme such as Multi-Dimensional Decomposition (MDD). In the Construction Phase, the identified objects are instantiated and combined. RTO.e, which is an extension of the RTO.k model proposed earlier by Kim and Kopetz (1994), plays the role of a connector and also that of a firewall between the two phases. In this paper, we present design tools that are required in developing RDSs. The tools provide a seamless system implementation method and an information base that can be utilized through the development process.

Aims: The purpose of this study was to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic resection for middle and low rectal cancers. Materials and Methods: From January 2004 to December 2011, review of prospectively collected database revealed a series of 97 laparoscopic resections for middle and low rectal cancer within 10 cm from the anal verge. Five patients with multiple primary cancers were excluded. Operation time, intra-operative blood loss, surgical complications, duration of hospital stay, retrieved lymph nodes, tumour, node, metastasis (TNM) stage and recurrence were retrospectively analysed. Results: Tumours were located within 5 cm of the anal verge in 28 patients (30.4%) and from 5 cm to 10 cm in 64 patients (69.6%). Abdominoperineal resection was performed in 12 patients (13%), and conversion to open surgery was necessary in four patients (4.3%). The mean operation time was 199.7 min (range 105-450 min) and the mean intra-operative blood loss was 169.9 mL (range 20-800 mL). The mean hospital stay was 11.8 days (range 5-45 days) and a mean of 12.2 lymph nodes were retrieved. The incidence of surgical complications was 11.9%, including anastomosis site leakage in five patients (5.4%). There were no mortalities resulting from laparoscopic surgery. The median follow-up period was 28.4 months (range 7-85 months). Recurrence occurred in eight patients (8.7%). Conclusions: Laparoscopic resection can be applied for middle and low rectal cancers with acceptable surgical and oncological outcomes.

See Article on Page 122-131 A chordoma is a rare, bone neoplasm that accounts for 1%-4% of all bone neoplasms [1]. Although it considered to be a low-grade neoplasm with a slow-growing pattern, its clinical course is very aggressive, with a locally-invasive, highly-recurrent character [2]. It has been reported to be predominant in men, and its peak incidence is between 50-60 years of age [3]. It arises from the sacrococcygeal region in approximately 40%-50% of cases, from the base of the skull (spheno-occipital/nasal) in 35%-40% of cases, and from vertebral bodies in 15%-20% of cases [2, 4, 5]. A chordoma usually present clinically with pain as the cardinal symptom. Neurologic symptoms tend to vary based on the location of the lesion. Jeys et al. [6] reviewed 33 patients with a chordoma arising from the sacrococcygeal region. Pain, typically dull and worse with sitting, was the most common presenting symptom in 85% of the patients. Pain commonly developed in the lower back and the sacrum. Other painful regions were the legs, buttocks, and the perianal and perineal regions. The classic symptoms of cauda equine (saddle anesthesia, leg parathesia, motor weakness, bladder dysfunction, bowel dysfunction) occurred in 70% of the patients. Urinary incontinence and outflow obstruction were frequent bladder dysfunction symptoms. The majority of bowel dysfunctions were due to constipation. Unfortunately, these symptoms are nonspecific in nature, and a chordoma has a slow-growing pattern with an insidious onset of symptoms. Therefore, it is often found at the late stages of the disease. Jeys et al. [6] reported that the mean duration of symptoms prior to diagnosis was 120 weeks (2.3 years; range, 0.5-8.0 years). The mean maximum tumor size at resection was 8.3 cm, with a mean volume of 614 cm3. Differential diagnosis is important for the surgical and the postsurgical management of a chordoma. The accurate diagnosis of tumors is of valuable prognostic significance. Fine-needle aspiration biopsy or core-needle biopsy in the case of bony lesions has been suggested to be the most oncologically sound approach to establish a diagnosis before resection, with care to avoid tumor seeding [5, 7]. The excellent capabilities of magnetic resonance imaging and computed tomography allow precise delineation of tumors in terms of volume and anatomic characteristics, and aid in diagnosis [8]. In this study, three of eight patients were misdiagnosed and had undergone primary surgery with an R1 margin at other hospitals. After re-resection, all three cases had recurrences. On the contrary, four patients had been diagnosed with preoperative core-needle biopsy and underwent primary surgery with a R0 resection. One of the four patients had a local recurrence after 18 months. The patient had an initial 12.5-cm × 13.0-cm tumor infiltrating the mesorectum [9]. With early accurate diagnosis, a complete en bloc resection with a R0 resection margin is a key point in the treatment of a chordoma. Rates of local recurrence, as well as survival, appear to depend on the achievement of a R0 resection margin. Tzortzidis et al. [10] reported that aggressive surgical approaches to achieve total resection resulted in long-term control in 50% of the cases. Aggressive surgical resection and reconstruction may require a multidisciplinary team approach.

The chronic myelogenous leukemic K562 cell line carrying Bcr-Abl tyrosine kinase is considered as pluripotent hematopoietic progenitor cells expressing markers for erythroid, granulocytic, monocytic, and megakaryocytic lineages. Here we investigated the signaling modulations required for induction of erythroid differentiation of K562 cells. When the K562 cells were treated with herbimycin A (an inhibitor of protein tyrosine kinase), ras antisense oligonucleotide, and PD98059 (a specific inhibitor of MEK), inhibition of ERK/MAPK activity and cell growth, and induction of erythroid differentiation were observed. The ras mutant, pZIPRas61leu-transfected cells, K562-Ras61leu, have shown a markedly decreased cell proliferation rate with approximately 2-fold doubling time, compared with the parental K562 cells, and about 60% of these cells have shown the phenotype of erythroid differentiation. In addition, herbimycin A inhibited the growth rate and increased the erythroid differentiation, but did not affect the elevated activity of ERK/MAPK in the K562-Ras61leu cells. On the other hand, effects of PD98059 on the growth and differentiation of K562-Ras61leu cells were biphasic. At low concentration of PD98059, which inhibited the elevated activity of ERK/MAPK to the level of parental cells, the growth rate increased and the erythroid differentiation decreased slightly, and at high concentration of PD98059, which inhibited the elevated activity of ERK/MAPK below that of the parental cells, the growth rate turned down and the erythroid differentiation was restored to the untreated control level. Taken together, these results suggest that an appropriate activity of ERK/MAPK is required to maintain the rapid growth and transformed phenotype of K562 cells.

See Article on Page 106-114 Serum carcinoembryonic antigen (CEA) is the most widely used tumor marker for the management of colorectal cancer. The preoperative serum CEA level has been reported to be one of prognostic parameters for the recurrence of colorectal cancers [1, 2]. Postoperative monitoring of the serum CEA level has been commonly used in the follow-up for colorectal cancers [3]. However, whether the preoperative serum CEA level has a prognostic significance according to individual stages in patients with colorectal cancer is controversial [4-7]. Harrison et al. [6] analyzed a large cohort of node-negative colon cancer patients (T1-4, N0, M0) to determine prognostic factors. The study demonstrated that the preoperative serum CEA elevation (>5 ng/mL) had a poor prognostic value in node-negative patients (T1-4, N0, M0). Another study showed that 5 ng/mL, as cutoff value for serum CEA, had no significant prognostic value within the different Dukes' stages and had borderline prognostic value in the Dukes' C stage [7]. Those trials to identify the prognostic value of serum CEA elevation within individual stages have some limitations. The biochemical characters of serum CEA are not well known. For those trials, hypotheses are necessary. Serum CEA has other biochemical characters, but not as a marker to predict increasing size of tumor or metastasis to lymph nodes. Serum CEA might be a sensitive marker, represents size and metastasis. Few studies have reported optimal cutoff values for serum CEA levels in patients with colorectal cancer. Reiter et al. [8] reported the results of a multivariate analysis of the prognostic value of serum CEA level in colorectal cancer. For preoperative serum CEA levels of ≥4 ng/mL vs. 4 ng/mL and 10 ng/mL vs. 17 ng/mL) (P < 0.001). According to stage, a significant difference in survival was observed only in patients with stage III tumors (P = 0.007). In this study, the authors tried to determine the individual optimal cutoff value of CEA according to TNM stage [10]. The conventional cutoff value of CEA (5 ng/mL) has no significant prognostic value in stage T1-2, N0 and stage T1-4, N2. Optimal cutoff values from the receiver operating characteristic curve were 7.4, 5.5 and 4.5 ng/mL for TNM stages I, II and III, respectively. Those for stages N0, N1 and N2 were 5.5, 4.8 and 3.5 ng/mL, respectively. The 5-year disease free survivals were significantly different with these cutoff values for each TNM and N stages. However, one has to consider that a sub-normal CEA level may be a cutoff value that can be used as a prognostic marker.

See Article on Page 299-303 Incisional hernias, with an incidence of 9 to 38%, remain one of the most common complications after an incision of the abdominal wall [1-3]. An incisional hernia is defined as a protrusion of intraperitoneal structures through a defect in the anterior abdominal wall fascia [4]. This means that wound healing often fails to occur when multiple predisposing factors, including surgical site infection, malnutrition, diabetes, immunosuppression, and morbid obesity, are present [5]. Incisional hernias are almost universally regarded as technical failures. Technical factors are related to suture material selection, type of fascial closure, ratio of suture to incision length [5]. In spite of many advances, such as new procedures for closing the abdominal wall and new suture materials, the incidence of incisional hernias has not been reduced in recent decades because the developments of incisional hernias is also related to many factors affecting the patients. Surgical site infection is one of the important risk factors for the development of an incisional hernia. Recently, Murray et al. [6] analyzed the incidence of incisional hernias related with surgical site infection in colorectal surgery. They reported that patients with a surgical site infection were 1.9 times more likely to have an incisional hernia than those without a surgical site infection (36.3% vs. 18.8%, P ≤ 0.01). In clean-contaminated and contaminated surgery, such as colorectal surgery, the incidence of surgical site infection has been reported as 3 to 30% [7, 8]. Thus, in colorectal surgery, more effort to prevent surgical site infection is needed. Morbid obesity is another important risk factor for the development of an incisional hernia and a parastomal hernia [9, 10]. Schreinemacher et al. [9] reported that hernias were more prevalent in patients with morbid obesity (body mass index of 30 and higher) and in patients with a temporary stoma wound (25.8% vs. 59.1%). De Raet et al. [10] reported that a waist circumference in excess of 100 cm increased the risk of developing a parastomal hernia (odds ratio, 1.009; 95% confidence interval, 1.002 to 1.016). Other factors, such as anemia, hypoproteinemia, malnutrition, diabetes, immunosuppression, male gender, and old age, are related to surgical wound dehiscence and incisional hernias [11]. Conditions that increase abdominal pressure, such as coughing, vomiting, distention, and ascites, also increase the incidence of incisional hernias. Surgeons have to be aware of poor wound healing conditions to prevent incisional hernias. Perioperative efforts to reduce risk factors and to select proper technical methods of wound closure are essential if the incidence of incisional hernias is to be reduced.

See Article on Page 89-93 Bezoars can be defined as retained concretions of animal or vegetable material in the gastrointestinal tract. Bezoars are classified according to their composition into phytobezoars (undigested vegetables), trichobezoars (hairs), lactobezoars (milk) and pharmacobezoars (medications) [1]. Phytobezoars are composed of undigested food fibers, such as cellulose, hemicellulose, lignin and fruit tannin. These fibers occur in fruits and vegetables such as celery, pumpkins, prunes, raisins, leeks, beets and persimmons. Especially, ingestion of persimmons is known to be a common cause of bezoars. Persimmon bezoars are also known as diospyrobezoars. In 1986, Krausz et al. [2] reported that 91.2% of 113 patients with phytobezoars had a history of persimmon intake. Kement et al. [3] also reported that excessive consumption of persimmons was identified in 40.5% of bezoar patients. Unripe persimmons contain soluble tannin. Tannin polymerizes in an acidic environment to form a glue-like coagulum, which can affix to other materials in the stomach [4]. A number of predisposing factors may contribute to the risk of bezoar formation. Previous gastric surgery was reported in 20 to 93% of patients with bezoars [2, 5-8]. In this paper, the authors reported that 35% (7 patients) of patients had had previous gastric surgery. The other predisposing factors observed in our study included mastication problems, diabetic gastroparesis and antacid drug use. Bezoars usually form in the stomach and can pass into the small bowel where they occasionally cause obstruction. Although bezoars are the most common type of foreign body lodged in any part of the gastrointestinal tract, the overall incidence of bezoar-induced intestinal obstruction remains relatively low. Incidence of intestinal obstruction caused by bezoars is 2 to 4% [9]. The differential diagnosis of intestinal obstruction secondary to bezoars is difficult before surgery because the clinical and the radiographic findings are similar to those of intestinal obstruction attributable to other causes. However, findings from recent studies suggest that sonography or computed tomography (CT) can be useful in diagnosing bezoars before surgery [6, 10]. CT scans demonstrate a well-defined round, heterogeneous intraluminal mass in the gastrointestinal tract. The mass can be outlined by the bowel wall and presents a characteristic internal gas bubble-soft tissue appearance [11-14]. Kement et al. [3] reported that abdominal CT was carried out in 16 patients and that bezoars were revealed in 14 (77.7%) of those patients before surgery. In this paper, the accuracy of abdominal CT in diagnosing bezoars was 47% (7 of 15 patients). The authors compared the clinical courses of three groups, patients who were preoperatively diagnosed with bezoars by using abdominal CT (group 3), patients who were not diagnosed using abdominal CT (group 2), and patients who did not undergo abdominal CT (group 1). In the group 3, because of the abdominal CT earlier surgery was possible (0.6 days vs. 4.9 days, P = 0.036), and the incidence of postoperative complications was lower (14.3% vs. 37.5%, 40%, P = 0.439). However, as the authors addressed, there are some limitations in this study. The hospital stay was little longer in group 3 than group 2, and heterogeneity of the patients' clinical courses is expected. In patients with intestinal obstructions, differential diagnosis is very important, especially in patients with a history of previous abdominal surgery. CT can help to make this differentiation. Therefore, CT should be performed whenever possible in all patients with bowel obstruction to establish the diagnosis and to avoid inappropriate treatment.

Purpose: The purpose of this study is to identify useful clinicopathologic factors for the prediction of lymph node metastasis in submucosally invasive colorectal carcinoma. Methods: A total of fifty-four cases of colorectal carcinomas with submucosal invasion were included. The patients underwent curative resection with en bloc lymph node dissection. Clinical features such as age, gender, tumor size and tumor location were reviewed. Histopathologic examinations for tumor growth type, differentiation, depth of tumor invasion, lymphovascular invasion, neural invasion, tumor budding and peritumoral inflammation were performed. The expression of E-cadherin, β-catenin, Smad4, p53 and Ki-67 were examined by immunohistochemistry. The correlation between the clinicopathologic factors and lymph node metastasis was evaluated. Results: From the 54 patients with submucosally invasivecolorectal carcinoma, lymph node metastasis was identified in 13 cases (24.1%). The incidence of lymph node metastasis was significantly higher in cases positive for lymphovascular invasion (55.6% vs. 17.8%, P=0.028) and positive for tumor budding (47.4% vs. 11.45%, P=0.006). Cases negative for Smad4 had a higher tendency for incidence of lymph node metastasis (28.6% vs. 15.8%, P=0.341). Other clinicopathologic and immunohistochemical features were irrelevant to the lymph node status. In multivariate analysis, only tumor budding was an independent predictor of lymph node metastasis (P=0.051). Conclusion: Lymphovascular invasion and tumor budding were predictive factors of lymph node metastasis in submucosally invasive colorectal carcinoma. The incidence of lymph node metastasis of submucosally invasive colorectal carcinoma was not low. Careful selection for avoiding surgery in submuocally invasive colorectal carcinoma should be considered.

Restorative proctocolectomy with ileal pouch-anal anastomosis is one of the surgical treatments of choice for patients with familial adenomatous polyposis. Although the risk of cancer developing in an ileal pouch is not yet clear, a few cases of adenocarcinoma arising in an ileal pouch have been reported. We report a case of adenocarcinoma in ileal pouch after proctocolectomy with ileal pouch-anal anastomosis. A 56-yr-old woman was diagnosed as having familial adenomatous polyposis. Total colectomy with ileorectal anastomosis was performed. Six years later, she underwent completion-proctectomy with ileal J pouch-anal anastomosis including anorectal mucosectomy for rectal cancer. After 7 yr, she presented with anal spotting. Endoscopic biopsies revealed adenocarcinoma at the ileal pouch. Resection of the ileal pouch and permanent ileostomy were performed. The risk of cancer in an ileal pouch and its prevention with regular surveillance must be emphasized.

Purpose: The use of prophylactic antibiotics is the current standard of care after elective colorectal surgery. The aim of this study was to compare the efficacy of antibiotic prophylaxis with dual antibiotic therapy and triple antibiotic therapy after elective colorectal surgery. Methods: We studied consecutive patients underwent elective colorectal surgery from January to June, 2007. Patients of triple-therapy group were administered second cephalosporin, metronidazole, and aminoglycoside for early 3 mo and dualtherapy group were administered second cephalosporin and metronidazole for next 3 mo. The prophylactic antibiotics were administered 2-3 doses for 24 hr after surgery. The surgery for diverticulitis, inflammatory bowel disease, and colon obstruction were excluded. Wound conditions were checked on alternate days during the hospital stay and follow up at least for 30 days after discharge. Results: Over 6 mo, 110 patients were enrolled (59 dual-therapy group, 51 triple-therapy group). In two group, sex, age, American Society of Anesthesiology score, body mass index, combined diseases, and location of disease were similar. Wound infection rate were 1.7% in dual-therapy group and 2.0% in triple-therapy group (P=1.0). Anastomotic leakage rate were 5.1% in dual-therapy group and 2.0% in triple-therapy group (P=0.622). Conclusion: The addition of aminoglycoside to dual antibiotic therapy, second cephalosporin-metronidazole showed no advantage in prevention of postoperative wound complications. Further studies are required to establish appropriate guideline of antibiotic prophylaxis after elective colorectal surgery.

Purpose: Colonic pouches have been used to improve the reservoir function of the neorectrum after a ultra-low anterior resection for treatment of rectal cancer. The purpose of this study was to compare the safety and the functional outcome between a straight anastomosis, an anastomosis using coloplasty, and that using a colonic J-pouch in patients who had undergone an ultralow anterior resection. Methods: From 2004 through 2006, 60 patients underwent a coloanal straight (straight group: n=23), coloplasty (coloplasty group: n=19), or colonic J-pouch (J-pouch group: n=18) anastomosis to the anal canal after a total mesorectal excision of the rectal cancer. We retrospectively reviewed the medical records of those patients for clinical outcomes according to the reservoir type. The median follow-up interval was 23.7 (4.4-40.9) mo. Results: The anastomotic leakage rate was higher in the coloplasty group (21.1%) than in the straight group (8.7%) or in the J-pouch group (0%), but the difference was not significant (P=0.1). The mean number of bowel movements per day was significantly lower in the coloplasty group (3.6) and in the pouch group (3.1) than in the straight group (6.2) (P=0.015). No statistically significant differences were found among the three groups regarding other functional outcomes, including use of antidiarrheal drugs (P=0.971), gas incontinence (P=0.256), fecal incontinence (P=0.544), use of pads (P=0.782), difficulty of evacuation (P=0.496), and use of enemas (P=0.712). Conclusion: Reconstruction with a coloplasty or a colonic J-pouch in patients undergoing a low colorectal or coloanal anastomosis after rectal cancer surgery seems to decrease the number of daily bowel movements compared to a straight anastomosis. However, the anastomotic leakage rate of coloplasty group was higher than that of the straight-anastomosis group.

Purpose: The purpose of this study is to evaluate the usefulness of positron emission tomography (PET)- computed tomography (CT) for preoperative tumor staging in cases of colorectal cancer. Methods: Between July 2006 and September 2007, seventy-six patients with a diagnosis of colorectal cancer (43 males and 33 females; mean age: 60.4±10.13 years; range: 34∼82 years) selected prospectively were studied for staging by using Chest X-ray, abdominal CT and PET-CT. Results: The sensitivities and the specificities for N-staging were 76.9% and 35.1% for CT, 61.8% and 66.7% for PET-CT, and both procedures showed a relatively low diagnostic accuracy (CT 57.9%, PET-CT 61.8%). In the PET-CT alone, six distant metastatic lesions and four multiple primary malignancies were found. The locations of the distant metastases were the liver, the axillary node, the common iliac node, the subclavicular node, the peritoneum, and the lung. The locations of the multiple primary maligancies in extracolonic sites were 3 in the thyroid and 1 in the nasopharynx. Conclusions: For N-staging, preoperative PET-CT is no more useful than CT, but PET-CT is required before surgery to find lesions that cannot be found with conventional studies.

An adenocarcinoid of the cecum is a tumor that has seldom been reported in the literature. Its has the histologic features of both an adenocarcinoma and a carcinoid tumor. However, the malignancy potential and the prognostic behavior are still unclear. We treated one patient with this unusual tumor. A 64-year-old man was admitted with a complaint of right lower quadrant abdominal pain for 2 months. On colonoscopy and histological examination, the patient was diagnosed as having a cecal adenocarcinoma. A radical right hemicolectomy was done. Postoperative histologic analysis revealed that the tumor was composed of well-differentiated adenocacinoma and carcinoid components. Lymph node metastases were found in the three lymph nodes with only the carcinoid component.

Purpose: Irinotecan is a recently developed active agent in colorectal cancer. The combination of irinotecan and 5-fluorouracil (5-FU)/lecovorin (LV), known as the FOLFIRI regimen, has been approved for patients with metastatic colorectal cancer. The purpose of this study was to assess the efficacy and toxicity of the FOLFIRI regimen in the treatment of metastatic colorectal cancer. Methods: We reviewed the records of 65 patients who had received the FOLFIRI regimen from Jan. 2002 to Dec. 2005. The combination chemotherapy consisted of irinotecan (150~180 mg/m on day 1, 15) as a 2~6 hour infusion followed by bolus infusion of 5-FU (400 mg/m) and continuous infusion of 5-FU (600 mg/m on days 1, 2, 15, 16), concurrently with LV (20 mg/m on day 1, 2, 15, 16) as a 2 hour infusion. Cycles were repeated in three-week intervals. Results: Of the 65 patients who had received the FOLFIRI regimen, 34 were male and 31 cases female. The median age was 54.4 years. The primary tumor sites were the colon in 29 cases (44.6%) and the rectum in 36 cases (56.4%). The metastatic sites were the liver in 33 cases (50.8%), the peritoneum in 21 (32.3%), the lung in 14 (21.5%), a lymph node in 4, and the pelvis in 2. Twenty-seven patients (41.5%) had received the combination chemotherapy as the first line. Of the patients who received more than 3 cycles, complete response was none. Partial responses were 3 (7.1%), stable disease status in 25 cases (59.5%) and progressive disease status in 14 cases (33.3%). The rate of progressive disease status for patients who had received FOLFIRI as the 2nd or the 3rd line were much higher than that of those who had received it as the 1st line chemotherapy. Early stops (

Tailgut cysts are rare congenital lesions. They are believed to develop from remnants of the embryonic hindgut. Malignancy in tailgut cyst is extremely unusual. We experienced a case of a carcinoid tumor arising within a tailgut cyst at the presacral space. A 40-year-old woman was admitted for acute anal pain. Digital rectal examination revealed a 2-cm-sized submucosal tumor in the posterior midline rectum 4 cm above the anal verge. On sigmoidoscopic examination, the overlying rectal mucosa seemed to be intact. We performed a transanal incisional biopsy. The pathological diagnosis of the tumor biopsy revealed a malignant neuroendocrine tumor. The patient underwent an abdominoperineal resection. The tumor proved to be mutilocular cysts with a solid component. The cysts were diagnosed as tailgut cysts that were lined by a variety of epithelial types, including inner columnar cells, outer cuboidal cells, and transitional cells. The solid component in the cysts was confirmed as a carcinoid tumor on microscopic examination. Six months after the operation, she was found to have liver and brain metastases.