A qualitative exploration of exercise motivation among colorectal cancer survivors: an application of the theory of planned behavior.

PURPOSE: The purpose of this qualitative study was to use semi-structured interviews and thematic analysis to elicit key influencing factors (i.e., behavioral, normative, and control beliefs) related to physical activity and exercise in colorectal cancer survivors. METHODS: Colorectal cancer survivors (N = 17) were recruited from exercise programs designed for colorectal cancer survivors at the Yonsei Cancer Center, Seoul, South Korea. A purposive sampling method was used. Interview questions were informed by the theory of planned behavior (TPB). Semi-structured face-to-face interviews were conducted, and open-ended questions addressed the research question. Interviews were transcribed verbatim and analyzed using thematic analysis. RESULTS: Participants were on average 2.2 years post-treatment. The mean age of the sample was 55.9 years. Key behavioral, normative, and control beliefs emerged in the data. For behavioral beliefs, colorectal cancer survivors believed that exercise would result in physical and psychological improvements, and improve their bowel problems. For normative beliefs, most colorectal cancer survivors wanted their oncologists' approval for participation of exercise. Family members, more specifically the spouse, were also influencing factors for colorectal cancer survivors adopting physical activity. The most frequently mentioned control belief was that supervised exercise with an exercise specialist made exercise participation easier. CONCLUSIONS AND IMPLICATIONS: Beliefs identified in this study can inform TPB-based physical activity interventions tailored for colorectal cancer survivors. While information alone may not lead to behavior change, integrating these beliefs with other influential factors can potentially enhance intervention efficacy and promote physical activity in this population.

Pretreatment MRI-detected extramural venous invasion as a prognostic and predictive biomarker for neoadjuvant chemoradiotherapy in non-metastatic rectal cancer: a propensity score matched analysis.

OBJECTIVES: This study evaluated pretreatment magnetic resonance imaging (MRI)-detected extramural venous invasion (pmrEMVI) as a predictor of survival after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC). MATERIALS AND METHODS: Medical records of 1184 patients with rectal adenocarcinoma who underwent TME between January 2011 and December 2016 were reviewed. MRI data were collected from a computerized radiologic database. Cox proportional hazards analysis was used to assess local, systemic recurrence, and disease-free survival risk based on pretreatment MRI-assessed tumor characteristics. After propensity score matching (PSM) for pretreatment MRI features, nCRT therapeutic outcomes according to pmrEMVI status were evaluated. Cox proportional hazards analysis was used to identify risk factors for early recurrence in patients receiving nCRT. RESULTS: Median follow-up was 62.8 months. Among all patients, the presence of pmrEMVI was significantly associated with worse disease-free survival (DFS; HR 1.827, 95% CI 1.285-2.597, p = 0.001) and systemic recurrence (HR 2.080, 95% CI 1.400-3.090, p < 0.001) but not local recurrence. Among patients with pmrEMVI, nCRT provided no benefit for oncological outcomes before or after PSM. Furthermore, pmrEMVI( +) was the only factor associated with early recurrence on multivariate analysis in patients receiving nCRT. CONCLUSIONS: pmrEMVI is a poor prognostic factor for DFS and SR in patients with non-metastatic rectal cancer and also serves as a predictive biomarker of poor DFS and SR following nCRT in LARC. Therefore, for patients who are positive for pmrEMVI, consideration of alternative treatment strategies may be warranted. CLINICAL RELEVANCE STATEMENT: This study demonstrated the usefulness of pmrEMVI as a predictive biomarker for nCRT, which may assist in initial treatment decision-making in patients with non-metastatic rectal cancer. KEY POINTS: • Pretreatment MRI-detected extramural venous invasion (pmrEMVI) was significantly associated with worse disease-free survival and systemic recurrence in patients with non-metastatic rectal cancer. • pmrEMVI is a predictive biomarker of poor DFS following nCRT in patients with LARC. • The presence of pmrEMVI was the only factor associated with early recurrence on multivariate analysis in patients receiving nCRT.

Postchemoradiation magnetic resonance imaging circumferential resection margin predicts treatment failure after multidisciplinary directed sphincter preservation in low rectal cancer.

BACKGROUND: This study aimed to review the magnetic resonance imaging (MRI) features of patients with low rectal cancer (LRC) undergoing preoperative chemoradiotherapy (CRT) and investigate the risk factors for treatment failure after sphincter preserving surgery following preoperative CRT based on multidisciplinary approach. OBJECTIVES: Patients who underwent standard CRT and sphincter preserving radical surgery for LRC between January 2000 and December 2011 were retrospectively reviewed. Sphincter preservation failure (SPF) was defined as any one of the following: positive pathologic circumferential resection margin, local recurrence, failure to repair ileostomy, or permanent stoma formation due to anastomotic complications. RESULTS: Among the 191 patients, there were no overall significant differences between sphincter preservation success (n = 161) and SPF (n = 30) groups. SPF group showed a higher MRI circumferential resection margins (mrCRM) positive rate before and after CRT (before CRT: 33.3% vs. 16.1%, p = 0.027; after CRT: 23.3% vs. 6.2%, p = 0.002). Multivariate analysis showed that only mrCRM after CRT was associated with SPF (hazard ratio = 4.596, p = 0.005). SPF group showed worse 5-year cancer-specific survival (51% vs. 92.7%, p < 0.001). CONCLUSIONS: MRI-based assessment of the tumor after CRT plays a crucial role in predicting the success and feasibility of sphincter preservation as well as oncological outcomes in patients with LRC.

Postoperative inpatient exercise facilitates recovery after laparoscopic surgery in colorectal cancer patients: a randomized controlled trial.

BACKGROUND: Early mobilization is an integral part of an enhanced recovery program after colorectal cancer surgery. The safety and efficacy of postoperative inpatient exercise are not well known. The primary objective was to determine the efficacy of a postoperative exercise program on postsurgical recovery of stage I-III colorectal cancer patients. METHODS: We randomly allocated participants to postoperative exercise or usual care (1:1 ratio). The postoperative exercise intervention consisted of 15 min of supervised exercise two times per day for the duration of their hospital stay. The primary outcome was the length of stay (LOS) at the tertiary care center. Secondary outcomes included patient-perceived readiness for hospital discharge, anthropometrics (e.g., muscle mass), and physical function (e.g., balance, strength). RESULTS: A total of 52 (83%) participants (mean [SD] age, 56.6 [8.9] years; 23 [44%] male) completed the trial. The median LOS was 6.0 days (interquartile range; IQR 5-7 days) in the exercise group and 6.5 days (IQR 6-7 days) in the usual-care group (P = 0.021). The exercise group met the targeted LOS 64% of the time, while 36% of the usual care group met the targeted LOS (colon cancer, 5 days; rectal cancer, 7 days). Participants in the exercise group felt greater readiness for discharge from the hospital than those in the usual care group (Adjusted group difference = 14.4; 95% CI, 6.2 to 22.6; P < 0.01). We observed a small but statistically significant increase in muscle mass in the exercise group compared to usual care (Adjusted group difference = 0.63 kg; 95% CI, 0.16 to 1.1; P = 0.03). CONCLUSION: Postsurgical inpatient exercise may promote faster recovery and discharge after curative-intent colorectal cancer surgery. TRIAL REGISTRATION: The study was registered at WHO International Clinical Trials Registry Platform (ICTRP; URL http://apps.who.int/trialsearch ); Trial number: KCT0003920 .

Long-term oncologic outcomes of single-incision laparoscopic surgery for colon cancer.

BACKGROUND: Studies find similar perioperative outcomes between single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for colon cancer. However, few have reported long-term outcomes of SILS versus CLS. We aimed to compare long-term postoperative and oncologic outcomes as well as perioperative outcomes between SILS and CLS for colon cancer. METHODS: A total of 641 consecutive patients who underwent laparoscopic surgery for colon cancer from July 2009 to September 2014 were eligible for the study. Data from 300 of these patients were used for analysis after propensity score-matching (n = 150 per group). Variables associated with short- and long-term outcomes were analyzed. RESULTS: The SILS group had a shorter mean total incision length, less postoperative pain, and a similar mean rate of incisional hernia (2.7% versus 3.3%) compared with the CLS group. The 7-year overall and disease-free survival rates were 92.7% versus 94% (p = 0.673) and 85.3% versus 84.7% (p = 0.688) in the SILS and CLS groups, respectively. CONCLUSIONS: Compared with CLS, SILS for colon cancer appeared to be safe in terms of perioperative and long-term postoperative and oncologic outcomes. The results suggested that SILS is a reasonable treatment option for colon cancer for a selected group of patients.

Single-incision laparoscopic surgery compared to conventional laparoscopic surgery for appendiceal mucocele: a series of 116 patients.

BACKGROUND: Although the safety and feasibility of conventional laparoscopic surgery (CLS) for appendiceal mucocele (AM) has been reported, studies on single-incision laparoscopic surgery (SILS) for AM have not been reported. Here, we aimed to compare the perioperative and short-term outcomes between SILS and CLS for AM and to evaluate the oncological safety of SILS. METHODS: We retrospectively analyzed the medical records of patients, diagnosed based on computed tomography findings, who underwent laparoscopic surgery for AM between 2010 and 2018 at one institution. We excluded patients strongly suspected of having malignant lesions and those with preoperative appendiceal perforation. Patients were divided into two groups-CLS and SILS. Pathological outcomes and long-term results were investigated. The median follow-up period was 43.7 (range: 12.3-118.5) months. RESULTS: Ultimately, 116 patients (CLS = 68, SILS = 48) were enrolled. Patient demographic characteristics did not differ between the groups. The preoperative mucocele diameter was greater in the CLS than in the SILS group (3.2 ± 2.9 cm vs. 2.3 ± 1.4 cm, P = 0.029). More extensive surgery (right hemicolectomies and ileocecectomies) was performed in the CLS than in the SILS group (P = 0.014). Intraoperative perforation developed in only one patient per group. For appendectomies and cecectomies, the CLS group exhibited a longer operation time than the SILS group (63.3 ± 24.5 min vs. 52.4 ± 17.3 min, P = 0.014); the same was noted for length of postoperative hospital stay (2.9 ± 1.8 days vs. 1.7 ± 0.6 days, P < 0.001). The most common AM etiology was low-grade appendiceal mucinous neoplasm (71/116 [61.2%] patients); none of the patients exhibited mucinous cystadenocarcinoma. Among these 71 patients, there were 8 patients with microscopic appendiceal perforation or positive resection margins. No recurrence was detected. CONCLUSIONS: SILS for AM is feasible and safe perioperatively and in the short-term and yields favorable oncological outcomes. Despite the retrospective nature of the study, SILS may be suitable after careful selection of AM patients.

Can better surgical outcomes be obtained in the learning process of robotic rectal cancer surgery? A propensity score-matched comparison between learning phases.

BACKGROUND: Although studies of robotic rectal cancer surgery have demonstrated the effects of learning on operation time, comparisons have failed to demonstrate differences in clinicopathological outcomes between unadjusted learning phases. This study aimed to investigate the learning curve of robotic rectal cancer surgery for clinicopathological outcomes and compare surgical outcomes between adjusted learning phases. Study design We enrolled 506 consecutive patients with rectal adenocarcinoma who underwent robotic resection by a single surgeon between 2007 and 2018. Risk-adjusted cumulative sum (RA-CUSUM) for surgical failure was used to analyze the learning curve. Surgical failure was defined as the occurrence of any of the following: conversion to open surgery, severe complications (Clavien-Dindo grade ≥ 3a), insufficient number of harvested lymph nodes (LNs), or R1 resection. Comparisons between learning phases analyzed by RA-CUSUM were performed before and after propensity score matching. RESULTS: In RA-CUSUM analysis, the learning curve was divided into two learning phases: phase 1 (1st-177th cases, n = 177) and phase 2 (178th-506th cases, n = 329). Before matching, patients in phase 2 had deeper tumor invasion and higher rates of positive LNs on pretreatment images and preoperative chemoradiotherapy. After matching, phase 1 (n = 150) and phase 2 (n = 150) patients exhibited similar clinical characteristics. Phase 2 patients had lower rates of surgical failure overall and these components: conversion to open surgery, severe complications, and insufficient harvested LNs. CONCLUSIONS: For robotic rectal cancer surgery, surgical outcomes improved after the 177th case. Further studies by other robotic surgeons are required to validate our results.

Prognosis of Synchronous Colorectal Liver Metastases After Simultaneous Curative-Intent Surgery According to Primary Tumor Location and KRAS Mutational Status.

BACKGROUND: Tumor location and KRAS mutational status have emerged as prognostic factors of colorectal cancer. We aimed to define the prognostic impact of primary tumor location and KRAS mutational status among synchronous colorectal liver metastases (CRLM) patients who underwent simultaneous curative-intent surgery (SCIS). METHODS: We compared the clinicopathologic characteristics and long-term outcomes of 227 patients who underwent SCIS for synchronous CRLM, according to tumor location and KRAS mutational status. We cross-classified tumor location and KRAS mutational status and compared survival outcomes between the four resulting patient groups. RESULTS: Forty-one patients (18.1%) had right-sided (RS) tumors and 186 (81.9%) had left-sided (LS) tumors. One-third of tumors (78/227) harbored KRAS mutations. The KRAS mutant-type (KRAS-mt) was more commonly observed among RS tumors than among LS tumors [21/41 (51.2%) vs. 57/186 (30.6%), p = 0.012]. Median follow-up time was 43.4 months. Patients with RS tumors had shorter survival times than those with LS tumors [median disease-free survival (DFS): RS, 9.9 months vs. LS, 12.1 months, p = 0.003; median overall survival (OS): RS, 49.7 months vs. LS, 88.8 months, p = 0.039]. RS tumors were a negative prognostic factor for DFS [hazard ratio (HR) 1.878, p = 0.001] and OS (HR 1.660, p = 0.060). RS KRAS-mt and LS KRAS wild-type (KRAS-wt) tumors had the worst and best oncological outcomes, respectively. CONCLUSION: Tumor location has a prognostic impact in patients who underwent SCIS for CRLM, and RS KRAS-mt tumors yielded the worst oncological outcome. These results may allow for more tailored multimodality treatments.

Prospective study of oncologic outcomes after laparoscopic modified complete mesocolic excision for non-metastatic right colon cancer (PIONEER study): study protocol of a multicentre single-arm trial.

BACKGROUND: The introduction of complete mesocolic excision (CME) with central vascular ligation (CVL) for right-sided colon cancer has improved the oncologic outcomes. Recently, we have introduced a modified CME (mCME) procedure that keeps the same principles as the originally described CME but with a more tailored approach. Some retrospective studies have reported the favourable oncologic outcomes of laparoscopic mCME for right-sided colon cancer; however, no prospective multicentre study has yet been conducted. METHODS: This study is a multi-institutional, prospective, single-arm study evaluating the oncologic outcomes of laparoscopic mCME for adenocarcinoma arising from the right side of the colon. A total of 250 patients will be recruited from five tertiary referral centres in South Korea. The primary outcome of this study is 3-year disease-free survival. Secondary outcome measures include 3-year overall survival, incidence of surgical complications, completeness of mCME, and distribution of metastatic lymph nodes. The quality of laparoscopic mCME will be assessed on the basis of photographs of the surgical specimen and the operation field after the completion of lymph node dissection. DISCUSSION: This is a prospective multicentre study to evaluate the oncologic outcomes of laparoscopic mCME for right-sided colon cancer. To the best of our knowledge, this will be the first study to prospectively and objectively assess the quality of laparoscopic mCME. The results will provide more evidence about oncologic outcomes with respect to the quality of laparoscopic mCME in right-sided colon cancer. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03992599 (June 20, 2019). The posted information will be updated as needed to reflect protocol amendments and study progress.

Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study.

BACKGROUND: Despite acceptable oncologic outcomes of sphincter preserving surgeries for low rectal cancer, bowel dysfunction occurs. This study aimed to compare the oncologic and functional bowel outcomes between ultralow anterior resection (ULAR) and intersphincteric resection (ISR) for low rectal cancer. METHODS: One hundred sixty-four patients who underwent ULAR with or without ISR for low rectal cancer between December 2010 and May 2018 were included. The Wexner and Memorial Sloan Kettering Cancer Center (MSKCC) scores were used to evaluate the bowel function of patients. Overall survival (OS) and disease-free survival (DFS) were compared between patients. RESULTS: The ISR group had higher incidence of major fecal incontinence than the ULAR group (75.9% vs 49.3%; P = .016). The median Wexner score decreased from 12 to 9 (P = .062) at 1-year follow-up. However, the frequency and urgency/soilage subscales of MSKCC score improved significantly in the ULAR group. ISR and follow-up interval less than 1-year significantly increased the major incontinence risk. The OS in the ULAR and ISR groups was 91.4% and 91.7%. Whereas the DFS in both groups was 79% and 79.2%, respectively. CONCLUSION: ULAR and ISR are comparable in oncologic outcomes. Severe bowel dysfunctions and major incontinence were noted in ISR group. Careful selection of patients is mandatory.

Late anastomotic leakage after anal sphincter saving surgery for rectal cancer: is it different from early anastomotic leakage?

PURPOSE: Although multiple studies have examined anastomotic leakage (AL) after low anterior resection (LAR), their definitions of AL varied, and few have studied late diagnosed AL after surgery. This study aimed to characterize late AL after anal sphincter saving surgery (SSS) for rectal cancer by examining clinical characteristics, risk factors, and management of patients with late AL compared with early AL. METHODS: Data from January 2005 to December 2014 were collected from a total of 1903 consecutive patients who underwent anal sphincter saving surgery for rectal cancer and were retrospectively reviewed. Late AL was defined as AL diagnosed more than 30 days after surgery. Variables and risk factors associated with early and late diagnosed AL were analyzed by multivariate logistic regression. RESULTS: Overall, early, and late rates of AL were 13.7%, 6.7%, and 7%, respectively. Receiving neoadjuvant chemoradiotherapy (nCRT) was a risk factor for developing late AL, but not early AL (OR, 3.032; 95% CI, 1.947-4.722; p < 0.001). Protective ileostomy did not protect against late AL. Among the 134 patients with late AL, 26 (19.4%) were classified as asymptomatic and 108 patients (80.6%) as symptomatic. The most frequent symptomatic complications related to late AL were fistula (42 cases, 39.7%), chronic sinus (33 cases, 31.1%), and stenosis (31 cases, 29.2%). CONCLUSION: Clinical characteristics, risk factors, and management of patients with late AL after SSS were different from early AL. Close attention should be given to consider late AL as the continuation of early AL.

Oncologic Outcomes of Self-Expandable Metallic Stent as a Bridge to Surgery and Safety and Feasibility of Minimally Invasive Surgery for Acute Malignant Colonic Obstruction.

BACKGROUND: Although self-expandable metal stents (SEMS) are widely used as a bridge to surgery (BTS) in patients with malignant colorectal cancer obstruction, there has been some debate about their effect on long-term oncological outcomes. Furthermore, data on the safety and feasibility of minimally invasive surgery (MIS) combined with stent placement are scarce. We aimed to determine the long-term oncological outcomes of SEMS as a BTS, and the short-term outcomes of SEMS used with minimally invasive colorectal surgery. METHODS: Data from patients who were admitted with malignant obstructing colon cancer between January 2006 and December 2015 were retrospectively reviewed; 71 patients underwent direct surgery and 182 patients underwent SEMS placement as a BTS. Long-term and short-term outcomes of the groups were compared. In a subgroup analysis of the BTS group, the short-term outcomes of conventional open surgery and MIS were compared. RESULTS: There were no differences in long-term oncologic outcomes between groups. The primary anastomosis rate was higher in the stent group than in the direct surgery group. In the stent group, postoperative complication rates were lower in the minimally invasive group than in the open surgery group. Time to flatus and time to soft diet resumption were shorter in the minimally invasive group, as was length of hospital stay. CONCLUSIONS: Elective surgery after stent insertion does not adversely affect long-term oncologic outcomes. Furthermore, MIS combined with stent insertion for malignant colonic obstruction is safe and feasible.

Predictive Factors for Bowel Dysfunction After Sphincter-Preserving Surgery for Rectal Cancer: A Single-Center Cross-sectional Study.

BACKGROUND: With increasing rates of sphincter preservation because of advances in preoperative chemoradiation, restoration of bowel continuity has become a main goal of rectal cancer treatment. However, in many patients, postoperative bowel dysfunction negatively affects the quality of life. OBJECTIVE: This study aimed to analyze predictors of bowel dysfunction after sphincter-preserving surgery in patients with rectal cancer. DESIGN: This was a cross-sectional study. SETTINGS: Assessment of bowel dysfunction was conducted between November 2015 and June 2017 at our institution. PATIENTS: A total of 316 patients with rectal cancer who underwent sphincter-preserving surgery between February 2009 and April 2017 and agreed with an interview for assessing bowel dysfunction were included. MAIN OUTCOME MEASURES: Bowel dysfunction was assessed with the Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner score. All the assessments were conducted face-to-face by the same interviewer. RESULTS: The median time interval between the restoration of bowel continuity and assessment was 10 months (interquartile range, 3-37), and the median total Memorial Sloan Kettering Cancer Center and Wexner scores were 65 (interquartile range, 58-73) and 6 (interquartile range, 0-11). The time interval was correlated with the Memorial Sloan Kettering Cancer Center scores (rho, 0.279) and Wexner scores (rho, -0.306). In a multivariate analysis, handsewn anastomosis and short time interval (≤1 year) were independently associated with poor bowel function (Memorial Sloan Kettering Cancer Center score ≤65). A short time interval (≤1 year), preoperative chemoradiation, and ileostomy were independently associated with major fecal incontinence (Wexner ≥8). LIMITATIONS: Selection bias may be inherent. CONCLUSIONS: Bowel function recovers with time after the restoration of bowel continuity. A short time interval, handsewn anastomosis, preoperative chemoradiation, and ileostomy were significantly associated with poor bowel function or major fecal incontinence. Surgeons should discuss postoperative bowel dysfunction and its predictive factors with the patients. See Video Abstract at http://links.lww.com/DCR/A930.

Totally robotic modified complete mesocolic excision and central vascular ligation for right-sided colon cancer: technical feasibility and mid-term oncologic outcomes.

BACKGROUND: Recently, an operative strategy involving complete mesocolic excision (CME) and central vascular ligation (CVL) for colonic cancer has been introduced. We aimed to describe our initial experience and assess the long-term outcomes of robotic modified CME (mCME) and CVL (mCME+CVL) for right-sided colon cancer. METHODS: Of the 677 patients with histologically confirmed, right-sided colon adenocarcinoma who underwent curative mCME+CVL between February 2008 and October 2016, 43 who were treated entirely using the robotic approach were included in this retrospective study. Survival rates were determined using the Kaplan-Meier method, and P values of < 0.05 indicated statistically significant differences. RESULTS: The total operation and docking times were 293 (180-644) min and 5 (3-19) min, respectively, with an estimated blood loss of 50 (10-400) mL. The time to soft diet was 4 (1-16) days and the length of hospitalization was 8 (4-48) days. Based on the Clavien-Dindo classification, grade I, II, IIIa, IIIb, and IV complications were noted in 3 (7.0%), 5 (11.7%), 2 (4.7%), 1 (2.3%), and 0 (0%) patients, respectively. The proximal and distal resection margins were 14 (4-54) and 19 (4-48) cm, respectively, and 29 (6-157) lymph nodes were harvested per patient. The patients were followed-up for a median of 55 (2-109) months, during which the overall survival rate, median disease-free period, disease-free survival rate, and tumor recurrence rate were 93.6%, 38 (2-109) months, 81.1%, and 16.3% (7 patients), respectively. CONCLUSIONS: Robotic mCME and CVL for right-sided colon cancer was feasible and safe. It can be added to the surgeon's toolbox as an optional strategy for the management of colon cancer patients.

MRI-based EMVI positivity predicts systemic recurrence in rectal cancer patients with a good tumor response to chemoradiotherapy followed by surgery.

BACKGROUND: This study aimed to determine the prognostic value of baseline magnetic resonance imaging-based extramural vascular invasion status (EMVI) among rectal cancer patients with a good tumor response to standard chemoradiotherapy followed by surgery. METHODS: A total of 359 patients with ypT0-2/N0 disease from The Yonsei Multicenter Colorectal Cancer Electronic Database were retrospectively included between January 2000 and December 2014. Magnetic resonance images and medical records were reviewed to investigate risk factors for tumor recurrence. RESULTS: When we compared patients without and with EMVI, significant differences were observed in the 5-year disease-free survival rate (DFS) (80.8% vs 57.8%, P = 0.005) and in the 5-year systemic recurrence-free survival rate (SRFS) (86.9% vs 64.3%, P = 0.007). In the multivariate analysis, both mrEMVI and APR independently predicted overall DFS (APR; HR 2.088, 95% CI: 1.082-4.031, P = 0.028, mrEMVI; HR: 2.729, 95% CI: 1.230-6.058, P = 0.014). mrEMVI was only independent prognostic factor for systemic recurrence with statistical significance (HR: 3.321, 95% CI: 1.185-9.309, P = 0.022). CONCLUSION: Even in rectal cancer patients with a good response to chemoradiotherapy followed by curative surgery, extramural vascular invasion and APR may predict poor disease-free survival outcomes. Intensified treatment strategy should be considered.

Surgical Outcomes After Open, Laparoscopic, and Robotic Gastrectomy for Gastric Cancer.

BACKGROUND: In contrast to the significant advantages of laparoscopic versus open gastrectomy, robotic gastrectomy has shown little benefit over laparoscopic gastrectomy. This study aimed to compare multi-dimensional aspects of surgical outcomes after open, laparoscopic, and robotic gastrectomy. METHODS: Data from 915 gastric cancer patients who underwent gastrectomy by one surgeon between March 2009 and May 2015 were retrospectively reviewed. Perioperative parameters were analyzed for short-term outcomes. Surgical success was defined as the absence of conversion to open surgery, major complications, readmission, positive resection margin, or fewer than 16 retrieved lymph nodes. RESULTS: This study investigated 241 patients undergoing open gastrectomy, 511 patients undergoing laparoscopic gastrectomy, and 173 patients undergoing robotic gastrectomy. For each approach, the respective incidences were as follows: conversion to open surgery (not applicable, 0.4%, and 0%; p = 0.444), in-hospital major complications (5.8, 2.7, and 1.2%; p = 0.020), delayed complications requiring readmission (2.9, 2.0, and 1.2%; p = 0.453), positive resection margin (1.7, 0, and 0%; p = 0.003), and inadequate number of retrieved lymph nodes (0.4, 4.1, and 1.7%; p = 0.010). Compared with open and laparoscopic surgery, robotic gastrectomy had the highest surgical success rate (90, 90.8, and 96.0%). Learning-curve analysis of success using cumulative sum plots showed success with the robotic approach from the start. Multivariate analyses identified age, sex, and gastrectomy extent as significant independent parameters affecting surgical success. Surgical approach was not a contributing factor. CONCLUSIONS: Open, laparoscopic, and robotic gastrectomy exhibited different incidences and causes of surgical failure. Robotic gastrectomy produced the best surgical outcomes, although the approach method itself was not an independent factor for success.

Intraoperative colonoscopy for the assessment and prevention of anastomotic leakage in low anterior resection for rectal cancer.

PURPOSE: Anastomotic leakage (AL) after stapled anastomosis in rectal cancer surgery is a major concern. Various types of intraoperative anastomotic air leakage tests (ALTs) have been proposed to reduce AL. This study aimed to evaluate the impact of intraoperative colonoscopy (IOC) as an intraoperative ALT in low anterior resection for rectal cancer. METHODS: A total of 1266 patients were retrospectively reviewed. Among them, 215 patients who underwent IOC as an ALT in rectal cancer surgery were identified. IOC was performed after anastomosis to visualize the anastomosis line and to perform an ALT by insufflating the neorectum. Propensity score matching was used to match this group at a 1:1 ratio with 215 patients who underwent ALT with a 250-mL bulb irrigation syringe. Anastomotic defects that were found intraoperatively were resolved either by means of primary repair of the anastomotic defect, if possible, or by performing a preventive diverting ileostomy. RESULTS: The patient characteristics, pathologic outcomes, and operation details showed no significant difference between the two groups. Comparison of the AL rate showed a significant difference between the groups (IOC group without intraoperative leaks vs. non-IOC group without intraoperative leaks 4.3 vs. 11.7%, P = 0.007). The incidence of preventive diverting ileostomy because of a positive ALT was significantly higher in the IOC group than in the non-IOC group (10 vs. 2 cases, P = 0.036). CONCLUSION: IOC can be a valuable method for the assessment of stapled anastomosis and has the additional benefit of directly visualizing the anastomosis line.

Long-term bowel functional outcomes following anal sphincter-preserving surgery for upper and middle rectal cancer: a single-center longitudinal study.

PURPOSE: Despite advances in neoadjuvant chemoradiotherapy and anal sphincter-preserving surgery for rectal cancer, bowel dysfunction is still unavoidable and negatively affects patients' quality of life. In this longitudinal study, we aimed to investigate the changes in bowel function with follow-up time and the effect of neoadjuvant chemoradiotherapy on bowel function following low anterior resection for rectal cancer. METHODS: In this study, 171 patients with upper or middle rectal cancer who underwent low anterior resection between 2012 and 2018 were included. Bowel function was assessed longitudinally with Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores every 6 months after restoration of bowel continuity. Patients with at least 2 follow-up visits were included. RESULTS: Overall, 100 patients received neoadjuvant chemoradiotherapy. Urgency, soilage, and fecal incontinence were noted within 24 months in the patients treated with neoadjuvant chemoradiotherapy. After 2 years of follow-up, significant bowel dysfunction and fecal incontinence were observed in the neoadjuvant chemoradiotherapy group. Low tumor level and neoadjuvant chemoradiotherapy were associated with delayed bowel dysfunction. CONCLUSION: Neoadjuvant chemoradiotherapy in combination with low tumor level was significantly associated with delayed bowel dysfunction even after 2 years of follow-up. Therefore, careful selection and discussion with patients are paramount.

Clinical Significance of Prognostic Nutrition Index in Patients with Crohn's Disease after Primary Bowel Resection.

PURPOSE: Although advancements in medical treatments have been made, approximately half of patients with intestinal Crohn's disease (CD) require intestinal resections during their lifetime. It is well-known that the nutritional status of CD patients can impact postoperative morbidity. The objective of this study was to evaluate the clinical significance of prognostic nutritional index (PNI) in patients with intestinal CD who underwent primary bowel resection. MATERIALS AND METHODS: We retrospectively investigated patients who were diagnosed with CD and underwent intestinal surgery at Severance Hospital between January 2005 and October 2018. The patients were divided into two groups: PNI ≤40 (n=150) and PNI >40 (n=77). We assessed the clinical significance of PNI in terms of the incidence of postoperative infectious complications (PICs) and the postoperative recurrence of CD. RESULTS: The low PNI group had significantly higher rates of infectious complications (32.0% vs. 10.4%, p=0.001) compared to the high PNI group. Multivariable analysis identified low PNI (≤40) and longer operation time (>180 min) as independent risk factors associated with PICs [odds ratio (OR)=2.754, 95% confidence interval (CI)=1.140-6.649, p=0.024; OR=2.986, 95% CI=1.451-6.143, p=0.003]. PICs were significantly associated with surgical recurrence (hazard ratio=2.217, 95% CI=1.064-4.617, p=0.034). CONCLUSION: Preoperative PNI could serve as a predictive factor for PICs in CD patients who undergo intestinal resection. Additionally, PICs are significantly associated with a higher risk of surgical recurrence in CD.