Short-term Outcomes of Single-port Versus Multiport Laparoscopic Surgery for Colon Cancer: The SIMPLE Multicenter Randomized Clinical Trial.

OBJECTIVE: To compare short-term perioperative outcomes of single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for colon cancer. SUMMARY BACKGROUND DATA: Although many studies reported short- and long-term outcomes of SPLS for colon cancer compared with MPLS, few have reported results of randomized controlled trials. METHODS: This was a multicenter, prospective, randomized controlled trial with a noninferiority design. It was conducted between August 2011 and June 2017 at 7 sites in Korea. A total of 388 adults (aged 19-85 yrs) with clinical stage I, II, or III adenocarcinoma of the ascending or sigmoid colon were enrolled and randomized. The primary endpoint was 30-day postoperative complication rates. Secondary endpoints were the number of harvested lymph nodes, length of the resection margin, postoperative pain, and time to functional recovery (bowel movement and diet). Patients were followed for 30 days after surgery. RESULTS: Among 388 patients, 359 (92.5%) completed the study (SPLS, n = 179; MPLS, n = 180). The 30-day postoperative complication rate was 10.6% in the SPLS group and 13.9% in the MPLS group (95% confidence interval, -10.05 to 3.05 percentage points; P < 0.0001). Total incision length was shorter in the SPLS group than in the MPLS group (4.6 cm vs 7.2 cm, P < 0.001), whereas the length of the specimen extraction site did not differ (4.4 cm vs 4.6 cm, P = 0.249). There were no significant differences between groups for all secondary endpoints and all other outcomes. CONCLUSIONS: Even though there was no obvious benefit to SPLS over MPLS when performing colectomy for cancer, our data suggest that SPLS is noninferior to MPLS and can be considered an option in selected patients, when performed by experienced surgeons.Trial registration: ClinicalTrials.gov Identifier: NCT01480128.

Quality of life and patient satisfaction after single- and multiport laparoscopic surgery in colon cancer: a multicentre randomised controlled trial (SIMPLE Trial).

BACKGROUND: The clinical benefits of single-port laparoscopic surgery (SPLS) in patients with colon cancer patients are unclear because only a few studies have reported on the quality of life (QoL) of such patients. This study aimed to compare the QoL and patient satisfaction between SPLS and multiport laparoscopic surgery (MPLS) in colon cancer. METHODS: The multicentre randomised controlled SIngle-port versus MultiPort Laparoscopic surgEry (SIMPLE) trial included patients with colon cancer who underwent radical surgery at seven hospitals in South Korea. We performed a pre-planned secondary analysis of the QoL data of 359 patients from that trial. The QoL was surveyed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 preoperatively and at 1, 3, 6, and 12 months postoperatively. Patient satisfaction was measured with a 5-point questionnaire at these postoperative time points. RESULTS: Overall, 145 and 147 patients were included in the SPLS and MPLS groups, respectively. Most QoL domains were similar between the groups. In the subgroup analysis of patients without adjuvant chemotherapy, patients in the SPLS group presented with significantly better global health status (p = 0.017), fatigue (p = 0.047), and pain (p = 0.005) scores and tended to have improved physical (p = 0.055), emotional (p = 0.064), and social (p = 0.081) functioning, with marginal significance at 1 month postoperatively, compared to those in the MPLS group. Patient satisfaction regarding surgery (p = 0.002) and appearance of the abdominal scar (p = 0.002) was significantly higher with SPLS than with MPLS at 12 months postoperatively. CONCLUSION: Patients who underwent SPLS without adjuvant chemotherapy had better global health status, fatigue status, and pain at 1 month postoperatively; however, these improvements were minimal and temporary. In the near future, the effect of SPLS on postoperative QoL should be confirmed through a randomised controlled trial targeting the QoL in colon cancer patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01480128.

Risk factors for postoperative delirium after colorectal surgery: a systematic review and meta-analysis.

PURPOSE: Postoperative delirium is common after any type of surgery and can lead to serious outcomes; thus, its prevention is important. Early assessment can help identify patients at higher risk of postoperative delirium. However, the risk factors for postoperative delirium in patients who underwent colorectal surgery are unclear. This meta-analysis aimed to identify the risk factors for postoperative delirium after colorectal cancer surgery. METHODS: We selected all articles related to postoperative delirium after colorectal surgery published up to March 2019. Studies using any method for diagnosing delirium were eligible. Ovid-Embase, Ovid-Medline, and the Cochrane library were searched. Two reviewers independently conducted quality assessment and data collection. The risk factors identified in the studies were recorded, and a meta-analysis was conducted. RESULTS: Of the 1216 studies initially screened, 1197 were reviewed by two independent reviewers. Finally, 14 articles were identified to be relevant for this review. In total, 11 of the 14 studies reported the risk factors for postoperative delirium. The incidence of postoperative delirium ranged from 8% to 54%. A total of 19 risk factors were identified, and we classified them into two categories as patient-related and treatment-related risk factors. CONCLUSION: Postoperative delirium is highly common in those undergoing colorectal surgery including cancer, with advanced old age, history of preoperative delirium and preoperative serum albumin level which are risk factors for POD. Larger multi-institutional randomized studies to address this issue are warranted in the future.

Delta neutrophil index as a prognostic marker in emergent abdominal surgery.

BACKGROUND: Delta neutrophil index (DNI) is the fraction of circulating immature granulocytes provided by a routine, complete blood cell analyzer. It is known to be a useful prognostic marker of sepsis. The aim of this study was to evaluate the role of DNI in the diagnosis and prognosis of patients who had undergone emergent surgery for an acute abdomen. METHODS: A total of 694 patients who had visited the emergency room for acute abdominal pain and undergone emergent abdominal surgery from May 2015 to September 2016 were retrospectively reviewed. Clinical characteristics, laboratory findings on the day of hospital visit, hospital stay, postoperative complications, and 30-day mortality were investigated. RESULTS: In the analysis of patients who had undergone an operation for acute peritonitis, the DNI was a good predictor for predicting 30-day mortality rate (area under the curve [AUC]: 0.826). It was not inferior to other laboratory values, including activated partial thromboplastin time (AUC: 0.729), C-reactive protein (AUC: 0.727), albumin (AUC: 0.834), prothrombin time (AUC: 0.816), and creatinine (AUC: 0.837) known to be associated with sepsis. Patients with high DNI displayed higher incidence of bacteremia and sepsis, longer hospital stay, higher postoperative complication rate, and higher 30-day mortality rate than patients with low DNI. Among patients diagnosed with acute appendicitis, the DNI was a useful marker for differentiating appendiceal perforation. CONCLUSION: The DNI was a practical and useful marker for predicting the prognosis of patients who needed emergent abdominal surgery.

Robotic versus laparoscopic intersphincteric resection for low rectal cancer: a systematic review and meta-analysis.

PURPOSE: Few studies have compared robotic and laparoscopic intersphincteric resection (ISR) in rectal cancer. Therefore, we performed a meta-analysis of recently published studies to compare perioperative outcomes of ISR for the treatment of low rectal cancer. METHODS: We performed a systematic literature search of the Ovid-Medline, Ovid-EMBASE, and Cochrane Central Register of Controlled Trials databases for studies comparing robotic and laparoscopic ISR in patients with low rectal cancer. Demographic and clinical data were extracted from articles that met the inclusion and exclusion criteria. Perioperative outcomes of interest included the rate of diverting stoma, open conversion rate, operation time, estimated blood loss, length of hospital stay, time to first flatus, and time to initiate the postoperative diet. Oncological outcomes included the number of retrieved lymph nodes, distal resection margin, proximal resection margin, circumferential resection margin, 3-year overall survival, 3-year disease-free survival, and local recurrence. Postoperative complications included overall complications, a Dindo-Clavien classification ≥ III, and anastomotic leakage. All outcomes were compared between the two groups. RESULTS: We included 5 retrospective cohort studies with a total of 510 patients undergoing 273 (53.5%) robotic ISR procedures and 237 (46.5%) laparoscopic ISR procedures. The robotic ISR group lower conversion rate, lower blood loss, and longer operation times than the laparoscopic group. We also noted that fewer lymph nodes were harvested in the robotic ISR group; however, this difference was not statistically significant. Other outcomes were similar between the two groups. CONCLUSIONS: Robotic and laparoscopic ISR showed comparable perioperative outcomes, functional outcomes, and 3-year oncologic outcomes; however, robotic ISR was associated with a lower conversion rate and less blood loss despite longer operation times compared to laparoscopic ISR. These findings suggest that robotic ISR maybe a safe and effective technique for treating low rectal cancer in selected patients. The potential oncologic and functional benefits of robotic ISR should be evaluated in larger randomized controlled trials.

Multicenter, randomized single-port versus multiport laparoscopic surgery (SIMPLE) trial in colon cancer: an interim analysis.

BACKGROUND: Single-port laparoscopic surgery (SPLS) was recently introduced as an innovative minimally invasive surgery method. Retrospective studies have revealed the safety and feasibility of SPLS for colon cancer treatment. However, no prospective randomized trials have been performed. The multicenter, randomized SIMPLE (single-port versus multiport laparoscopic surgery) trial aimed to investigate short-term perioperative outcomes of SPLS for colon cancer treatment, compared with multiport laparoscopic surgery (MPLS). METHODS: Between August 2011 and April 2014, a total of 194 patients with colon cancer were recruited from seven hospitals in Korea. Patients were randomly allocated into the SPLS group (n = 99) or MPLS group (n = 95). The primary endpoint was postoperative complications. Operative, postoperative, and pathologic outcomes were analyzed after 50% of the patient study population had been recruited. RESULTS: The patients' demographic characteristics, operative times, estimated blood volume losses, numbers of harvested lymph nodes, and lengths of both resection margins were not significantly different between groups. In the SPLS group, the rates of conversion to MPLS and open surgery were 12.9 and 2.2%, respectively. Postoperative complications occurred in 10.8% of the SPLS, and 12.5% of the MPLS patients (p = 0.714). Times to functional recovery, pain scores, and amounts of analgesia were similar between groups. CONCLUSION: The results of this interim analysis suggested that SPLS is technically safe and appropriate when used for radical resection of colon cancer. (ClinicalTrials.gov Identifier: NCT01480128).

Intracorporeal Traction of the Rectum with a Beaded Plastic Urinary Drainage Bag Hanger: Comparison with Conventional Laparoscopic Rectal Cancer Surgery.

BACKGROUND: Laparoscopic rectal cancer surgery with proper total mesorectal excision is a challenge for colorectal surgeons during trouble shooting. We used a beaded plastic urinary drainage bag hanger to encircle the rectum and clamp laparoscopic rectal transaction in this study. METHODS: Sixty-three patients with rectal cancer underwent laparoscopic radical rectal resection with curative intent between February 2015 and December 2015. Plastic beaded form urinary Foley catheter bag hanger was inserted intracorporeally via right lower 12-mm trocar, encircling the rectal tube distal to the rectal lesion followed by fastening. Thirty patients in the rectal resection group (28 laparoscopic, 2 robotic-assisted) using the commercial beaded plastic hanger for Foley catheter drainage were compared to 33 patients who underwent conventional laparoscopic rectal resection. RESULTS: Low anterior resection was performed for both groups. The Foley bag hanger group had less operation time (162.6 min vs. 187.3 min, p = 0.006) and fewer numbers of stapler cartilage (1.6 vs. 2.1, p = 0.001). CONCLUSIONS: Intracorporeal ligation of the rectum with a beaded plastic Foley catheter bag hanger could be used as a valuable method for rectal handling and transaction in laparoscopic rectal cancer surgery.

Learning curve for single-port laparoscopic colon cancer resection: a multicenter observational study.

BACKGROUND: The aim of this study was to investigate the learning curves (LCs) of single-port laparoscopic surgery (SPLS) for colon cancer using multidimensional statistical analyses. Although SPLS yields better cosmetic results and comparable short-term outcomes compared to conventional laparoscopic surgery, its technical difficulties make surgeons hesitant to try SPLS. Moreover, the LCs of SPLS for colon cancer are not well delineated. METHODS: Data were collected from patients who underwent SPLS for colon cancer in seven Korean institutions between May 2009 and May 2015. The LCs were analyzed using the moving average method and the cumulative sum control chart (CUSUM) for operation time and surgical failure. Surgical failure was defined as the any conversion, postoperative complications, or less than 12 harvested lymph nodes from surgical specimens. RESULTS: A total of 356 patients were included in this study. Six and three surgeons performed 282 anterior resections (ARs) and 74 right colectomies (RCs), respectively. On the basis of the moving average method and CUSUM for operation time and surgical failure, the LCs for AR were 18, 16, 35, 13, 36, and 13 cases for surgeons A-F, respectively. However, the LCs for RC were 6 and 15 cases for surgeons D and E, respectively, and were ambiguous for one surgeon. CONCLUSIONS: For surgeons experienced in conventional laparoscopic colorectal surgery, the LCs of SPLS for colon cancer ranged from 6 to 36 cases, which is shorter than the LCs reported for conventional laparoscopic surgery.

PHLDA3 overexpression in hepatocytes by endoplasmic reticulum stress via IRE1-Xbp1s pathway expedites liver injury.

OBJECTIVE: Endoplasmic reticulum (ER) stress is involved in liver injury, but molecular determinants are largely unknown. This study investigated the role of pleckstrin homology-like domain, family A, member-3 (PHLDA3), in hepatocyte death caused by ER stress and the regulatory basis. DESIGN: Hepatic PHLDA3 expression was assessed in HCV patients with hepatitis and in several animal models with ER stress. Immunoblottings, PCR, reporter gene, chromatin immunoprecipitation (ChIP) and mutation analyses were done to explore gene regulation. The functional effect of PHLDA3 on liver injury was validated using lentiviral delivery of shRNA. RESULTS: PHLDA3 was overexpressed in relation to hepatocyte injury in patients with acute liver failure or liver cirrhosis or in toxicant-treated mice. In HCV patients with liver injury, PHLDA3 was upregulated in parallel with the induction of ER stress marker. Treatment of mice with tunicamycin (Tm) (an ER stress inducer) increased PHLDA3 expression in the liver. X box-binding protein-1 (Xbp1) was newly identified as a transcription factor responsible for PHLDA3 expression. Inositol-requiring enzyme 1 (IRE1) (an upstream regulator of Xbp1) was required for PHLDA3 induction by Tm, whereas other pathways (c-Jun N-terminal kinase (JNK), protein kinase RNA-like endoplasmic reticulum kinase (PERK) and activating transcription factor 6 (ATF6)) were not. PHLDA3 overexpression correlated with the severity of hepatocyte injury in animal or cell model of ER stress. In p53-deficient cells, ER stress inducers transactivated PHLDA3 with a decrease in cell viability. ER stress-induced hepatocyte death depended on serine/threonine protein kinase B (Akt) inhibition by PHLDA3. Lentiviral delivery of PHLDA3 shRNA to mice abrogated p-Akt inhibition in the liver by Tm, attenuating hepatocyte injury. CONCLUSIONS: ER stress in hepatocytes induces PHLDA3 via IRE1-Xbp1s pathway, which facilitates liver injury by inhibiting Akt.

Early recurrence in patients undergoing curative surgery for colorectal cancer: is it a predictor for poor overall survival?

PURPOSE: This study evaluated the prognostic value of early recurrence in patients who have undergone curative resection for colorectal cancer. METHODS: A total of 1,159 consecutive patients who underwent curative resection for non-metastatic colorectal cancer from December 1998 to December 2007 were reviewed. The predictive factors for early recurrence postoperatively and the prognostic factors were analyzed. RESULTS: Of the 1,159 patients, postoperative recurrence was identified in 280 (24.1%) patients, and 96 (34.3%) of the 280 patients with recurrence were designed as early recurrence (less than 1 year postoperatively). In multivariate analysis, tumor location, tumor diameter, number of retrieved lymph nodes, and lymphovascular invasion were the independent predictors for early recurrence. The early recurrence group had a significantly lower overall survival rate than that of the non-early recurrence group for both colon cancer (P < 0.001) and rectal cancer (P < 0.001). The overall survival rate for stage III tumors significantly differed between the early and non-early recurred patients (P < 0.001), whereas the rate did not differ between the patients with stage II tumors (P = 0.364). In multivariate analysis, early recurrence was an independent predictor for unfavorable overall survival. Moreover, differentiation, N category, and postoperative chemotherapy were the independent predictors for overall survival for the patients with both early and overall recurrence. CONCLUSION: Poor survival was associated with early postoperative recurrence for patients who underwent curative resection for colorectal cancer. The use of adjuvant chemotherapy prolonged the survival of patients, irrespective of the interval of recurrence.

Usefulness of plasma epigenetic changes of five major genes involved in the pathogenesis of colorectal cancer.

PURPOSE: The purpose of present study was to investigate the methylation status of the promoter region in five genes (mothers against decapentaplegic homolog 4, fragile histidine triad protein, death-associated protein kinase 1, adenomatous polyposis coli (APC), and E-cadherin), which are known to be involved in the pathogenesis of colorectal cancer (CRC) and its clinicopathological significance. METHODS: The study subjects were 60 CRC patients, 40 patients with adenomatous colorectal polyp and 60 healthy control individuals. We further enrolled a total of 16 patients (two patients with Crohn's disease, two patients with ulcerative colitis, one patient with serrated adenoma, and 11 patients with colorectal cancer). The methylation states of the five genes were determined in peripheral blood plasma using methylation-specific polymerase chain reaction single-strand conformation polymorphism analysis. RESULTS: This study showed the most sensitive epigenetic markers, E-cadherin (60 %), followed by APC (57 %), for detecting CRC. E-cadherin and APC had similar specificities and amplified 84 and 86 %, respectively, of CRC patients compared to non-CRC patients. Additionally, APC was the only marker to be significantly increased (OR = 6.67, 95 % CI = 1.19-23.4, P = 0.045) and the most sensitive (57 %) and specific (89 %) marker in stage I CRC. Though we have not examined the paired cancer tissues and plasma, there was relatively high concordant rate (60-80 %) in our limited number of colorectal cancer patients. CONCLUSIONS: Five genes, promoter methylation, in plasma were statistically significant risk factors in CRC patients. In this study, E-cad and APC genes may be particularly useful epigenetic biomarkers in plasma for the detection of CRC. Additionally, APC may able to identify early potential CRC.

Oncologic safety of stent as bridge to surgery compared to emergency radical surgery for left-sided colorectal cancer obstruction.

BACKGROUND: There are still concerns about the oncologic safety of stent insertion for colorectal cancer obstruction. This study investigated whether the use of stents as a bridge to surgery negatively affect the long-term outcome compared to curative surgery for left-sided colorectal cancer obstruction. METHODS: Between January 2004 and December 2009, patients with left-sided colorectal cancer obstruction without distant metastasis were retrospectively reviewed. Forty-three patients underwent radical resection after preoperative stent insertion (stent group), whereas 48 underwent emergency surgery with curative intent (surgery group). The short- and long-term outcomes between the two groups were compared. RESULTS: The stent and surgery groups had similar demographics. There were no significant differences in primary anastomosis, laparoscopic-assisted surgery, operation time, time until first defecation and oral intake after surgery, postoperative hospital stay, and reoperation. The stent group had an average hospital stay 7 days longer than the surgery group. During the median follow-up period of 48.1 months, the 5-year disease-free survival rates were not significantly different between the stent and surgery groups (47.2 vs. 48.9%, respectively; p = 0.499). Overall, the 5-year survival rate was also similar in the two groups (70.4 vs. 76.4%, respectively; p = 0.941). CONCLUSIONS: For left-sided colorectal cancer obstruction, stent insertion followed by surgery showed short-term advantages and similar oncologic outcomes compared to surgery without preoperative intervention. Stent insertion as a bridge to surgery is a safe and feasible treatment option for patients with colorectal cancer obstruction.

Risk factors for permanent stoma after low anterior resection for rectal cancer.

PURPOSE: This study evaluated the risk factors influencing permanent stoma after curative resection of rectal cancer and compared the long-term survival of patients according to the stoma state. METHODS: From January 2004 to December 2010, 895 consecutive rectal cancer patients with histological-confirmed adenocarcinoma who received low anterior resection with curative intent at the Department of Colon and Rectal Surgery, Chonnam National University Hwasun Hospital, were evaluated retrospectively. Patient demographics, times of stoma reversal, and number/reason of permanent stoma were evaluated. RESULTS: Three hundred fifteen patients (35.2 %) had a diverting stoma of temporary intent among 895 rectal adenocarcinoma patients. Loop ileostomy was performed in 271 patients (86.0 %). A total of 256 (81.3 %) of 315 stoma patients received stoma closure. The mean period between primary surgery and stoma closure was 5.6 months (range, 1-44 months). Seventy-three patients (23.2 %) were confirmed with permanent stoma. Multivariate analysis showed stage IV (hazard ratio (HR), 3.380; 95 % confidence interval (CI), 1.192-18.023; p = 0.027), anastomosis-related complication (HR, 3.299; 95 % CI, 1.397-7.787; p = 0.006), colostomy type (HR, 7.276, 95 % CI, 2.454-21.574; p = 0.000), systemic metastasis (HR, 2.698; 95 % CI, 1.1.288-5.653; p = 0.009), and local recurrence (HR, 4.231; 95 % CI, 1.724-10.383; p = 0.002) were independent risk factors for permanent stoma. CONCLUSIONS: On postoperative follow-up, in patients with anastomotic complication, tumor progression with local recurrences and systemic metastasis may cause permanent stoma.

High-frequency minisatellite instability of the mitochondrial genome in colorectal cancer tissue associated with clinicopathological values.

Most studies of mitochondrial DNA (mtDNA) mutations in colorectal cancer have used case-control and case-database comparisons without searching their clinical relevance. This study was to investigate colorectal cancer tissue-specific mtDNA mutations from 54 matched colorectal cancer and adjacent normal tissues and then to evaluate their clinical values. This study focused on analyzing control region including mtDNA minisatellites and coding regions. Cancer tissue-specific mtDNA mutations were found in over half of the patients (59%). The patterns of mtDNA mutations were substitution only (13%), mtDNA minisatellite instability (mtMSI) (20%) and both mutations combined (26%). mtMSI in colorectal cancer was mainly occurred in the 303 polyC (35%) and 16184 poly C (19%) minisatellite. mtDNA copy number and hydrogen peroxide level were significantly increased in colorectal cancer tissue. The amount of mtDNA large deletions was significantly decreased in colorectal cancer tissue compared with those from matched normal mucosa (p = 0.03). The activity of the mitochondrial respiratory chain enzyme complexes I, II and III in colorectal cancer tissues was impaired. mtDNA haplogroup B4 might be closely associated with colorectal cancer risk. The patient group harboring cancer tissue-specific mtDNA mutations showed larger tumor sizes (p = 0.005) and more advanced TNM stages (p = 0.002). Thus, mtDNA mutations in colorectal cancer might be implicated in risk factors that induce poor outcomes and tumorigenesis.

Factors influencing oncological outcomes in patients who develop pulmonary metastases after curative resection of colorectal cancer.

BACKGROUND: The prognostic factors after pulmonary resection in patients with colorectal pulmonary metastases remain controversial. OBJECTIVE: The study aimed to identify the predicting factors for oncological outcomes after curative resection in patients with colorectal cancer and pulmonary metastases. DESIGN: This study is a retrospective review of prospectively collected data. SETTING: This study was conducted at a tertiary care hospital/referral center in South Korea. PATIENTS: Between January 2000 and June 2010, 105 patients who developed pulmonary metastases after curative resection for colorectal cancer were enrolled. Forty-eight patients underwent pulmonary resection, and the remaining 58 were given chemotherapy and/or best supportive care. MAIN OUTCOME MEASURES: The primary outcomes measured were the predictive factors of survival and recurrence. RESULTS: During the 35.9-month median follow-up period, 3- and 5-year overall survival rates were 54.6% and 30.4%. On multivariate analysis, absence of adjuvant chemotherapy after pulmonary metastases (p = 0.003), presence of extrapulmonary metastases (p = 0.001), elevated prelaparotomy serum CEA level (p = 0.015), and absence of pulmonary resection (p = 0.048) were independent prognostic factors for poor overall survival. In patients who underwent pulmonary resection, the 3-year pulmonary recurrence-free survival rate was 78.3%. On multivariate analysis, elevated prelaparotomy serum CEA level (p = 0.018) and disease-free interval ≤ 12 months (p = 0.008) were independent risk factors associated with pulmonary re-recurrence after pulmonary resection. LIMITATIONS: This study took place at a single institution and had a small sample size. CONCLUSION: Although we admit, to some degree, the benefits of the selection mechanism, pulmonary metastasectomy from colorectal cancer may improve survival after curative resection of colorectal cancer. Adjuvant chemotherapy, extrapulmonary metastases, and prelaparotomy CEA value are independent prognostic factors for overall survival. Prelaparotomy serum CEA level may be an especially reliable predictor of both overall survival and recurrence-free survival after pulmonary metastasectomy in patients who undergo curative resection for colorectal cancer.

Schwannoma of ascending colon treated by laparoscopic right hemicolectomy.

Schwannomas of the colon are rare and are difficult to diagnose preoperatively, since they often defy endoscopic and radiographic detection. Immunohistochemical stains are useful postoperatively to confirm this tumor, but more reliable diagnostic techniques (such as colonoscopic biopsy with immunohistochemistry) have emerged to enhance preoperative diagnostic accuracy. Here we report an instance of schwannoma arising in the ascending colon, where immunohistochemical staining of a preoperative biopsy facilitated diagnosis. After laparoscopic resection, histologic examination was confirmatory.

Laparoscopic intersphincteric resection for low rectal cancer.

BACKGROUND: Laparoscopic intersphincteric resection (ISR) after neoadjuvant chemoradiation is helpful in the management of patients with low rectal cancer. With the advent of this technique, the need for performance of abdominoperineal resection seems to have decreased in patients with very low rectal tumors. The aim of the present study was to evaluate the feasibility, the functional outcome, and the short-term oncologic outcomes of laparoscopic ISR for low rectal adenocarcinoma at our institution. METHODS: We retrospectively reviewed the data of 111 consecutive patients who underwent laparoscopic ISR for low rectal adenocarcinoma between July 2005 and December 2009. Demographic status, surgical outcomes, functional outcome data, and oncologic outcome data were collected. RESULTS: The mean distance of the tumor from the anal verge was 3.4 cm (range: 1-5 cm). The mean operative time was 214.7 min (range, 150-450 min). The mean distal resection margin was 1.3 ± 1.1 cm. Morbidity occurred in 24 patients (21.6%), including anastomotic leakage in 2 patients (1.8%). The mean Wexner continence score after stoma repair was 7.5 ± 2.7 (range: 2 ~ 19), and 9.8 in total ISR, 7.3 in partial ISR (P = 0.071). The 3-year overall survival rate was 92.8%, and the 3-year disease-free survival rate was 73.0%. Local recurrence was noted in 6 of the 111 patients with TNM stage I to III (5.4%). The patients with lesions at 2 cm to the dentate line had a 7.07-fold greater risk of local recurrence, including a 13.42-fold greater risk of lateral pelvic wall recurrence and perineal recurrence (95% Confidence interval [CI], 1.141-158.006; P = 0.009) than in those who had lesions more than 2 cm from the anal verge (95% CI, 1.290-38.832; P = 0.011). CONCLUSIONS: Laparoscopic ISR after neoadjuvant chemoradiation can be recommended as a technically feasible, minimally invasive, and a sphincter-saving procedure with acceptable functional and short-term oncologic outcomes in patients with very low rectal cancer.

Laparoscopic low anterior resection for hematogenous rectal metastasis from gastric adenocarcinoma: a case report.

BACKGROUND: Gastric cancer is one of the most common malignancies in the world and is the second most common cause of cancer-related death in Korea. Colorectal metastases from gastric adenocarcinoma are known to be very rare. We report an unusual case of rectal metastasis of gastric adenocarcinoma. CASE PRESENTATION: We report a case of a 43-year-old female patient with gastric cancer who first presented with epigastric pain. The endoscopic and radiologic findings were suggestive of Borrmann type III advanced gastric cancer with linitis plastica. Radical total gastrectomy with D2 lymph node dissection was performed. The pathology report was AJCC TNM Stage II gastric adenocarcinoma (T3N0M0). On follow up at 34 months after surgery, the patient complained of difficulty in defecation. On colonoscopy, a hard, indurated extraluminal mass was detected 7 cm proximal to the anal verge. The biopsy demonstrated chronic nonspecific colitis. Abdominal CT, rectal MRI and PET-CT revealed rectal metastasis from gastric cancer. Laparoscopic ultralow anterior resection with diverting ileostomy was performed. The pathology report was metastatic adenocarcinoma, and this diagnosis was identical to the gastric pathology reported in the previous pathology report. The patient was discharged after the 11th postoperative day with no adverse events. CONCLUSION: Rectal metastasis from gastric cancer is known to be very rare. However, metastatic gastric adenocarcinoma should be considered as a differential diagnosis for patients presenting with a colorectal mass and a past history of gastric cancer.

Trimetallic coordination cage formation for nitrate encapsulation: transformation of kinetic products into thermodynamic products.

A procedure for the formation of a nitrate-encapsulating tripalladium(II) cage via self-assembly of Pd(NO3)2 with 1,3-bis(dimethyl(pyridin-4-yl)silyl)propane (L) was developed. The self-assembly reaction initially produces spiro-type macrocycles, PdL2, and finally results in transformation into a nitrate-encapsulated cage, [(NO3)@Pd3L6], in the mother liquor. The reaction of PdX2 (X- = BF4-, ClO4-, PF6-, and CF3SO3- instead of NO3-) with L gives rise to a spiro species, PdL2, as the final product, and anion exchange of the spiro products, [PdL2](X)2, with NO3- produces the tripalladium cage [(NO3)@Pd3L6].

Prognostic Impact of Carcinoembryonic Antigen Levels in Rectal Cancer Patients Who Had Received Neoadjuvant Chemoradiotherapy.

PURPOSE: Carcinoembryonic antigen (CEA) is a useful marker for rectal cancer. The aim of this study was to investigate the prognostic impact of CEA level according to neoadjuvant chemoradiotherapy (nCRT) in rectal cancer patients who underwent radical surgery. METHODS: A total of 245 patients with rectal cancer who underwent radical surgery were retrospectively evaluated. Serum CEA level was measured preoperatively and postoperatively. We compared survival outcomes based on CEA level before and after surgery according to nCRT. RESULTS: Of the 245 patients, elevation of CEA level was observed preoperatively in 79 and postoperatively in 30, respectively. Eighty-seven (35.5%) patients received nCRT, and elevated CEA level was a significant prognostic factor both before and after surgery. In patients who had not received nCRT, an elevated CEA level was a significant prognostic factor before surgery but was not significant after surgery. In a multivariate analysis for prognostic factors, elevation of preoperative CEA level was an independent prognostic factor of disease-free survival (DFS) regardless of nCRT. Postoperative CEA level was an independent prognostic factor of DFS in patients who had received nCRT but was not a factor in patients who had not received nCRT. CONCLUSION: Serum CEA level was an independent prognostic factor both preoperatively and postoperatively in rectal cancer patients who had received nCRT.