Stereotactic Navigation-Assisted Laparoscopic Resection of Challenging Low Pelvic Tumors: A Case Series.

(1) Introduction: The laparoscopic approach to low pelvic tumors is challenging and hindered by suboptimal tumor visualization and dissection, with possible oncological failure. Stereotactic navigation provides real-time image guidance that may optimize safety, accuracy, and precision when dissecting challenging low pelvic tumors. (2) Methods: Preoperative CT images were acquired with eight skin-fixed fiducials and loaded into a navigation system. A patient tracker was mounted on the bed side. Patient-to-image paired point registration was performed, and an instrument tracker was mounted on a laparoscopic instrument and calibrated for instrument tracking. Surgical operations were performed with real-time stereotactic navigation assistance. (3) Results: Three patients underwent stereotactic navigation surgery. Fiducial registration errors were good to optimal (±1.9, ±3.4, and ±3.4 mm). Lesions were easily identified and targeted with real-time navigation. Surgeries were uneventful. Histopathology examinations identified one retro-rectal schwannoma, one lateral pelvic recurrence from rectal adenocarcinoma, and one advanced anal canal carcinoma. No navigation-related complications, readmissions, or postoperative mortalities were observed. (4) Conclusions: The application of laparoscopic stereotactic navigation surgery to complex low pelvic tumors is feasible and could impact oncological surgical quality by enabling tumor targeting and ensuring resection margins. Further wider series are needed to confirm stereotactic navigation's impact on challenging low pelvic tumors.

Phloroglucinol Enhances Anagen Signaling and Alleviates H2O2-Induced Oxidative Stress in Human Dermal Papilla Cells.

Phloroglucinol (PG) is one of the abundant isomeric benzenetriols in brown algae. Due to its polyphenolic structure, PG exhibits various biological activities. However, the impact of PG on anagen signaling and oxidative stress in human dermal papilla cells (HDPCs) is unknown. In this study, we investigated the therapeutic potential of PG for improving hair loss. A non-cytotoxic concentration of PG increased anagen-inductive genes and transcriptional activities of ß-Catenin. Since several anagen-inductive genes are regulated by ß-Catenin, further experiments were performed to elucidate the molecular mechanism by which PG upregulates anagen signaling. Various biochemical analyses revealed that PG upregulated ß-Catenin signaling without affecting the expression of Wnt. In particular, PG elevated the phosphorylation of protein kinase B (AKT), leading to an increase in the inhibitory phosphorylation of glycogen synthase kinase 3 beta (GSK3ß) at serine 9. Treatment with the selective phosphoinositide 3-kinase/AKT inhibitor, LY294002, restored the increased AKT/GSK3ß/ß-Catenin signaling and anagen-inductive proteins induced by PG. Moreover, conditioned medium from PG-treated HDPCs promoted the proliferation and migration of human epidermal keratinocytes via the AKT signaling pathway. Subsequently, we assessed the antioxidant activities of PG. PG ameliorated the elevated oxidative stress markers and improved the decreased anagen signaling in hydrogen peroxide (H2O2)-induced HDPCs. The senescence-associated ß-galactosidase staining assay also demonstrated that the antioxidant abilities of PG effectively mitigated H2O2-induced senescence. Overall, these results indicate that PG potentially enhances anagen signaling and improves oxidative stress-induced cellular damage in HDPCs. Therefore, PG can be employed as a novel therapeutic component to ameliorate hair loss symptoms.

Impact of COVID-19 infection during the postoperative period in patients who underwent gastrointestinal surgery: a retrospective study.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has led to significant global casualties. This study examines the postoperative impact of COVID-19 on patients who underwent gastrointestinal surgery, considering their heightened vulnerability to infections and increased morbidity and mortality risk. Methods: This retrospective observational study was conducted at a tertiary center and patients who underwent gastrointestinal surgery between January 2022 and February 2023 were included. Postoperative COVID-19 infection was defined as the detection of severe acute respiratory syndrome coronavirus 2 RNA by RT-PCR within 14 days after surgery. Propensity score matching was performed including age, sex, American Society of Anesthesiology physical status classification, and emergency operation between the COVID-19-negative (-) and -positive (+) groups. Results: Following 1:2 propensity score matching, 21 COVID-19(+) and 42 COVID-19(-) patients were included in the study. In the COVID-19(+) group, the postoperative complication rate was significantly higher (52.4% vs. 23.8%, P = 0.023). Mechanical ventilator requirement, intensive care unit (ICU) admission, and readmission rate did not significantly differ between the 2 groups. The median length of ICU (19 days vs. 4 days, P < 0.001) and hospital stay (18 vs. 8 days, P = 0.015) were significantly longer in the COVID-19(+) group. Patients with COVID-19 had a 2.4 times higher relative risk (RR) of major complications than patients without COVID-19 (RR, 2.37; 95% confidence interval, 1.254-4.467; P = 0.015). Conclusion: COVID-19 infection during the postoperative period in gastrointestinal surgery may have adverse outcomes which may increase the risk of major complications. Preoperative COVID-19 screening and protocols for COVID-19 prevention in surgical patients should be maintained.

Conversational artificial intelligence (chatGPT™) in the management of complex colorectal cancer patients: early experience.

INTRODUCTION: In 2022 chatGPT™ (OpenAI, San Francisco) was introduced to the public. The complex reasoning and the natural language processing (NLP) ability of the AI platform has generated much excitement about the potential applications. This study conducted a preliminary analysis of the chatGPT™'s ability to formulate a management plan in accordance with oncological principles for patients with colorectal cancer. METHODOLOGY: Colorectal cancer cases discussed in the multidisciplinary tumor (MDT) board at a single tertiary institution between September 2022 and January 2023 were prospectively collected. The treatment recommendations made by the chatGPT™ for Stage IV, recurrent, synchronous colorectal cancer were analysed for adherence to oncological principles. The recommendations by chatGPT™ were compared with the decision plans made by the MDT. RESULTS: In all cases, the chatGPT™ was able to adhere to oncological principles. The recommendations in all 30 cases factored in the patient's overall health and functional status. The oncological management recommendation concordance rate between chatGPT™ and the MDT was 86.7%. CONCLUSIONS: This study shows a high concordance rate of the chatGPT™'s recommendations with that given by the MDT in the management of complex colorectal patients. This will need to be verified in a larger prospective study.

Recurrence Patterns and Risk Factors after Curative Resection for Colorectal Cancer: Insights for Postoperative Surveillance Strategies.

This study aimed to assess recurrence patterns and related risk factors following curative resection of colorectal cancer (CRC). This retrospective observational study was conducted at a tertiary care center, including 2622 patients with stage I-III CRC who underwent curative resection between 2008 and 2018. Hazard rates of recurrence were calculated using a hazard function. The primary outcome was the peak recurrence time after curative resection and secondary outcomes were prognostic factors associated with recurrence. Over a median follow-up period of 53 months, the overall, locoregional and systemic recurrence rates were 8.9%, 0.7%, and 8.5%, respectively. Recurrence rates were significantly higher for rectal cancer (14.9% overall, 4.4% locoregionally, and 12.3% systemically) than for colon cancer (all p < 0.001). The peak recurrence time was 11 months, with variations in hazard rates and curves depending on the tumor location, stage, and risk factors. Patients with AL or CRM involvement exhibited a distinct pattern, with a high hazard rate in the early postoperative period. Understanding these recurrence patterns and risk factors is crucial for establishing effective postoperative surveillance strategies. Our findings suggested that short-interval surveillance should be considered during the first 2 years post-surgery, particularly for high-risk patients who should receive early attention.

Diagnostic Accuracy of Carcinoembryonic Antigen (CEA) in Detecting Colorectal Cancer Recurrence Depending on Its Preoperative Level.

BACKGROUND: Serum carcinoembryonic antigen (CEA) increase in patients with colorectal cancer (CRC) recurrence was observed to vary depending on their initial values. This study aimed to evaluate the diagnostic accuracy of CEA for detecting CRC recurrence in patients with normal and elevated initial CEA levels. METHODS: A total of 261 CRC recurrence patients who underwent curative resection were included and divided into two groups, normal and elevated initial CEA. Analysis was performed comparing patient, tumor, and recurrence characteristics retrospectively. RESULTS: There were 192 patients with normal and 69 with high initial CEA levels. Patient and tumor characteristics were similar. Eighty-six patients had elevated CEA at the time of recurrence, and the overall sensitivity of CEA for recurrence was 33.0%. In the high initial CEA group, 59.4% exhibited increased CEA level at recurrence, whereas in patients with normal initial CEA levels, only 23.4% showed elevated levels (p < 0.001). Patients with both high CEA preoperatively and at recurrence had more local recurrence, but there was no statistical significance (p = 0.053), and the rate of lung metastasis was higher in patients whose CEA remained normal at recurrence (38.3% vs. 24.4%, p = 0.026). The overall survival of patients with elevated CEA at recurrence was worse than those with normal CEA levels (56.9% vs. 42.4%, p = 0.003). CONCLUSION: The diagnostic accuracy of CEA for detecting recurrence depends on initial CEA level. Regardless of the initial CEA level, elevation at recurrence was significantly associated with overall survival in patients with recurrent CRC.

Laparoscopic Extraperitoneal Approach for Lateral Pelvic Node Dissection in Rectal Cancer: Techniques and Short-Term Outcomes.

BACKGROUND: Lateral pelvic lymph node dissection has been performed selectively in rectal cancer cases; however, it involves highly skilled techniques because of the complex adjacent anatomical structures. MATERIALS AND METHODS: Laparoscopic EP-LPND was performed in Korea University Anam Hospital from June 2018, and short-term surgical outcomes were analyzed from June to December 2018. Among the patients with histologically diagnosed rectal adenocarcinoma, patients who were suspected Lateral pelvic lymph node metastasis at magnetic resonance imaging were selected for this procedure. RESULTS: Seven patients underwent laparoscopic extraperitoneal approach for lateral pelvic lymph node dissection in the study period. The mean number of retrieved lymph node was 4.57, and metastatic lymph nodes were identified in 3 patients (42.8%). All of the lymph nodes with suspected metastasis preoperatively were removed in postoperative images. There was no immediate postoperative complication beyond the moderate grade associated with lateral pelvic lymph node dissection. The median follow-up was 9 months, and there were no local recurrence nor complications related to sexual and voiding functions. CONCLUSIONS: The laparoscopic extraperitoneal approach might be an efficient way to perform lateral pelvic lymph node dissection using the same principles as the conventional method without violation of the peritoneum.

How to do: superior rectal artery sparing anterior resection for sigmoid colon cancer - surgical option for vasculopathic patients.

Superior rectal artery sparing oncological anterior resection in vasculopathic patients.

Quality of laparoscopic camera navigation in robot-assisted versus conventional laparoscopic surgery for rectal cancer: An analysis of surgical videos through a video processing computer software.

BACKGROUND: To compare laparoscopic camera navigation (LCN) quality between robot-assisted laparoscopic surgery (RALS) and conventional laparoscopic surgery (CLS). METHODS: 20 recordings were selected by propensity score matching and subjected to Python® software to generate single frames at one second intervals. For each frame, the pixel where the camera should be centred, based on instrument position, current action (dissection/haemostasis/traction) in the frame, was detected. LCN quality was reviewed by two independent surgeons to evaluate erroneous LCN. RESULTS: RALS had higher incidence of centred views (83.1 ± 4.02% vs. 76.0 ± 2.38%, p < 0.05) and a shorter distance between actual and optimal frame centres (123.3 ± 9.8 vs. 144.8 ± 13.9, p < 0.05) compared to CLS. Erroneous camera navigations were more frequent in CLS regarding total time of horizontal alignment failure (2.1 ± 2.2 vs. 6.0 ± 5.4 min, p = 0.063) and number of excessive zoom-in visualization (0.1 ± 0.3 vs. 1.9 ± 1.4, p = 0.003). CONCLUSIONS: RALS provided higher LCN quality than did CLS, emphasising the benefits of a surgeon-controlled view.

Midline incision vs. transverse incision for specimen extraction is not a significant risk factor for developing incisional hernia after minimally invasive colorectal surgery: multivariable analysis of a large cohort from a single tertiary center in Korea.

BACKGROUND: Incisional hernia (IH) is a commonly encountered problem even in the era of minimally invasive surgery (MIS). Numerous studies on IH are available in English literature, but there are lack of data from the Eastern part of the world. This study aimed to evaluate the risk factors as well as incidence of IH by analyzing a large cohort collected from a single tertiary center in Korea. METHODS: Among a total number of 4276 colorectal cancer patients who underwent a surgical resection from 2006 to 2019 in Korea University Anam Hospital, 2704 patients (2200 laparoscopic and 504 robotic) who met the inclusion criteria were analyzed. IH was confirmed by each patient's diagnosis code registered in the hospital databank based on physical examination and/or computed tomography findings. Clinical data including specimen extraction incision (transverse or vertical midline) were compared between IH group and no IH group. Risk factors of developing IH were assessed by utilizing univariable and multivariable analyses. RESULTS: During the median follow-up of 41 months, 73 patients (2.7%) developed IH. Midline incision group (n = 1472) had a higher incidence of IH than that of transverse incision group (n = 1232) (3.5% vs. 1.7%, p = 0.003). The univariable analysis revealed that the risk factors of developing IH were old age, female gender, obesity, co-morbid cardiovascular disease, transverse incision for specimen extraction, and perioperative bleeding requiring transfusion. However, on multivariable analysis, specimen extraction site was not significant in developing IH and transfusion requirement was the strongest risk factor. CONCLUSIONS: IH development after MIS is uncommon in Korean patients. Multivariable analysis suggests that specimen extraction site can be flexibly chosen between midline and transverse incisions, with little concern about risk of developing IH. Careful efforts are required to minimize operative bleeding because blood transfusion is a strong risk factor for developing IH.

Laparoscopic en bloc lateral pelvic exenteration for locally advanced and recurrent rectal cancer.

This study describes minimally invasive lateral pelvic compartment en bloc excision for rectal cancer.

Characteristics and outcomes of colorectal cancer surgery by age in a tertiary center in Korea: a retrospective review.

PURPOSE: Colorectal cancer (CRC) occurs in all age groups, and the application of treatment may vary according to age. The study was designed to identify the characteristics of CRC by age. METHODS: A total of 4,326 patients undergoing primary resection for CRC from September 2006 to July 2019 were reviewed. Patient and tumor characteristics, operative and postoperative data, and oncologic outcome were compared. RESULTS: Patients aged 60 to 69 years comprised the largest age group (29.7%), followed by those aged 50 to 59 and 70 to 79 (24.5% and 23.9%, respectively). Rectal cancer was common in all age groups, but right-sided colon cancer tended to be more frequent in older patients. In very elderly patients, there were significant numbers of emergency surgeries, and the frequencies of open surgery and permanent stoma were greater. In contrast, total abdominal colectomy or total proctocolectomy was performed frequently in patients in their teens and twenties. The elderly patients showed more advanced tumor stages and postoperative ileus. The incidence of adjuvant treatment was low in elderly patients, who also had shorter follow-up periods. Overall survival was reduced in older patients with stages 0 to 3 CRC (P<0.001), but disease-free survival did not differ by age (P=0.391). CONCLUSION: CRC screening at an earlier age than is currently undertaken may be necessary in Korea. In addition, improved surgical and oncological outcomes can be achieved through active treatment of the growing number of elderly CRC patients.

Impact of D3 lymph node dissection on upstaging and short-term survival in clinical stage I right-sided colon cancer.

BACKGROUND: D3 lymph node dissection is becoming the standard procedure for the treatment of advanced right colon cancer and has shown increasing evidence of its oncologic benefit. However, a clear indication for its application is lacking and data on this topic is unsatisfactory. Thus, the necessity for D3 lymph node dissection in clinical stage I right colon cancer remains controversial. METHODS: We retrospectively analyzed data from clinical stage I right colon cancer patients who underwent radical surgery at three hospitals of Korea university medical center between January 2015 and June 2018. We compared surgical complications and short-term oncologic outcomes between D2 and D3 lymph node dissections in these patients. RESULTS: Among 512 patients, 122 (23.8%) were clinical stage I. Of these, 88 and 34 patients received D2 and D3 lymph node dissection, respectively. There were no statistically significant differences in clinicopathologic variables and surgical outcomes between the two groups. Upstaging occurred in 16 patients (47.1%) in the D3 group and 23 patients (26.1%) in the D2 group. There were four recurrences in the D2 group but no recurrence in the D3 group. Log-rank tests showed no statistically significant difference in disease-free survival rates between the two groups (p = 0.210). CONCLUSION: There was no significant difference in disease-free survival rates between D2 and D3 lymph node dissection in clinical stage I right colon cancer patients. However, recurrence occurred in the D2 group. Efforts to improve the accuracy of clinical staging are required and more studies with better quality are needed.

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.