Potential benefit of superior to inferior dissection during laparoscopic extended right hemicolectomy

Various approaches can be used for performing laparoscopic right hemicolectomy for right-sided colon cancer. However, laparoscopic complete mesocolic excision with central vessel ligation using these approaches may sometimes present with difficulties of various factors. This video article presents a laparoscopic extended right hemicolectomy using a superior-to-inferior approach. The superior approach has potential benefits in that it exposes the superior mesenteric vessels and gastrocolic trunk.

Comparison of oncologic outcome of abdominoperineal resection versus sphincter saving resection for low lying rectal cancer

Purpose@#The present study compares the peri/postoperative and oncological outcomes of abdominoperineal resections (APR) and sphincter saving resection (SSR) for low lying rectal cancer. @*Methods@#Between January 2001 and December 2014, 176 patients who underwent SSR (n = 67) and APR (n = 109) for low rectal cancer, without stage IV, were retrieved from a retrospective database. @*Results@#With a median follow-up of 66.5 months. The mean total number of harvested lymph nodes was 16.7 (SSR) versus 17.1 (APR) (P = 0.801). The advanced T stage was higher in the APR group (82.6%) versus the SSR group (55.2%) (P = 0.006). The positive rate of lymph nodes after surgery was significantly higher in the APR group (45.9%) versus SSR group (25.4%) (P < 0.05). The 5-year overall survival rates for SSR and APR were 87.3% and 67.6%, respectively (P < 0.005). The 5-year disease-free survival rate (DFS) was 83.6% (SSR) versus 65.5% (APR) (P = 0.002). The recurrence rate was higher in the APR group (34.9%) versus the SSR group (14.9%) (P = 0.004). Local recurrence rate was not different between the two groups. However, distant recurrence rate was significantly higher in the APR group (26.6% vs. 11.9%, P = 0.023). In multivariate analysis, node positive (N0 vs. N1-2) was an independent prognostic factor for DFS (P < 0.005). @*Conclusion@#Based on the present data, SSR achieved better 5-year oncological outcome than APR. The positive lymph node ratio in the N stage after surgery was higher in the APR group and this seems to have an effect on the oncological outcomes of the APR group.

Epigenetic inactivation of RUNX3 in colorectal cancer

PURPOSE: Emerging evidence indicates that runt-related transcription factor 3 (RUNX3) is an important tumor suppressor gene in several cancer types, including colorectal cancer (CRC). However, the clinical significance of RUNX3 inactivation in CRC remains unclear. The aim of this study was to examine the correlation between clinicopathologic factors and RUNX3 hypermethylation/expression in CRC. METHODS: Sixty-two CRC patients who were treated at the Soonchunhyang University College of Medicine were recruited in this study. The hypermethylation of CpG islands in the RUNX3 promoter and the expression of RUNX3 mRNA were identified by methylation-specific polymerase chain reaction (PCR) and reverse transcriptase-PCR, respectively. The expression of RUNX3 was determined by immunohistochemical staining. RESULTS: Of the 62 CRC tissue samples, 20 (32.3%) presented hypermethylated RUNX3 promoters. Aberrant RUNX3 hypermethylation was found to be associated with vascular (P = 0.006) and lymphatic (P = 0.002) invasion. Hypermethylation of RUNX3 was associated with poor survival outcomes (P = 0.038). However, expression of RUNX3 was not a prognostic factor (P = 0.363). CONCLUSION: Hypermethylation of RUNX3 may be a predictor of a poor prognosis in CRC.

Surgery of multiple lymphangioma in small bowel: a rare case report of chronic gastrointestinal bleeding

Small bowel lymphangioma is a rare benign tumor of the lymphatic system, characterized by the presence of dilated lymphatic spaces and significant gastrointestinal bleeding. Small bowel lymphangiomas are rare in adults and case reports are few. Lymphangiomas in the jejunum or ileum are extremely rare and account for less than 1% of all lymphangiomas. The case reported herein is of an older patient (70-year-old male) with melena and chronic anemia (hemoglobin count < 5 g/dL) who had small-sized multiple lymphangiomas in his small bowel (jejunum). Surgical resection was performed after failure of treatment by gastroenteroscopy. Final pathological analysis revealed lymphangioma with thrombus and hemorrhage. After surgery, he no longer had decreased hemoglobin count, nor symptoms of anemia and melena. Also, at the last follow-up visit, the patient's hemoglobin count patient was normal and he returned to normal daily functions.

CORRIGENDUM: Correction of funding statement in ACKNOWLEDGEMENTS section: Epigenetic inactivation of RUNX3 in colorectal cancer

Correction of funding statement in ACKNOWLEDGEMENTS section.

Clinical outcomes of surgical management for primary gastrointestinal diffuse large B-cell lymphoma: At a single institution experience

PURPOSE: The study aimed to analyze peri/postoperative outcomes and long-term oncologic outcomes after surgical management for primary gastrointestinal diffuse large B-cell lymphoma (DLBL).METHODS: Between January 2001 and December 2013, 19 patients who underwent surgery for primary gastrointestinal DLBL were retrieved from a retrospective database.RESULTS: With a median follow up of 49.2 months, the most common tumor locations were the terminal ileum and cecum (n=14, 73.7%) and stomach (n=4, 21.1%). The most common clinical symptoms were abdominal pain (n=15, 78.9%) and intussusceptions (n=5, 26.3%). None of the patients had B symptoms. Emergency surgery was undertaken in 36.8% (n=7) of the patients. Mean mass size was 8.4 cm; 4 patients (21.1%) had a bulky mass (>10 cm). The International Prognostic Index (IPI) scores were low (n=11, 57.9%), low-intermittent (n=7, 36.8%), and high-intermittent (n=1, 5.3%). Patients' staging was IE (n=9, 47.4%), IIE (n=8, 42.1%), and IVE (n=2, 10.5%) based on the Ann Arbor staging system, and I (n=2, 10.5%), II1 (n=5, 26.4%), IIE (n=10, 52.6%), and IV (n=2, 10.5%) based on the Lugano staging system. B-lymphocyte antigen CD20 was positive in most patients (n=17, 89.5%) and Ki-67 was high (>70%) in 12 patients (63.2%). Two types of chemotherapy were administered: cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisolone (n=5, 26.3%), rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisolone (n=13, 68.4%). The 5-year disease-free survival rate was 94.4% and the 5-year overall survival rate was 89.5%.CONCLUSION: Surgery for primary gastrointestinal DLBL is feasible and acceptable. Low staging of primary gastrointestinal DLBL has good prognosis.

Oncologic outcomes of squamous cell carcinoma of the anal canal after chemoradiation therapy

PURPOSE: The aim of this study is to analyze the oncological outcomes of squamous cell carcinoma (SCC) of the anal canal after chemoradiation therapy (CRT) in a single institution.METHODS: Fifty-one patients with anal SCC who had been treated with CRT between January 2000 and December 2010 were analyze data single center in Korea.RESULTS: Forty-eight patients exhibited clinical complete response. After a median follow-up of 42.1 months, 13 patients (25.5%) showed recurrence. The disease-free survival (DFS) rate was 63.4% at 5 and 10 years. The overall survival (OS) rates were 83.6% (5 years) and 75.2% (10 years). Stage I: DFS, 100%; OS, 100%; stage II: DFS, 85.7%; OS, 100%; stage IIIA: DFS, 68.6%; OS, 87.5%; stage IIIB: DFS, 34.7%; OS, 48.4%; and stage IV: DFS and OS, 0%. The local recurrence patterns were as follows: pelvic node (n=4, 7.8%), inguinal node (n=1, 2.0%), and inguinal and pelvic node (n=1, 2.0%). The systemic recurrence patterns were as follows: lung (n=2, 3.9%), para-aortic node (n=1, 2.0%), and extrapelvic site (n=2, 3.9%). N-stage represented a single independent prognostic factor for recurrence (P<0.05).CONCLUSION: CRT for SCC of the anal canal is effective for oncological outcomes and sphincter preservation. The initial nodal status may affect the oncological outcome.

Comparison of a Hemorrhoidectomy With Ultrasonic Scalpel Versus a Conventional Hemorrhoidectomy

PURPOSE: A variety of instruments, including circular staplers, ultrasonic scalpels, lasers, and bipolar electrothermal devices, are currently used when performing a hemorrhoidectomy. This study compared outcomes between hemorrhoidectomies performed with an ultrasonic scalpel and conventional methods. METHODS: The study was a randomized prospective review of data available between May 2013 and December 2013, involving 50 patients who had undergone a hemorrhoidectomy for grade III or IV internal hemorrhoids. The hemorrhoidal pedicle was coagulated with an ultrasonic device in the ultrasonic scalpel group (n = 25) and sutured with 3-0 vicryl material after excision in the conventional method group (n = 25). RESULTS: The patients' demographics, clinical characteristics, and lengths of hospital stay were similar in both groups. The mean ages of the conventional and the ultrasonic scalpel groups were, respectively, 20.8 ± 1.6 and 22.4 ± 5.0 years (P = 0.240). In comparison with the conventional method group, the ultrasonic scalpel group had a shorter operation time (P < 0.005), less postoperative pain on the visual analogue scale score (for example, P = 0.211 on postoperative day 1), and less postoperative bleeding (P = 0.034). No significant differences in postoperative complications were observed between the 2 groups. CONCLUSION: A hemorrhoidectomy using an ultrasonic scalpel is an effective and safe procedure. The ultrasonic scalpel reduces the operation time, the postoperative blood loss, and the postoperative pain. Long-term follow-up with larger-scale studies is required to evaluate normal activity after a hemorrhoidectomy performed with an ultrasonic scalpel.

Trocar Site Hernia after Use of an 8-mm Bladeless Trocar in Robotic Colorectal Surgery

Port site hernias are a rare complication after laparoscopic and robotic surgery. The current case is an 8-mm port site hernia which occurred after robot-assisted colorectal surgery. A 70-year-old female with a BMI (body mass index) of 25.7 was diagnosed as rectosigmoid colon cancer. She underwent a robot-assisted low anterior resection with double-stapled anastomosis for AJCC (American Joint Committee on Cancer) stage IIIB. After the main procedure, fascial defects in the supra-pubic and the supra-umbilical site were closed with a routine procedure (12 mm). Thirty two months after surgery, she developed an incisional hernia in the left mid abdomen (8-mm port). Recognition of the potential for a port site hernia using an 8-mm bladeless trocar port as well as a 12-mm port is essential in robotic surgery. Patients with risk factors for a port site hernia may require complete port site closure.

Colon Stricture After Ischemia Following a Robot-Assisted Ultra-Low Anterior Resection With Coloanal Anastomosis

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

Oncologic Outcomes of a Laparoscopic Right Hemicolectomy for Colon Cancer: Results of a 3-Year Follow-up

PURPOSE: The purpose of the study is to evaluate the oncologic outcomes of a laparoscopic-assisted right hemicolectomy for the treatment of colon cancer and compare the results with those of previous randomized trials. METHODS: From June 2006, to December 2008, 156 consecutive patients who underwent a laparoscopic right hemicolectomy with a curative intent for colon cancer were evaluated. The clinicopatholgic outcomes and the oncologic outcomes were evaluated retrospectively by using electronic medical records. RESULTS: There were 84 male patients and 72 female patients. The mean possible length of stay was 7.0 +/- 1.5 days (range, 4 to 12 days). The conversion rate was 3.2%. The total number of complications was 30 (19.2%). Anastomotic leakage was not noted. There was no mortality within 30 days. The 3-year overall survival rate of all stages was 93.3%. The 3-year overall survival rates according to stages were 100% in stage I, 97.3% in stage II, and 84.8% in stage III. The 3-year disease-free survival rate of all stages was 86.1%. The 3-year disease-free survival rates according to stage were 96.2% in stage I, 90.3% in stage II, and 75.6% in stage III. The mean follow-up period was 36.3 (3 to 60) months. CONCLUSION: A laparoscopic right hemicolectomy for the treatment of colon cancer is technically feasible and safe to perform in terms of oncologic outcomes. The present data support previously reported randomized trials.