Trans-abdominal single-incision robotic surgery with the da Vinci SP® surgical system for 8 cases of retrorectal tumour.

BACKGROUND: This study aimed to evaluate transabdominal single-incision robotic surgery using the da Vinci SP (dVSP, Intuitive Surgical, Sunnyvale, CA, USA) surgical system for retrorectal tumours. METHODS: Eight patients who underwent surgical excision of retrorectal tumours using the dVSP surgical system were retrospectively analysed. RESULTS: Five patients (62.5%) had tumours positioned above the levator ani muscle, two (25.0%) had that extending across the levator ani muscle, and one (12.5%) had that located below the levator ani muscle. All surgical procedures were successfully completed without any intraoperative complications. The median operative, docking, and console times were 198, 6, and 145 min, respectively. Two patients (25.0%) experienced postoperative complications classified as Clavien-Dindo grade II. The median duration of follow-up was 6.5 months, and no recurrence was observed. CONCLUSIONS: In our early experience of eight patients, retrorectal tumours can be safely excised with the dVSP surgical system, even at very low tumour levels.

Short-term outcomes of single-incision robotic colectomy versus conventional multiport laparoscopic colectomy for colon cancer.

Since the da Vinci SP (dVSP) surgical system was introduced, single-incision robotic surgery (SIRS) for colorectal diseases has gained increasing acceptance. Comparison of the short-term outcomes between SIRS using dVSP and those of conventional multiport laparoscopic surgery (CMLS) was performed to verify its efficacy and safety in colon cancer. The medical records of 237 patients who underwent curative resection for colon cancer by a single surgeon were retrospectively reviewed. Patients were divided into two groups according to surgical modality: SIRS (RS group) and CMLS (LS group). Intra- and postoperative outcomes were analyzed. Of the 237 patients, 140 were included in the analysis. Patients in the RS group (n = 43) were predominantly female, younger, and had better general performance than those in the LS group (n = 97). The total operation time was longer in the RS group than in the LS group (232.8 ± 46.0 vs. 204.1 ± 41.7 min, P < 0.001). The RS group showed faster first flatus passing (2.5 ± 0.9 vs. 3.1 ± 1.2 days, P = 0.003) and less opioid analgesic requirement (analgesic withdrawal within 3 postoperative days: 37.2% vs. 18.6%, P = 0.018) than the LS group. The RS group showed a higher immediate postoperative albumin level (3.9 ± 0.3 vs. 3.6 ± 0.4 g/dL, P < 0.001) and lower C-reactive protein level (6.6 ± 5.2 vs. 9.3 ± 5.5 mg/dL, P = 0.007) than the LS group during the postoperative period. On multivariate analysis after adjusting for deviated patient characteristics, no significant difference was observed in short-term outcomes, except for operation time. SIRS with dVSP showed short-term outcomes comparable with those of CMLS for colon cancer.

Validity of C-Reactive Protein as a Surrogate Marker for Infectious Complications After Surgery for Colorectal Cancer.

Background: This study aimed to establish a threshold of C-reactive protein (CRP) level for early detection of post-operative infectious complications after surgery for colorectal cancer. Patients and Methods: In this single-center, retrospective analysis, we studied the data of 178 patients who underwent surgery for colorectal cancer between January 2018 and February 2022. Elective surgery with curative intent was performed, and serum CRP levels were measured on five consecutive days after surgery. Receiver operating characteristic curves were utilized to assess the cutoff point of the CRP level with maximum predictive value, Results: A total of 59 cases of early post-operative complications, including pneumonia, wound infection, intra-abdominal infection, and anastomotic leakage were evaluated. During the monitoring period, patients with complications had higher CRP level than those without complications. The cutoff points on the five post-operative days were estimated to be 6.50, 10.83, 11.44, 6.67, and 5.71 mg/dL, respectively, and they were correlated to the occurrence of infectious complications. Higher CRP levels were associated with greater blood loss during surgery (p = 0.003) and increased length of hospital stay (p < 0.001) than did lower CRP levels. Conclusions: C-reactive protein monitoring in the early post-operative period is a cost-effective test that can be easily performed to predict the occurrence of infectious complications. It may be helpful in improving surgical outcomes, shortening the length of hospital stay and appropriate antibiotic administration.

Body composition index obtained by using a bioelectrical impedance analysis device can be a predictor of prolonged operative time in patients undergoing minimally invasive colorectal surgery.

PURPOSE: Obesity has been known to contribute to technical difficulties in surgery. Until now, body mass index (BMI) has been used to measure obesity. However, there are reports that BMI does not always correspond to the visceral fat. Recently, bioelectrical impedance analysis (BIA) has been used for body composition analysis. This study aimed to evaluate the usefulness of the body composition index obtained using a BIA device in predicting short-term postoperative outcomes. METHODS: Data of patients who underwent elective major colorectal surgery using minimally invasive techniques were reviewed retrospectively. Body composition status was recorded using a commercial BIA device the day before surgery. The relationship between BMI, body composition index, and short-term postoperative outcomes, including operative time, was analyzed. RESULTS: Sixty-six patients were enrolled in this study. In the correlation analysis, positive correlation was observed between BMI and body composition index. BMI and body composition index were not associated with short-term postoperative outcomes. Percent body fat (odds ratio, 4.226; 95% confidence interval [CI], 1.064-16.780; P=0.041) was found to be a statistically significant factor of prolonged operative time in the multivariate analysis. Correlation analysis showed that body fat mass was related to prolonged operative time (correlation coefficients, 0.245; P=0.048). In the area under curve analysis, body fat mass showed a statistically significant predictive probability for prolonged operative time (body fat mass: area, 0.662; 95% CI, 0.531-0.764; P=0.024). CONCLUSION: The body composition index can be used as a predictive marker for prolonged operative time. Further studies are needed to determine its usefulness.

Is restrictive transfusion sufficient in colorectal cancer surgery? A retrospective study before and during the COVID-19 pandemic in Korea.

PURPOSE: Blood transfusion is one of the most common procedures used to treat anemia in colorectal surgery. Despite controversy regarding the adverse effects of blood products, surgeons have maintained standards for administering blood transfusions. However, this trend was restrictive during the COVID-19 pandemic because of a shortage of blood products. In this study, we conducted an analysis to investigate whether the restriction of blood transfusions affected postoperative surgical outcomes. METHODS: Medical records of 318 patients who underwent surgery for colon and rectal cancer at Ewha Womans University Mokdong Hospital between June 2018 and March 2022 were reviewed retrospectively. The surgical outcomes between the liberal and restrictive transfusion strategies in pre- and post-COVID-19 groups were analyzed. RESULTS: In univariate analysis, postoperative transfusion was associated with infectious complications (odds ratio [OR], 1.705; 95% confidence interval [CI], 1.015-2.865; P=0.044). However, postoperative transfusion was not an independent risk factor for the development of infectious complications in multivariate analysis (OR, 1.305; 95% CI, 0.749-2.274; P=0.348). In subgroup analysis, there was no significant association between infectious complications and the hemoglobin threshold level for the administration of a transfusion (OR, 1.249; 95% CI, 0.928-1.682; P=0.142). CONCLUSION: During colorectal surgery, the decision to perform a blood transfusion is an important step in ensuring favorable surgical outcomes. According to the results of this study, restrictive transfusion is sufficient for favorable surgical outcomes compared with liberal transfusion. Therefore, modification of guidelines is suggested to minimize unnecessary transfusion-related side effects and prevent the overuse of blood products.

Efficacy of a rehabilitation program using minor muscles in colorectal cancer patients with chemotherapy-induced neuropathy: preliminary study.

Purpose: Chemotherapy-induced peripheral neuropathy (CIPN) is one of the common reasons that colorectal cancer patients cannot maintain their routine chemotherapy schedules. Some medications are used for pain relief; however, the effect of medication is disappointing. We carried out this study to confirm that a rehabilitation program using minor muscles might provide a valuable aid in symptom relief of CIPN. Methods: Eleven colorectal cancer patients participated in the basic craftwork program which encouraged the use of the minor muscles of the hands to make and decorate the handicrafts and it was held for 2 hours once a week, for a total of four times. There were no limitations in the stage of cancer or types of chemotherapy to participate the program. Questionnaires were obtained from participants before and after the basic handicrafts program. Results: Of the 11 patients (3 men, 8 women; mean age, 53.0±11.2 years), six received 5-fluorouracil (5-FU) chemotherapy, four received FOLFOX4 (combination of 5-FU, leucovorin, and oxaliplatin) chemotherapy, and one received 5-FU, FOLFOX4, and FOLFIRI (combination of 5-FU, leucovorin, and irinotecan) chemotherapy sequentially. Patients attended the program a mean of 3.8±0.4 times. Common symptoms of CIPN were "throbbing pain," "aching pain," and "numbness." The mean score of the questionnaires between pre- and post-program was 34.1±31.7 points and 24.4±21.5 points each, and it was significantly decreased (P=0.040). Conclusion: Patients often suffered from CIPN symptoms like throbbing or aching pain and numbness during their adjuvant chemotherapy. A rehabilitation program using minor muscles for CIPN is expected to be effective.

Meta-analysis of transanal versus laparoscopic total mesorectal excision for rectal cancer: a 'New Health Technology' assessment in South Korea.

PURPOSE: Under the South Korea's unique health insurance structure, any new surgical technology must be evaluated first by the government in order to consider whether that particular technology can be applied to patients for further clinical trials as categorized as 'New Health Technology,' then potentially covered by the insurance sometime later. The aim of this meta-analysis was to assess the safety and efficacy of transanal total mesorectal excision (TaTME) for rectal cancer, activated by the National Evidence-based Healthcare Collaborating Agency (NECA) TaTME committee. METHODS: We systematically searched Ovid-MEDLINE, Ovid-Embase, Cochrane, and Korean databases (from their inception until August 31, 2019) for studies published that compare TaTME with laparoscopic total mesorectal excision (LaTME). End-points included perioperative and pathological outcomes. RESULTS: Sixteen cohort studies (7 for case-matched studies) were identified, comprising 1,923 patients (938 TaTMEs and 985 LaTMEs). Regarding perioperative outcomes, the conversion rate was significantly lower in TaTME (risk ratio, 0.19; 95% confidence interval, 0.11-0.34; P < 0.001); whereas other perioperative outcomes were similar to LaTME. There were no statistically significant differences in pathological results between the 2 procedures. CONCLUSION: Our meta-analysis showed comparable results in preoperative and pathologic outcomes between TaTME and LaTME, and indicated the benefit of TaTME with low conversion. Extensive evaluations of well-designed, multicenter randomized controlled trials are required to come to unequivocal conclusions, but the results showed that TaTME is a potentially beneficial technique in some specific cases. This meta-analysis suggests that TaTME can be performed for rectal cancer patients as a 'New Health Technology' endorsed by NECA in South Korea.

Robotic single-incision right hemicolectomy with extended lymphadenectomy using the da Vinci SP Surgical Platform.

The da Vinci SP Surgical System (dVSP; Intuitive Surgical, Sunnyvale, CA, USA) was introduced to overcome this limitation of single-incision laparoscopic surgery. This new surgical platform has been demonstrated favorable performance in colorectal surgery and its use has been increasing. And, in accordance with the increment of adoption of dVSP, the indication to apply this platform has been expanding. Herein, we report a technique of right hemicolectomy with extended lymphadenectomy beyond conventional lymph node dissection using dVSP.

Computed tomography based cross-sectional anatomy of the pelvis predicts surgical outcome after rectal cancer surgery.

PURPOSE: Narrow pelvis has been considered an adverse factor for postoperative and oncologic outcomes after rectal cancer surgery. The aim of this study was to investigate the validity of using only axial CT scan images to calculate the pelvic cross-sectional area for the prediction of adverse outcomes after rectal cancer surgery. METHODS: The medical records of patients who underwent rectal cancer surgery were reviewed and analyzed retrospectively. Axial images of CT scan were used to measure the pelvic cross-sectional area. Pelvic surgical site infection (SSI), positive resection margin, and early local recurrence were adopted as end-points to analyze the impact of pelvimetry on surgical outcome. RESULTS: The mean pelvic cross-sectional area was 84.3 ± 10.9 cm2. Males had significantly smaller pelvic areas than females (P < 0.001). Comparing pelvic cross-sectional areas according to the surgical outcomes, the results indicated that patients with pelvic SSI and local failure (positive resection margin or local recurrence within 1 year) have significantly smaller cross-sectional-area than SSI and local failure-free patients (P = 0.013 and P = 0.031). A calculated cross-sectional area of 88.8 cm2 was determined as the cutoff value for the prediction of pelvic SSI and/or local failure, which was significant in a validating analysis. CONCLUSION: The pelvic cross-sectional area obtained from a routine axial CT scan image was associated with pelvic SSI, positive resection margin, and early local recurrence. It might be an intuitive, feasible, and easily adoptable method for predicting surgical outcomes.

Initial clinical experience of single-incision robotic colorectal surgery with da Vinci SP platform.

BACKGROUND: The da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) was introduced to overcome the limitations of single-incision laparoscopic surgery, which is challenging due to its restrictions regarding triangulation and retraction. The purpose of this article is to describe the initial experience with single-incision surgery using the da Vinvci Single-Port Platform (dVSP). METHODS: The medical records of patients with colorectal disease, who underwent single-incision robotic surgery using the dVSP, were retrospectively reviewed. RESULTS: Five patients with appendiceal and colorectal cancer, and two with diverticulitis were enrolled. All procedures were completed using a pure single-incision approach, with an exception for low anterior resection. There were two minor complications. For patients with colorectal cancer, the number of retrieved lymph nodes and status of the resection margin were acceptable, and cosmetic results were satisfactory. CONCLUSION: The dVSP is a novel surgical platform that can be used as an alternative surgical modality for colorectal surgery.

Initial Clinical Experience of Pure Single-Incision Robotic Right Hemicolectomy with da Vinci SP Platform.

The da Vinci SP Surgical System (dVSP; Intuitive Surgical, Sunnyvale, CA, USA) was introduced to perform pure single-incision surgery in 2018. This new surgical platform demonstrated favorable performance compared with the positive aspect of single-incision laparoscopic surgery and robot surgery. To date, its use has mainly been in urological and gynecological procedures. We report a case of successful robotic single-incision right hemicolectomy for cecal cancer with the dVSP.

Epidermal growth factor-mediated Rab25 pathway regulates integrin ß1 trafficking in colon cancer.

BACKGROUND: Integrins play a critical role in carcinogenesis. Integrin ß1 localization is regulated by the guanosine-5'-triphosphate hydrolase Rab25 and integrin ß1 levels are elevated in the serum of colon cancer patients; thus, the present study examined the effects of epidermal growth factor (EGF) and Rab25 on integrin ß1 localization in colon cancer cells. METHODS: HCT116 human colon cancer cells were treated with increasing concentrations of EGF, and cell proliferation and protein expression were monitored by MTT and western blot analyses, respectively. Cell fractionation was performed to determine integrin ß1 localization in the membrane and cytosol. Integrin ß1 extracellular shedding was monitored by enzyme-linked immunosorbent assays (ELISAs) with culture supernatants from stimulated cells. HCT116 cells were transfected with Rab25-specific siRNA to determine the significance of Rab25 in integrin ß1 trafficking in the presence of EGF. RESULTS: Total integrin ß1 expression increased in response to EGF and subsequently decreased at 24 h post-stimulation. A similar decrease was observed in purified membrane fractions, whereas no changes were observed in cytosolic levels. ELISAs using media from stimulated cell cultures demonstrated increased integrin ß1 levels corresponding to the decrease observed in membrane fractions, suggesting that EGF induces integrin receptor shedding. EGF stimulation in Rab25-knockdown cells resulted in integrin ß1 accumulation in the membrane, suggesting that Rab25 promotes integrin endocytosis. CONCLUSIONS: Integrin ß1 is shed from colon cancer cells in response to EGF stimulation in a Rab25-dependent manner. These results further the present understanding of the role of integrin ß1 in colon cancer progression.

Prognostic factors and treatment outcomes for patients with Fournier's gangrene: a retrospective study.

Fournier's gangrene is a gas-forming, necrotising soft tissue infection affecting the perineum. It spreads rapidly along the deep fascial planes and is associated with a high mortality rate. With a growing elderly population with comorbidities, the frequency of severe cases of Fournier's gangrene is expected to increase. We retrospectively reviewed 20 patients diagnosed with Fournier's gangrene at our institution from 2003 to 2014 and analysed data. Thirteen patients had diabetes mellitus, two had been diagnosed with liver cirrhosis, and four were chronic alcoholics. Of 15 patients admitted to an intensive care unit, 11 underwent colostomy, and 4 required skin grafts for wound healing. The wide wounds of two patients were healed using vacuum-assisted closure (VAC® ) dressing without additional surgery. The mortality rate was 25%, and the patients whose Fournier's gangrene severity index (FGSI) score was higher than 9 points or whose blood urea nitrogen (BUN) level was higher than 50 mg/dl had a poor prognosis. In order to treat Fournier's gangrene, aggressive surgical treatment, including wide debridement and stoma creation, should be considered as soon as possible to improve survival rates. Additionally, VAC dressing is helpful in healing the wide debridement wound without additional reconstructive surgery.

Silencing the livin gene enhances the cytotoxic effects of anticancer drugs on colon cancer cells.

PURPOSE: Livin is associated with drug response in several cancers. The aim of this study was to investigate the effect of silencing the livin gene expression on anticancer drug response in colorectal cancer. METHODS: siRNA was transfected at different concentrations (0, 10, and 30nM) into HCT116 cells, then cells were treated with either 5-fluorouracil (FU)/leucovorin (LV) or oxaliplatin (L-OHP)/5-FU/LV. Cellular viability and apoptosis were evaluated following silencing of livin gene expression combined with treatment with anticancer drugs. RESULTS: Livin gene expression was effectively suppressed by 30nM siRNA compared with control and 10nM siRNA. The 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide assay showed that proliferation was effectively inhibited in cells treated with a combination of both siRNA and an anticancer drug, compared to cells treated with siRNA-Livin or anticancer drug alone. In particular, the combination of 30nM siRNA and L-OHP/5-FU/LV resulted in a 93.8% and 91.4% decrease, compared to untreated control or L-OHP/5-FU/LV alone, respectively. Cellular proliferation was most effectively suppressed by a combination of 30nM of siRNA and L-OHP/5-FU/LV compared to other combinations. CONCLUSION: siRNA-mediated down-regulation of livin gene expression could significantly suppress colon cancer growth and enhance the cytotoxic effects of anticancer drugs such as 5-FU and L-OHP. The results of this study suggest that silencing livin gene expression in combination with treatment with anticancer drugs might be a novel cancer therapy for colorectal cancer.

Guidelines for the Diagnosis and Treatment of Chronic Functional Constipation in Korea, 2015 Revised Edition.

The Korean Society of Neurogastroenterology and Motility first published guidelines for chronic constipation in 2005 and was updated in 2011. Although the guidelines were updated using evidence-based process, they lacked multidisciplinary participation and did not include a diagnostic approach for chronic constipation. This article includes guidelines for diagnosis and treatment of chronic constipation to realistically fit the situation in Korea and to be applicable to clinical practice. The guideline development was based upon the adaptation method because research evidence was limited in Korea, and an organized multidisciplinary group carried out systematical literature review and series of evidence-based evaluations. Six guidelines were selected using the Appraisal of Guidelines for Research & Evaluation (AGREE) II process. A total 37 recommendations were adopted, including 4 concerning the definition and risk factors of chronic constipation, 8 regarding diagnoses, and 25 regarding treatments. The guidelines are intended to help primary physicians and general health professionals in clinical practice in Korea, to provide the principles of medical treatment to medical students, residents, and other healthcare professionals, and to help patients for choosing medical services based on the information. These guidelines will be updated and revised periodically to reflect new diagnostic and therapeutic methods.

Acute hyperammonemic encephalopathy after 5-fluorouracil based chemotherapy.

5-Fluorouracil (5-FU) based chemotherapy has been commonly used to treat metastatic or advanced colon cancer as an adjuvant chemotherapy. Although the side effects of 5-FU such as gastrointestinal problems and neutropenia and thrombocytopenia are common, not many cases of 5-FU related encephalopathy are reported. Hyperammonemic encephalopathy is a rare central nervous system toxicity following 5-FU chemotherapy manifesting as altered mental status with elevated ammonia levels with no radiologic abnormality. We report one case of 5-FU induced hyperammonemic encephalopathy occurring after Folfox4 (oxaliplatin, folinic acid and 5-fluorouracil) chemotherapy in a colon cancer patient who presented with confused mental status soon after the chemotherapy and review the 5-FU related encephalopathy.

Oncologic outcomes in rectal cancer with close distal resection margins: a retrospective analysis.

PURPOSE: The assurance of a negative resection margin is significant in rectal cancer as it indicates a reduced risk of local recurrence; thus, sufficient length of the resection margin is strongly required. The purpose of this study was to analyze the relationship between the length of the distal resection margin (DRM) and local recurrence or survival rate and to evaluate the possibility of performing sphincter-conserving surgery. METHODS: The medical records of 218 rectal cancer patients were analyzed. Patients were classified into three groups according to the length of the DRM as follows: group 1, DRM < 1 cm; group 2, 1 cm ≤ DRM ≤ 2 cm; and group 3, DRM > 2 cm. RESULTS: Of 218 patients enrolled, 81 were in group 1, 66 in group 2, and 71 in group 3. The 5-year survival rates were 78.2%, 78.2%, and 76.8% for groups 1, 2, and 3, respectively, and there were no statistically significant differences in survival (P = 0.913). Local recurrence was found in 2 patients in group 1, 1 patient in group 2, and 1 patient in group 3; there were no statistically significant differences in local recurrence (P = 0.908). CONCLUSION: A DRM of < 1 cm did not impair the oncologic outcomes of rectal cancer patients. Our results indicated that surgeons should keep in mind to consider the option of sphincter-conserving surgery with adjuvant chemoradiotherapy even in very low rectal cancer.

Role of ß1-Integrin in Colorectal Cancer: Case-Control Study.

PURPOSE: In the metastatic process, interactions between circulating tumor cells (CTCs) and the extracellular matrix or surrounding cells are required. ß1-Integrin may mediate these interactions. The aim of this study was to investigate whether ß1-integrin is associated with the detection of CTCs in colorectal cancer. METHODS: We enrolled 30 patients with colorectal cancer (experimental group) and 30 patients with benign diseases (control group). Blood samples were obtained from each group, carcinoembryonic antigen (CEA) mRNA for CTCs marker and ß1-integrin mRNA levels were estimated by using reverse transcription-polymerase chain reaction, and the results were compared between the two groups. In the experimental group, preoperative results were compared with postoperative results for each marker. In addition, we analyzed the correlation between the expressions of ß1-integrin and CEA. RESULTS: CEA mRNA was detected more frequently in colorectal cancer patients than in control patients (P = 0.008). CEA mRNA was significantly reduced after surgery in the colorectal cancer patients (P = 0.032). ß1-Integrin mRNA was detected more in colorectal cancer patients than in the patients with benign diseases (P < 0.001). In colorectal cancer patients, expression of ß1-integrin mRNA was detected more for advanced-stage cancer than for early-stage cancer (P = 0.033) and was significantly decreased after surgery (P < 0.001). In addition, expression of ß1-integrin mRNA was significantly associated with that of CEA mRNA in colorectal cancer patients (P = 0.001). CONCLUSION: In conclusion, ß1-integrin is a potential factor for forming a prognosis following surgical resection in colorectal cancer patients. ß1-Integrin may be a candidate for use as a marker for early detection of micrometastatic tumor cells and for monitoring the therapeutic response in colorectal cancer patients.

The availability of computed tomography for pulmonary staging in colorectal cancer.

PURPOSE: Chest computed tomography is performed frequently for the preoperative pulmonary staging in colorectal cancers (CRCs) regardless of the result of chest x-ray (CXR) due to its high sensitivities and specificities. The advancement of CT technology detects more indeterminate lung lesions that may require further investigations, referrals and follow-up. The aim of this study was to suggest a guideline for performing chest CT for preoperative pulmonary staging in colorectal cancer. METHODS: We performed a retrospective analysis of the records of patients who had chest CT preformed without the evidence of metastasis on CXR for preoperative pulmonary staging. RESULTS: Of 21 patients with metastatic nodules on chest CT, 23.8% showed pulmonary metastasis on positron emission tomography, 47.6% showed extrapulmonary metastasis on preoperative evaluation and 61.9% showed elevated serum carcinoembryonic antigen level above 10 ng/mL. These results showed significant value compared to patients without metastatic nodules. But, in analyzing patients with or without indeterminate nodules in the three contents listed above, there was no significance. CONCLUSION: In the patients with CRC who show normal CXR and exhibit positivity in PET, preoperative extrapulmonary metastasis and elevated serum CEA level above 10 ng/mL preoperatively, chest CT would be helpful in preoperative staging.