Universal Screening for Lynch Syndrome Compared with Pedigree-Based Screening: 10-Year Experience in a Tertiary Hospital / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Universal screening for Lynch syndrome (LS) refers to routine tumor testing for microsatellite instability (MSI) among all patients with colorectal cancer (CRC). Despite its widespread adoption, real-world data on the yield is lacking in Korean population. We studied the yield of adopting universal screening for LS in comparison with pedigree-based screening in a tertiary center. @*Materials and Methods@#CRC patients from 2007-2018 were reviewed. Family histories were obtained and were evaluated for hereditary nonpolyposis colorectal cancer (HNPCC) using Amsterdam II criteria. Tumor testing for MSI began in 2007 and genetic testing was offered using all available clinicopathologic data. Yield of genetic testing for LS was compared for each approach and step. @*Results@#Of the 5,520 patients, tumor testing was performed in 4,701 patients (85.2%) and family histories were obtained from 4,241 patients (76.8%). Hereditary CRC (LS or HNPCC) was present in 69 patients (1.3%). MSI-high was present in 6.9%, and 25 patients had confirmed LS. Genetic testing was performed in 41.2% (47/114) of MSI-high patients, out of which 40.4% (19/47) were diagnosed with LS. There were six additional LS patients found outside of tumor testing. For pedigree-based screening, Amsterdam II criteria diagnosed 55 patients with HNPCC. Fifteen of these patients underwent genetic testing, and 11 (73.3%) were diagnosed with LS. Two patients without prior family history were diagnosed with LS and relied solely on tumor testing results. @*Conclusion@#Despite widespread adoption of routine tumor testing for MSI, this is not a fail-safe approach to screen all LS patients. Obtaining a thorough family history in combination with universal screening provides a more comprehensive ‘universal’ screening method for LS.

Clinical outcomes of surgical management for recurrent rectal prolapse: a multicenter retrospective study

Purpose@#There are few reports on outcomes following surgical repair of recurrent rectal prolapse. The purpose of this study was to examine surgical outcomes for recurrent rectal prolapse. @*Methods@#We conducted a multicenter retrospective study of patients who underwent surgery for recurrent rectal prolapse. This study used data collected by the Korean Anorectal Physiology and Pelvic Floor Disorder Study Group. @*Results@#A total of 166 patients who underwent surgery for recurrent rectal prolapse were registered retrospectively between 2011 and 2016 in 8 referral hospitals. Among them, 153 patients were finally enrolled, excluding 13 patients who were not followed up postoperatively. Median follow-up duration was 40 months (range, 0.2–129.3 months). Methods of surgical repair for recurrent rectal prolapse included perineal approach (n = 96) and abdominal approach (n = 57). Postoperative complications occurred in 16 patients (10.5%). There was no significant difference in complication rate between perineal and abdominal approach groups. While patients who underwent the perineal approach were older and more fragile, patients who underwent the abdominal approach had longer operation time and admission days (P < 0.05). Overall, 29 patients (19.0%) showed re-recurrence after surgery. Among variables, none affected the re-recurrence. @*Conclusion@#For the recurrent rectal prolapse, the perineal approach is used for the old and fragile patients. The postoperative complications and re-recurrence rate between perineal and abdominal approach were not different significantly. No factor including surgical method affected re-recurrence for recurrent rectal prolapse.

Comparison of oncologic outcomes between patients with Lynch syndrome and sporadic microsatellite instability-high colorectal cancer

Purpose@#Long-term oncologic differences in outcome between groups of patients with Lynch syndrome (LS) colorectal cancer (CRC) and sporadic CRC with microsatellite instability-high (MSI-H) are the focus of investigation in the current study. @*Methods@#Patients registered in the Korean Hereditary Tumor Registry and 2 tertiary referral hospitals treated for stage I– III CRC between 2005 and 2015 were retrospectively analyzed. Detection for both groups was performed using pedigree, microsatellite instability, and mismatch repair (MMR) gene testing. Multivariate analyses for overall survival (OS) and disease-free survival (DFS) were conducted. @*Results@#Cases of LS (n = 77) and sporadic CRC with MSI-H (n = 96) were identified. LS CRC patients were younger in age and displayed tumor sidedness, typically involving left-sided colon and rectum, compared to patients with sporadic CRC with MSI-H. OS and DFS were lower for LS CRC relative to CRC with MSI-H (OS, 72.7% vs. 93.8%, P = 0.001; DFS, 71.4% vs. 88.5%, P = 0.001). In multivariate analyses, tumor sidedness, stage, and chemotherapy were independent factors for OS and DFS. LS CRC was a prognostic factor for poorer OS (hazard ratio, 2.740; 95% confidence interval, 1.003–7.487; P = 0.049), but not DFS. @*Conclusion@#Our findings indicate that LS CRC is associated with poorer outcomes compared to sporadic CRC with MSI-H, presenting distinct clinical features. In view of the current lack of knowledge on genetic and molecular mechanisms, appropriate management taking into consideration the difficulty of identification of CRC with hypermutable tumors harboring heterogeneity is essential.

Oncologic comparison between nonradical management and total mesorectal excision in good responders after chemoradiotherapy in patients with mid-to-low rectal cancer

Purpose@#This study was performed to compare the oncologic outcomes between nonradical management and total mesorectal excision in good responders after chemoradiotherapy. @*Methods@#We analyzed 75 patients, who underwent 14 watch-and-wait, 30 local excision, and 31 total mesorectal excision, in ycT0–1N0M0 based on magnetic resonance imaging after chemoradiotherapy for advanced mid-to-low rectal cancer in 3 referral hospitals. The nonradical management group underwent surveillance with additional sigmoidoscopy and rectal magnetic resonance imaging every 3–6 months within the first 2 years. @*Results@#Nonradical management group had more low-lying tumors (P < 0.001) and less lymph node metastasis based on magnetic resonance imaging (P = 0.004). However, cT stage, ycT, and ycN stage were not different between the 2 groups. With a median follow-up period of 64.7 months, the 5-year locoregional failure rate was higher in the nonradical management group than in the total mesorectal excision group (16.7% vs. 0%, P = 0.013). However, the 5-year overall survival and disease-free survival rates of the nonradical management and total mesorectal excision groups were not different (95.2% vs. 93.5%, P = 0.467; 76.4% vs. 83.6%, P = 0.665; respectively). @*Conclusion@#This study shows that nonradical management for ycT0–1N0 mid-to-low rectal cancer may be an alternative treatment to total mesorectal excision under proper surveillance and management for oncologic events.

Comparison of oncologic outcomes between patients with Lynch syndrome and sporadic microsatellite instability-high colorectal cancer

Purpose@#Long-term oncologic differences in outcome between groups of patients with Lynch syndrome (LS) colorectal cancer (CRC) and sporadic CRC with microsatellite instability-high (MSI-H) are the focus of investigation in the current study. @*Methods@#Patients registered in the Korean Hereditary Tumor Registry and 2 tertiary referral hospitals treated for stage I– III CRC between 2005 and 2015 were retrospectively analyzed. Detection for both groups was performed using pedigree, microsatellite instability, and mismatch repair (MMR) gene testing. Multivariate analyses for overall survival (OS) and disease-free survival (DFS) were conducted. @*Results@#Cases of LS (n = 77) and sporadic CRC with MSI-H (n = 96) were identified. LS CRC patients were younger in age and displayed tumor sidedness, typically involving left-sided colon and rectum, compared to patients with sporadic CRC with MSI-H. OS and DFS were lower for LS CRC relative to CRC with MSI-H (OS, 72.7% vs. 93.8%, P = 0.001; DFS, 71.4% vs. 88.5%, P = 0.001). In multivariate analyses, tumor sidedness, stage, and chemotherapy were independent factors for OS and DFS. LS CRC was a prognostic factor for poorer OS (hazard ratio, 2.740; 95% confidence interval, 1.003–7.487; P = 0.049), but not DFS. @*Conclusion@#Our findings indicate that LS CRC is associated with poorer outcomes compared to sporadic CRC with MSI-H, presenting distinct clinical features. In view of the current lack of knowledge on genetic and molecular mechanisms, appropriate management taking into consideration the difficulty of identification of CRC with hypermutable tumors harboring heterogeneity is essential.

Oncologic comparison between nonradical management and total mesorectal excision in good responders after chemoradiotherapy in patients with mid-to-low rectal cancer

Purpose@#This study was performed to compare the oncologic outcomes between nonradical management and total mesorectal excision in good responders after chemoradiotherapy. @*Methods@#We analyzed 75 patients, who underwent 14 watch-and-wait, 30 local excision, and 31 total mesorectal excision, in ycT0–1N0M0 based on magnetic resonance imaging after chemoradiotherapy for advanced mid-to-low rectal cancer in 3 referral hospitals. The nonradical management group underwent surveillance with additional sigmoidoscopy and rectal magnetic resonance imaging every 3–6 months within the first 2 years. @*Results@#Nonradical management group had more low-lying tumors (P < 0.001) and less lymph node metastasis based on magnetic resonance imaging (P = 0.004). However, cT stage, ycT, and ycN stage were not different between the 2 groups. With a median follow-up period of 64.7 months, the 5-year locoregional failure rate was higher in the nonradical management group than in the total mesorectal excision group (16.7% vs. 0%, P = 0.013). However, the 5-year overall survival and disease-free survival rates of the nonradical management and total mesorectal excision groups were not different (95.2% vs. 93.5%, P = 0.467; 76.4% vs. 83.6%, P = 0.665; respectively). @*Conclusion@#This study shows that nonradical management for ycT0–1N0 mid-to-low rectal cancer may be an alternative treatment to total mesorectal excision under proper surveillance and management for oncologic events.

Safety and Efficacy of Single-Port Laparoscopic Ileostomy in Palliative Settings

Purpose@#Single-port laparoscopic techniques can be optimized with confined incisions. This approach has an intraoperative advantage of excellent visualization of the correct intestinal segment for exteriorization, along with direct visual control of the extraction to avoid twisting. However, only a few studies have verified the efficacy of the technique. Thus, this study assessed the results of single-port laparoscopic stoma creation for fecal diversion, specifically focusing on feasibility, safety, and efficacy. @*Methods@#Patients who underwent single-incision enterostomy performed by a single surgeon were included. Data on demographics, indications for and chosen procedure, and operation results were retrospectively collected and analyzed. @*Results@#Between April 2015 and January 2018, a total of 13 patients (8 males, 5 females) with a mean age of 57.7 years (range, 41–83 years) underwent single-port ileostomy creation. The most common reason for diversion was palliative ileostomy for colon obstruction or fistula from peritoneal malignancy (n = 12), followed by colonic fistula with necrotizing pancreatitis (n = 1). There were no cases of conversion to open or multiport laparoscopic surgery. The mean operative time was 54 minutes (range, 37–118 minutes), and the median length of hospital stay was 8 days (range, 2–211 days). A postoperative complication, aspiration pneumonia, was documented in 1 patient and treated conservatively. The mean duration of bowel movement was 0.7 days (range, 0–4 days). All stomas had good function, and there was no 30-day mortality. @*Conclusion@#Single-port laparoscopic ileostomy in patients with a palliative setting could be a safe and feasible option for fecal diversion.

The Change of Metabolic Syndrome Prevalence and Its Risk Factors in Korean Adults for Decade: Korea National Health and Nutrition Examination Survey for 2008–2017

Background@#Metabolic syndrome is a nationwide health problem, which is associated with the development of cardiovascular diseases, diabetes, and chronic renal failure. The prevalence of metabolic syndrome in Korea significantly increased from 1998 to 2007. After that, the prevalence was stable in female but still increasing in male. The objective of this study was to evaluate how the prevalence and risk factors for metabolic syndrome changed in Korean adults through the last decade. @*Methods@#Data from the Korea National Health and Nutrition Examination Survey 2008 to 2017 was used. National Cholesterol Education Program Adult Treatment Panel III were used to define metabolic syndrome. We compared how each metabolic syndrome component and the risk factors changed through the years. @*Results@#A total of 51,177 (30,092 female and 21,085 male) people were included in this study. The prevalence of metabolic syndrome in male increased from 24.5% in 2008 to 28.1% in 2017, whereas that in female was stable at 20.5% in 2008 from 18.7% in 2017. Waist circumference measurements and fasting glucose levels increased through the decade in male, whereas only fasting glucose levels increased in female. @*Conclusion@#Since the last decade, the prevalence of metabolic syndrome in Korean adults has increased in male but remained stable in female. Lifestyle intervention in male, namely ceasing smoking and drinking could prevent increasing metabolic syndrome prevalence in Korean adults.

Effects of an Internet-based informational video on preoperative anxiety in patients with colorectal cancer

PURPOSE: Surgery is the primary curative treatment for colorectal cancer; however, it remains a frightening procedure that can cause stress and pain in affected patients. Therefore, patients typically experience significant anxiety during the preoperative period, which has been associated with poorer outcome after surgery. This study aimed to evaluate the effect of an Internet-based informational video on preoperative anxiety level in patients with colorectal cancer.

β-Carotene Inhibits Activation of NF-κB, Activator Protein-1, and STAT3 and Regulates Abnormal Expression of Some Adipokines in 3T3-L1 Adipocytes

BACKGROUND: Oxidative stress occurs in white adipose tissue and dysregulates the expression of adipokines secreted from adipocytes. Since adipokines influence inflammation, supplementation with antioxidants might be beneficial for preventing oxidative stress-mediated inflammation in adipocytes and inflammation-associated complications. β-Carotene is the most prominent antioxidant carotenoid and scavenges reactive oxygen species in various tissues. The purpose of this study was to determine whether β-carotene regulates the expression of adipokines, such as adiponectin, monocyte chemoattractant protein-1 (MCP-1), and regulated on activation, normal T cell expressed and secreted (RANTES) in 3T3-L1 adipocytes treated with glucose/glucose oxidase (G/GO). METHODS: 3T3-L1 adipocytes were cultured with or without β-carotene and treated with G/GO, which produces H2O2. mRNA and protein levels in the medium were determined by a real-time PCR and an ELISA. DNA binding activities of transcription factors were assessed using an electrophoretic mobility shift assay. RESULTS: G/GO treatment increased DNA binding affinities of redox-sensitive transcription factors, such as NF-κB, activator protein-1 (AP-1), and STAT3. G/GO treatment reduced the expression of adiponectin and increased the expression of MCP-1 and RANTES. G/GO-induced activations of NF-κB, AP-1, and STAT3 were inhibited by β-carotene. G/GO-induced dysregulation of adiponectin, MCP-1, and RANTES were significantly recovered by treatment with β-carotene. CONCLUSIONS: β-Carotene inhibits oxidative stress-induced inflammation by suppressing pro-inflammatory adipokines MCP-1 and RANTES, and by enhancing adiponectin in adipocytes. β-Carotene may be beneficial for preventing oxidative stress-mediated inflammation, which is related to adipokine dysfunction.

Discrepancy of Medical Terminology Regarding Colorectal Surgery Between South and North Korea

PURPOSE: We aimed to investigate the extent of heterogeneity in medical terminology between South and North Korea by comparing medical terms related to the colorectal system. METHODS: North Korean medical terms were collected from the sections on diseases of the small intestine and colon in a surgery textbook from North Korea, and those terms were compared with their corresponding terms in a South Korean medical terminology textbook. The terms were categorized as either identical, similar, showing disparity, or not used in South Korea. In a subsection analysis, the terms were allocated to pathophysiology, diagnosis, symptoms and examination, drugs, testing, treatment, or others according to the categorization used in the textbook. RESULTS: We found 705 terms in the North Korean textbook, most of which were pathophysiological terms (206, 29.2%), followed by diagnostic terms (165, 23.4%) and symptom and examination terms (122, 17.3%). Treatment-, drug-, and testing-related terms constituted 15.5%, 5.8%, and 4.1% of the 705 terms, respectively. There were 331 identical terms (47.0%) and 146 similar terms (20.7%); 126 terms (17.9%) showed disparity. Another 102 terms (14.5%) were not used in South Korea. The pathophysiological terms were the least heterogeneous, with 61.2% being identical terms used in both countries. However, 26.8% of the terms in the drug category were not used in South Korea. CONCLUSION: The present study showed that less than 50% of the terms for the colorectal system used in South and North Korea were identical. As the division between South and North Korea persists, the heterogeneity of medical terminology is expected to increase.

Discrepancies in general surgery medical terminology between South and North Korea / 한국의학교육

PURPOSE: The purpose of this study was to categorize surgery-related medical terminologies used in South and North Korea and to compare and analyze discrepancies observed in the terms. METHODS: This study collected medical terminology used in the North Korean medical book “Surgery” and compared it to medical terminology found in the medical glossary of South Korea. The order of the subtitle was described according to the Instruction to Authors. RESULTS: In total, there were 2,168 individual medical terms, of which only 1,004 words (46.3%) were identical to South Korean medical terms. There were 581 similar terms (26.8%), 265 different terms (12.2%), and 318 terms that are nonexistent in South Korea (14.7%). CONCLUSION: Less than half of the medical terms used in North Korea match those used in South Korea. It is expected that the prolongation of the current division of South and North Korea will only worsen this discrepancy. Further efforts to bridge the gap through academic exchange between South Korea and North Korea are required in preparation for an era of reunification.

Colonoscopy education for surgical residents in Korea: a national survey of Korean Surgical Skill Study Group

PURPOSE: A standardized colonoscopy training program surgical residents is still unestablished. The aim of this study was to assess the current status of colonoscopy training for surgical residents and collect the opinions on the direction for future colonoscopy education. METHODS: A questionnaire survey containing 24 items was conducted by sending an email to 310 colorectal surgeons in 84 training hospitals across the country. RESULTS: One hundred fifteen staff surgeons (115 of 310, 37%) of 84 institutions returned fully completed questionnaires. Most surgeons were working at tertiary hospitals with more than 5 years of clinical experience. About half of the responding surgeons answered that they perform colonoscopy in clinical practice and the main purpose of colonoscopy was follow-up after colorectal resection. Only 9 of 84 hospitals (10.7%) had a regular program on colonoscopy training for surgical residents. Most of colonoscopy education was conducted irregularly in a form of staff lecture, conferences or hands-on workshops. According to the future directions, 72 of 115 surgeons (62.6%) answered judging competency in colonoscopy should be needed for professional qualification of the surgeon. About 50 cases of colonoscopy seem appropriate during the 4-year-training of surgical residency, especially during the third- and fourth-year. CONCLUSION: This survey shows colonoscopy education for surgical residents is still insufficient in Korea and that most surgeons feel that regular colonoscopy training is needed during the surgical residency period. There needs to be efforts to standardize the education program as well as various institutional and academic societal supports to achieve this goal.

Clinical Efficacy of Selective Focal Ablation by Navigable Percutaneous Disc Decompression Device in Patients With Cervical Herniated Nucleus Pulposus

OBJECTIVE: To evaluate the clinical efficacy and safety following percutaneous disc decompression, using navigable disc decompression device for cervical herniated nucleus pulposus (HNP). METHODS: Twenty subjects diagnosed with cervical HNP and refractory to conservative management were enrolled for the study. The herniated discs were decompressed under fluoroscopic guidance, using radiofrequency ablation device with navigable wand. The sagittal and axial plain magnetic resonance images of the clinically significant herniated disc, decided the space between the herniated base and outline as the target area for ablation. Clinical outcome was determined by Numeric Rating Scale (NRS), Neck Disability Index (NDI), and Bodily Pain scale of Short Form-36 (SF-36 BP), assessed after 48 weeks. After the procedure, we structurally matched the magnetic resonance imaging (MRI) and C-arm images through bony markers. The wand position was defined as being ‘correct’ if the tip was placed within the target area of both AP and lateral views; if not, the position was stated as ‘incorrect’. RESULTS: The average NRS fell from 7 to 1 at 48 weeks post procedure (p<0.05). In addition, statistically significant improvement was noted in the NDI and SF-36BP (p<0.05). The location of the wand tip resulted in 16 correct and 4 incorrect placements. Post-48 weeks, 3 of the incorrect tip cases and 1 correct tip case showed unsuccessful outcomes. CONCLUSION: The study demonstrated the promising results and safety of the procedure. Thus, focal plasma ablation of cervical HNP with navigable wand can be another effective treatment option.

Comparison of Clinical Characteristics Between Patients With Different Causes of Vocal Cord Immobility

OBJECTIVE: To analyze the clinical characteristics between neurogenic and non-neurogenic cause of vocal cord immobility (VCI). METHODS: The researchers retrospectively reviewed clinical data of patients who underwent laryngeal electromyography (LEMG). LEMG was performed in the bilateral cricothyroid and thyroarytenoid muscles. A total of 137 patients were enrolled from 2011 to 2016, and they were assigned to either the neurogenic or non-neurogenic VCI group, according to the LEMG results. The clinical characteristics were compared between the two groups and a subgroup analysis was done in the neurogenic group. RESULTS: Among the 137 subjects, 94 patients had nerve injury. There were no differences between the neurogenic and non-neurogenic group in terms of demographic data, underlying disease except cancer, and premorbid events. In general characteristics, cancer was significantly higher in the neurogenic group than non-neurogenic group (p=0.001). In the clinical findings, the impaired high pitched ‘e’ sound and aspiration symptoms were significantly higher in neurogenic group (p=0.039 for impaired high pitched ‘e’ sound; p=0.021 for aspiration symptoms), and sore throat was more common in the non-neurogenic group (p=0.014). In the subgroup analysis of neurogenic group, hoarseness was more common in recurrent laryngeal neuropathy group than superior laryngeal neuropathy group (p=0.018). CONCLUSION: In patients with suspected vocal cord palsy, impaired high pitched ‘e’ sound and aspiration symptoms were more common in group with neurogenic cause of VCI. Hoarseness was more frequent in subjects with recurrent laryngeal neuropathy. Thorough clinical evaluation and LEMG are important to differentiate underlying cause of VCI.

Reduced Port Laparoscopic Reversal of Hartmann's Procedure Using the Colostomy Site

Utilization of the colostomy site for laparoscopic reversal of Hartmann's procedure was recently introduced, and several studies have shown the feasibility of the procedure, which allows the colostomy site to serve as an access port for the operation. We demonstrate a method utilizing an accessory 5 mm trocar to assist in the operation while employing a colostomy-deepened glove port.

Chronological Change of the Sac after Endovascular Aneurysm Repair

PURPOSE: The purpose of this study was to evaluate the potential risk factors of type II endoleak and sac growth after endovascular aneurysm repair (EVAR) and the outcomes of secondary interventions. MATERIALS AND METHODS: Ninety seven patients underwent elective EVAR for infrarenal abdominal aortic aneurysms in two tertiary centers between April 2005 and July 2013. Clinical and imaging parameters were compared among sac growth (>5 mm) and non-growth groups. Risk factors associated with sac growth and persistent type II endoleak were analyzed. The outcomes of reinterventions for persistent type II endoleak were determined. RESULTS: Sac growth was observed in 20 cases (20.6%) and endoleak was found in 90% of them compared to 28.6% (22/77) in the non-growth group (P<0.001). The majority of endoleaks were type II (36/40) and 80.5% were persistent. Sac diameter, neck diameter and number of patent accessory arteries were also statistically significant for sac growth. On multivariate analysis, grade of calcification at the neck, grade of mural thrombus at the inferior mesenteric artery and number of patent accessory arteries were risk factors of persistent type II endoleak. Twenty six reinterventions were done for 16 patients with persistent type II endoleak, with a technical success rate of 88.5%, yet 55.5% showed sac growth regardless of technical success. There were no ruptures during the follow-up period. CONCLUSION: Sac growth after EVAR was mostly associated with persistent type II endoleak. Secondary interventions using transarterial embolization is partially effective in achieving clinical success.

Hybrid Repair of Suprarenal Abdominal Aortic Aneurysm: Antegrade Debranching with Endovascular Aneurysm Repair

We report a hybrid repair approach to the treatment of abdominal aortic aneurysm in patients with complex anatomies when typical endovascular aneurysm repair is limited due to juxtarenal involvement. A 63-year-old man presented with a 3-day history of fever and abdominal pain. He was diagnosed with acute cholecystitis along with incidental findings of two separate aneurysms of the abdominal aorta: a 3.7 cm saccular aneurysm at the suprarenal level, and a 6.6 cm fusiform aneurysm above the iliac bifurcation. He was treated with a hybrid technique involving an open approach for antegrade debranching of the superior mesenteric artery, and renal arteries and endovascular stent placement for treatment of an abdominal aortic aneurysm. The procedure was successfully completed with no adverse events as of the most recent 6-month outpatient follow-up.