Usefulness of direct W-plasty application to wound debridement for minimizing scar formation in the ED.

PURPOSE: A suture line placed with the same direction as the relaxed skin tension line leads to good healing, but a suture line with over 30 degrees of angle from the relaxed skin tension line leads to longer healing time and more prominent scarring. W-plasty is widely used to change the direction of the scar or to divide it into several split scars. In this study, we applied W-plasty to patients with facial lacerations in the emergency department. METHODS: From June 2012 to December 2014, 35 patients underwent simple repair or W-plasty for facial lacerations. Patients in the simple repair group underwent resection following a thermal margin, and the W-plasty group was resected within a pre-designed margin of W-shaped laceration. We assessed prognosis using the Stony Brook Scar Evaluation Scale (SBSES) after 10 days (short-term) and six months (long-term), respectively, following suture removal. RESULTS: Among 35 patients, 15 (42.9%) underwent simple debridement and 20 (57.1%) underwent W-plasty. In the W-plasty group, there was no difference between short-term and long-term follow-up showing high SBSES, but in the simple debridement group, long-term follow-up SBSES significantly decreased. W-plasty SBSES was higher than simple debridement at short-term as well as long-term follow-up. CONCLUSION: We experienced good results of direct W-plasty application at six-month long-term follow-up. Therefore, W-plasty application is more effective in reducing scar appearance than a simple debridement method for facial laceration patients with an angle of 30 degrees or more to the relaxed skin tension line.

Transanal single-port microsurgery for rectal tumors: minimal invasive surgery under spinal anesthesia.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) for rectal tumors has been introduced as an alternative approach to transanal endoscopic microsurgery (TEM). TEM has some limitations, such as the need for special equipment, expensive cost, and steep learning curve. In this study, we address the technical feasibility of TAMIS under spinal anesthesia and its short-term postoperative outcomes. METHODS: From July 2011 to September 2012, 25 consecutive patients with middle or upper third rectal masses underwent TAMIS. Tumors were located 6-17 cm from the anal verge. After spinal anesthesia, a single-incision laparoscopic surgery port was inserted into the anal canal. With this access, conventional laparoscopic instruments, including a grasper and monopolar electrocautery and suction device, were used to perform the transanal excision. A hook-type monopolar electrocautery or harmonic scalpel was used for dissection. The defect of the rectum was closed by interrupted sutures. Data concerning demographics, details of operative procedure, postoperative pain, and pathologic results were collected prospectively. To evaluate anal sphincter injury, an endoanal ultrasonography and fecal incontinence severity index survey were performed at 3-6 months after the operation. RESULTS: Of the 25 patients, nine had adenocarcinomas, nine had neuroendocrine tumors, three had tubular adenomas with high-grade dysplasia, three had tubular adenomas, one had a tubulovillous adenoma, and one had a gastrointestinal stromal tumor. The median distance from the tumor mass to the anal verge was 9.0 (range 6-17) cm. The median operative time was 45.0 (range 20-120) min. All patients received TAMIS without conversion to laparoscopic resection. There were no intraoperative complications or postoperative morbidity. The median postoperative hospital stay was 3.0 (range 2-7) days. No sphincter injury was detected by endoanal ultrasonography. CONCLUSIONS: TAMIS under spinal anesthesia is a safe and feasible technique for resection of middle and upper rectal masses. Spinal anesthesia is adequate for this procedure.

Value of glucose transport protein 1 expression in detecting lymph node metastasis in patients with colorectal cancer.

BACKGROUND: There are limited data on the use of glucose transport protein 1 (GLUT-1) expression as a biomarker for predicting lymph node metastasis in patients with colorectal cancer. GLUT-1 and GLUT-3, hexokinase (HK)-II, and hypoxia-induced factor (HIF)-1 expressions may be useful biomarkers for detecting primary tumors and lymph node metastasis when combined with fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT). AIM: To evaluate GLUT-1, GLUT-3, HK-II, and HIF-1 expressions as biomarkers for detecting primary tumors and lymph node metastasis with 18F-FDG-PET/CT. METHODS: This retrospective study included 169 patients with colorectal cancer who underwent colectomy and preoperative 18F-FDG-PET/CT at Chungbuk National University Hospital between January 2009 and May 2012. Two tissue cores from the central and peripheral areas of the tumors were obtained and were examined by a dedicated pathologist, and the expressions of GLUT-1, GLUT-3, HK-II, and HIF-1 were determined using immunohistochemical staining. We analyzed the correlations among their expressions, various clinicopathological factors, and the maximum standardized uptake value (SUVmax) of PET/CT. RESULTS: GLUT-1 was found at the center or periphery of the tumors in 109 (64.5%) of the 169 patients. GLUT-1 positivity was significantly correlated with the SUVmax of the primary tumor and lymph nodes, regardless of the biopsy site (tumor center, P < 0.001 and P = 0.012; tumor periphery, P = 0.030 and P = 0.010, respectively). GLUT-1 positivity and negativity were associated with higher and lower sensitivities of PET/CT, respectively, for the detection of lymph node metastasis, regardless of the biopsy site. GLUT3, HK-II, and HIF-1 expressions were not significantly correlated with the SUVmax of the primary tumor and lymph nodes. CONCLUSION: GLUT-1 expression was significantly correlated with the SUVmax of 18F-FDG-PET/CT for primary tumors and lymph nodes. Clinicians should consider GLUT-1 expression in preoperative endoscopic biopsy in interpreting PET/CT findings.

Early rehabilitation versus conventional care after laparoscopic rectal surgery: a prospective, randomized, controlled trial.

BACKGROUND: Although early rehabilitation programs have been reported to be effective after laparoscopic colectomy, there is no report of the efficacy of rehabilitation programs after rectal cancer surgery. This study was designed to evaluate the efficacy of an early rehabilitation program after laparoscopic low anterior resection for mid or low rectal cancer in a randomized, controlled trial. METHODS: Ninety-eight patients who had undergone a laparoscopic low anterior resection with defunctioning ileostomy were randomized on a 1:1 basis to an early rehabilitation program (n = 52) or conventional care (n = 46). The primary endpoint was recovery rate at 4 days postoperatively. The secondary endpoints were recovery time, postoperative hospital stay, complications, readmission rates, pain on a visual analogue scale, and quality of life (QOL) according to Short Form 36. RESULTS: The recovery rates were not different in both groups (rehabilitation, 25 % vs. conventional, 13 %, p = 0.135). Recovery time and postoperative hospital stay was similar between the groups (rehabilitation, 137 h [107-188] vs. conventional, 146.5 h [115-183], p = 0.47; 7.5 days [7-11] vs. 8.0 days [7-10], p = 0.882). The complication rates did not differ between the two groups, but more complications were noted in the rehabilitation program group (42.3 vs. 24.0 %, p = 0.054), which was related to postoperative ileus (28.8 vs. 13.0 %, p = 0.057) and acute voiding difficulty (19.6 vs. 4.7 %, p = 0.032). There was no readmission within 1 month of surgery. Pain and QOL were similar in both groups. CONCLUSIONS: This randomized trial did not show that an early rehabilitation program is beneficial after laparoscopic low anterior resection. Our results confirm that postoperative ileus and acute voiding difficulty are major obstacles to fast-track surgery for mid or low rectal cancer. This study was registered (registration number NCT00606944).

Podoplanin, α-smooth muscle actin or S100A4 expressing cancer-associated fibroblasts are associated with different prognosis in colorectal cancers.

The interactions between the tumor microenvironment and tumor cells determine the behavior of the primary tumors. Whether cancer-associated fibroblasts (CAF) have a tumor progressive or a protective role likely depends on the type of tumor cells and the CAF subpopulation. In the present study, we analyzed the prognostic significance of CAF subpopulations in colorectal cancer (CRC). CAF phenotypes were analyzed in 302 CRC patients by using antibodies against podoplanin (PDPN), α-smooth muscle actin (α-SMA), and S100A4. The relationship between the CAF phenotypes and 11 clinicopathological parameters were evaluated and their prognostic significance was analyzed from the disease-free and overall survival times. We observed that at the tumor invasive front, PDPN CAFs were present in 40% of the cases, and S100A4 or α-SMA CAFs were detected in all the cases. PDPN/S100A4 and α-SMA/S100A4 dual-stained CAFs were observed in 10% and 40% of the cases, respectively. The PDPN(+) CAFs were associated with 6 favorable clinicopathological parameters and prolonged disease-free survival time. The PDPN(-)/α-SMA(high) CAFs were associated with 6 aggressive clinicopathological parameters and tended to exhibit shorter disease-free survival time. On the other hand, the PDPN(-)/S100A4(high) CAFs were associated with 2 tumor progression parameters, but not with disease prognosis. The PDPN(+) CAF phenotype is distinct from the α-SMA or S100A4 CAFs in that it is associated with less aggressive tumors and a favorable prognosis, whereas the PDPN(-)/α-SMA(high) or PDPN(-)/S100A4(high) CAFs are associated with tumor progression in CRC. These findings suggest that CAFs can be a useful prognostic biomarker or potential targets of anti-cancer therapy in CRC.

Impact on clinical outcomes of renin-angiotensin system inhibitors against doxorubicin-related toxicity in patients with breast cancer and hypertension: A nationwide cohort study in South Korea.

BACKGROUND: Although doxorubicin (DOX) is a commonly used potent chemotherapeutic agent in patients with breast cancer, its cardiotoxic effect is a concern, particularly in patients with hypertension. Antihypertensive renin-angiotensin system (RAS) inhibitors may potentially play a role in preventing overt heart failure (HF) due to DOX toxicity. This study aimed to evaluate whether the use of RAS inhibitors improves clinical outcomes in patients with hypertension and breast cancer undergoing DOX-containing chemotherapy. METHODS: A total of 54,344 female patients who were first diagnosed with breast cancer and initiated into DOX therapy between 2008 and 2015 were recruited from a nationwide Korean cohort. Patients were divided into two groups: with and without hypertension (HT, n = 10,789; non-HT, n = 43,555), and the RAS inhibitor group (n = 1,728) was sub-classified from the HT group. Two propensity score-matched cohorts were constructed to compare the clinical outcomes between non-HT and HT groups and between non-HT and RAS inhibitor groups. The primary outcome was the composite of HF and death. RESULTS: After propensity score matching, the HT group had a higher risk for HF (adjusted hazard ratio [HR] = 1.30, 95% confidence intervals [95% CI] = 1.09-1.55) compared to the non-HT group, but there was no significant difference in primary outcome between the two groups. The RAS inhibitor group had a lower risk for primary outcome (adjusted HR = 0.78, 95% CI = 0.65-0.94) and death (adjusted HR = 0.81, 95% CI = 0.66-0.99) compared to the non-HT group. CONCLUSIONS: Hypertension is a risk factor for HF in patients with breast cancer undergoing DOX chemotherapy. However, the RAS inhibitors used to treat hypertension may contribute to decreased mortality and improved clinical outcomes.

Apical-node metastasis in sigmoid colon or rectal cancer: is it a factor that indicates a poor prognosis after high ligation?

PURPOSE: The prognostic significance of apical-node metastasis around the inferior mesenteric artery (IMA) remains unclear. We investigated the oncological relevance of apical-node metastasis detected after high ligation of the IMA in stage III sigmoid colon or rectal cancer. METHODS: Between May 2003 and December 2007, 229 consecutive patients with stage III sigmoid colon or rectal cancer, who had undergone curative resection with high ligation, were analyzed. Cox proportional regression model was used to identify the prognostic factors for disease-free survival. RESULTS: Thirty-one patients (13.5%) had apical-node metastases: 0% with T0-1, 3.8% with T2, 11.5% with T3, and 29.3% with T4 disease (p = 0.017). Additionally, the factors related to apical-node metastasis were tumor size, number of metastatic lymph nodes, lymph-node ratio, and N-stage. Multivariate analysis showed that the lymph-node ratio (odds ratio (OR) = 40.53, 95% confidence interval (CI) = 8.41-195.22, p < 0.001) was an independent prognostic factor for disease-free survival but that apical-node metastasis was not a factor that predicted a poor outcome (OR = 1.53, 95% CI = 0.81-2.91, p = 0.192). Apical-node metastasis was not a prognostic factor for disease-free survival on multivariate analysis of the subgroups based on tumor location (sigmoid colon cancer: OR = 1.42, 95% CI = 0.42-1.82, p = 0.577; rectal cancer: OR = 1.82, 95% CI = 0.82-4.06, p = 0.141). CONCLUSIONS: This study suggests that apical-node metastasis is not a poor prognostic factor for stage III sigmoid colon or rectal cancer after high ligation.

Clinical significance of the number of retrieved lymph nodes in early gastric cancer with submucosal invasion.

The prognosis of early gastric cancer (EGC) with submucosal invasion is favorable; however, several cases of recurrence have been reported even after curative gastrectomy. This study aimed to investigate risk factors and evaluate the clinical significance of the number of retrieved lymph nodes (LNs) in EGC with submucosal invasion. We retrospectively analyzed the data of 443 patients with gastric cancer with submucosal invasion after curative gastrectomy for recurrent risk factors. Recurrence was observed in 22 of the 443 gastric cancer patients with submucosal invasion. In the univariate analysis, the risk factors for recurrence were the number of retrieved LNs ≤ 25 and node metastasis. In the multivariate analysis, retrieved LNs ≤ 25 (hazard ratio [HR] = 5.754, P-value = .001) and node metastasis (HR = 3.031, P-value = .029) were independent risk factors for recurrence after curative gastrectomy. Body mass index was related to retrieved LNs ≤ 25 in univariate and multivariate analyses (HR = .510, P = .002). The number of retrieved LNs and node metastases were independent risk factors for EGC with submucosal invasion. For EGC with submucosal invasion, retrieved LNs > 25 are necessary for appropriate diagnosis and treatment.

Clinical impact of surgical treatment for the spontaneously ruptured resectable hepatocellular carcinoma: A single institution experience.

Spontaneously ruptured hepatocellular carcinoma (srHCC) is a fatal complication of hepatocellular carcinoma (HCC). In addition, emergency treatment is frequently fraught with difficulties. This study aimed to investigate the prognosis and recurrence pattern in patients undergoing hepatectomy for the srHCC. This retrospective study included 11 patients with srHCC treated using either emergency hepatectomy or emergency transarterial embolization (TAE) followed by staged hepatectomy between January 2015 and December 2019. The patients visited the emergency room because of a sudden rupture of HCC without being diagnosed with HCC. We analyzed the prognosis, recurrence rate, and survival in these patients after hepatectomy. Four of the 11 patients in this study were classified as Child-Pugh class A and 7 as Child-Pugh class B. Nine patients visited for sudden onset of abdominal pain, and 2 for sudden onset of shock. The median hemoglobin level at the time of the visit was 11.5 g/dL (interquartile range: 9.8-12.7). Five patients underwent one-stage hepatectomy and 6 underwent emergency TAE hemostasis followed by staged hepatectomy. Median overall survival and recurrence-free survivals were 23 and 15 months, respectively. Recurrence occurred in 7 patients (4 in the one-stage group and 3 in the staged group). Among patients with recurrence, 6 had intrahepatic recurrence and 3 peritoneal metastases. Patients with srHCC who undergo staged hepatectomy can achieve a relatively good prognosis. The most common sites of recurrence after hepatectomy are intrahepatic and peritoneal. Peritoneal metastases are more likely to occur after one-stage hepatectomy.

Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial.

PURPOSE: Although laparoscopic surgery may permit earlier recovery compared with open surgery, no published randomized controlled trial has investigated the benefit of a multimodal rehabilitation program after laparoscopic colonic resection. This study aimed to evaluate the efficacy of a rehabilitation program after laparoscopic colon surgery in the context of a randomized controlled trial. METHODS: Between September 2007 and October 2009, 100 patients who had received laparoscopic colon surgery were selected for the study and randomly assigned on a 1:1 basis to a rehabilitation program group with early mobilization and diet (n = 46) or conventional care group (n = 54). The rehabilitation program group received early oral feeding, early ambulation, and regular laxative. The primary outcome was recovery time, measured with criteria of tolerable diet for 24 hours, safe ambulation, analgesic-free, and afebrile status without major complications. Secondary outcomes were postoperative hospital stay, complications, quality of life by Short Form 36, pain by visual analog scale, and readmission. This study was registered (ID number NCT00606944, http://register.clinicaltrials.gov). RESULTS: Recovery time was shorter in the rehabilitation program group than in the conventional care group (median (interquartile range), 4 (3-5) d vs 6 (5-7) d, respectively; P < .0001). There was no difference in postoperative hospital stay between the 2 groups (rehabilitation program group, 7 (6-8) d vs conventional care group, 8 (7-9) d; P = .065). There was no difference in complication rates between the rehabilitation program group and conventional care group (10.9% vs 20.4%, respectively; P = .136). Quality of life and pain were similar in both groups. There were no readmissions or mortality. CONCLUSIONS: A rehabilitation program with early mobilization and diet after laparoscopic colon surgery results in reduced recovery time without increased complications. These results suggest that a multimodal rehabilitation program may increase the short-term benefits after laparoscopic colon surgery.

Risk factors for persistent anal incontinence after restorative proctectomy in rectal cancer patients with anal incontinence: prospective cohort study.

BACKGROUND: This study evaluated the notion that preoperative anal incontinence might be a potent predictive factor for anal incontinence (AI) after restorative proctectomy in rectal cancer patients. The principal objective of this study was to determine the risk factors for persistent anal incontinence following restorative proctectomy. METHODS: This study was designed as a single-center, prospective cohort study of a single group of 93 patients who had AI before restorative proctectomy for rectal cancer. The study group was re-evaluated for the presence of AI 12 months after restorative proctectomy or ileostomy takedown. Incontinence severity was determined using the Fecal Incontinence Severity Index (FISI). Logistic regression analysis was performed to identify the clinicopathologic factors associated with persistent AI. RESULTS: Fifteen patients were excluded from analysis due to death within the 12 months after surgery (n = 7), no ileostomy repair (n = 5), loss to follow-up (n = 2), or previous treatment for anal incontinence (n = 1). At 12 months, 53 of 78 patients (67.9%) had persistent AI and 25 patients (32.1 %) had recovered. Multivariate analysis demonstrated that preoperative FISI scores higher than 30 (OR = 11.61, 95% CI 1.43-94.01, p = 0.022) and lower tumor location 5 cm or less from the anal verge (OR = 84.46, 95% CI 3.91-1822.85, p = 0.005) were independent factors for persistent AI. CONCLUSIONS: Anal incontinence may persist after restorative proctectomy in rectal cancer patients with high preoperative incontinence scores and lower tumor location. Therefore, this information should be provided when restorative proctectomy is offered for rectal cancer patients.

Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial.

BACKGROUND: The safety and short-term efficacy of laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy has not been demonstrated. The aim of the randomised Comparison of Open versus laparoscopic surgery for mid and low REctal cancer After Neoadjuvant chemoradiotherapy (COREAN) trial was to compare open surgery with laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy. METHODS: Between April 4, 2006, and Aug 26, 2009, patients with cT3N0-2 mid or low rectal cancer without distant metastasis after preoperative chemoradiotherapy were enrolled at three tertiary-referral hospitals. Patients were randomised 1:1 to receive either open surgery (n=170) or laparoscopic surgery (n=170), stratified according to sex and preoperative chemotherapy regimen. Short-term outcomes assessed were involvement of the circumferential resection margin, macroscopic quality of the total mesorectal excision specimen, number of harvested lymph nodes, recovery of bowel function, perioperative morbidity, postoperative pain, and quality of life. Analyses were based on the intention-to-treat population. Patients continue to be followed up for the primary outcome (3-year disease-free survival). This study is registered with ClinicalTrials.gov, number NCT00470951. FINDINGS: Two patients (1.2%) in the laparoscopic group were converted to open surgery, but were included in the laparoscopic group for analyses. Estimated blood loss was less in the laparoscopic group than in the open group (median 217.5 mL [150.0-400.0] in the open group vs 200.0 mL [100.0-300.0] in the laparoscopic group, p=0.006), although surgery time was longer in the laparoscopic group (mean 244.9 min [SD 75.4] vs 197.0 min [62.9], p<0.0001). Involvement of the circumferential resection margin, macroscopic quality of the total mesorectal excision specimen, number of harvested lymph nodes, and perioperative morbidity did not differ between the two groups. The laparoscopic surgery group showed earlier recovery of bowel function than the open surgery group (time to pass first flatus, median 38.5 h [23.0-53.0] vs 60.0 h [43.0-73.0], p<0.0001; time to resume a normal diet, 85.0 h [66.0-95.0] vs 93.0 h [86.0-121.0], p<0.0001; time to first defecation, 96.5 h [70.0-125.0] vs 123 h [94.0-156.0], p<0.0001). The total amount of morphine used was less in the laparoscopic group than in the open group (median 107.2 mg [80.0-150.0] vs 156.9 mg [117.0-185.2], p<0.0001). 3 months after proctectomy or ileostomy takedown, the laparoscopic group showed better physical functioning score than the open group (0.501 [n=122] vs -4.970 [n=128], p=0.0073), less fatigue (-5.659 [n=122] vs 0.098 [n=129], p=0.0206), and fewer micturition (-2.583 [n=122] vs 4.725 [n=129], p=0.0002), gastrointestinal (-0.400 [n=122] vs 4.331 [n=129], p=0.0102), and defecation problems (0.535 [n=103] vs 5.327 [n=99], p=0.0184) in repeated measures analysis of covariance, adjusted for baseline values. INTERPRETATION: Laparoscopic surgery after preoperative chemoradiotherapy for mid or low rectal cancer is safe and has short-term benefits compared with open surgery; the quality of oncological resection was equivalent.

Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review.

Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.

Intraoperative technical difficulty during laparoscopy-assisted surgery as a prognostic factor for colorectal cancer.

BACKGROUND: Laparoscopy-assisted surgery has technical drawbacks compared with open surgery, although laparoscopic surgery has become widely adopted with evidence of oncological safety for colon cancer treatment. The oncological risk of technical difficulties during laparoscopic surgery for colorectal cancer has not been previously reported. We aimed to investigate whether a technical difficulty encountered during laparoscopic surgery can be considered a recurrence-related factor for colorectal cancer. METHODS: Data from 427 patients who underwent laparoscopic surgery for colorectal cancer between May 2003 and December 2007 were analyzed. An intraoperative technical difficulty was defined as a significant deviation from the ordinary surgical procedure. All conversions to open surgery and iatrogenic bowel perforation during laparoscopic surgery were included as technical difficulties. The Cox proportional-hazards regression model was used to evaluate the recurrence-related factor in the various risk factors including technical difficulty. RESULTS: Technical difficulties were found in 44 (10.3%) patients, which included 17 (3.9%) conversions to open surgery and 10 (2.4%) with iatrogenic bowel injury. Technical difficulties were encountered more frequently in men compared with women (13.5% vs 6.0%, P = .013), and for cancers located in the mid and low rectum, splenic flexure, and descending colon. The recurrence rates were higher in patients with technical difficulties (local recurrence, 2.6% vs 6.7%, P < .05; systemic recurrence, 6.3% vs 13.6%, P < .05) with a mean follow-up duration of 45.9 months. Multivariate analysis by the Cox proportional-hazards regression model showed that a technical difficulty was an independent factor related to recurrence after laparoscopic surgery (odds ratio, 2.374; 95% CI, 1.006-5.600; P = .048). CONCLUSIONS: This study has demonstrated that a technical difficulty during laparoscopy-assisted surgery jeopardizes oncological safety. It is suggested that surgeons should be prepared to minimize technical difficulties during laparoscopy-assisted surgery.

Successful treatment of basaloid squamous cell carcinoma in the rectosigmoid colon: A case report and review of literature.

BACKGROUND: Compared with colorectal adenocarcinoma, basaloid squamous cell carcinomas (BSCCs) arising in the colorectum are rare and have very poor prognosis. To date, only nine cases have been reported. Most BSCCs are extensively involved in metastasis to the lymph node, liver, and lung at diagnosis. Despite many clinicians attempting to effectively treat BSCCs, therapeutic consensus has not been established due to lack of information. CASE SUMMARY: A 58-year-old woman presented with abdominal pain, diarrhea, fever, and hematochezia. She was referred from a department of gynecology and was diagnosed with a suspicious leiomyosarcoma of the rectum or a pedunculated myoma of the uterus. An exophytic growing mass at the right lateral wall of the rectum with an internal cystic portion and hemorrhage was observed on magnetic resonance imaging. The patient underwent low anterior resection and total hysterectomy with bilateral salphingo-oophorectomy. Histopathological findings revealed a cellular mass with a solid growth pattern and few glandular structures, many foci of intratumoral necrosis, and a palisading pattern. The pathologist diagnosed tumor as a BSCC, and the patient received chemotherapy with fluorouracil/leucovorin without radiotherapy. The patient is currently alive 8 years after the surgery with no manifestations of metastatic colon cancer. CONCLUSION: Our case suggest that curative resection and chemotherapy play important roles in improving survival, and radiotherapy may be an option to avoid radiation-associated enteritis.

Endoscopic radial incision and cutting technique for treatment-naive stricture of colorectal anastomosis: Two case reports.

BACKGROUND: Anastomotic stenosis (AS) after colorectal surgery was treated with balloon dilation, endoscopic procedure or surgery. The endoscopic procedures including dilation, electrocautery incision, or radial incision and cutting (RIC) were preferred because of lower complication rates than surgery and are less invasive. Endoscopic RIC has a greater success rate than dilation methods. Most reports showed that repeated RICs were needed to maintain patency of the anastomosis. We report that single session RIC was applied only to treatment-naive patients with AS. CASE SUMMARY: Two female patients presented with AS. One patient had advanced rectal cancer and the other had a refractory stenosis following surgery for endometriosis at sigmoid colon. The endoscopic RIC procedure was performed as follows. A single small incision was carefully made to increase the view of the proximal colon and the incision was expanded until the surgical stapling line. Finally, we made a further circumferential excision with endoscopic knife along the inner border of the surgical staple line. At the end of the procedure, the standard colonoscope was able to pass freely through the widened opening. All patients showed improved AS after a single session of RIC without immediate or delayed procedure-related complications. Follow-up colonoscopy at 7 and 8 mo after endoscopic RIC revealed intact anastomotic sites in both patients. No treatment-related adverse events or recurrence of the stenosis was demonstrated during follow-up periods of 20 and 23 mo. CONCLUSION: The endoscopic RIC may play a role as one of treatment options for treatment-naive AS with short stenotic lengths.

Penile metastasis in rectal cancer with pathologic complete response after neoadjuvant chemoradiotherapy: The first case report and literature review.

RATIONALE: Penile metastasis in rectal cancer is very rare and often originates from prostatic or bladder cancer. The prognosis of penile metastasis is poor and its treatments are more often palliative than curative due to association with disseminated metastases. Pathologic complete response (pCR) in rectal cancer with neoadjuvant chemoradiotherapy (CRT) has been shown to be surrogate marker of favorable long-term outcomes and currently has no report of penile metastasis. Here, we first report isolated penile metastasis in rectal cancer with pCR after neoadjuvant CRT. PATIENT CONCERN: The patient was a 74-year-old male with metastasis to the glans penis from rectal cancer diagnosed 9 months after abdominoperineal resection. Physical examination revealed palpable multiple nodules on the glans penis. DIAGNOSIS: Penile biopsy revealed metastatic carcinoma from the rectal cancer. INTERVENTION: Chemotherapy was started as soon as possible, because patient suffered urinary discomfort by rapid growing metastatic lesions. He is currently receiving palliative chemotherapy with modified FOLFOX-6 (mFOLFOX-6; oxaliplatin with 5-fluorouracil and folinic acid) plus bevacizumab. OUTCOME: The patient is still alive 4 months after diagnosis with markedly decreased metastatic lesions. LESSON: We propose that although penile metastasis in rectal cancer with pCR after preoperative neoadjuvant CRT is extremely rare, it might help to start early palliative chemotherapy and clinicians should be aware of this possibility.

Laparoscopic management for stump appendicitis: A case series with literature review.

INTRODUCTION: Appendectomy is one of the most common emergency surgical operations. Stump appendicitis is a rare complication after appendectomy and is caused by acute inflammation of the remnant part of the appendix. Because of the low index of suspicion owing to a previous history of appendectomy, the diagnosis of stump appendicitis is often delayed. METHODS: Between January 2008 and December 2017, 6 patients were diagnosed with stump appendicitis with or without perforation at a single institution. They had undergone operative management with laparoscopic approach. The clinical data of these patients were retrospectively analyzed by reviewing the medical records and pathologic reports. RESULTS: Five patients were male, with a mean age of 42.4 years (range 11-77 years). The time interval after initial appendectomy ranged from 2 weeks to 30 years. Three patients underwent laparoscopic completion appendectomy, and the others underwent laparoscopic ileocecectomy. The mean hospital stay was 9 days (range 5-13 days). There were no cases of open conversion. CONCLUSIONS: Stump appendicitis is a rare complication after appendectomy. A laparoscopic procedure can be performed for management of stump appendicitis with or without perforation.