Clinical Analysis of 40 Patients with Familial Adenomatous Polyposis (FAP)

Purpose: This study was carried to find the clinical characteristics of incidence and the phenotype of familial adenomatous polyposis (FAP). Methods: This retrospective analysis was performed on 40 patients who were diagnosed as having FAP and who underwent surgery due to FAP from June 1985 to April 2005. The operative method, extra- colonic symptoms, and number of polyps were analyzed. Results: From June 1985 to April 2005, 0.65% (40 patients) of all surgically treated colon-cancer patients were diagnosed as having FAP. Seventeen patients had familial history, and 23 patients were neither aware of any familial history nor had taken any tests. The primary symptoms were hematochezia, diarrhea, mucous discharge, constipation, and abdominal pain, but 5 patients had no specific symptoms. The mean age was 38.0 years. A total colectomy with ileostomy was performed in 19 cases, a total colectomy with ileorectal anastomosis in 2 case, and a total proctocolectomy with ileal J pouch anal anastomosis in 17 cases. One case was only diagnosed as having a FAP without surgical treatment, and one cases had palliative surgery due to carcinomatosis. Thirty-five cases had more than one hundred polyps, and 5 cases had less than one hundred polyps with a higher mean age of 62.2 (50∼74) years and having no familial history. Extracolonic manifestations, were congenital hypertrophy of the retinal pigment epithelium, submandibular tumor, thyroid cancer, and intraabdominal desmoid tumor. The polyps could develop in other organs, such as the stomach or the duodenum. Because they can progress to cancer, a gastroduodenoscopy needs to be done. As for result, 17 cases underwent endoscopic gastroduodenoscopy, and among them, 9 cases had multiple adenomas. Conclusions: FAP has been considered as a rare disease. Because of its association with early development of colorectal cancer, measures for early detection of the disease and for identification of other family members at risk should be performed. Furthermore, early prophylactic treatment should be undertaken to reduce the incidence of cancer in these conditions. For early detection and better outcome, clinical and radiological examination and treatment for extracolonic manifestations and extracolonic tumor (thyroid cancer, desmoid tumor, medulloblastoma, hepatoblastoma) are necessary.ope

Analysis of Factors Affecting the Degree of Difficulty in Total Mesorectal Excision for Rectal Cancer: Investigation of the Factors Affecting Incomplete Resection and the Resection Time

Purpose: The aim of this study was to estimate the degree of difficulty in total mesorectal excisions (TMEs) for rectal cancer by using statistical methods after analysis of factors affecting the resection time and incomplete resection. Methods: A total of 63 patients who underwent a total mesorectal excision for rectal cancer were evaluated. MRI pelvimetry data {(transverse diameter (TD), obstetric conjugate (OC), interspinous distance (ID), sacrum length (SL), sacrum depth (SD)}, tumor size (TS), T stage, and body mass index (BMI) were prospectively analyzed. A stepwise multiple regression analysis was performed to determine the operating time prediction equation by using these variables, and the differences in the mean operating time hased on gross evaluations of each specimen were analyzed. Results: A stepwise multiple regression with the operating time as a dependent variable led to the following equation: Operation time (min)=35.726-2.162×TD (cm)-×OC (cm)+2.671×SL (cm)+1.274×TS (cm),with r2=0.533 and SEE=5.438. The mean operating time according to a gross evaluation of the TME specimen was 20.0±7.3 min in complete TME cases (n=42) and 27.9±7.2 min in incomplete TME cases (n=21) (P＜0.001). Conclusions: MRI pelvimetry data (TD, OC, SL) and tumor size were factors affecting the operation time in TMEs for rectal cancer, and the operating time could be predicted by using the equation of the present study. Also, the mean operating time in incomplete TME cases was longer than that in complete TME cases. Thus, the degree of difficulty of an operation for rectal cancer can be predicted by using these factors.ope

Isolated Splenic Metastasis from Colorectal Carcinoma

Most splenic metastasis occurs in patients with the widespread visceral metastasis. However, isolated splenic metastasis is very rare. Here we report an isolated splenic metastasis in a patient with colon cancer without any other metastasis and a review of the literature are presented. A 57-year female underwent right hemicolectomy for adenocarcinoma of ascending colon on February, 2004 and the stage of carcinoma was T3N2M0. On August 2004, she hospitalized due to isolated splenic metastasis. The serum carcinoembryonic antigen level was 1.69 ng/ml. An abdominal CT scan revealed a 1 cm sized metastatic mass at the hilum of the spleen. The same finding was shown on MRI and PET. There was no other recurrence or metastatic evidence in radiologic study. Splenectomy was performed and pathologic result of the splenic tumor was metastatic adenocarcinoma from colon cancer. After operation, she was treated with adjuvant chemotherapy. It may be necessary to attend the splenic metatasis in patients who underwent curative resection for colorectal cancer even though splenic metastasis is very rare.ope

Clinicopathological Features of Retrorectal Tumors in an Adult - A Case Report and Review of the Literatures -

Retrorectal tumors are particularly rare among the adult population, occurring in 1 of 40,000 hospital admissions. Clinical diagnosis is difficult and is often delayed because of vague symptoms. This study aimed to investigate the clinicopathological features of retrorectal tumors. Between January 1999 and March 2005, 10 patients were diagnosed with retrorectal tumors at the Department of Surgery, Yonsei University Medical Center, and their medical records were reviewed. We analyzed chief complaints, imaging studies, surgical approaches and pathologic examinations. Out of 10 patients, 8 were female and 2 were male. The mean age was 42.8 years. Four patients had no symptoms. Perianal and abdominal pain were the most common presentations. CT and MRI were the most frequently performed imaging studies. Surgery was performed in 9 patients. Postoperative pathologic diagnosis was possible in 9 patients. An epidermal cyst was the most common tumor (4 patients); others included a mature teratoma, an adenocarcinoma from a tail gut cyst, a duplication cyst, a neurogenic tumor, and a smooth muscle cell tumor. Imaging techniques like CT scans, MRI and TRUS are helpful to determine the size and the extent of a tumor and its relationship to the surrounding anatomical structures for the operative approach. A surgical resection is the standard of treatment and demonstrates good results and a good prognosis.ope

Robotic Anterior Resection for Sigmoid Colon Cancer: Short-term Outcome of a Pilot Study

Purpose: The DaVinci system is new emerging device for performing colorectal surgery. However, in the era of laparoscopic sigmoid colon cancer surgery, there are few previous reports on using the DaVinci system for sigmoid colon cancer. Therefore, the aim of this study is to evaluate the safety and feasibility of using the DaVici system for anterior resection in patients with sigmoid colon cancer, as compared with conventional laparoscopic anterior resection. Methods: Between March 2007 and Jun 2007, 7 sigmoid colon cancer patients underwent robotic anterior resection using the da Vinci Surgical system, and 9 patients underwent conventional laparoscopic anterior resection. The patients’ characteristics, the perioperative clinical results and the pathologic details were prospectively collected and compared between the two groups. Results: The patient characteristics were not significantly different between the two groups. The mean operation time were 205.9±17.6 in the robotic group and 102.4±25.0 in the laparoscopic group (p=0.001). The change of the hemoglobin level, the number of days until peristalsis and the average length of stay were not different between the groups. Also, the pathologic details were not different between the groups. There were no complications or conversion in the both groups. Conclusion: Our data demonstrates that robotic anterior resection is feasible and effective for sigmoid colon cancer patients. However, we could not find better outcomes for robotic anterior resection as compared with conventional laparoscopic anterior resectionope

Oncologic Outcomes and Safety after Tumor-specific Mesorectal Excision for Resectable Rectal Cancer: A Single Institution’s Experience with 1,276 Patients with Rectal Cancer

PURPOSE: The purpose of this work was to review the oncologic outcomes and the operative safety of a tumor- specific mesorectal excision (TSME) for resectable rectal cancer. The risk factors for recurrence and survival were analyzed, and the changes in the sphincter-preserving rate with time were analyzed. METHODS: A total of 1,276 patients with rectal cancer who underwent curative surgery between 1989 and 2003 were analyzed retrospectively. The enrolled patients were registered in the Colorectal Cancer Database and were followed prospectively. RESULTS: The pathologic stages were stage I in 330 (25.9%), II in 403 (31.6%), and III in 543 (42.6%). Postoperative complications developed in 263 patients (20.6%). The rates of anal sphincter preservation were 32.6% between 1989 and 1993, 56.8% between 1994 and 1998, and 69.4 % between 1999 and 2003. With a mean follow-up of 69.4 months, the overall local recurrence (LR) rate was 5.4%. The 5-year LR rates were 3.8% in stage I, 4.7% in stage II, and 8.4% in stage III (P=0.016). A multivariate analysis revealed that the risk factors affecting LR were pN (0.005) and preoperatively increased serum CEA (P=0.008). The 5-year cancer-specific survival rates were 93.8% in stage I, 84.5% in stage II, and 64.5% in stage III (P=0.021). A multivariate analysis revealed that the factors affecting cancer-specific survival were pN (P=0.012) and circumferential resection margin (P<0.001). CONCLUSIONS: TSME for resectable rectal cancer showed acceptable operative morbidity and excellent oncologic outcomes. The trend toward sphincter preservation was obvious, and the shortening of the distal resection margin without deteriorating the oncologic outcomes was one of the major enabling factorsope

Mucinous Histology as a Predictive Marker of 5-Fluorouracil-based Adjuvant Chemotherapy for Colon Cancer

Purpose: The aim of this study was to evaluate the value of mucinous histology as a predictive marker of 5-Fluorouracil (FU)-based adjuvant chemotherapy in stage II, III colon cancer. Methods: Between January 1995 and December 2004, 987 patients who underwent curative resections for stage II, III sporadic colon cancer were classified into two groups, a mucinous carcinoma (MC) group and a non-mucinous carcinoma (NMC) group, based on the histology of the primary tumor. The differences in their clinicopathological characteristics and the prognostic impact of 5-FU-based adjuvant chemotherapy for various tumor histologies were analyzed. Results: Of the 987 patients, MCs accounted for 6.8% (68 patients). MCs were more frequently located in the Rt. Colon (P<0.001) and were more frequently seen in young patients (less than 40 yr old) (P=0.028). The 5-yr survival rates between MC and NMC did not show any statistically significant difference. Patients, including both MC and NMC patients, who received 5-FU-based chemotherapy, revealed a better overall survival rate than patients with no adjuvant chemotherapy. In the multivariate analysis for the prognosis in NMC patients, 5-FU-based adjuvant chemotherapy, initial negative nodal status, and preoperative CEA <5 ng/mL were statistically significant prognostic factors (P values: <0.001, <0.001, and <0.001, respectively). In contrast, there was no statistically independent significance of 5-FU-based adjuvant chemotherapy in MC patients. Conslusion: In stage II and stage III sporadic colon cancer patients, response to 5-FU-based adjuvant chemotherapy in MC patients might be poor than it is in NMC patientsope

Local Pelvic Recurrence after Curative Resection of the Rectal Cancer: Classification and Prognosis

Purpose: The management of local recurrence after curative surgery of the rectal cancer remains difficult clinical problems to surgeons. This study was performed to analyze the outcomes of patients with local pelvic recurrence according to its recurrence type. Methods: A total 109 patients with local recurrence were evaluated. Among the 109 patients 62 were local recurrence alone and 47 were both local and systemic recurrence. The recurrence type was classified as Central, Anterior, Posterior, Lateral and Perineal recurrence according to the relation of the tumor location and either intra pelvic organ and/or fixed pelvic structure. Results: Only 26 (23.9%) of the 109 patients had curative resection and the remaining 83 (76.1%) patients had palliative exploration or nonsurgical procedure. The resectability according to the recurrence type showed that the Central and Anterior type was higher than other type of recurrences (P=0.001). When the primary operation was Abdominoperineal Resection (APR) the resectability was poorer than Low Anterior Resection (LAR) (P=0.0001). When comparing the patients with local recurrence alone, the 5 year survival rate was significantly higher patients treated by curative resection than palliative or non-resection group (P=0.002). Mean follow up period was 44.2±30.0 months and mean recurrence time between primary operation and recurrence was 26.0±22.7 months. Conclusions: Resection for central type of the recurrent is potentially curative, however treatment failure was common when the recurrence invaded fixed pelvic structure. Our data suggest that local pelvic recurrence should be treated with radical resection as can as possible.ope

Safety and Feasibility of Laparoscopic Low Anterior Resection in Early Learning Curve

Purpose: After the final report of Clinical Outcomes of Surgical Therapy (COST) study group, the application of laparoscopic surgery in colon cancer a spread widely. However, laparoscopic surgery in the rectum is still regarded as a complicated procedure to start due to technical difficulties and a steep learning curve. The aim of this study was to show the safety and technical feasibility of a laparoscopic low anterior resection at an early time on the learning curve in comparison with open low anterior resection. Methods: The learning curves of one colorectal surgeon in open and laparoscopic low anterior resections were retrospectively compared. The compared factors were clinicopathologic characteristics, operation time, and the factors associated with postoperative recovery, morbidity and mortality. Results: There were no significant differences in age or sex between two groups. The operation time was significantly longer in the laparoscopy group (P＜0.001) In the view point of postoperative recovery, the laparoscopy group showed significant advantages in hospital stay (P＜0.001), the passage of flatus (P＜0.001), the number of analgesics used (P=0.03), and the removal of foley catheter (P=0.001). There were no conversions in the laparoscopy group, and the complication rate was lower in the laparoscopy group (10.7% vs. 17.6%). There was no postoperative mortality in either group. Conclusions: Even though the operation time was significantly longer in the laparoscopy group, a laparoscopic low an terior resection appears to have some benefits in postoperative recovery and morbidity. In terms of surgical outcomes, a laparoscopic low anterior resection can be performed safely even in early times on the learning curve.ope

Comparison between the Initial 25 Cases and the Last 25 Cases of Laparoscopic Colorectal Resection during a Learning Period and According to the Clinicopathologic Outcomes

Purpose: The present study was designed to investigate the clinicopathologic results of performing laparoscopic colorectal resection during a learning curve period. Methods: A prospective analysis of 50 consecutive patients who underwent elective laparoscopic colorectal surgery was conducted between April 2006 and September 2006. We monitored the learning curve of one surgeon. The perioperative clinical results, complications and pathologic details were evaluated prospectively. The 50 patients were divided into two chronological groups (the 25 early cases and the 25 late cases). Statistical analysis between the two groups was performed to evaluate the different outcomes and with taking into account the progressively increasing experience. Results: A total of 45 cases had colorectal cancer. The operative procedure was executed by the standard laparoscopic technique and according to the tumor location, with proper lymph node dissection. Curative resection was performed for the all malignant cases. The remaining 5 cases all involved benign disease. The overall complication and conversion rates were 12% and 6%, respectively. All the complications were treated conservatively. The pathologic outcomes for the malignant cases were acceptable, with no differences being manifested between the two groups. The complication rate and the length of stay were decreased in the late group. Conclusion: Laparoscopic colorectal resection can be performed safely and effectively. The clinicopathologic outcomes were acceptable even though the cases of the present study were done during the learning curve period of a surgeon.ope