Cost analysis of single-incision versus conventional laparoscopic surgery for colon cancer: A propensity score-matching analysis

BACKGROUND/OBJECTIVE: Although many studies have demonstrated similar perioperative outcomes for single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for colon cancer, few have directly compared the costs of them. We aimed to compare costs between SILS and CLS for colon cancer. METHODS: We analyzed the clinical outcomes and overall hospital costs of patients who underwent laparoscopic surgery for colon cancer from July 2009 to September 2014 at our institution; 288 were used for analysis after propensity score matching. The total hospital charge, including fees for the operation, anesthesia, preoperative diagnosis, and postoperative management was analyzed. RESULTS: The total hospital charges were similar in both groups ($8770.40 vs.$8352.80, P = 0.099). However, the patients' total hospital bill was higher in the SILS group than in the CLS group ($4184.82 vs.$3735.00, P < 0.001) mainly due to the difference of the cost of access devices. There was no difference in the additional costs associated with readmission due to late complications between the two groups ($2383.08 vs.$2288.33, P = 0.662). Incremental cost-effectiveness ratio for total incision length in 'total hospital charge' and patient's bill and government's bill in 'cost of instruments and supplies' were -$107.08/1 cm, -$109.70/1 cm, and $80.64/1 cm, respectively. CONCLUSION: SILS for colon cancer yielded similar costs as well as perioperative and long-term outcomes compared with CLS. Therefore, SILS can be considered a reasonable treatment option for colon cancer for selective patients.ope

직장암의 수술 전 화학방사선요법 후 형태계측 변화와 바이오마커 발현을 이용한 병리학적 완전관해 예측 노모그램

Dept. of Medicine/박사Numerous molecular markers and imaging tools have been studied to predict pathologic complete remission (pCR) after preoperative chemoradiotherapy (CRT) for rectal cancer. However, none of these has not shown definite outcomes. The aim of this study is to develop a nomogram to predict pCR by analyzing relevant biomarkers and endoscopic findings. Tumor specimens have been collected prospectively from 120 patients before preoperative CRT in patients with rectal cancer between November 2011 and April 2014. All patients underwent curative resection with total mesorectal excision at 8 weeks after completeness of preoperative CRT. Using reverse transcriptase polymerase chain reaction (RT-PCR) analysis, mRNA expression levels of seven candidate biomarkers (p53, p21, Ki-67, VEGF, CD133, CD24, CD44) were evaluated from fresh tumor samples before CRT. The expression of mRNA was indicated with ΔCt by correction according to the expression of GAPDH (target Ct – GAPDH Ct). The relative quantity of mRNA in pathologic complete remission (pCR) tissue to that in non-pCR tissue was calculated from the relative ratios of 2-ΔCt between two conditions. Lower ΔCt and Higher 2-ΔCt mean higher expression of mRNA. Endoscopic evaluation has been done pre- and post-preoperative CRT. Clinical complete remission by endoscopic finding was no visualization of tumor, white scar, and red scar. Clinical variables were also evaluated. Univariate and multivariate logistic regression analysis with clinical and biologic variables were used to make a predictive model for pCR. Nomogram was developed in a training set (n=80) and validated in external validation set (n=40). Both discrimination and calibration were measured by the area under a receiver operating characteristic (ROC) curve (AUC) and calibration plot, respectively. The pCR was shown in 24 patients (30%). Among seven biomarkers, the mRNA expression levels of four biomarkers (p53, p21, Ki67, CD133) significantly correlated with pCR in training set. Patients showing low expression of p53 and/or high expression of p21, Ki67, CD133 exhibited a significantly greater pCR rate. Among 27 patients showing endoscopic clinical complete response (cCR) after preoperative CRT, 17 patients (63.0%) demonstrated pCR. Lower tumor location showed a higher pCR rate than middle tumor [19 (38.8%) vs. 5(16.1%), p = 0.031]. By logistic regression analysis, tumor location, endoscopic finding after preCRT and four biomarkers (p53, p21, Ki67, CD133) were significantly correlated with pCR. Based on the multivariate prediction model with these variables, a nomogram were drawn for prediction for pCR, and which showed good discrimination ability in training set (AUC=0.945) and validation set (AUC=0.922). The calibration plot demonstrated good agreement between actual and predicted pCR in both patient set. The nomogram for prediction of pCR may be useful in treatment decisions after preoperative CRT to select complete responders for a wait-and-see policy or sphincter preserving surgery. 직장암의 수술 전 화학방사선요법 치료 후 병리학적 완전관해를 예측하기 위해 수 많은 분자 수준의 표지자와 영상학적 도구들이 사용되어 왔다. 하지만 종양의 치료 반응 평가에 대한 명확한 결과를 보여주는 방법은 없었다. 본 연구의 목적은 관련 바이오마커 및 내시경 소견을 분석함으로써 병리학적 완전관해를 예측하는 노모그램을 제시하는 것이다. 종양 검체는 2011년 11월에서 2014년 4월 사이 수술 전 화학방사선요법을 시행 받기 전의 직장암 환자 120명으로부터 전향적으로 채취되었다. 모든 환자는 수술 전 화학방사선요법 종료 후 8주 뒤에 전직장간막 절제술로 근치적 수술을 받았다. 역전사 중합효소 연쇄반응 (RT-PCR) 분석을 통하여 신선 종양 검체로부터 7 개의 바이오마커 (p53, p21, Ki-67, VEGF, CD133, CD24, CD44)의 mRNA 발현 수준을 평가하였다. mRNA의 발현 정도는 GAPDH의 발현 정도에 따라 교정 (목표 Ct – GAPDH Ct)하여 ΔCt로 나타내었다. 병리학적으로 완전관해를 보이지 않은 검체의 mRNA에 대한 완전관해를 보인 검체의 mRNA의 상대적인 양은 두 검체의 2-ΔCt 값의 상대비로 계산하였다. 낮은 ΔCt와 높은 2-ΔCt 값은 mRNA의 발현 수준이 높다는 것을 의미한다. 내시경 검사는 선행 항암방사선 치료 전과 후(선행 항암방사선 치료 종료 후 4주 뒤)에 실시하였다. 내시경 검사를 통해 임상적으로 완전 관해를 판단한 기준은 육안적으로 종양이 보이지 않고, 백색 반흔 혹은 적색 반흔이 남아있는 경우로 하였다. 임상적 변수 또한 평가하였다. 병리학적 완전관해 예측모델을 구축하기 위해 임상변수 및 생물학적 변수를 로지스틱 회기 모형을 이용하여 단변량 및 다변량 분석을 시행하였다. 80명의 훈련 집합(training set)에 대하여 노모그램 (Nomogram)을 개발하고 40명의 외부 검증 집합 (validation set)에서 검증을 ...ope

Long-term Oncologic Outcome and Its Relevant Factors in Anal Cancer in Korea: A Nationwide Data Analysis

Purpose: Anal cancer is a rare disease in Korea, and thus survival analyses are limited by small sample sizes. This study used the Korea Central Cancer Registry (KCCR) for a survival analysis and for assessing characteristics of anal cancer in a large sample of Koreans. Methods: From the KCCR, data on 3,615 patients who were diagnosed and treated for anal cancer from 1993 to 2015 were retrieved. Clinicopathologic variables including age, sex, histological type, and Surveillance Epidemiology and End Results (SEER) stage were reviewed, and a survival analysis was performed according to these variables. Results: The 5-year relative survival rate improved from 39.7% in 1993-1995 to 66.5% in 2011-2015. Squamous cell carcinoma was the most common and showed the highest survival rate. Males and older patients (≥40 years and ≥70 years) showed poor prognoses. Conclusion: The survival rate for anal cancer in Korea has improved steadily over time. The characteristics related to survival were the histological type, sex, and age. These statistics will be fundamental for future Korean anal cancer research.ope

New Perspectives on Predictive Biomarkers of Tumor Response and Their Clinical Application in Preoperative Chemoradiation Therapy for Rectal Cancer

Preoperative chemoradiation therapy (CRT) is the standard treatment for patients with locally advanced rectal cancer (LARC) and can improve local control and survival outcomes. However, the responses of individual tumors to CRT are not uniform and vary widely, from complete response to disease progression. Patients with resistant tumors can be exposed to irradiation and chemotherapy that are both expensive and at times toxic without benefit. In contrast, about 60% of tumors show tumor regression and T and N down-staging. Furthermore, a pathologic complete response (pCR), which is characterized by sterilization of all tumor cells, leads to an excellent prognosis and is observed in approximately 10-30% of cases. This variety in tumor response has lead to an increased need to develop a model predictive of responses to CRT in order to identify patients who will benefit from this multimodal treatment. Endoscopy, magnetic resonance imaging, positron emission tomography, serum carcinoembryonic antigen, and molecular biomarkers analyzed using immunohistochemistry and gene expression profiling are the most commonly used predictive models in preoperative CRT. Such modalities guide clinicians in choosing the best possible treatment options and the extent of surgery for each individual patient. However, there are still controversies regarding study outcomes, and a nomogram of combined models of future trends is needed to better predict patient response. The aim of this article was to review currently available tools for predicting tumor response after preoperative CRT in rectal cancer and to explore their applicability in clinical practice for tailored treatment.ope

Characteristics and Survival of Korean Patients With Colorectal Cancer Based on Data From the Korea Central Cancer Registry Data.

PURPOSE: The incidence of colorectal cancer (CRC) in Korea has increased remarkably during the past few decades. The present study investigated the characteristics and survival of patients with CRC in Korea as a function of time, tumor distribution, stage, sex, and age. METHODS: We retrieved clinical data on 326,712 CRC patients diagnosed between 1996 and 2015 from the Korea Central Cancer Registry. The incidence and the 5-year relative survival rates were compared across time period, tumor distribution, stage, sex, and age group. RESULTS: The percentage of patients with colon cancer increased from 49.5% in 1996-2000 to 66.4% in 2011-2015 while the percentage of patients with rectal cancer decreased from 50.5% to 33.6%. The 5-year relative survival rates for all CRCs improved from 58.7% in 1996-2000 to 75.0% in 2011-2015. For 1996-2000, survival rates were highest for patients with left-sided colon cancers, followed by those with right-sided, transverse, rectal, rectosigmoid cancers. For 2011-2015, the survival rates for patients with left-sided cancers were highest, followed by those with rectosigmoid, rectal, transverse, and right-sided colon cancers. Patients with local and regional, but not distant, SEER (Surveillance, Epidemiology, and End Results) stage tumors experienced significantly increased survival rates for 2006-2010 and 2011-2015. The proportion of CRC patients by age decreased in the order ≥70, 60-69, 50-59, 40-49, ≤39 years whereas survival rates decreased in the order 50-59, 60-69, 40-49, ≤39, ≥70 years. CONCLUSION: Korean CRC has some distinct characteristics and survival patterns in terms of tumor distribution, stage, sex, and age. With time, survival outcomes have improved for both local and regional, but not distant, stage tumors.ope

Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution

PURPOSE: This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR. METHODS: Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts. RESULTS: Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]). CONCLUSION: The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.ope

Operative safety and oncologic outcomes in rectal cancer based on the level of inferior mesenteric artery ligation: a stratified analysis of a large Korean cohort

Purpose: To compare high and low inferior mesenteric artery (IMA) ligation in a large number of patients, and investigate the short-term and long-term outcomes. Methods: This retrospective study compared outcomes between high IMA ligation and low IMA ligation with dissection of lymph nodes (LNs) around the IMA origin. A total of 1,213 patients underwent elective low anterior resection with double-stapling anastomosis for stage I-III rectal cancer located ≥6 cm from the anal verge (835 patients underwent IMA ligation at the IMA origin; 378 patients underwent IMA ligation directly distal to the root of the left colic artery along with dissection of LNs around the IMA origin). Results: There was no difference in anastomotic leakage rate between groups. The 2 groups did not significantly differ in intraoperative blood loss, perioperative complications, total number of harvested LNs, and metastatic IMA LNs. However, more metastatic LNs were harvested in the high-tie than in the low-tie group (1.3 ± 2.9 vs. 0.8 ± 1.9, P = 0.002), and the incidence of positive pathologic nodal status was higher in the high-tie group (37.9% vs. 28.6%, P = 0.001). The 5-year local recurrence-free and metastasis-free survival rates were similar between groups, as were the 5-year overall and cancer-specific survival rates. Conclusion: Low IMA ligation with dissection of LNs around the IMA origin showed no differences in anastomotic leakage rate compared with high IMA ligation, without affecting oncologic outcomes. High IMA ligation did not seem to increase the number of total harvested LNs, whereas the ratio of metastatic apical LNs were similar between groups.ope

Prevention of perineal hernia after laparoscopic and robotic abdominoperineal resection: review with illustrative case series of internal hernia through pelvic mesh

This review is intended to raise awareness of placing a pelvic mesh to prevent perineal hernias in cases of minimally invasive (MIS) abdominoperineal resections (APR) and, in doing so, causing internal hernias through the mesh. In this article, we review the published literature and present an illustrative series of 4 consecutive cases of early internal hernia through a pelvic mesh defect. These meshes were placed to prevent perineal hernias after laparoscopic or robotic APRs. The discussion centres on 3 key questions: Should one be placing a pelvic mesh following an APR? What are some of the technical details pertaining to the initial mesh placement? What are the management options related to internal hernias through such a mesh?ope

Herniation after deep circumflex iliac artery flap: two cases of rare complication.

Herniation after harvesting of deep circumflex iliac artery (DCIA) flap is a known but not a common complication. It occurs about 2.8 to 9 % according to the literatures and can proceed to a more severe complication such as bowel obstruction. There are several factors that exacerbate the risk: surgical factors, operator factor, and patient factors. Surgical factors include large anatomical defect and denervation of related muscles. Operator factor stands for unpunctual suture technique. Patient factors represent obesity, diabetes, pulmonary disease, smoking habits, and so on. Thus, herniation might occur regardless of meticulous suture. Herein, we would like to report two cases of herniation after DCIA flap harvesting and repaired by Lichtenstein tension-free hernioplasty with literature review.ope

Duplicated Inferior Vena Cava Recognized during Laparotomy

Duplicated inferior vena cava (IVC) is a congenital anomaly seen rarely in the general population. Patients with IVC variants usually do not present any symptoms and are found incidentally in many cases. However, physicians are urged to recognize the presence of such anomalies during diagnostic or invasive procedures as these variants of blood vessel systems can impose substantial implications in certain clinical situations. Subsequently, information about IVC variants may become critical if surgical injuries or predisposing conditions act as life-threatening risks to patients during medical procedures. We present a case of duplicated IVC in a 68˗year˗old female patient with rectal cancer where an IVC anomaly was found during surgical resection of her tumor. From our experience, we emphasize the importance of having the knowledge of IVC variations in patients undergoing invasive surgical procedures which may involve large vessels.ope