Purpose This study aimed to compare the wound cosmesis of a single-incision approach on scar assessment after laparoscopic surgery for colon cancer.
Methods This study included 32 patients undergoing single-port laparoscopic surgery (SPLS) and 61 patients undergoing multiport laparoscopic surgery (MPLS) for colon cancer at 3 tertiary referral hospitals between September 2011 and December 2019. We modified and applied the Korean version of the Patient and Observer Scar Assessment Scale (POSAS) to assess cosmetic outcomes. To assess the interobserver reliability using intraclass correlation coefficient values for the Observer Scar Assessment Scale (OSAS), the surgeons evaluated 5 images of postoperative scars.
Results No significant differences were observed in the time before the return of normal bowel function, time to sips of water and soft diet initiation, length of in-hospital stay, and postoperative complication rate. The SPLS group had a shorter total incision length than the MPLS group. The POSAS favored the SPLS approach, revealing significant differences in the Patient Scar Assessment Scale (PSAS), OSAS, and overall scores. The SPLS approach was an independent factor influencing the POSAS, PSAS, and OSAS scores. Eleven colorectal surgeons had a significantly substantial intraclass coefficient.
Conclusion The cosmetic outcomes of SPLS as assessed by the patients and surgeons were superior to those of MPLS in colon cancer. Reducing the number of ports is an independent factor affecting scar assessment by patients and observers.
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Recent advances in the management of rectal cancer have dramatically changed the clinical practice of colorectal surgeons because the main focus of rectal cancer treatment has changed from sphincter-saving to an organ-preserving strategies. Modifying the delivery of systemic chemotherapy to improve patients’ survival is another progress in colorectal cancer management, known as total neoadjuvant therapy (TNT). TNT is a new strategy used by colorectal surgeons to improve the quality of life and survival of patients after treatment. TNT poses limitations or obstacles, such as overtreatment issues in patients with stage I rectal cancer. However, considering the quality-of-life issues in patients with low-lying rectal cancer necessitating a permanent colostomy, the indication for TNT will be expanded. This review summarizes the recently conducted clinical trials and foresees future perspectives on TNT.
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Malignant disease,Prognosis and adjuvant therapy,Colorectal cancer,Minimally invasive surgery,Surgical technique
Gyung Mo Son, In Young Lee, Yoon Suk Lee, Bong-Hyeon Kye, Hyeon-Min Cho, Je-Ho Jang, Chang-Nam Kim, Kil Yeon Lee, Suk-Hwan Lee, Jun-Gi Kim, On behalf of The Korean Laparoscopic Colorectal Surgery Study Group
Ann Coloproctol. 2021;37(6):434-444. Published online December 8, 2021
Colon cancer treatment is on the way to evolution over several decades. The minimally invasive surgery has improved postoperative short-term outcomes. Adjuvant chemotherapy has prolonged the survival of advanced colon cancer patients. Hohenberger proposed the noble concept of complete mesocolic excision (CME) which consists of 3 components: plane surgery, sufficient longitudinal bowel resection, and central vascular ligation (CVL). Mesocolic plane surgery shares the same surgical principle of total mesorectal excision, which is maintaining the intact mesothelial envelope. However, there remain debates about the extent of bowel resection and the level of CVL for maximizing lymph node dissection. There is no solid clinical evidence for the oncological necessity and benefit of extended radical dissection in right hemicolectomy. CME with CVL based on open surgery has been adopted in laparoscopic surgery. So, it is also necessary to look at how the CME could be transformed and successfully implanted in the laparoscopic era. Recent rapid advances in surgical technology and cancer biology are preparing for fundamental changes in cancer surgery. In this study, we reviewed the history, oncological necessity, and compatibility of CME for the right hemicolectomy in the laparoscopic era and outline the new perspectives on the evolution of cancer surgery.
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Purpose Recently, laparoscopic reversal of Hartmann’s colostomy was performed with favorable outcomes by many surgeons. We partially applied the concepts of single-port laparoscopic procedure through the colostomy site to remove intraperitoneal adhesion during initial step of the laparoscopic Hartmann’s reversal. This study aimed to evaluate the feasibility and safety of the laparoscopic reversal of Hartmann’s colostomy with the application of single-port laparoscopic techniques through the colostomy site.
Methods From October 2008 to November 2018, the laparoscopic Hartmann’s reversal was attempted in 20 patients. After colostomy take-downs, the single-port device was installed at the colostomy site and the single-port laparoscopic procedure was performed to remove intraperitoneal adhesions to provide space for additional trocars. After additional trocars were inserted, the descending colon and rectal stump were mobilized, and the colorectal anastomosis was completed. We retrospectively reviewed the medical records and analyzed the data to identify the perioperative complication rates as the primary outcome.
Results Of the 20 patients, 3 patients (15.0%) had open conversions due to severe adhesions. Intraoperative small bowel injuries occurred in 2 patients (10.0%) and these were repaired through the colostomy site. Postoperative complications developed in 4 patients (20.0%) and were managed with medical treatments or wound closures under local anesthesia.
Conclusion The single-port laparoscopic procedure through the colostomy site is sufficiently safe in order to complete the Hartmann’s reversal. We recommend that the colostomy site should be used as the access route into the abdominal cavity for the Hartmann’s reversal.
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Purpose To delineate the learning curve (LC) for laparoscopic appendectomy (LA) performed by residents according to seniority in training.
Methods Between October 2015 and November 2016, 150 patients underwent LA by three residents (in their first, second, and third year of training) under supervision. The patients were non-randomly assigned to each resident. The data were reviewed and analyzed retrospectively from prospectively collected database. The perioperative outcomes were compared between the three residents including operation time, complication, conversion, and so on. The LCs were evaluated by the moving average method and cumulative sum control chart (CUSUM) for operation time and surgical completion.
Results Baseline characteristics and perioperative outcomes were similar except for age and location of the appendix among the three groups. Operation time was not different among the three residents (43.9, 45.3, and 48.4 min for A, B, and C, respectively). The moving average method for operation time showed a decreasing tendency for all residents. CUSUM for operation time showed that the peak points occurred at the 24th, 18th, and 31st cases for resident A, B, and C, respectively. In terms of surgical failure, residents A, B, and C reached steady states after the 35th, 11th, and 16th cases, respectively. Perforation of the appendix base was the only risk factor for surgical failure.
Conclusion The LC for LA by residents was 11-35 cases according to multidimensional statistical analyses. The accumulation of surgical experience of residents might affect the LC, especially for surgical completion rather than for operation time.
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Methods The English LARS score questionnaire was translated into Korean using the forward-and-back translation method. A total of 146 patients who underwent radical surgery for rectal cancer answered the Korean version of the LARS score questionnaire including an anchor question assessing the impact of bowel function. Participants answered the questionnaire once more after 2 weeks.
Results The Korean LARS score questionnaire showed high convergent validity in terms of high correlation between the LARS score and quality of life (perfect fit 55.5% vs. moderate fit 37.6% vs. no fit 6.8%, respectively; P < 0.001). The LARS score also showed good discriminative validity between groups of patients differing by sex (29 for males vs. 25 for females; P = 0.014), tumor level (29 for ≤8 cm vs. 24 for >8 cm; P = 0.021), and radiotherapy (32 for yes vs. 24 for no; P = 0.001). The LARS score also demonstrated high reliability at test-retest with no difference between scores at the first and second tests (intraclass correlation coefficient: Q1 = 0.932; Q2 = 0.909, Q3 = 0.944, Q4 = 0.931, and Q5 = 0.942; P < 0.001, respectively).
Conclusion The Korean version of the LARS score questionnaire has proven to be a valid and reliable tool for measuring LARS in Korean patients with rectal cancer.
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Purpose Stoma takedown is a frequently performed procedure with considerable postoperative morbidities. Various skin closure techniques have been introduced to reduce surgical site infections. The aim of this study was to assess postoperative outcomes after stoma takedown during a long-term follow-up period.
Methods Between October 2006 and December 2015, 84 consecutive patients underwent a colostomy or ileostomy takedown at our institution. Baseline characteristics and perioperative outcomes were analyzed through retrospective reviews of medical records.
Results The proportion of male patients was 60.7%, and the mean age of the patients was 59.0 years. The overall complication rate was 28.6%, with the most common complication being prolonged ileus, followed by incisional hernia, anastomotic leakage, surgical site infection, anastomotic stenosis, and entero-cutaneous fistula. The mean follow-up period was 64.3 months. The univariate analysis revealed no risk factors related to overall complications or prolonged ileus.
Conclusion The postoperative clinical course and long-term outcomes following stoma takedown were acceptable. Stoma takedown is a procedure that can be performed safely.
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Ann Coloproctol. 2018;34(3):144-151. Published online June 30, 2018
Purpose This study compared the oncologic impact of postoperative chemotherapy and chemoradiotherapy on patients with rectal cancer without preoperative chemoradiation.
Methods This retrospective study analyzed 713 patients with a mean follow-up of 58 months who had undergone radical resection for stage II/III rectal cancer without preoperative treatment in nine hospitals from January 2004 to December 2009. The study population was categorized a chemotherapy group (CG, n = 460) and a chemoradiotherapy group (CRG, n = 253). Five-year overall survival (OS) and disease-free survival (DFS) were analyzed, and independent factors predicting survival were identified.
Results The patients in the CRG were significantly younger (P < 0.001) and had greater incidences of low rectal cancer (P < 0.001) and stage III disease (P < 0.001). Five-year OS (P = 0.024) and DFS (P = 0.012) were significantly higher in the CG for stage II disease; however, they were not significantly different for stage III disease. In the multivariate analysis, independent predictive factors were male sex, low rectal cancer and stage III disease for OS and male sex, abdominoperineal resection, stage III disease and tumor-positive circumferential margin for DFS. However, adjuvant therapy type did not independently affect OS (hazard ratio [HR], 1.243; 95% confidence interval [CI], 0.794–1.945; P = 0.341) and DFS (HR, 1.091; 95% CI, 0.810–1.470; P = 0.566).
Conclusion Adjuvant therapy type did not affect survival of stage II/III rectal cancer patients without neoadjuvant chemoradiotherapy. These results suggest that adjuvant therapy can be chosen based on the patient’s condition and the policies of the surgeons and hospital facilities.
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This study aimed to identify the risk factors for surgical site infections (SSIs) in patients undergoing colorectal cancer surgery and to determine whether significantly different SSI rates existed between the short prophylactic antibiotic use group (within 24 hours) and the long prophylactic antibiotic use group (beyond 24 hours).
Methods
The medical records of 327 patients who underwent colorectal resection due to colorectal cancer from January 2010 to May 2014 at a single center were retrospectively reviewed, and their characteristics as well as the surgical factors known to be risk factors for SSIs, were identified.
Results
Among the 327 patients, 45 patients (13.8%) developed SSIs. The patients were divided into two groups according to the duration of antibiotic use: group S (within 24 hours) and group L (beyond 24 hours). Of the 327 patients, 114 (34.9%) were in group S, and 213 (65.1%) were in group L. Twelve patients (10.5%) in group S developed SSIs while 33 patients (15.5%) in group L developed SSIs (P = 0.242). History of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were independent risk factors for SSIs.
Conclusion
This study shows that discontinuation of prophylactic antibiotics within 24 hours after colorectal surgery has no significant influence on the incidence of SSIs. This study also showed that history of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were associated with increased SSI rates.
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The usefulness of mechanical bowel preparation (MBP) in colon surgery was recently challenged by many multicenter clinical trials and meta-analyses. The objectives of this study were to investigate current national opinions about MBP and prophylactic antibiotics (PA) and to provide preliminary data for developing future Korean guidelines for MBP and PA administration in colorectal surgery.
Methods
A questionnaire was mailed to 129 colorectal specialists. The questionnaires addressed the characteristics of the hospital, the MBP methods, and the uses of oral and intravenous antibiotics.
Results
A total of 73 questionnaires (56.6%) were returned. First, in regard to MBP methods, most surgeons (97.3%) used MBP for a mean of 1.36 days. Most surgeons (98.6%) implemented whole bowel irrigation and used polyethylene glycol (83.3%). Oral antibiotic use was indicated in over half (52.1%) of the responses, the average number of preoperative doses was three, and the mean time of administration was 24.2 hours prior to the operation. Finally, the majority of responders stated that they used intravenous antibiotics (95.9%). The responses demonstrated that second-generation cephalosporin-based regimens were most commonly prescribed, and 75% of the surgeons administered these regimens until three days after the operation.
Conclusion
The results indicate that most surgeons used MBP and intravenous antibiotics and that half of them administered oral PA in colorectal surgery preparations. The study recommends that the current Korean guidelines should be adapted to adequately reflect the medical status in Korea, to consider the medical environment of the various hospitals, and to establish more accurate and relevant guidelines.
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