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The oncological outcomes of laparoscopic rectal cancer surgery were evaluated in recent multicenter randomized clinical trials (RCTs). The MRC-CLASSIC, COLOR II, and COREAN trials found no differences in local recurrence or diseasefree survival rate between laparoscopic and open surgery. However, the noninferiority of laparoscopic surgery with respect to open surgery for rectal cancer was not established on statistical analysis in the ACOSOG Z6051 and the ALaCaRT trials. Quality of total mesorectal excision (TME) is one of the most important prognostic factors. Incomplete TME had unfavorable oncologic outcomes compared to complete TME. Although TME quality can be clearly identified on pathologic evaluation, there is controversy regarding the acceptable range of oncologically safe TME for laparoscopic surgery. It is not certain whether near-complete TME has an unfavorable oncologic impact and whether laparoscopic surgery with near-complete TME is an oncological threat. Therefore, the surgical community will be interested in the long-term outcomes and meta-analyses of ongoing large-scale RCTs. Laparoscopic rectal cancer surgery has been steadily improving its safety for oncology surgery, which has been reported consistently in various multicenter RCTs. To improve surgical quality, colorectal surgeons should choose the most appropriate surgical technique, including laparoscopic surgery.
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Purpose Surgery is the only treatment for anal fistula. Many surgical techniques have been described. The aim of this study was to communicate the authors’ preliminary experience in the use of a recently proposed, simplified technique.
Methods This was a prospective study of 28 patients admitted from January 13, 2016 through July 20, 2017. Patients were managed with the ligation of intersphincteric fistula tract (LIFT) technique and results were observed and documented, including recurrence rate, incontinence rate, and other postoperative complications.
Results A total of 28 patients were studied. The mean operation time was 31 minutes (range, 23–44 minutes), and there were no intra- and postoperative complications. The overall complete healing rate was 85.7%, and the recurrence rate was 14.2%. Follow-up was conducted at 1, 3, and 6 months.
Conclusion Many surgical techniques have been described for the treatment of anal fistula. The correct choice of surgical technique out of available procedures is the most important factor for proper treatment and reducing the risk of recurrence or incontinence. In the authors’ experience, the LIFT technique is simple and easy to learn, and is a good choice for the treatment of simple anal fistula; however, a tailored surgery remains the gold standard for this condition.
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Hamid Nasrolahi, Sepideh Mirzaei, Mohammad Mohammadianpanah, Ali Mohammad Bananzadeh, Maral Mokhtari, Mohammad Reza Sasani, Ahmad Mosalaei, Shapour Omidvari, Mansour Ansari, Niloofar Ahmadloo, Seyed Hasan Hamedi, Nezhat Khanjani
Ann Coloproctol. 2019;35(5):242-248. Published online October 31, 2019
Purpose Currently, neoadjuvant chemoradiation (CRT) followed by total mesorectal resection is considered the standard of care for treating locally advanced rectal cancer. This study aimed to investigate the efficacy and feasibility of adding induction chemotherapy to neoadjuvant CRT in locally advanced rectal cancer.
Methods This phase-II clinical trial included 54 patients with newly diagnosed, locally advanced (clinical T3–4 and/or N1–2, M0) rectal cancer. All patients were treated with 3 cycles of preoperative chemotherapy using the XELOX (capecitabine + oxaliplatin) regimen before and after a concurrent standard long course of CRT (45–50.4 Gy) followed by standard radical surgery. Pathologic complete response (PCR) rate and toxicity were the primary and secondary endpoints, respectively.
Results The study participants included 37 males and 17 females, with a median age of 59 years (range, 20–80 years). Twenty-nine patients (54%) had clinical stage-II disease, and 25 patients (46%) had clinical stage-III disease. Larger tumor size (P = 0.006) and distal rectal location (P = 0.009) showed lower PCR compared to smaller tumor size and upper rectal location. Pathologic examinations showed significant tumor regression (6.1 ± 2.7 cm vs. 1.9 ± 1.8 cm, P < 0.001) with 10 PCRs (18.5%) compared to before the intervention. The surgical margin was free of cancer in 52 patients (96.3%). Treatment-related toxicities were easily tolerated, and all patients completed their planned treatment without interruption. Grade III and IV toxicities were infrequent.
Conclusion The addition of induction chemotherapy to neoadjuvant CRT is an effective and well-tolerated treatment approach in patients with rectal cancer.
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Watch and wait strategies for rectal cancer: A systematic review In Ja Park Precision and Future Medicine.2022; 6(2): 91. CrossRef
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Purpose We assessed the clinical outcomes of a seton procedure combined with early versus late institution of infliximab (IFX) therapy.
Methods This retrospective study comprised 76 patients who underwent surgery for perianal fistula associated with Crohn disease between January 2014 and November 2017. All patients underwent loose seton drainage combined with IFX therapy. Patients categorized as the early group (EG, 49 patients) received IFX therapy within 30 days of completion of the seton procedure. Patients categorized as the late group (LG, 27 patients) received IFX therapy >30 days after the seton procedure. IFX therapy was administered as induction and maintenance therapy.
Results There were no statistically significant intergroup differences in clinical characteristics of the patients. The mean follow-up was 21.0 ± 11.6 months in the EG and 34.5 ± 18.4 months in the LG (P = 0.001). The mean interval between seton procedure and IFX induction therapy was 12.2 days in the EG and 250.2 days in the LG (P = 0.002). Complete remission was observed in 32 patients (65.3%) in the EG and 17 patients (63.0%) in the LG (P = 0.844). Fistula recurrence was observed in 6 patients (7.9%). All recurrences occurred in a previous perianal fistula tract.
Conclusion Patients showed a good response to a seton procedure combined with IFX therapy regardless of the time of initiation of IFX therapy.
The use of core descriptors from the ENiGMA code study in recent literature: a systematic review Saher‐Zahra Khan, Andrea Arline, Kate M. Williams, Matthew J. Lee, Emily Steinhagen, Sharon L. Stein Colorectal Disease.2024; 26(3): 428. CrossRef
Impact of Seton Use on Clinical, Patient-Reported, and Healthcare Resource Utilization Outcomes in Complex Crohn’s Perianal Fistulas: A Systematic Literature Review Ian White, Chitra Karki, Parnia Geransar, Lilia Leisle, Sophia Junker, Phillip Fleshner Inflammatory Bowel Diseases.2024;[Epub] CrossRef
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Mesenchymal stem cells in perianal Crohn’s disease H. Guadalajara, M. García-Arranz, M. Dolores Herreros, K. Borycka-Kiciak, A. L. Lightner, D. García-Olmo Techniques in Coloproctology.2020; 24(8): 883. CrossRef
Purpose The efficacy of adjuvant chemotherapy (AC) in stage IIa colon cancer is controversial. This study aimed to investigate the factors influencing survival in patients with stage IIa colon cancer, the role of AC, and the indications for AC utilization by surgical oncologists.
Methods Between January 2004 and December 2010, 736 patients with stage IIa colon cancer underwent curative resection in 1 of 6 participating hospitals. Factors related to survival were identified and analyzed according to whether AC was administered or not. After high- and low-risk groups were identified, their respective results were analyzed.
Results The 5-year overall survival (OS) of stage IIa colon cancer was 90.3%. With the exception of poorly differentiated histology, indications for AC did not include typical high-risk factors. The indications for AC were significantly younger patients, higher body mass index (BMI), lower American Society of Anesthesiologists (ASA) physical status classification, and higher histologic grade. BMI, preoperative carcinoembryonic antigen, and harvested lymph node (LN) count were significant factors for disease-free survival, while BMI and ASA physical status classification were significant factors for OS in the chemotherapy group. In the high-risk group, AC was associated with increased OS in univariate analysis. BMI and harvested LN count were statistically significant in multivariate analysis.
Conclusion Surgical oncologists consider the patient’s condition and postoperative course rather than high-risk factors to determine use of AC. Regardless of AC use, both the extent of surgery and the patient’s subsequent status affected the survival rate in the high-risk group. None of the factors identified influenced survival rate in the low-risk group.
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Use of ascitic CEA levels as a predictive value for distant metastasis in high-risk stage II and III colorectal cancer Abdullah Al-Sawat, Jung Hoon Bea, Seung-Rim Han, Hyo Jin Lee, Mi Ran Yoon, Yoon Suk Lee, Do Sang Lee, Chul Seung Lee, In Kyu Lee International Journal of Colorectal Disease.2022; 37(2): 365. CrossRef
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Purpose The laparoscopic rectopexy has become increasingly popular with verified stability, surgical route selection should be tailored to individual patient characteristics rather than operative risk. The perineal approach is useful in young male patients who need to preserve fertility. This study aimed to compare the characteristics of men and women who underwent Delorme-Thiersch procedures and analyze the postoperative outcomes of the perineal approach by sex.
Methods We retrospectively reviewed the medical records of 293 patients who underwent Delorme-Thiersch operations in Seoul Song Do Colorectal Hospital between January 2011 and September 2017. Patient clinical characteristics and postoperative complications were analyzed by sex. We analyzed surgical outcomes with preoperative and 3-month postoperative incontinence questionnaires, constipation levels, and anal manometry.
Results In this study, men with rectal prolapse were younger than women with the same condition. American Society of Anesthesiologists physical status classifications were higher in women and women had more L-spine X-ray and pudendal nerve terminal motor latency test abnormalities. Anorectal manometry pressures were higher in men. Men also had longer operation times and hospital stays and more postoperative complications (8 T ring infections, 6 patients with bleeding, 3 with strictures, 2 with severe pain, and 2 with rectal perforations). The recurrence rate was higher among women.
Conclusion Men with rectal prolapse were younger, healthier, and had relatively better anorectal function than women. The Delorme-Thiersch operation in men promoted lower recurrence rates and was advantageous in preserving the fertility of young patients, but the incidence of complications was also higher in men. Adequate counseling and preparation for the possibility of complications are needed.
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Purpose Tailgut cysts are rare congenital or developmental lesions that arise from vestiges of the embryological hindgut. They are usually present in the presacral space. We report our single-center experience with managing tailgut cysts.
Methods We conducted a retrospective analysis of 24 patients with tailgut cyst treated surgically at the Colorectal Surgery Department of Severance Hospital, Yonsei University, Seoul, South Korea, between 2007–2018.
Results This study included 24 patients (18 females) with a median age of 51.5 years (range, 21–68 years). Ten cases were symptomatic and 14 were asymptomatic. Cysts were retrorectal in 21 patients. Cysts were below the coccyx level in 16 patients, opposite the coccyx in 6, and above the coccyx in 2. Cysts were supralevator in 5 patients, had a supra- and infralevator extension in 18 patients, and were infralevator in 1. Ten patients were managed using an anterior laparoscopic approach, 11 using a posterior approach, and 3 using a combined approach. Mean cyst size was 5.5 ± 2.7 cm. Postoperative complications were Clavien-Dindo (CD) classification grade II in 9 patients (37.5%) and CD grade III in 1 (4.2%). The posterior approach group showed the highest rate of complications (P = 0.021). Patients managed using a combined approach showed a larger cyst size (P < 0.001), longer operation times (P < 0.001), and a greater likelihood of tumor level above the coccyx (P = 0.002) compared to other approaches. The tumors of 2 male patients were malignant: 1 was a neuroendocrine tumor treated with radiotherapy, while the other was a closely followed adenocarcinoma. Median follow-up was 12 months (range, 1–66 months) with no recurrence.
Conclusion Tailgut cysts are uncommon but can cause perineal or pelvic pain. Complete surgical excision via an appropriate approach according to tumor size, location, and correlation with adjacent pelvic floor muscles is the key treatment.
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Ann Coloproctol. 2019;35(5):275-281. Published online October 31, 2019
Purpose We investigated the sensitivity of various evaluating modalities in predicting a pathologic complete response (pCR) after preoperative chemoradiation therapy (PCRT) for locally advanced rectal cancer (LARC).
Methods From a population of 2,247 LARC patients who underwent PCRT followed by surgery at Asan Medical Center, Seoul, Korea from January 2007 to June 2016, we retrospectively analyzed 313 patients (14.1%) who showed a pCR after surgery. Transrectal ultrasound (TRUS), high-resolution magnetic resonance imaging (MRI), abdominopelvic computed tomography (AP-CT), and endoscopy were performed within 2 weeks prior to surgery.
Results Of the 313 patients analyzed, 256 (81.8%) had a pCR after radical surgery and 57 (18.2%) showed total regression after local excision. Preoperative TRUS, MRI, and AP-CT were performed in 283, 305, and 139 patients, respectively. Among these 3 groups, a prediction of a pCR of the primary tumor was made in 41 (14.5%), 51 (16.7%), and 27 patients (19.4%), respectively, before surgery. A prediction of a clinical N0 stage was made in 204 patients (88.3%) using TRUS, 130 (52.2%) using MRI, and 78 (65.5%) using AP-CT. Of the 211 patients who underwent endoscopy, 87 (41.2%) had a mention of clinical CR in their records. A prediction of a pathologic CR was made for 124 patients (39.6%) through at least one diagnostic modality.
Conclusion The various evaluation methods for predicting a pCR after PCRT show a predictive sensitivity of 0.15–0.41 for primary tumors and 0.52–0.88 for lymph nodes. Endoscopy is a relatively superior modality for predicting the pCR of the primary tumor of LARC patients.
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