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BACKGROUND: We investigated the prognostic significance of tumor regression grade (TRG) after preoperative chemoradiation therapy (preop-CRT) for locally advanced rectal cancer especially in the patients without lymph node metastasis. METHODS: One-hundred seventy-eight patients who had cT3/4 tumors were given 5,040 cGy preoperative radiation with 5-fluorouracil/leucovorin chemotherapy. A total mesorectal excision was performed 4-6 weeks after preop-CRT. TRG was defined as follows: grade 1 as no cancer cells remaining; grade 2 as cancer cells outgrown by fibrosis; grade 3 as a minimal presence or absence of regression. The prognostic significance of TRG in comparison with histopathologic staging was analyzed. RESULTS: Seventeen patients (9.6%) showed TRG1. TRG was found to be significantly associated with cancer-specific survival (CSS; P = 0.001) and local recurrence (P = 0.039) in the univariate study, but not in the multivariate analysis. The ypN stage was the strongest prognostic factor in the multivariate analysis. Subgroup analysis revealed TRG to be an independent prognostic factor for the CSS of ypN0 patients (P = 0.031). TRG had a stronger impact on the CSS of ypN (-) patients (P = 0.002) than on that of ypN (+) patients (P = 0.521). In ypT2N0 and ypT3N0, CSS was better for TRG2 than for TRG3 (P = 0.041, P = 0.048), and in ypN (-) and TRG2 tumors, CSS was better for ypT1-2 than for ypT3-4 (P = 0.034). CONCLUSION: TRG was found to be the strongest prognostic factor in patients without lymph node metastasis (ypN0), and different survival was observed according to TRG among patients with a specific histopathologic stage. Thus, TRG may provide an accurate prediction of prognosis and may be used for f tailoring treatment for patients without lymph node metastasis.

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AIM: To evaluate whether the incorporation of a novice first assistant into a laparoscopic team affects operative outcomes after laparoscopic sigmoidectomy for sigmoid colon cancer. METHODS: Sixty-five patients who underwent laparoscopic sigmoidectomy were prospectively enrolled in this study between March 2008 and October 2008. One surgeon with a novice first assistant during the study period carried out all operations. Outcomes of this population were compared with those of 50 patients (control group) that underwent laparoscopic sigmoidectomy between March 2007 and February 2008 by the same surgeon with an experienced first assistant. The 65 patients operated upon with the involvement of the novice (the patients group) were allocated to 2 groups by case number, that is, to an early group (case numbers 1 to 10) and to a late group (case numbers 11 to 65). RESULTS: Mean operative times were 233+/-50 minutes in the control group, 305+/-113 minutes in the early group, and 226+/-58 minutes in the late group (P=0.04). Multiple regression analysis showed that in the early group, body mass index and tumor diameter significantly contributed to operative time. The incidences of intraoperative and postoperative complications were not significantly different in the early, late, and control groups. CONCLUSIONS: The incorporation of a novice first assistant into a laparoscopic team was not found to affect operative outcomes adversely. However, in terms of operative time, novice assistants probably need experience of around 10 cases before they can be viewed as fully competent surgical team members during laparoscopic sigmoidectomy.

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Among women with intestinal endometriosis, the sigmoid colon and rectum are the most commonly involved areas. Sometimes, the differential diagnosis of colorectal endometriosis from carcinoma of the colon and rectum is difficult due to similar colonoscopic and radiologic findings. From October 2002 to September 2007, we performed five operations with curative intent for rectal and sigmoid colon cancer that revealed intestinal endometriosis. Colonoscopic and radiologic findings were suggestive of carcinoma of rectum and sigmoid colon, such as rectal cancer, sigmoid colon cancer and gastrointestinal stromal tumor (GIST). Anterior resection was performed in two patients, low anterior resection was performed in one patient and laparoscopic low anterior resection was done in two patients. We suggest to consider also intestinal endometriosis in reproductive women presenting with gastrointestinal symptoms and an intestinal mass of unknown origin.

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BACKGROUND/AIMS: Primary colorectal signet-ring cell carcinoma (SRC) is a rare type of mucin-containing adenocarcinoma and little information exists about its clinicopathological features. METHODS: The clinicopathological features of 27 patients with primary colorectal SRC were compared with non-signet-ring cell mucinous carcinoma (MC) and non-mucinous adenocarcinoma (NMC). To analyze survival and recurrence, we used matched control groups. RESULTS: The mean age of patients in SRC was significantly younger than that of NMC (p = 0.003). The ratio of metastatic lymph nodes to harvested lymph nodes was also significantly higher in SRC (48.5 +/- 30.6) than in either MC (29.8 +/- 26.3; p = 0.009) or NMC (22.0 +/- 21.6; p = 0.003). In stage II and III, SRC was found to be associated with a worse cancer-specific survival and a higher systemic recurrence rates than either NMC or MC. CONCLUSIONS: Primary colorectal SRC has distinctive clinicopathological features and is associated with a poorer prognosis than the other histological subtypes.

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BACKGROUND: The purpose of this study is to review the clinical outcomes of patients who received extended lymph node dissection for radiologically diagnosed extramesenteric lymph node metastasis. PATIENTS AND METHODS: The authors reviewed clinical characteristics, short-term operative outcomes, and long-term oncologic outcomes of 151 patients who had received total mesorectal excision plus extended lymph node dissection for the treatment of radiologically diagnosed extramesenteric lymph node metastasis. RESULTS: The positive predictive value of the radiologic diagnosis of extramesenteric lymph node metastasis was 86.4% for lateral nodes and 40.0% for para-aortic nodes. It showed improvement over time. Perioperative mortality occurred in 3 patients (2.0%) and morbidity in 31 patients (20.5%). Pathologic examinations revealed metastatic para-aortic lymph nodes in 43 patients (PA) and metastatic lateral pelvic nodes in 36 patients (LP), while in 21 patients, metastasis was found in both (LP + PA). Both cancer-specific survival (CSS) and disease-free survival (DFS) were significantly different according to the extent of node metastasis (CSS: P < .001; DFS: P < .001) and univariate and multivariate analyses for prognostic factors revealed that the lymph node status as to location was the only factor. CONCLUSION: Patients with extramesenteric lymph node metastasis may be a distinct subgroup with poor prognosis. Extended lymph node dissection may have a role for those patients. However, the optimal treatment strategy remains inconclusive, for which further clinical research is necessary.

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PURPOSE: We determined the prognostic value of carcinoembryonic antigen (CEA) clearance after tumor resection with serial evaluation of postoperative CEA levels in rectal cancer. METHODS: Between 1994 and 2004, we retrospectively reviewed 122 patients with rectal cancer whose serum CEA levels were measured on the preoperative day and postoperative days 7 and 30. Patients with preoperative CEA levels <5.0 ng/ml were excluded. An exponential trend line was drawn using the three CEA values. Patients were categorized into three groups based on R(2) values calculated through trend line, which indicates the correlation coefficient between exponential graph and measured CEA values: exponential decrease group (group 1: 0.9 < R(2) < or = 1.0), nearly exponential decrease group (group 2: 0.5 < R(2) < or = 0.9), and randomized clearance group (group 3: 0.5 < or = R(2)). We then analyzed the CEA clearance pattern as a prognostic indicator. RESULTS: With a median follow-up of 57 months, the 5-year overall survival was 62.3% vs. 48.1% vs. 25% and the 5-year disease-free survival was 58.6% vs. 52.7% vs. 25% among groups 1, 2, and 3 (P = 0.014, P = 0.027, respectively) in patients with stage III rectal cancer. For those with stage II rectal cancer, the 5-year overall survival rate of group 1 was significantly better than groups 2 and 3 (88.8% vs. 74.1%, respectively, P = 0.021). CONCLUSIONS: The postoperative pattern of CEA clearance is a useful prognostic determinant in patients with rectal cancer. Patients with a randomized pattern of CEA clearance after tumor resection should be regarded as having the possibility of a persistent CEA source and may require consideration of intensive follow-up or adjuvant therapy.

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BACKGROUND: The purpose of the present study was to investigate risk factors associated with local recurrence in patients with locally advanced rectal cancer who received preoperative chemoradiotherapy in combination with total mesorectal excision (TME). METHODS: Rectal cancer patients who were treated with neoadjuvant chemoradiation with TME were studied. We compared 26 patients who developed local recurrence with 119 recurrence-free patients during the follow-up period. RESULTS: The median follow-up period was 52 months (range: 14-131 months). Based on the use of univariate and multivariate analyses, circumferential margin involvement (p = 0.02), the presence of lymphovascular or perineural invasion (p = 0.02), and positive nodal disease (p = 0.03) were contributing factors for local recurrence. The local recurrence rate was different between ypN(+) patients and ypN(-) patients with more than 12 nodes retrieved (p = 0.01). There was no difference in local recurrence rates between ypN(+) patients and ypN(-) patients with < 12 nodes (p = 0.35) or between ypN(-) patients with < 12 nodes or > or = 12 nodes (p = 0.18). CONCLUSIONS: Patients with circumferential margin involvement, the presence of lymphovascular or perineural invasion, and positive nodal disease should be regarded as a high-risk group. We also determined that lymph node retrieval (< 12 nodes) in patients with node-negative disease was a risk factor for local recurrence.

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OBJECTIVE: This study was designed to determine whether the number of lymph nodes retrieved influence staging and survival in patients with stage II and III rectal cancer that undergo tumor-specific mesorectal excision. SUMMARY BACKGROUND DATA: The prognostic impact of the retrieved nodes has been emphasized in patients with colorectal cancer, but few studies have focused on patients with rectal cancer. METHODS: A total of 900 patients who underwent tumor-specific mesorectal excision with curative intent and adjuvant chemoradiation therapy for stage II and III rectal cancer from January 1989 to December 2006 were analyzed. RESULTS: Cancer-specific survival (CSS) of stage II patients with less than 15 nodes (25th percentile) was not different from stage III patients, but CSS was better in stage II patients with more than 15 nodes. When using cutoff values of the 25th and 50th percentiles (22 and 31 nodes), recurrence-free survival (RFS) was statistically different among subgroups of stage II and III patients. In multivariate analysis, stage II disease with less than 15 nodes retrieved was an adverse factor for CSS and RFS. In Kaplan-Meier survival analysis, using cutoff values, the difference for CSS was not significant with 22 and more nodes and the difference for RFS was not observed with 23 and more nodes. CONCLUSIONS: The number of lymph nodes retrieved is closely associated with survival and recurrence in patients with stage II rectal cancer and, for more accurate prognostic stratification, at least 22 and 23 nodes seem to be necessary, respectively, for CSS and for RFS.

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BACKGROUND: We aimed to assess factors associated with the number of nodes retrieved and the impact of the number of lymph nodes in rectal cancer patients who underwent neoadjuvant chemoradiation with radical surgery. METHODS: A total of 258 patients were enrolled. Lymph nodes were retrieved from specimens using a manual dissection technique. RESULTS: Of the 258 patients, nine patients had an absence of lymph nodes (ypNx), 150 patients had a node-negative status (ypN(-)) and 99 patients had node-positive disease (ypN(+)). An advanced ypT classification (ypT3,4) and larger tumor (>4 cm) were associated with an increased number of nodes retrieved. The pretreatment CEA level (>5 ng/ml) and ypN(+) classification were significant risk factors for cancer specific and recurrence free survival. There was no significant difference of oncological outcomes among ypNx patients and a subset of ypN(-) patients based on the number of nodes retrieved using three cutoff values (1-11, 12-25, and 25-65 nodes). CONCLUSIONS: In a neoadjuvant setting, ypN(+) disease was an independent risk factor for oncological outcomes. An absence of nodes does not represent an inferior oncological outcome. The number of nodes does not seen to impact survival and recurrence in ypN(-) patients.

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BACKGROUND: Self-expanding metallic stents (SEMS) have been used as a bridge to surgery in patients with obstruction by colorectal cancer, but the oncologic safety of this technique has not yet been established. The aim of the present study was to compare the outcomes of bridge to surgery after SEMS insertion and nonobstructing elective surgery. METHODS: Between October 1999 and July 2007, 35 patients who had left-sided colon malignancy obstruction and underwent surgical resection after SEMS insertion (group A) were matched to 350 patients who underwent elective surgery for nonobstructing left-sided colon cancer based on stage II, III, and IV malignancies according to the 2001 American Joint Committee on Cancer (group B). Group B was randomly extracted from the colorectal database of our institute. The two groups were compared for clinicopathologic variables, complications, and survival rate. RESULTS: There were no significant differences in clinicopathologic variables between group A and group B. However, the stoma formation rate was statistically different between the two groups (p = 0.003). Self-expanding metallic stent insertion had an adverse effect on the 5-year overall survival rate (A vs. B, 38.4% vs. 65.6%, respectively; p = 0.025) and the 5-year disease-free survival rate (A vs. B, 48.3% vs. 75.5%, respectively; p = 0.024). CONCLUSIONS: These data show that insertion of SEMS as a bridge to surgery in the management of left-sided colon cancer obstruction is possibly associated with adverse oncologic outcomes compared with nonobstructing elective surgery, but it is unclear what magnitude of this effect is related to the underlying obstruction rather than to the SEMS.

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The term "obstructive colitis" refers to ulceroinflammatory lesions occurring in the colon proximal to a completely or partially obstructing lesion. It has been referred to by various terms in the literature. This entity differs from the carcinoma of the colon that complicates true ulcerative colitis where there is involvement distal to the neoplasm as well as proximal to it. Although it has appeared in the literature over several decades, it remains an uncommon and troublesome disease. In Yonsei University Medical Center, for 11 years from January 1996 to December 2006 we encountered seven patients with obstructing colorectal carcinoma complicated by obstructive colitis. Here we report our cases to share our experience and to review the literature to facilitate the recognition and proper management of this rare disease entity.

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BACKGROUND: The aim of this study is to compare the short-term results between robotic-assisted low anterior resection (R-LAR), using the da Vinci Surgical System, and standard laparoscopic low anterior resection (L-LAR) in rectal cancer patients. METHODS: 113 patients were assigned to receive either R-LAR (n = 56) or L-LAR (n = 57) between April 2006 and September 2007. Patient characteristics, perioperative clinical results, complications, and pathologic details were compared between the groups. Moreover, macroscopic grading of the specimen was evaluated. RESULTS: Patient characteristics were not significantly different between the groups. The mean operation time was 190.1 +/- 45.0 min in the R-LAR group and 191.1 +/- 65.3 min in the L-LAR group (P = 0.924). The conversion rate was 0.0% in the R-LAR groups and 10.5% in the L-LAR group (P = 0.013). The serious complication rate was 5.4% in the R-LAR group and 19.3% in the L-LAR group (P = 0.025). The specimen quality was acceptable in both groups. However, the mesorectal grade was complete (n = 52) and nearly complete (n = 4) in the R-LAR group and complete (n = 43), nearly complete (n = 12), and incomplete (n = 2) in the L-LAR group (P = 0.033). CONCLUSION: R-LAR was performed safely and effectively, using the da Vinci Surgical System. The use of the system resulted in acceptable perioperative outcomes compared to L-LAR.

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BACKGROUND: This study was designed to evaluate the operative safety and long-term oncologic outcomes of sphincter-preserving surgery based on sharp mesorectal excision for rectal cancer. METHODS: Between January 1989 and June 2004, 931 patients underwent sphincter-preserving surgery based on sharp mesorectal excision. The operative safety and oncologic outcomes were assessed for the periods of 1989-1996 (n = 208) and 1997-2004 (n = 723). Total mesorectal excision (TME)-based sphincter-preserving surgery was performed during the period of 1989-1996. A multidisciplinary team approach and tailored mesorectal excision, which is the differential removal of the mesorectum, were our standard treatment for patients with rectal cancer during the period of 1997-2004. RESULTS: The use of preoperative chemoradiation (P < 0.001), ultralow anterior resection with coloanal anastomosis (P = 0.01), diverting stoma (P = 0.001), and <2 cm of a distal resection margin (P = 0.01) were more common during the period of 1997-2004. There were no differences between the two periods with regard to perioperative complications (P = 0.2), such as anastomosis leakage (2.4% vs. 3.6%). Cancer-specific survival rates (79.1% vs. 79.6%, P = 0.7) and local recurrence (8.4% vs. 8.6%, P = 0.99) did not differ significantly for the two periods. CONCLUSIONS: Based on sharp mesorectal excision, operative safety and oncologic outcomes were not compromised by technical advances in sphincter-preserving surgery using tailored mesorectal excision and a shortened distal margin.

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BACKGROUND: Over the past several years, preoperative chemoradiotherapy (CRT) has contributed remarkably to make more sphincter-preserving procedure (SPP) possible for lower rectal cancer. The aim of this study was to compare the outcomes between abdominoperineal resection (APR) and SPP after preoperative CRT in patients with locally advanced lower rectal cancer. METHODS: A retrospective investigation was conducted with a total of 122 patients who underwent radical surgery combined with preoperative CRT for locally advanced lower rectal cancer. Of these, 50 patients underwent APR and 72 received SPP. Surgery was performed 6-8 weeks after completion of preoperative CRT. Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated. RESULTS: Circumferential resection margin (CRM) involvement (P = 0.037) and postoperative complication rate (P = 0.032) were significantly different between APR and SPP. Patients who underwent APR had a higher 5-year local recurrence (22.0% vs. 11.5%, P = 0.028) and lower 5-year cancer-specific survival (52.9% vs. 71.1%, P = 0.03) rate than those who underwent SPP. Pathologic N stage was the most critical predictor for local recurrence and survival. CONCLUSIONS: Our study shows that APR following preoperative CRT exhibited more adverse oncologic outcomes compared with SPP. This result may be due to higher rates of CRM involvement in APR even with preoperative CRT. We suggest that sharp perineal dissection and wider cylindrical excision at the level of the anorectal junction are required to avoid CRM involvement and improve oncologic outcomes in patients who undergo APR following preoperative CRT.

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BACKGROUND: We compared outcomes in patients with solitary colorectal liver metastases treated by either hepatic resection (HR) or radiofrequency ablation (RFA). METHODS: A retrospective analysis from a prospective database was performed on 67 consecutive patients with solitary colorectal liver metastases treated by either HR or RFA. RESULTS: Forty-two patients underwent HR and 25 patients underwent RFA. The 5-year overall and local recurrence-free survival rates after HR (50.1% and 89.7%, respectively) were higher than after RFA (25.5% and 69.7%, respectively) (P = .0263 and .028, respectively). In small tumors less than 3 cm (n = 38), the 5-year survival rates between HR and RFA were similar, including overall (56.1% vs 55.4%, P = .451) and local recurrence-free (95.7% vs 85.6%, P = .304) survival rates. On multivariate analysis, tumor size, metastases treatment, and primary node status were significant prognostic factors. CONCLUSIONS: HR had better outcomes than RFA for recurrence and survival after treatment of solitary colorectal liver metastases. However, in tumors smaller than 3 cm, RFA can be recommended as an alternative treatment to patients who are not candidates for surgery because the liver metastases is poorly located anatomically, the functional hepatic reserve after a resection would be insufficient, the patient's comorbidity inhibits a major surgery, or extrahepatic metastases are present.

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BACKGROUND: In patients undergoing total mesorectal excision (TME), the clinical variables most relevant to anastomotic recurrence have not been identified. We evaluated factors associated with anastomotic recurrence in patients undergoing TME and the impact of a reduced distal margin on anastomotic recurrence. METHODS: Thirty-eight patients with anastomotic recurrence were compared with 876 patients who received curative rectal cancer surgery. Patients were compared according to: (1) the presence of anastomotic recurrence (recurrence vs. recurrence-free), (2) distal margin length (< or =10 mm vs. >10 mm) and (3) additional treatment (none, adjuvant, or neoadjuvant). The risk factors for anastomotic recurrence were analyzed. RESULTS: In the recurrence group, an advanced T stage (T3 and T4) (P = 0.01) microscopic distal margin involvement (P = 0.002) and an elevated CEA level (>5 ng/ml) (P = 0.04) were more commonly found. The incidence of anastomotic recurrence was not higher in the distal margin < or =10 mm group and did not differ according to additional treatment. The multivariate analysis showed that an advanced T stage (T3 and T4) and microscopic distal margin involvement were risk factors for anastomotic recurrence. CONCLUSION: A distal margin < or =10 mm appears to be acceptable in terms of anastomotic recurrence. Patients with a positive distal margin, on the postoperative pathology, should be considered at high risk for anastomotic recurrence.

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The anal sphincter preservation rate (ASPR) according to tumor level and neoadjuvant chemoradiotherpy (CRT) has not been fully evaluated. Therefore, the aim of this study was to evaluate the correlation between the tumor level, neoadjuvant CRT, and the ASPR in rectal cancer patients. We studied 544 patients (tumor level, 0-6 cm) who underwent curative resection for rectal cancer between 1991 and 2005. Patients were divided six into groups according to tumor level over 1-cm intervals, and the ASPR was evaluated in patients with and without neoadjuvant CRT according to tumor level. Sphincter preservation surgery was performed in 191 patients, and 86 patents underwent neoadjuvant CRT. The overall ASPR was 43.0% (37/86) in patients with neoadjuvant CRT and 33.6% (154/458) in patients without neoadjuvant CRT (P=0.094). In an analysis according to tumor level, the ASPR was 0.0 vs 0.0% in

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BACKGROUND: The da Vinci system is a newly developed device for colorectal surgery, therefore experience of its use for rectal cancer surgery is limited and there are no reports describing the use of four robotic arms with this system. The aim of this study is to evaluate the safety and feasibility of the four-arm da Vinci system for total mesorectal excision in rectal cancer patients. METHODS: Clinicopathologic data were prospectively collected on nine patients who underwent robotic total mesorectal excision using four robotic arms for the treatment of mid or low rectal cancer between November 2006 and Febuary 2007. Patient demographics, perioperative clinical outcomes, and pathology results with macroscopic grading (complete, nearly complete, incomplete) were evaluated. RESULTS: nine patients with mid or low rectal cancer underwent robotic total mesorectal excison using four robotic arms without serious complications. The mean length of hospital stay was 7.4 +/- 1.3 days (range 5.0-10.0 days) and the mean operating time was 220.8 +/- 49.4 min (range 153-315 min). Macroscopic grading of the specimen was complete in eight patients and nearly complete in one patient. There were no cases of conversion. CONCLUSION: In the present study, we accomplished nine robot-assisted rectal resections safely and effectively.

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