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Purpose: Single-incision laparoscopic surgery was developed recently and has the benefit of reducing the number of incisions. Its application in colectomy has been published only in case reports. The present study evaluated our early results of single-incision laproscopic surgery in a series of 8 patients who underwent colectomy for various colorectal pathologies., Methods: Eight patients underwent single-incision laparoscopic colectomy for cancer (n = 5), polyps (n = 2), and diverticulitis (n = 1) during the study period. The data on the operations and outcomes were collected prospectively and analyzed., Results: The median age of the patients was 78 years (range, 49-88). The operations were right colectomy (n = 6), left colectomy (n = 1), and anterior resection (n = 1). The median operating time was 175 minutes (range, 103-260) and the median blood loss was 55 mL (range, 20-200). The average length of the incision was 3.4 cm (range, 3.0-5.0). One patient required conversion to hand-assisted laparoscopy with a 5-cm incision. The median hospital stay was 3.5 days (range, 3-6) and 1 patient had ileus after the operation. There was no mortality and no reintervention within 30 days. In patients with cancer, all of the resection margins were clear. The median number of lymph nodes examined was 13.5 (range, 9-36)., Conclusions: Single-incision laparoscopic surgery can be applied to colectomy safely. Oncologic resection similar to conventional laparoscopy can be performed with this technique. Further studies are needed to evaluate the outcomes against those of conventional laparoscopic resection.

Purpose: Published studies comparing the addition of chewing gum to standardized postoperative care to shorten postoperative ileus showed controversial results. This study was designed to conduct a systematic review of all relevant trials on chewing gum to reduce postoperative ileus after colorectal resection., Methods: All published trials that compared the additional use of gum chewing with standard postoperative management were identified from Ovid MEDLINE, EMBASE, CINAHL, and All Evidence-Based Medicine Reviews between January 1991 and January 2007. The clinical outcomes were extracted and meta-analysis was performed by Forest plot review., Results: Five randomized, controlled trials with 158 (94 males) patients with mean age of 61.9 years were included. Seventy-eight patients received an addition of gum chewing and 80 had standard postoperative care for colorectal resection. Operating time (P = 0.78) and blood loss (P = 0.48) were similar. All patients tolerated the gum without any side-effects. With combined standard postoperative care and gum chewing, the patients passed flatus 24.3 percent earlier (weighted mean difference, -20.8 hours; P = 0.0006) and had bowel movement 32.7 percent earlier (weighted mean difference, -33.3 hours; P = 0.0002). They were discharged 17.6 percent earlier than those having ordinary postoperative treatment (weighted mean difference, -2.4 days; P < 0.00001). The gum-chewing group was associated with similar overall postoperative complication rate (odds ratio, 0.45; P = 0.05) with individual complication showing a trend favoring gum chewing, although they were not of statistical significance. Readmission (odds ratio, 0.36; P = 0.24) and reoperation rates (odds ratio, 1.36; P = 0.83) of the two groups were similar., Conclusions: The use of gum chewing in the postoperative period is a safe method to stimulate bowel motility and reduce ileus after colorectal surgery.

Purpose: The study was designed to identify the risk factors associated with anastomotic leakage after an intraperitoneal large-bowel anastomosis in patients with colorectal malignancy., Methods: The prospectively collected data of patients who underwent colorectal resection for malignancy with primary anastomosis above the pelvic peritoneal reflection for malignancy between 1996 and 2004 were reviewed. Thirty-five variables were evaluated using univariate and multivariate analysis., Results: A total of 1,417 patients were studied and anastomotic leakage occurred in 25 patients (1.8 percent). Twenty-two patients (88 percent) required reoperation for anastomotic leakage. The hospital stay (28 vs. 10 days, P < 0.001) and mortality rate (32 vs. 4 percent, P < 0.001) of patients with anastomotic leakage were significantly increased compared with those without leakage. Multivariate analysis showed that American Society of Anesthesiologists Grade 3 to 5 (P = 0.04; odds ratio, 5.6; 95 percent confidence interval, 1.6-15.3) and emergency operation (P = 0.03; odds ratio, 4.6; 95 percent confidence interval, 1.9-9.8) were independent factors associated with anastomotic leakage. The risk of anastomotic leakage was 8.1 percent (odds ratio, 10.5; 95 percent confidence interval, 2.7-26.8) if both factors were present., Conclusions: Intraperitoneal anastomosis after large-bowel resection is associated with a low leakage rate. Emergency surgery and a high American Society of Anesthesiologists grade are independent factors associated with an increased incidence of leakage. A temporary diverting stoma to protect the primary anastomosis or even avoidance of anastomosis could be considered for patients with the two risk factors present.

Purpose: This study was designed to compare the outcomes of laparoscopic anterior resection with open operation for mid and upper rectal cancer., Methods: A total of 265 patients who underwent elective laparoscopic or open anterior resection for cancer of the mid and upper rectum from June 2000 to December 2004 were included. Data about the patients' demographics, operative details, postoperative outcome, and disease status were collected prospectively. Comparison of the outcome between laparoscopic and open resection was performed., Results: The median age of the 265 patients was 69 (range, 27-91) years, and laparoscopic anterior resection was performed in 98 patients (37 percent). There was no difference in the age, gender, comorbidities, and level of tumor between the two groups. The operating time was longer in the laparoscopic group (200 vs. 127 minutes; P < 0.01), but the blood loss was less (200 vs. 250 ml; P = 0.027). The overall operative mortality was 1.8 percent, and the complication rate was 27.9 percent. Significantly more patients with early diseases (Stage I and Stage II) were operated with laparoscopic approach. There was no difference in the mortality or morbidity between the two groups. Anastomotic leakage occurred in five patients with open resection and one with laparoscopic resection (P = 0.418). Patients with laparoscopic resection had an earlier return of bowel function and earlier resumption of diet as well as a shorter median hospital stay (7 vs. 8 days; P < 0.001). With the median follow-up of the surviving patients for 21.2 months, the three-year local recurrence rates for those with open and laparoscopic resection were 4.9 and 3.3 percent, respectively (P = 0.513). In patients with Stage I and Stage II disease, the three-year cancer-specific survivals for open and laparoscopic resection were 89.8 and 88.6 percent, respectively (P = 0.882), whereas those of patients with Stage III disease were 65.6 and 55.5 percent, respectively (P = 0.911)., Conclusions: Laparoscopic anterior resection for mid and proximal rectal cancer is a safe option with short-term advantages compared with open operation. The oncologic outcomes of patients who underwent laparoscopic anterior resection were not compromised, with similar local recurrence rate and the cancer-specific survival rate as patients who underwent open resection.

Purpose: This study examined the accuracy of Portsmouth Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity system (P-POSSUM) in predicting the mortality of patients who underwent operations for obstructing colorectal cancer. It also is attempted to analyze the actual mortality and the predicted P-POSSUM mortality of different surgical options for obstructing left-sided cancer., Methods: Data on patients who underwent surgery for obstructing colorectal cancer during 1998 to 2002 were collected. Mortality predicted by P-POSSUM was compared to the actual mortality with the method of linear analysis. The accuracy of using P-POSSUM to predict mortality in this group of patients was assessed by Hosmer and Lemeshow goodness of fit test and Receiver Operator Characteristic curve analysis. The predicted and actual mortality of patients who underwent different surgical options also were analyzed., Results: A total of 160 patients were included in the study and 18 patients died postoperatively. The operative mortality was 11.3 percent. P-POSSUM predicted overall mortality of 15 percent. The observed and predicted mortality was found to have no significant lack of fit (chi-squared = 5.98; degree of freedom = 3; P = 0.11). The area under Receiver Operator Characteristic curve analysis was 0.75. For patients with left-sided tumors, P-POSSUM predicted mortality and actual mortality of patients who had resection without anastomosis were both significantly higher than patients with single-stage resection and primary anastomosis (P = 0.044 and 0.011, respectively)., Conclusions: P-POSSUM system is valid for prediction of overall mortality in patients with operations for obstructing colorectal cancer. Estimation of P-POSSUM predicted mortality during operation and its ability to correlate with choice of procedure is an area that is worth further study in emergency colorectal surgery.

Background: This study aimed to evaluate the oncological outcome of patients who had Stage II rectal cancer and underwent curative nonsphincter-ablation surgery without adjuvant radiation., Patients and Methods: During the study period from August 1993 to December 2002, 224 patients (141 men) with Stage II cancer underwent curative anterior resection or Hartmann's procedure without adjuvant radiation. Data were collected prospectively. The oncologic outcomes of these patients were studied and the risk factors for recurrence and survival were analyzed., Results: The median age of the patients was 69 (range, 27-89) years and the median level of the tumor from the anal verge was 8 (range, 3-20) cm. Four patients (1.8 percent) died in the postoperative period and postoperative complications occurred in 74 patients (33 percent). The median follow-up time of the surviving patients was 43.6 months. The actuarial five-year recurrence rate was 25.4 percent, whereas the five-year actuarial local and systemic recurrence rates were 6.1 percent and 20 percent, respectively. On multivariate analysis, independent factors associated with a higher recurrence rate included lymphovascular invasion, perineural invasion, and absence of chemotherapy. The overall and cancer-specific survival rates of the patients were 71.1 percent and 81.1 percent, respectively. On multivariate analysis, only adjuvant chemotherapy (P = 0.024; hazard ratio = 6.04; 95 percent confidence interval, 1.27-28.74) and the absence of lymphovascular invasion (P = 0.002; hazard ratio = 3.77; 95 percent confidence interval, 1.63-8.77) were independent factors associated with significantly better cancer-specific survival., Conclusion: A low local recurrence rate can be achieved in patients with Stage II rectal cancer treated with nonsphincter-ablation surgery without adjuvant radiation. Postoperative chemotherapy is associated with a lower recurrence rate and higher survival rates. Further study is warranted to define the role of adjuvant chemotherapy in patients with rectal cancer.

Purpose: This study was designed to evaluate the outcomes of self-expanding metallic stents as a palliative treatment for malignant obstruction of the colon and rectum., Methods: The insertion of self-expanding metallic stents was attempted for palliation in 52 patients (33 males; mean age, 66.5 +/- 16.4 years) with colorectal obstruction caused by advanced malignancies. The stents were inserted under endoscopic and fluoroscopic guidance. The data on the success of the procedure, the complications, and the outcomes of the patients were collected prospectively., Results: Thirty patients had locally advanced or disseminated primary colorectal cancers, and 22 had recurrent cancer of colorectal or other primaries. Successful insertion of the stent was achieved in 50 patients. The median survival of the patients was 88 (range, 3-450) days. Complications occurred in 13 patients (25 percent). These included perforation of the colon (n=1), migration or dislodgement of the stents (n=8), severe tenesmus (n=1), colovesical fistula (n=1), and tumor ingrowth (n=2). Insertion of a second stent was required in eight patients. Subsequent operations were performed in nine patients, and stoma creation was required in seven patients., Conclusions: Self-expanding metallic stents are highly effective in relieving malignant colorectal obstruction. The complication rate is acceptable and palliation can be achieved in the majority of the patients without a stoma.

Metastasis of breast cancer to the colon is rare. We report a case of a 49-year-old female who presented with a stenotic tumor of the descending colon five years after treatment of breast cancer with mastectomy and pedicled transverse rectus abdominis musculocutaneous flap. Laparotomy showed a diffusely infiltrated tumor over the descending colon. Anterior resection with loop ileostomy was performed, and the pathology showed that the colonic wall and the mesentery were diffusely infiltrated with poorly differentiated adenocarcinoma, which stained strongly for cytokeratin 7. The histologic diagnosis is consistent with colonic metastasis from ductal carcinoma of breast origin. In a patient with a history of breast cancer, colonic metastasis from the breast primary cancer should be considered, especially if the colonic lesion is scirrhous in nature. The incision for laparotomy and the probable stoma site should be planned carefully in females after breast reconstructive surgery.

Introduction: The treatment of malignant obstruction of the left colon or rectum usually requires emergency surgery on poor-risk patients, and the creation of a stoma is usually inevitable. With the use of self-expanding metallic stents, the prompt relief of large-bowel obstruction without surgery has become possible. This report describes our results in the use of self-expanding metallic stents in the treatment of left-sided colonic obstruction resulting from advanced malignancies., Methods: From November 1997 to March 1999, insertion of self-expanding metallic stents was attempted in 24 patients with acute left-sided colonic obstruction caused by primary or recurrent malignancies. All the procedures were performed by colorectal surgeons. The guidewire was inserted through the channel of the endoscope, and its position was confirmed with fluoroscopy. Uncovered Wallstent esophageal endoprostheses were used in all except the first case. The insertion and deployment of the stents were under both endoscopic and fluoroscopic guidance., Results: There were 24 patients (15 males) with a mean age of 63.6 (range, 36-98) years. Thirteen patients had primary colorectal cancer and 11 had recurrent cancers (colorectal cancer, 5; gastric cancer, 5; other, 1). In the treatment of primary colorectal cancer, seven procedures were palliative, and no subsequent surgery was planned because of extensive liver metastasis or poor medical risk. The other six patients underwent elective resection after mechanical bowel preparation. There was no mortality related to the procedure. Stenting was successful in the relief of obstruction in 23 patients. Perforation of the colon occurred in one patient, and an emergency Hartmann's operation was performed. Migration of the stents occurred in three patients. Only 3 of the 18 patients in the palliation group required the subsequent creation of stomas., Conclusion: The use of the self-expanding metallic stents can achieve rapid and effective nonsurgical means to relieve left-sided colonic obstruction. It provides good palliation for unresectable advanced tumors that cause colonic obstruction. It may also have a role in the temporary relief of obstruction so that subsequent colonic resection can be performed under elective conditions.

Purpose: The study purpose was to evaluate the results of continuous, single-layer colon and rectal anastomoses using a monofilament absorbable suture material (Maxon)., Methods: Four hundred ninety-two consecutive patients undergoing five hundred colon and rectal anastomoses with the above technique were evaluated for outcome, including anastomotic leakage, stricture, and other complications, by means of chart review., Results: Three patients (0.6 percent) died after surgery and 7 (1.4 percent) developed clinical evidence of anastomotic leakage. Twenty-four percent developed some postoperative complications, most of which were minor., Conclusions: Continuous, single-layer colorectal anastomosis using monofilament absorbable suture can be performed safely, quickly, and with a favorable cost ratio. Handsewn anastomoses should still be part of the armamentarium of the well-trained surgeon.

Purpose: Rubber band ligation is a common office procedure for hemorrhoids. Triple rubber band ligation in a single session has been shown to be a safe and economical way of treating hemorrhoids. However, postligation discomfort after triple rubber band ligation is not uncommon. The aim of this study was to evaluate the effectiveness of local anesthetic injection to the banded hemorrhoidal tissue in reducing postligation discomfort., Methods: Patients attending an outpatient clinic for symptomatic hemorrhoids suitable for triple rubber band ligation were randomly assigned to two groups. In the treatment group rubber band ligation was performed at three columns of hemorrhoids, and 1 to 2 ml of 2 percent lignocaine was injected into the banded hemorrhoidal tissue. In the control group triple rubber band ligation was performed in a similar manner, but local anesthetic was not given. Patients were followed up by telephone at the second week and in the clinic after six weeks., Results: From April to August 1996, 101 patients entered the trial and were treated with triple rubber band ligation. Sixty-two patients were randomly assigned to the local anesthetic injection group and 39 to the control group. Overall good to excellent results occurred in 89 percent of patients, and there was no difference between the two groups. Postligation pain occurred in 26 and 20 percent of patients in the treatment and control groups, respectively (P > 0.05). Postligation tenesmus occurred in 32 and 41 percent of patients in the treatment and control groups, respectively (P > 0.05). No patients suffered from septic complications or bleeding that required transfusion., Conclusion: Triple rubber band ligation in a single session is a safe, economical, and effective way of treating symptomatic hemorrhoids. Postligation pain and tenesmus occurred in 24 and 37 percent, respectively. Discomfort was usually tolerable. Local anesthetic injection to the banded hemorrhoidal tissue did not help to reduce postligation discomfort.