Search

Background: The appropriateness of the laparoscopic approach for the resection of rectal cancer has been controversial, although it is well established in colon cancer. This is a phase II study of laparoscopic abdominoperineal resection (APR) in the treatment of lower rectal cancers., Methods: Patients with lower rectal adenocarcinoma located within 6 cm above the anal verge were recruited and subjected to laparoscopic APR. The surgical principle included en bloc resection with high ligation of inferior mesenteric vessels by no-touch isolation and total mesorectal excision. Details of the surgical procedures are presented in the video. The technical efficiency and outcome of this surgical approach were evaluated prospectively. This study was approved by the institutional review board of National Taiwan University Hospital (NTUH)., Results: A total of 22 patients were enrolled in the study from January 2003 to December 2004 under the ethical guidelines of clinical trials in NTUH. There were 12 females and 10 males, with an age distribution of 62.5 +/- 10.4 years. The body mass index was 24.8 +/- 4.0 kg/m2. Physical status (American Society of Anesthesiology classification) was class I in 12, class II in eight, and class III in two patients. Tumor size was 44.0 +/- 12.0 mm in diameter. Two patients were in pathologic TNM stage I, 14 in stage II, and six in stage III. The operation time was 214.0 +/- 28.4 min. Blood loss was 54.0 +/- 14.0 ml. Because the tumor specimen was retrieved from a perineal wound, the five 5 to 12 mm working ports constituted the abdominal wound. There were no major complications. However, wound infection of port sites was detected in one patient. The patients had a quick convalescence, as evaluated by the length of postoperative ileus (48.0 +/- 12.0 h), length of hospitalization (8.0 +/- 2.0 days), and degree of postoperative pain (3.5 +/- 0.5 visual analogue scale). Return to partial activity, full activity, and work was 2.0 +/- 0.5, 4.0 +/- 0.8, and 6.0 +/- 0.5 weeks, respectively. The number of cleared lymph nodes was 14.0 +/- 2.0. During follow-up (median, 18 months; range, 6-30), lung metastasis and local pelvic recurrence developed in one and two patients, respectively. Besides the expenses covered by the National Bureau of Health Insurance of Taiwan, the additional payment by patients undergoing laparoscopic procedures was NTD 24,000 +/- 3000 (1 U.S. dollar = 32 NTD)., Conclusions: In our clinical setting, laparoscopic APR can be performed with good technical efficiency, quick functional recovery, and mild disability. The short-term oncologic results of laparoscopic APR seem to be acceptable, but further long-term follow-up for these patients is mandatory to define the oncologic outcomes of this approach.

Background/aims: Recurrence of rectal cancer remains a major clinical problem. This study was conducted to evaluate the impact of K-ras and p53 mutations on the recurrence of rectal cancer., Methodology: A total of 166 resected Dukes' B2 stage rectal carcinomas were collected between January 1990 and April 1994. The stored frozen tissues were retrieved for immunocytochemistry of p53 and genomic analysis of K-ras and p53 genes. The data of K-ras and p53 gene mutations were correlated with clinicopathological variables. The concordance of immunocytochemistry with genomic analysis in the survey of p53-mutations was examined. The follow-up data were analyzed by Kaplan-Meier estimator., Results: Sixty-nine patients (41.6%) developed recurrent tumor. A significantly higher recurrence rate (p = 0.0013) and shorter median recurrence time were noted in p53 mutated than non-mutated cancers. Mutations in K-ras gene do not significantly increase the risk of tumor recurrence (p = 0.1702). K-ras and p53 mutations are not associated with clinicopathological parameters (p > 0.05). Kappa statistic indicates highly significant reproducibility between immunocytochemistry and genomic analysis for p53 mutations (p < 0.0001)., Conclusions: Presence of p53 mutation significantly increases the recurrence rate and shortens the recurrence time of the resected rectal cancers. Pre-operative routine check for p53 mutations by immunocytochemistry may be beneficial in choosing the optimal surgical strategy for rectal cancer.

Background/aims: The relative contribution and interrelated compensation of sympathetic signals among sympathetic components in pelvic plexus remain undefined. This study was designed to investigate the genitourinary function in response to autonomic nerve preservation and severance using a canine model., Methodology: Eighteen mongrel dogs were randomly divided into 3 groups which received severance of the hypogastric nerves on either the right side, left side, or on both sides. The hypogastric nerves and sacral sympathetic trunks were electrically stimulated and the contraction pressure of the internal urethral orifice was measured immediately, at 1- and 3-month intervals. The ejaculation function and the length of time required to reach sexual orgasm were evaluated by manual penis-stimulation., Results: The difference between the left and right sides of the normal hypogastric nerve in contribution to sympathetic signals was insignificant. Compared with the hypogastric nerve, the bilateral sacral sympathetic trunks were functionally trivial in controlling the closure of the internal urethral orifice. The preserved side of the hypogastric nerve compensated for the loss of sympathetic signals of the severed side within 1 month and, thereafter, remained stationary. In contrast, the functional compensation of bilateral sacral sympathetic trunks for the severed bilateral hypogastric nerves was insignificant. When the hypogastric nerve was preserved in one or both sides, all dogs maintained normal antegrade ejaculation. If bilateral hypogastric nerves were severed, 50.0% (3/6) of the dogs lost both emission and ejaculation function; 33.3% (2/6) presented with retrograde ejaculation; and, 16.7% (1/6) presented with combined retrograde ejaculation and reduced antegrade ejaculation. The time required to reach sexual orgasm was not affected by the severance of the hypogastric nerve., Conclusions: The normal genitourinary function could be maintained only when at least one side of the hypogastric nerve was preserved.

Background/aims: Superlow anterior resection remains a technical challenge because it involves bowel resection and anastomosis in deep, limited pelvic space. Some modifications of the standard double stapling technique are thus needed to facilitate the procedure, making it safer, easier and more reliable., Methodology: A Roticulator is applied to make the first staple if the pelvic space is wide enough. A puncture hole is made manually in the closed rectal stump with the anvil tip under direct vision. If the pelvis is too narrow to apply a Roticulator, a purse-string suture is first placed before bowel resection, and is then tied securely around the anvil shaft to close the rectal stump. In either condition, the anvil and the attached sigmoid colon are pushed manually to evert the closed rectal stump. The stapled end-to-end anastomosis is then made outside the anus., Results: From July 1994 to June 1996, 42 superlow anterior resections were performed using the modified techniques. There were only 2 cases of anastomotic leakage. The function results were acceptable., Conclusions: The modified techniques are safe, effective and easy to perform. Their major advantages are that the stapled anastomosis is made under direct vision and without the hindrance of pelvic tissue.