New techniques have been developed to treat severe anastomotic strictures after rectal surgery. This report describes a new approach using transanal minimally invasive surgery for the treatment of complete anastomotic occlusion. A 49-year-old man presented with a completely occluded anastomosis after low anterior resection with temporary ileostomy for rectal cancer. The lumen was completely obstructed with a blind wall. A transanal surgical approach was used to treat the obstruction. Water-soluble radiopaque contrast medium was injected intraoperatively to identify the proximal lumen, and an incision was made by electrocautery until the luminal diameter was sufficient. There was no sign of bleeding or perforation after surgery. The patient underwent ileostomy takedown after all the chemotherapy sessions were completed. This report shows that transanal minimally invasive surgery is safe and feasible for the treatment of complete anastomotic occlusions requiring invasive interventions.

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Objectives. The “Sick Lobe” hypothesis states that breast cancers evolve from entire lobes or portions of lobes of the breast where initiation events have occurred early in development. The implication is that some cancers are isolated events and others are truly multi-focal but limited to single lobar-ductal units. Methods. This is a single surgeon retrospective review of early stage breast cancer lumpectomy patients treated from 1/2000 to 2/2005. Ductal endoscopy was used direct lumpectomy surgical margins by defining ductal anatomy and mapping proliferative changes within the sick lobe for complete excision. Results. Breast conservation surgery for stage 0–2 breast cancer with an attempt to perform endoscopy in association with therapeutic lumpectomy was performed in 554 patients (successful endoscopy in 465 cases). With an average followup of >5 years for the entire group, annual hazard rate for local failure in traditional lumpectomy without ductal mapping was 0.97%/yr. and for lumpectomy with ductal mapping and excision of entire sick lobe was 0.18%/yr. With endoscopy, 42% of patients were found to have extensive disease within their “sick lobe.” Conclusions. Targeting breast cancer lumpectomy using endoscopy and excision of regional associated proliferation seems associated with lower recurrence in this non-randomized series.

Purpose Transanal excision (TAE) is an alternative surgical procedure for early rectal cancer. This study compared long-term TAE outcomes, in terms of survival and local recurrence (LR), with total mesorectal excision (TME) in patients with pathologically confirmed T1 rectal cancer. Methods T1 rectal adenocarcinoma patients who underwent surgery from 1990 to 2011 were retrospectively reviewed. Patients that were suspected to have preoperative lymph node metastasis were excluded. Demographics, recurrence, and survival were analyzed based on TAE and TME surgery. Results Of 268 individuals, 61 patients (26%) underwent TAE, which was characterized by proximity to the anus, submucosal invasion depth, and lesion infiltration, compared with TME patients (P < 0.001–0.033). During a median follow-up of 10.4 years, 12 patients had systemic and/or LR. Ten-year cancer-specific survival in the TAE and TME groups was not significantly different (98% vs. 100%). However, the 10-year LR rate in the TAE group was greater than that of TME group (10% vs. 0%, P < 0.001). Although 5 of the 6 TAE patients with LR underwent salvage surgery, one of the patients eventually died. The TAE surgical procedure (hazard ratio, 19.066; P = 0.007) was the only independent risk factor for LR. Conclusion Although long-term survival after TAE was comparable to that after TME, TAE had a greater recurrence risk than TME. Thus, TAE should only be considered as an alternative surgical option for early rectal cancer in selected patients.

BACKGROUND Endometriosis is a common disease for women of reproductive age. However, when it involves intestines, it is difficult to diagnose preoperatively because its symptoms overlap with other diseases and the results of evaluations can be unspecific. Thus it is important to know the clinical characteristics of intestinal endometriosis and how to exactly diagnose. AIM To analyze patients in whom intestinal endometriosis was diagnosed after surgical treatments, and to evaluate the clinical characteristics of preoperatively misdiagnosed cases. METHODS We retrospectively reviewed the pathologic reports of 30 patients diagnosed as having intestinal endometriosis based on surgical specimens between January 2000 and December 2017. We reviewed their clinical characteristics and surgical outcomes. RESULTS Twenty-three (76.6%) patients showed symptoms associated with endometriosis, with dysmenorrhea being the most common ( n = 9, 30.0%). Thirteen patients (43.3%) had a history of pelvic surgeries. Ten patients (33.3%) had a history of treatment for endometriosis. Only 4 patients (13.3%) had a diagnosis of endometriosis based on endoscopic biopsy findings. According to preoperative evaluations, 13 patients (43.3%) had an initial diagnosis of pelvic endometriosis and 17 patients (56.6%) were misdiagnosed as having other diseases. The most common misdiagnosis was submucosal tumor in the large intestine ( n = 8, 26.7%), followed by malignancies of the colon/rectum ( n = 3, 10.0%) and ovary ( n = 3, 10.0%). According to the Clavien-Dindo classification, 5 complications were grade I or II and 2 complications were grade IIIa. The median follow-up period was 26.9 (0.6-132.1) mo, and only 1 patient had a recurrence of endometriosis. CONCLUSION Intestinal endometriosis is difficult to diagnose preoperatively because it mimics various intestinal diseases. Thus, if women of reproductive age have ambiguous symptoms and signs with nonspecific radiologic and/or endoscopic findings, intestinal endometriosis should be included in the differential diagnosis.

In colorectal cancer, whereas mucinous adenocarcinoma (MAC) has several poor clinical prognostic factors compared to adenocarcinoma (AC), the prognosis of MAC remains controversial. We evaluated the prognosis of MAC without distant metastasis and the effects of adjuvant chemotherapy using health insurance registry data managed by South Korea. Patients with colorectal cancer between January 2014 and December 2016 were included (AC, 22,050 [96.8%]; MAC, 729 [3.2%]). We observed no difference in overall survival (OS) between AC and MAC in stages I and II. However, MAC showed a worse OS than AC in stage III disease, especially in patients administered chemotherapy (p < 0.001). These findings persisted after propensity score matching of clinical characteristics between AC and MAC. In addition, transcriptome analysis of The Cancer Genome Atlas (TCGA) data showed increased chemoresistance-associated pathways in MAC compared to AC. In consensus molecular subtypes (CMS) classification, unlike in AC, CMSs 1, 3, and 4 comprised most of MAC and the proportions of CMSs 3 and 4 increased with stage progression. These results suggest clues to overcome resistance to chemotherapy and develop targeted treatments in MAC.

Purpose: This study sought to delineate the learning curve (LC) for laparoscopic appendectomy (LA) in surgical residency according to seniority and experience.Methods: Between October 2015 and November 2016, 150 patients underwent LA performed by one of 3 residents (who were in their first [A], second [B], or third [C] year of training) under supervision. The patients were nonrandomly assigned to each resident. Data from a prospectively collected database were reviewed and analyzed retrospectively. Perioperative outcomes including operation time, complications, and conversion were compared among the 3 residents. The LC was evaluated using the moving average method and cumulative sum control chart (CUSUM) for operation time and surgical completion.Results: Baseline characteristics and perioperative outcomes were similar among the 3 groups except for age and location of the appendix. The operation time did not vary among the 3 residents (43.9, 45.3, and 48.4 minutes for A, B, and C, respectively; P=0.392). The moving average method for operation time showed a decreasing tendency for all residents. CUSUM results for operation time revealed peak points achieved at the 24th, 18th, and 31st cases for residents A, B, and C, respectively. In terms of surgical failure, residents A, B, and C reached steady states after their 35th, 11th, and 16th cases, respectively. Perforation of the appendix base was the only risk factor for surgical failure.Conclusion: The resident LC for LA was 11 to 35 cases according to multidimensional statistical analyses. The accumulation of surgical experience among residents might influence the LC for surgical completion but not that for operation time.

Background and Aim Ultralow anterior resection (uLAR) is a sphincter-saving procedure for very low-lying rectal cancers. This procedure, however, has complications related to defecation which can aggravate the patient's quality of life postoperatively. In this study, we compared the anthropometric and nutritional parameters after uLAR and abdominoperineal resection (APR). Methods We retrospectively reviewed the data of patients who underwent either uLAR or APR in 2012 for rectal cancers within 3 cm from the anal verge. Data including body weight, body mass index (BMI), levels of total protein, albumin, and hemoglobin and lymphocyte count were analyzed. We compared the changes of these parameters before operations to 3 years after discharge between uLAR and APR groups by ANOVA for repeated measures and Bonferroni comparison method. Results After 3 years of discharge, the body weight and BMI of the APR group were fully recovered to the preoperative levels; however, those of the uLAR group did not. The hemoglobin level in the APR group was recovered to the preoperative level within 3 months of discharge; however, that in the uLAR group was recovered after 1 year of discharge. Conclusions Recovery of anthropometric and nutritional status of patients was more stable after APR than after uLAR. These findings might indirectly reflect the low anterior syndrome effect of uLAR and help colorectal surgeons in selecting better surgical methods and in better counseling patients with very low-lying rectal cancer.