Purpose: Although partial mesorectal excision (PME) and total mesorectal excision (TME) is primarily indicated for the upper and lower rectal cancer, respectively, few studies have evaluated whether PME or TME is more optimal for middle rectal cancer. Methods: This study included 671 patients with middle and upper rectal cancer who underwent robot-assisted PME or TME. The 2 groups were optimized by propensity score matching of sex, age, clinical stage, tumor location, and neoadjuvant treatment. Results: Complete mesorectal excision was achieved in 617 of 671 patients (92.0%), without showing a difference between the PME and TME groups. Local recurrence rate (5.3% vs. 4.3%, P>0.999) and systemic recurrence rate (8.5% vs. 16.0%, P=0.181) also did not differ between the 2 groups, in patients with middle and upper rectal cancer. The 5-year disease-free survival (81.4% vs. 74.0%, P=0.537) and overall survival (88.0% vs. 81.1%, P=0.847) also did not differ between the PME and TME groups, confined to middle rectal cancer. Moreover, 5-year recurrence and survival rates were not affected by distal resection margins of 2 cm (P=0.112) to 4 cm (P>0.999), regardless of pathological stages. Postoperative complication rate was higher in the TME than in the PME group (21.4% vs. 14.5%, P=0.027). Incontinence was independently associated with TME (odds ratio [OR], 2.009; 95% confidence interval, 1.015–3.975; P=0.045), along with older age (OR, 4.366, P<0.001) and prolonged operation time (OR, 2.196; P=0.500). Conclusion PME can be primarily recommended for patients with middle rectal cancer with lower margin of >5 cm from the anal verge.

Purpose: This study was designed to determine the feasibility of preoperative chemoradiotherapy (PCRT) in patients with clinical T2N0 distal rectal cancer. Methods: Patients who underwent surgery for clinical T2N0 distal rectal cancer between January 2008 and December 2016 were included. Patients were divided into PCRT and non-PCRT groups. Non-PCRT patients underwent radical resection or local excision (LE) according to the surgeon’s decision, and PCRT patients underwent surgery according to the response to PCRT. Patients received 50.0 to 50.4 gray of preoperative radiotherapy with concurrent chemotherapy. Results: Of 127 patients enrolled, 46 underwent PCRT and 81 did not. The mean distance of lesions from the anal verge was lower in the PCRT group (P=0.004). The most frequent operation was transanal excision and ultralow anterior resection in the PCRT and non-PCRT groups, respectively. Of the 46 patients who underwent PCRT, 21 (45.7%) achieved pathologic complete response, including 15 of the 24 (62.5%) who underwent LE. Rectal sparing rate was significantly higher in the PCRT group (11.1% vs. 52.2%, P<0.001). There were no significant differences in 3- and 5-year overall survival and recurrence-free survival regardless of PCRT or surgical procedures. Conclusion PCRT in clinical T2N0 distal rectal cancer patients increased the rectal sparing rate via LE and showed acceptable oncologic outcomes. PCRT may be a feasible therapeutic option to avoid abdominoperineal resection in clinical T2N0 distal rectal cancer.

Purpose: The prognostic significance and treatment of lateral pelvic lymph node metastasis (mLPLN) in rectal cancer patients receiving neoadjuvant chemoradiotherapy (nCRT) are not well understood. In this study, we evaluated the impact of mLPLN identified in imaging modality on outcomes. Methods: Between January 2008 and December 2016, 1,535 patients who underwent radical resection following nCRT were identified. The association between mLPLN and disease-free survival (DFS), overall survival (OS), local recurrencefree survival (LRFS), and pelvic recurrence-free survival (PRFS) was analyzed, along with risk factors associated with OS and DFS. Results: Overall, 329 (21.4%) of the 1,535 patients experienced disease recurrence; 71 (4.6%) had local recurrence, 25 (1.6%) had pelvic recurrence, and 312 (20.3%) had distant recurrence. The pre- and post-nCRT mLPLN (–) groups had better DFS, LRFS, PRFS, and OS than the (+) groups. LPLN sampling (LPLNs) was implemented in 24.0% of the pre-nCRT mLPLN (+) group and in 28.8% of the post-nCRT mLPLN (+) group. There was no significant difference in OS and LRFS between LPLNs group and no LPLNs group in pre- and post-nCRT mLPLN (+) groups. Pre-nCRT mLPLN was associated with poor OS (hazard ratio [HR], 1.43; P = 0.009) and post-nCRT mLPLN was associated with poor DFS (HR, 1.49; P = 0.002). Conclusion Pre- and post-nCRT mLPLN (+) have different prognostic effects. Post-nCRT mLPLN appears to be more important for disease control. However, pre-nCRT mLPLN should not be disregarded when devising a treatment strategy since it is an independent risk factor for OS.

An ectopic pancreas rarely transforms into a malignancy, and the symptoms vary from patient to patient. The most commonly observed site of an ectopic pancreas is the antrum of the stomach. A 59-year-old male patient with severe abdominal pain underwent CT. A 9.6 cm-sized well-defined exophytic huge mass with heterogenic density was located between the stomach distal antrum and duodenum. A malignant submucosal tumor was suspected because of the exophytic dirty huge mass. Initially, surgery was considered to confirm the histological evaluation. After 2 months, the abdominal pain disappeared, and the follow-up MRI scan showed a decrease in size, which contained a necrotic component inside. It was confirmed that the parenchymal tissue was the pancreas. The pathology through EUS-guided fine needle aspiration (EUS-FNA) was normal pancreatic acinar cells, smooth muscle fragments, squamous cyst, and some neutrophils (abscess). Walled-off necrosis occurs as a complication of acute pancreatitis with parenchymal tissues and surrounding tissues, but complications of ectopic pancreatitis occurred in this case. Abdominal pain due to ectopic pancreas leading to the formation of a giant abscess has been reported as a very rare case. Diagnosis through biopsy is most important when a malignant submucosal tumor is suspected. In addition, it is important to determine the clinical features, examination findings, such as EUS, CT, and MRI, and the changes according to the follow-up period. This paper reports a case of ectopic pancreas, resulting in necrotic tissue and walled-off necrosis, abdominal pain, and spontaneous improvement.

Purpose: Carcinoma arising from Crohn disease (CD) is rare, and there is no clear guidance on how to properly screen for at-risk patients and choose appropriate care. This study aimed to evaluate the clinicopathological characteristics, treatment, and oncologic outcomes of CD patients diagnosed with colorectal cancer (CRC). Methods: Using medical records, we retrospectively enrolled a single-center cohort of 823 patients who underwent abdominal surgery for CD between January 2006 and December 2015. CD-associated CRC patients included those with adenocarcinoma, lymphoma, or neuroendocrine tumors of the colon and rectum. Results: Nineteen patients (2.3%) underwent abdominal surgery to treat CD-associated CRC. The mean duration of CD in the CD-associated CRC group was significantly longer than that in the benign CD group (124.7 ± 77.7 months vs. 68.9 ± 60.2 months, P = 0.006). The CD-associated CRC group included a higher proportion of patients with a history of perianal disease (73.7% vs. 50.2%, P = 0.035) and colonic location (47.4% vs. 6.5%, P = 0.001). Among 19 CD-associated CRC patients, 17 (89.5%) were diagnosed with adenocarcinoma, and of the 17 cases, 15 (88.2%) were rectal adenocarcinoma. On multivariable analyses for developing CRC, only colonic location was a risk factor (relative risk, 7.735; 95% confidence interval, 2.862–20.903; P = 0.001). Conclusion Colorectal malignancy is rare among CD patients, even among patients who undergo abdominal surgery. Rectal adenocarcinoma accounted for most of the CRC, and colonic location was a risk factor for developing CRC.

Purpose: During diverting ileostomy reversal for rectal cancer patients who underwent previous sphincter-saving surgery, the extent of adhesion formation around the ileostomy site affects operative and postoperative outcomes. Anchoring sutures placed at the time of the ileostomy procedure may reduce adhesions around the ileostomy. This study aimed to evaluate the effects of anchoring sutures on the degree of adhesion formation and the postoperative course at the time of ileostomy reversal. Methods: Patients who underwent sphincter-saving surgery with diverting ileostomy for rectal cancer between January 2013 and December 2017 were enrolled. Variables including the peritoneal adhesion index (PAI) score, operation time, the length of resected small bowel, operative complications, and postoperative hospital stay were collected prospectively and compared between the anchoring group (AG) and non-anchoring group (NAG). Results: A total of 90 patients were included in this study, with 60 and 30 patients in the AG and NAG, respectively. The AG had shorter mean operation time (46.88 ± 16.37 minutes vs. 61.53 ± 19.36 minutes, P = 0.001) and lower mean PAI score (3.02 ± 2.53 vs. 5.80 ± 2.60, P = 0.001), compared with the NAG. There was no significant difference in the incidence of postoperative complications between the AG and NAG (5.0% vs. 13.3%, respectively; P = 0.240). Conclusion Anchoring sutures at the formation of a diverting ileostomy could decrease the adhesion score and operation time at ileostomy reversal, thus may be effective in improving perioperative outcomes.

Purpose: Upper gastrointestinal (GI) tract involvement in Crohn disease (CD) is rare and effectiveness of surgical treatment is limited. The aim of this study was to evaluate characteristics and surgical outcomes of upper GI CD. Methods: Medical records of 811 patients who underwent intestinal surgery for CD between January 2006 and December 2015 at a single institution were reviewed. Upper GI CD was defined by involvement of the stomach to the fourth portion of duodenum, with or without concomitant small/large bowel CD involvement according to a modification of the Montreal classification. Results: We identified 24 patients (21 males, 3 females) who underwent surgery for upper GI CD. The mean age at diagnosis was 27 ± 12 years, the mean age at surgery was 33 ± 11 years, and the mean duration of CD was 73.6 ± 56.6 months.Fifteen patients (62.5%) had history of previous perianal surgery. Ten patients (41.7%) had duodenal or gastric stricture and 14 patients (58.3%) had penetrating fistula; patients with fistula were significantly more likely to develop complications (57.1% vs. 20.0%, P = 0.035). One patient with stricture had surgical recurrence. In seven patients with fistula, fistula was related to previous anastomosis. Patients with fistula had significantly longer hospital stays than those with stricture (16 days vs. 11 days, P = 0.01). Conclusion Upper GI CD is rare among CD types (2.96%). In patients with upper GI CD, penetrating fistula was associated with longer hospital stay and more complications.