Does the diameter of colonic stent influence the outcomes in bridge-to-surgery patients with malignant large bowel obstruction?

PURPOSE: This study investigated the short- and long-term outcomes of 18- and 22-mm-diameter self-expandable metallic stent (SEMS) as a bridge to surgery (BTS) in patients with malignant large bowel obstruction (MLBO). METHODS: Sixty-nine pathological stage II and III colorectal cancer patients who underwent BTS were included in this multi-institutional retrospective study. Patients were divided into two groups regarding the diameter of SEMS: an 18-mm group (n = 30) and a 22-mm group (n = 39). RESULTS: There was no significant difference in the clinical success rate, but both of the two re-obstructions observed occurred in the 18-mm group. The 18-mm group showed a trend toward a higher incidence of overall postoperative complications (Clavien-Dindo grading ≥ II) than the 22-mm group (33.3% vs. 10.3%, P = 0.061). The 3-year disease-free and overall survival showed no significant differences between the 18- and 22-mm groups (78.2% vs. 68.8%, P = 0.753 and 92.8% vs. 82.1%, P = 0.471, respectively). CONCLUSION: SEMS of 18 and 22 mm diameter confer statistically equivalent short- and long-term outcomes as a BTS.

Significance of the 7th postoperative day neutrophil-to-lymphocyte ratio in colorectal cancer.

PURPOSE: High neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation and is associated with poor survival in localized or metastatic cancer. Preoperative NLR in colorectal cancer reportedly correlates with recurrence-free survival and is useful as a recurrence prediction factor. No reports have yet investigated recurrence factors using postoperative NLR. This study assessed the predictive value of NLR preoperatively and on the first (NLR1) and seventh day (NLR7) postoperatively in patients with stage II colorectal cancer. METHODS: We performed a retrospective cohort study involving patients undergoing colorectal resection at a single institution between January 2012 and December 2016; we used medical records of 176 consecutive patients with stage II colorectal cancer undergoing curative tumor resection. NLRs as well as clinical, histopathologic, and laboratory data were analyzed. Univariate and multivariate analyses were conducted to identify prognostic factors associated with recurrence-free survival (RFS). RESULTS: Univariate analysis revealed that elevated NLR, NLR7, and lymphatic invasion were significantly associated with decreased RFS (p < 0.05). NLR7 was revealed as significant via multivariate analysis (p = 0.013). The 3-year RFS rate was 87.1% for patients with normal NLR7 and 70.3% for those with elevated NLR7. CONCLUSION: Elevated seventh-day postoperative NLR is a significant independent predictor of reduced RFS for patients with stage II colorectal cancer and may be a potential biomarker for identifying candidates for adjuvant chemotherapy.

G12V and G12C mutations in the gene KRAS are associated with a poorer prognosis in primary colorectal cancer.

PURPOSE: The increased incidence of colorectal cancer (CRC) has necessitated the development of novel prognostic and predictive factors from which new diagnostic tests could evolve. Evidence suggests the KRAS gene represents such a factor; its mutations are considered to be early indicators of CRC progression. This study assessed the prognostic impact of specific known KRAS codon 12/13 mutations on survival in patients with CRC. METHODS: Formalin-fixed paraffin-embedded tissue blocks or sections from primary were obtained from patients registered between 2014 and 2016 for genomic DNA extraction. KRAS gene was analyzed by direct sequencing or Luminex assay. The primary endpoint was the frequency of KRAS gene mutations and the secondary endpoints were differences in KRAS mutation rates by various stratification factors. Univariate and multivariate analyses were performed to investigate relationships between KRAS mutation rates and patient background factors. RESULTS: Sequencing of 200 CRC primary tumor samples demonstrated 74 (37.5%) with KRAS mutations in codons 12 (77%; 57/74) and 13 (23%; 17/74), all of which were TNM stages I-III. Tumors with KRAS mutations were more frequently located in the right side of the colon. Multivariate analysis indicated that G12V or G12C mutations were associated with poor prognosis [hazard ratio (HR) = 3.77, 95% confidence interval (CI), 1.54-8.39 and HR = 6.57; 95% CI, 1.90-17.7, respectively] in terms of recurrence-free survival. CONCLUSION: KRAS codon 12G-to-V or G-to-C mutations are independent prognostic factors in patients with stage I-III CRC.

Totally Extraperitoneal (TEP) Removal of an Infected Mesh by Laparoscopy after Open Preperitoneal Repair: Initial Case Report.

Prosthetic mesh infection after open or laparoscopic hernia repair is a rare complication. Superficial wound infection can be resolved by treatment with a combination of antibiotics and wound drainage, whereas deep-seated mesh infection, which can lead to chronic groin sepsis, usually requires removal of the mesh. A 56-year-old Japanese man was admitted to our hospital for the treatment of deep-seated mesh infection. The patient had undergone inguinal hernia repair at another hospital 18 months earlier. The operation was prosthetic mesh repair via an anterior approach. The patient developed deep-seated mesh infection despite conservative treatment for infection, such as abscess drainage and antibiotic therapy. Since the patient eventually developed chronic groin sepsis, he was referred to our hospital, and infected mesh was removed successfully by laparoscopic surgery via a totally extraperitoneal approach. The laparoscopic approach provides several advantages, including less postoperative pain, a shorter hospital stay, and earlier rehabilitation. Furthermore, seeding of the abdominal cavity with pus never occurs with this approach unlike the laparoscopic transabdominal preperitoneal approach.

[A Case of Long-Term Survival after Nine Surgeries for Recurrent Sigmoid Colon Cancer].

A 67-year-old man was operated for sigmoid colon cancer. Histopathological examination revealed pT3 (SS), N0, M0, Stage Ⅱ cancer. In March 2005, abdominal computed tomography (CT) showed recurrences in the abdominal wall and associated localized dissemination. The patient underwent chemotherapy using TS-1 and CPT-11; however, the disease progressed. Therefore, surgery was performed to resect the recurrences. A re-recurrence developed during the adjuvant chemotherapy. The patient was operated 9 times for recurrences, which were macroscopically resectable, in addition to chemotherapy and radiation. It has been 3 years and 7 months since the last operation, and he is alive with no recurrence. Metachronous peritoneal seeding and distant metastasis developed, but we have observed that surgical resection of each recurrence can prolong patient survival. We conclude that surgical resection can become a treatment of choice for resectable metachronous peritoneal seeding from colon cancer.

Serum total bilirubin elevation is a predictor of the clinicopathological severity of acute appendicitis.

PURPOSE: Elevation of the serum total bilirubin (STB) level not stemming from hepatic dysfunction or biliary obstruction may be seen in cases of acute appendicitis. This paper deals with the clinical significance of such elevations. METHODS: Data from 410 appendectomized patients classified into two groups (a high preoperative STB group and a normal preoperative STB group) were analyzed to reveal the significance of preoperative hyperbilirubinemia. We also examined whether the preoperative STB level might serve as a risk factor for gangrenous appendicitis by a multivariate analysis. RESULTS: Gangrenous appendicitis was more common in the high preoperative STB group (p < 0.001). The multivariate analysis revealed that an elevated preoperative STB level (odds ratio 1.7919) was a risk factor for gangrenous appendicitis. CONCLUSION: In patients with an elevated preoperative STB level, it is very likely that the inflammation is severe and that the disease has progressed to a severe condition histopathologically; therefore, meticulous attention should be paid to the selection of the surgical procedure, as well as to the postoperative clinical course.

[A case of adenosquamous carcinoma of the ascending colon].

A 6 8-year-old man was admitted to our hospital with lower abdominal pain. Lower gastrointestinal endoscopy showed type 2 advanced cancer in the ascending colon. Histopathological examination after endoscopical biopsy revealed both moderately differentiated adenocarcinoma and well-differentiated squamous carcinoma. Subsequently, right hemicolectomy was performed. The tumor was 55 × 40 mm in size and was diagnosed as an adenosquamous carcinoma A, type 2, pSS, pN0, sH0, sP0, sM0, fStageII. Adenosquamous carcinoma is extremely rare, represents about 0.1% of all colorectal cancer, and usually has a poor prognosis. Thirty-one months after surgery, the patient is still in good health and displays no signs of recurrence.

[Trans-anal resection for recurrence of a very low rectal anastomosis at the suture line after colorectal cancer surgery].

When a relatively small anastomotic recurrence of colorectal cancer is detected in the low rectum, trans-anal resection (TAR) might be an option both for curative intent and for preservation of anal function. We report 3 such cases. Case No. 1: A 58-year-old woman presented with an anastomotic recurrence of sigmoid colon cancer. Low anterior resection(LAR)was performed. Two small recurrent nodules were detected at the suture line 1 year after LAR, which were successfully treated with TAR. The depth of the nodules indicated T2 cancer. The patient remained cancer free 5 years after TAR. Case No. 2: A 56-year-old man developed a severe anastomotic stenosis and an anastomotic recurrence 6 months after LAR for low rectal cancer. TAR was performed circumferentially to resect both the stricture and the recurrence. The depth of the nodule indicated T2 cancer. The patient was cancer free for 7 years after TAR. Case No. 3: A 54-year-old man developed 2 small recurrent nodules at the suture line after LAR for low rectal cancer. TAR was performed. The depth of the nodule indicated T1 cancer. One of the nodules was not resected, which necessitated intersphincteric resection (ISR) 10 months later. In conclusion, in cases of a relatively small recurrence of low rectal anastomosis after colorectal cancer surgery, TAR is an effective treatment option.

[Transurethral resection of a intravesical recurrence of a tumor after resection of sigmoid colon cancer].

A 66-year-old man presented to the urology clinic with hematuria. Cystoscopy with biopsy was performed for suspected bladder cancer, and a pathological diagnosis of adenocarcinoma was made. Colonoscopy revealed sigmoid colon cancer, and he was referred to our hospital. Computed tomography (CT) and magnetic resonance imaging (MRI) showed sigmoid colon cancer with urinary bladder invasion. Sigmoidectomy with lymph node dissection and partial cystectomy were performed under laparotomy. The pathological diagnosis was moderately differentiated adenocarcinoma: T4b (bladder), N1, M0, and the bladder margin was negative. Four months after surgery, CT revealed a small mass in the bladder. Cystoscopy showed a papillary pedunculated tumor at the bladder trigone, and a transurethral resection was performed. Pathological examination revealed a moderately differentiated adenocarcinoma, similar to the prior sigmoid colon cancer, which was diagnosed as an intravesical recurrence of the tumor. More than 8 years after the transurethral resection, the patient has shown no signs of recurrence.

Giant epidermoid cyst of the spleen with elevated CA 19-9 production managed laparoscopically: report of a case.

True splenic cysts are uncommon and are associated with elevated serum and intracystic tumor marker CA 19-9 levels. A 33-year-old woman presented to our hospital with a chief complaint of epigastralgia. Computed tomography of the abdomen showed a 10-cm cystic lesion in the spleen. The serum carbohydrate antigen (CA) 19-9 level was 3,347 U/mL (normal, <37 U/mL). Total laparoscopic splenectomy was performed, and the serum level of CA 19-9 had normalized 2 weeks later. Pathological examination showed a benign true epidermal cyst of the spleen with strong immunohistological staining for CA 19-9. Splenic epidermoid cysts most often occur in young women, and laparoscopic surgery to remove cysts of this type is minimally invasive. Thus, laparoscopic surgery should be the method of first choice for most cases of splenic benign true cyst.