Preoperative D-dimer Value and Lower Limb Venous Ultrasound for Deep Venous Thrombosis Prevents Postoperative Symptomatic Venous Thromboembolism in Patients Undergoing Colorectal Surgery: A Retrospective Study.

Objectives: Preoperative deep venous thrombosis (DVT) can cause potentially life-threatening postoperative venous thromboembolism (VTE). Lower limb venous ultrasound (LLVU) is a modality that can detect DVT. However, the threshold for performing preoperative LLVU in the population undergoing colorectal resection is controversial. In this context, we evaluated whether a preoperative D-dimer value can identify patients who benefit from LLVU from the perspective of preventing postoperative symptomatic VTE. Methods: Patients undergoing colorectal resection in our institute from 2013 to 2020 were retrospectively enrolled (n=2071). We divided the patients into two groups: the clinical indication group (CG: including patients from 2013 to 2016, n=875) and the D-dimer-orientated group (DG: including patients from 2017 to 2020, n=1196). In the CG, LLVU was performed when DVT was clinically suspected; in the DG, preoperative LLVU was performed in patients with a preoperative D-dimer>1.0 µg/ml. Results: In the surveyed period, 277 LLVUs were performed, among which DVT was detected in 34 cases (12.3%). In the CG, DVT was detected in 0.7% of patients, whereas in the DG, it was detected in 2.3% of patients. Postoperative symptomatic VTE was significantly reduced in the DG at both 3 and 6 months after surgery (p=0.041 and 0.020, respectively). Moreover, Multivariate analysis showed that a past medical history of PE and treatment following the CG protocol were independent risk factors for postoperative symptomatic VTE within 6 months of surgery (p<0.0001 and =0.036, respectively). Conclusions: LLVU in patients with a preoperative D-dimer>1.0 µg/ml is a useful method to prevent postoperative symptomatic VTE.

Elevated Preoperative Serum Vascular Endothelial Growth Factor Does Not Predict Poor Outcomes in Curatively Resected Non-metastatic Colorectal Cancer Treated Without Neoadjuvant Therapy.

BACKGROUND/AIM: Vascular endothelial growth factor (VEGF) influences colorectal cancer (CRC) progression and is a key target in the treatment for metastatic CRC. However, the oncological impact of preoperative circulating VEGF in non-metastatic CRC (non-mCRC) has not been clearly elucidated. Herein, we have investigated the prognostic significance of elevated preoperative serum VEGF concentration in curatively resected non-mCRC without neoadjuvant therapy. PATIENTS AND METHODS: A total of 474 patients with pStage I-III CRC who underwent curative resection without neoadjuvant therapy were included. The relationship between preoperative serum VEGF concentration and clinicopathologic characteristics, overall survival (OS), and recurrence-free survival (RFS) were investigated. RESULTS: The median follow-up duration was 47.4 months. No significant relationship between preoperative VEGF and clinicopathologic characteristics including tumor markers, pStage, and lymphovascular invasion was identified; however, VEGF values were wide-ranged in every pStage. Patients were categorized into four groups as follows: VEGF < median, median to 75th percentile, 75th percentile to 90th percentile, and ≥90th percentile. A tendency for a difference in 5-year OS (p=0.064) and RFS (p=0.089) was observed among the groups; however, OS and RFS were not correlated with VEGF elevation. In multivariate analyses, VEGF ≥90th percentile was paradoxically associated with better RFS. CONCLUSION: Preoperative elevated serum VEGF concentration was associated with neither worse clinicopathological characteristics nor worse long-term outcomes in curatively resected non-mCRC. The prognostic value of preoperative circulating VEGF in initially resectable non-mCRC remains limited.

[Peritoneal Mesothelioma Diagnosed with a Sister Mary Joseph's Nodule].

In August 2022, a 59-year-old female noted a mass in her umbilicus and sought evaluation at Toyokawa City Hospital. Abdominal computed tomography(CT)scan revealed a 1.6 cm mass in the umbilical region, ascites in the pelvis, and increased absorption in the omentum. Peritoneal dissemination of the carcinoma and Sister Mary Joseph's nodule due to an unknown primary tumor were suspected because no abnormalities were detected during upper and lower gastrointestinal endoscopy. She underwent an umbilical lumpectomy and diagnostic laparoscopy to establish a definitive diagnosis. The surgical findings included numerous white nodules throughout the abdominal cavity. The umbilical mass and omental white nodules were resected. A final diagnosis of epithelial peritoneal mesothelioma was made based on the histopathologic examination. In general, peritoneal mesothelioma has a poor prognosis, and early treatment is essential; however, making a timely definitive diagnosis is difficult. Peritoneal mesothelioma should be included in the differential diagnosis for a patient with unexplained ascites and abdominal pain. Diagnostic laparoscopy and biopsy will facilitate the establishment of a definitive diagnosis.

The DOLFIN method: a novel laparoscopic Billroth-I gastroduodenostomy for gastric cancer with duodenal invasion.

BACKGROUND: Laparoscopic Billroth-I gastroduodenostomy using a delta-shaped anastomosis is safe and feasible. However, it is often difficult to perform in patients who have a short posterior wall of the duodenum. Thus, we have developed a new method named duodenal overlap functional anastomosis with linear stapler (DOLFIN). We hereby report the technical details of the new method and our preliminary experience performing it. METHODS: After the completion of lymphadenectomy, the duodenum was transected craniocaudally with an endoscopic linear stapler. The hepatoduodenal mesentery was dissected approximately 4 cm along the duodenal bulb, and the anastomosis between the posterior wall of the stomach and the lesser curvature of the duodenum was created. The common entry hole was then transected using an endoscopic linear stapler, and the anastomosis was finally completed. RESULTS: There were 36 patients with gastric cancer who underwent laparoscopic distal gastrectomy (LDG) or robotic distal gastrectomy (RDG) with B-I reconstruction using DOLFIN. There were no postoperative complications classified as C-D grade 3 or more and complications related to anastomosis, such as anastomotic leak or stenosis. CONCLUSIONS: Our DOLFIN gastroduodenostomy can be performed safely. In addition, it results in good postoperative outcomes. A long-term comparative study is required to further evaluate the clinical usefulness of this method.

Cancer cell­induced tissue inhibitor of metalloproteinase­1 secretion by cancer­associated fibroblasts promotes cancer cell migration.

Cancer­associated fibroblasts (CAFs) are one of the major components of the cancer stroma in the tumor microenvironment. The interaction between cancer cells and CAFs (cancer­stromal interaction; CSI) promotes tumor progression, including metastasis. Recently, the tissue inhibitor of metalloproteinase­1 (TIMP­1) was reported to promote cancer cell migration and metastasis, which is contrary to its anticancer role as an inhibitor of matrix metalloproteinase. Moreover, CAF­derived TIMP­1 is reported to regulate CAF activity. In the present study, we investigated the effect of TIMP­1 on colon cancer cell migration in vitro. The TIMP­1 secretion levels from the CAFs and cancer cell lines were comparatively measured to determine the main source of TIMP­1. Furthermore, the effect of CSI on TIMP­1 secretion was investigated using the Transwell co­culture system. Cancer cell migration was evaluated using the wound­healing assay. The results demonstrated that TIMP­1 promoted the migration of LoVo cells, a colon cancer cell line, whereas TIMP­1 neutralization inhibited the enhanced migration. The TIMP­1 levels secreted from the cancer cells were approximately 10 times less than those secreted from the CAFs. TIMP­1 secretion was higher in CAFs co­cultured with cancer cells than in monocultured CAFs. Furthermore, the migration of LoVo cells increased upon co­culturing with the CAFs. TIMP­1 neutralization partially inhibited this enhanced migration. These results suggest that CAFs are the primary source of TIMP­1 and that the TIMP­1 production is enhanced through CSI in the tumor microenvironment, which promotes cancer cell migration.

The Interaction Between Cancer-associated Fibroblasts and Cancer Cells Enhances Bcl-xL and Mcl-1 in Colorectal Cancer.

BACKGROUND/AIM: The acquisition of resistance to apoptosis is one of the biggest problems in colorectal cancer (CRC) treatment. This study aimed to elucidate the mechanisms of resistance to apoptosis with a focus on interleukin (IL)-6 produced by the interaction between cancer cells and cancer-associated fibroblasts (CAFs). MATERIALS AND METHODS: DLD-1 and HCT116 cell lines were treated with IL-6 and furthermore co-cultured with CAFs. The expression levels of Bcl-xL, Mcl-1 and phosphorylation of STAT3 were evaluated by western blotting. We also performed immunostaining for CRC specimens and evaluated the correlation between CAFs invasion and Bcl-xL/Mcl-1 expression. RESULTS: Both IL-6 and co-culturing enhanced Bcl-xL, Mcl-1 and the phosphorylation of STAT3. Immunohistochemistry showed a positive correlation between CAFs and Bcl-xL/Mcl-1. These results showed that the interaction between CAFs and cancer cells enhances Bcl-xL and Mcl-1 through the IL-6/STAT3 signaling pathway. CONCLUSION: Our findings provide new potential therapeutic targets and strategies for CRC treatment.

Robotic total gastrectomy with thrombectomy and portal vein reconstruction for gastric cancer and portal vein tumor thrombus.

BACKGROUND: Gastric cancer with portal vein tumor thrombus (PVTT) is poor prognosis, and the treatment remains challenging. Regarding surgery, there are only reports of highly invasive laparotomy. We report some techniques of the completely robotic total gastrectomy with thrombectomy and portal vein reconstruction for the patient with gastric cancer and PVTT for the first time. CASE PRESENTATION: A 79-year-old man was diagnosed with a 5-cm gastric cancer on the side of the lesser curvature from the middle of the gastric body to the cardia. Computed tomography revealed a massive PVTT extending from the left gastric vein to the portal trunk (28 x 16 mm). There were no other distant metastases. After 3 cycles of the chemotherapy, the PVTT shrank to 19 x 12 mm. After obtaining informed consent from the patient, robotic total gastrectomy with regional lymphadenectomy and thrombectomy were performed. We used the da Vinci Xi Surgical System. A 3-cm incision was made at the umbilicus, and a wound retractor was placed. Five additional ports were placed. The right side suprapancreatic lymph nodes were performed at the time of the thrombectomy. It was important to identify the precise extent of the PVTT with intraoperative ultrasonography before the thrombectomy. After PVTT identification, the portal trunk was clamped above and below the tumor thrombus with vascular clips. The membrane on the anterior wall of the portal trunk around the PVTT was carefully incised with da Vinci Scissors. The tumor thrombus was completely enucleated without separation. The incised part of the portal trunk was reconstructed with continuous 5-0 synthetic monofilament nonabsorbable polypropylene sutures. After removing the vascular clamps, we made sure there was no leakage from the portal vein and no tumor thrombus remnants with intraoperative ultrasonography. Robotic total gastrectomy with lymphadenectomy and Roux-en-Y reconstruction were performed. The patient was discharged without complications. The patient has remained alive for 30 months after surgery. CONCLUSIONS: Robotic total gastrectomy with thrombectomy and portal vein reconstruction is a safe, minimally invasive, and precise surgery. It may contribute to improved prognosis of gastric cancer with PVTT when combined with chemotherapy.

Combination of extramural venous invasion and lateral lymph node size detected with magnetic resonance imaging is a reliable biomarker for lateral lymph node metastasis in patients with rectal cancer.

PURPOSE: Pathological extramural venous invasion (EMVI) is defined as the active invasion of malignant cells into veins beyond the muscularis propria in colorectal cancer. It is associated with poor prognosis and increases the risk of disease recurrence. Specific findings on MRI (termed MRI-EMVI) are reportedly associated with pathological EMVI. In this study, we aimed to identify risk factors for lateral lymph node (LLN) metastasis related to rectal cancer and to evaluate whether MRI-EMVI could be a new and useful imaging biomarker to help LLN metastasis diagnosis besides LLN size. METHODS: We investigated 67 patients who underwent rectal resection and LLN dissection for rectal cancer. We evaluated MRI-EMVI grading score and examined the relationship between MRI-EMVI and LLN metastasis. RESULTS: Pathological LLN metastasis was detected in 18 cases (26.9%), and MRI-EMVI was observed in 32 cases (47.8%). Patients were divided into two cohorts, according to LLN metastasis. Multivariate analyses demonstrated that higher risk of LLN metastasis was significantly associated with MRI-EMVI (P = 0.0112) and a short lateral lymph node axis (≥ 5 mm) (P = 0.0002). The positive likelihood ratios of MRI-EMVI alone, LLN size alone, and the combination of both factors were 2.12, 4.84, and 16.33, respectively. Patients negative for both showed better 2-year relapse-free survival compared to other patients (84.4% vs. 62.1%, P = 0.0374). CONCLUSIONS: MRI-EMVI was a useful imaging biomarker for identifying LLN metastasis in patients with rectal cancer. The combination of MRI-EMVI and LLN size can improve diagnostic accuracy.

Clinical importance of carcinoembryonic antigen messenger RNA level in peritoneal lavage fluids measured by transcription-reverse transcription concerted reaction for advanced gastric cancer in laparoscopic surgery.

BACKGROUND: Transcription-reverse transcription concerted reaction (TRC) is recognized as a useful method for detecting free cancer cells in the peritoneal cavity and predicting peritoneal recurrence in patients with gastric cancer. Nonetheless, the clinical significance of TRC in laparoscopic surgery remains unclear. This study aimed to evaluate the clinical importance of carcinoembryonic antigen (CEA) messenger RNA (mRNA) level in peritoneal lavage fluids measured by TRC in laparoscopic surgery for locally advanced gastric cancer. METHODS: We enrolled patients with locally advanced gastric cancer who underwent laparoscopic gastrectomy. Peritoneal lavage fluids were collected prior to gastrectomy, and the TRC method was employed to quantify CEA mRNA in peritoneal washes. Overall survival (OS), recurrence-free survival (RFS), and peritoneal recurrence-free survival (PRFS) were analyzed using the Kaplan-Meier method and compared using the log-rank test. Adjusted Cox proportional hazards regression models were used to calculate the hazard ratios (HRs) for CEA mRNA positivity. RESULTS: A total of 100 patients were analyzed in this study. Overall, 22 patients (22%) exhibited CEA mRNA positivity in peritoneal lavage fluids, as measured by TRC. No significant association between CEA mRNA levels and clinicopathological characteristics was observed. Patients who were CEA mRNA-positive in peritoneal lavage fluids had significantly worse OS, RFS, and PRFS than those who were CEA mRNA-negative (p = 0.0059, p < 0.0001, and p = 0.0022, respectively). In the univariate Cox model, the HR for all-cause mortality in CEA mRNA-positive versus CEA mRNA-negative patients was 3.60 (95% CI, 1.33-9.55; p = 0.0129). Multivariate analysis revealed that CEA mRNA positivity was a significant independent factor for recurrence. CONCLUSIONS: TRC enables the detection of free cancer cells in the peritoneal cavity and CEA mRNA levels can help predict the prognosis, even in laparoscopic gastrectomy.

The expression of carcinoembryonic antigen mRNA in the lavage of the dissected area of the lateral lymph nodes influences the lateral recurrence of lower rectal cancer.

PURPOSE: To determine whether or not migrating cancer cells are present on the surgical plane after lateral lymph node dissection (LLND) for lower rectal cancer and related to lateral recurrence (LR), we evaluated the lavage of LLND areas by reverse-transcription polymerase chain reaction (RT-PCR) to check the expression of CEA mRNA in the residual cancer cells. METHODS: Thirty patients who underwent curative LLND were enrolled. Lavage was collected after LLND and subjected to RT-PCR to detect CEA mRNA. The median follow-up to check for recurrence was 31.4 months. RESULTS: CEA mRNA was detected in 9 of the 46 dissected areas. Based on the receiver operating characteristic curves, the cut-off value of PCR was set at 0.025. This cut-off point classified five patients into the high-expression group for CEA mRNA. During follow-up, LR developed in 1 of 40 low-expression areas of CEA mRNA and 3 of 6 high-expression areas. The LR rate was higher in the high-expression group than in the low-expression group (p = 0.015). A multivariate analysis showed that the high expression of CEA mRNA was likely an independent prognostic factor of LR. CONCLUSION: The expression of CEA mRNA in the lavage of LLND areas indicates the presence of residual cancer cells that cause LR.

Postoperative aggressive diuresis prevents postoperative tissue edema and complications in patients undergoing distal pancreatectomy.

PURPOSE: Intraoperative fluid restriction is reported to be associated with reduced postoperative tissue edema and decreased incidence of postoperative pancreatic fistula (POPF) in pancreatic surgery. However, there is limited information regarding the postoperative approach to prevent postoperative tissue edema and reduce POPF. METHODS: Patients undergoing distal pancreatectomy from 2013 to 2018 in our institute were retrospectively enrolled (n = 128). The patients were classified into the two groups: an early diuresis group (ED group: patients administered diuretic agents on postoperative day 2 or earlier between 2016 and 2018, n = 69) and a conventional diuresis group (CD group: patients administered diuretic agents on postoperative day 3 or later between 2013 and 2015, n = 59). Postoperative tissue edema assessed by CT imaging and the incidence of clinically relevant POPF (CR-PF; grade B or C) were compared. RESULTS: Postoperative tissue edema was significantly reduced in the ED group (p < 0.0001). The incidence of CR-PF was lower in the ED group (19% vs. 32%, p = 0.082), especially in patients with postoperative diuresis on POD 1 (12%, p = 0.044). CONCLUSION: Early and aggressive postoperative diuresis potentially reduced postoperative visceral tissue edema. This postoperative approach to prevent tissue edema may reduce the incidence of CR-PF in pancreatic surgery.

The clinical impact of robot-assisted laparoscopic rectal cancer surgery associated with robot-assisted radical prostatectomy.

INTRODUCTION: Robot-assisted laparoscopic surgery has been performed in various fields, especially in the pelvic cavity. However, little is known about the utility of robot-assisted laparoscopic rectal cancer surgery associated with robot-assisted radical prostatectomy (RARP). We herein report the clinical impact of robot-assisted laparoscopic rectal cancer surgery associated with RARP. METHODS: We experienced five cases of robot-assisted laparoscopic rectal cancer surgery associated with RARP. One involved robot-assisted laparoscopic abdominoperineal resection with en bloc prostatectomy for T4b rectal cancer, and one involved robot-assisted laparoscopic intersphincteric resection combined with RARP for synchronous rectal and prostate cancer. The remaining three involved robot-assisted laparoscopic low anterior resection (RaLAR) after RARP. For robot-assisted laparoscopic rectal cancer surgery, the da Vinci Xi surgical system was used. RESULTS: We could perform planned robotic rectal cancer surgery in all cases. The median operation time was 529 min (373-793 min), and the median blood loss was 307 ml (32-1191 ml). No patients required any transfusion in the intra-operative or immediate peri-operative period. The circumferential resection margin was negative in all cases. There were no complications of grade ≥III according to the Clavien-Dindo classification and no conversions to conventional laparoscopic or open surgery. CONCLUSION: Robot-assisted laparoscopic surgery associated with RARP is feasible in patients with rectal cancer. The long-term surgical outcomes remain to be further evaluated.

Risk Factors for Outlet Obstruction in Patients with Diverting Ileostomy Following Rectal Surgery.

OBJECTIVES: Anastomotic leakage is one of the most severe complications of rectal cancer surgery. A diverting ileostomy was constructed for the purpose of reducing anastomotic failure risk. Outlet obstruction (OO) is one of the complications of diverting stoma that results in a lack of fecal discharge from the stoma. Detailed etiologies and preventive measures for outlet obstruction have not yet been identified. METHODS: We studied 125 patients who underwent rectal resection, anastomosis, and elective ileostomy. We evaluated the incidence of outlet obstruction and looked for any relationship between perioperative factors and outlet obstruction. RESULTS: Outlet obstruction was detected in 20 cases (16.0%). Outlet obstruction occurred 9 days after surgery in most cases. Inserting a decompressing tube improved obstructive symptoms in 4 days. Patients were divided into two cohorts according to the occurrence of outlet obstruction. Postoperative hospital stay was longer in the outlet obstruction group (19 vs. 15 days; p = 0.0003). A multivariate analysis identified that younger patients, a postoperative thicker rectus abdominis muscle at the stoma passage and high output syndrome were independent risk factors for outlet obstruction. CONCLUSIONS: Younger patients, a postoperative thicker rectus abdominis muscle at stoma passage and high output syndrome were independent risk factors for outlet obstruction.

Exploratory analysis of lateral pelvic sentinel lymph node status for optimal management of laparoscopic lateral lymph node dissection in advanced lower rectal cancer without suspected lateral lymph node metastasis.

BACKGROUND: Total mesorectal excision (TME) and lateral lymph node dissection (LLND) without radiotherapy (RT) are standard treatment for lower cT3/4 rectal cancers in Eastern countries. In comparative studies, both TME + LLND and RT + TME yield good local control. Although Japanese guidelines recommend LLND for locally advanced rectal cancers below the peritoneal reflection, LLND dissection of clinically negative lateral pelvic lymph nodes (LPLN) is controversial, and laparoscopic TME + LLND is technically challenging and time-consuming. New optical instruments for laparoscopy allow easy perioperative sentinel lymph node (SLN) identification using ICG. The SLN concept may facilitate accurate diagnosis of LPLN involvement, and thus reduce LLND in laparoscopic rectal cancer surgery. Here we investigated lateral pelvic SLN navigation surgery for SLN detection during laparoscopic rectal cancer surgery. METHODS: This study included 21 patients with clinical StageII/III lower rectal cancer without LPLN enlargement, who underwent curative laparoscopic surgery. All patients underwent TME, followed by lateral SLN identification and biopsy using ICG, and then laparoscopic LLND. ICG fluorescence imaging was conducted using the laparoscopic near-infrared camera system. RESULTS: Lateral SLNs were successfully identified in 16 (76.2%) of the 21 patients. Among the 15 patients without SLN tumor metastasis, the dissected lateral non-SLNs were all negative. CONCLUSIONS: A lack of metastasis in the lateral pelvic SLN seems to reflect a lack of metastases to all lateral LNs. Our present results suggest that this laparoscopic ICG-guided SLN strategy may be a low-risk and time-saving method to prevent laparoscopic LLND in cases with negative lateral pelvic lymph nodes.

A phase II study of the safety of olanzapine for oxaliplatin based chemotherapy in coloraectal patients.

Olanzapine has exhibited efficacy as an antiemetic agent when used with 5-HT3 receptor antagonists, dexamethasone, and NK1 receptor antagonists for patients receiving highly emetogenic chemotherapy. In addition, several studies have reported the efficacy or safety of olanzapine in patients receiving moderately emetogenic chemotherapy, including carboplatin, irinotecan, and oxaliplatin. However, no reports of olanzapine use have focused on patients receiving oxaliplatin-based chemotherapy. Therefore, we analyzed the safety of antiemetic therapy using olanzapine, palonosetron, aprepitant, and dexamethasone in colorectal cancer patients undergoing oxaliplatin-based chemotherapy. This study was a prospective phase II single-institution study of 40 patients (median age 60 years, 23 patients were male). The primary endpoint was the incidence of adverse events, and the exploratory endpoints were the rate of chemotherapy-induced nausea and vomiting. Almost all patients (90%) had a performance status of 0. All patients received the scheduled antiemetic therapy. The most common adverse event was somnolence (n = 7 patients, 17.5%). All adverse events were grade 1. Thirty-six patients were included in the exploratory analysis of efficacy. No patients experienced vomiting during the first 120 h after chemotherapy, and complete response and complete control were both 86.1%. The rate of total control was 55.6% during the same time period. Olanzapine use with 5-HT3 receptor antagonists, dexamethasone, and NK1 receptor antagonists was safe for colorectal cancer patients receiving oxaliplatin-based chemotherapy.

Efficacy of intraoperative ICG fluorescence imaging evaluation for preventing anastomotic leakage after left-sided colon or rectal cancer surgery: a propensity score-matched analysis.

BACKGROUND: Intestinal perfusion at the anastomotic site is thought to be one of the most influential risk factors for postoperative anastomotic leakage (AL). We evaluated the efficacy of indocyanine green (ICG) fluorescence imaging at the stump of the proximal colon in left-sided colectomy or rectal resection in terms of decreasing the incidence of AL. METHODS: Prospectively collected data were retrospectively evaluated. Patients who underwent left-sided colectomy or rectal resection were enrolled (ICG group; n = 197), and patients who had undergone a similar procedure before the ICG group were enrolled from the charts as historical controls (HC group; n = 187). After ICG evaluation, anastomosis was performed where fluorescence was sufficient. The incidence of AL was compared between the ICG and HC groups. Propensity score (PS)-matched data were analyzed to clarify the risk of AL. RESULTS: AL occurred in 6 patients (3.3%) in the ICG group and 17 (10.7%) in the HC group. ICG evaluation revealed 179 patients with good fluorescence and 18 with poor/none perfusion (9.1%). The transection line was changed in all patients with poor/none fluorescence. Three of these 18 patients developed AL (16.7%), though transection line was changed at which is thought to be good. We hope AL in poor/none fluorescence can be prevented at the same rate of cases with good fluorescence. Actually, the rate of that was significantly higher compared with good fluorescence patients (P = 0.038). 93 patients in each group were compared by PS-matched data analysis, which showed the AL rate in the ICG group was significantly lower than that in the HC group (3.2% vs 10.8%, respectively; P = 0.046). CONCLUSIONS: Even though this study has limitations of comparison of data prospectively collected and retrospectively analyzed, intraoperative ICG fluorescence imaging evaluation could significantly decrease the incidence of AL.

Laparoscopic-assisted disinvagination and polypectomy for multiple intussusceptions induced by small intestinal polyps in patients with Peutz-Jeghers syndrome: a case report.

BACKGROUND: Peutz-Jeghers syndrome (PJS) is a very rare autosomal dominant genetic disorder characterized by hamartomatous polyps in the gastrointestinal tract and hyperpigmentation of the lips, hands, and feet. The hamartomatous polyps in the small intestine often cause intussusception and bleeding. CASE PRESENTATION: A 62-year-old male was hospitalized for treatment of deep vein thrombosis and pulmonary embolism. In the small intestine, computed tomography showed three small polyps with intussusceptions. Since the patient had gastrointestinal polyposis and pigmentation of his lips, fingers, and toes, he was diagnosed with PJS. After an inferior vena cava filter was placed, he underwent laparoscopic-assisted surgery. The polyps causing intussusception were resected as far as possible without intestinal resection, since they had caused progressive anemia and might cause intestinal obstruction in the future. The patient was discharged from the hospital on postoperative day 9 without complications. CONCLUSIONS: Laparoscopic-assisted disinvagination and polypectomy is a useful, minimally invasive treatment for multiple intussusceptions caused by small intestinal polyps in patients with PJS.

Accurate localization of rectal cancer using near infrared ray-guided surgery with intra-operative colonoscopy and da Vinci Firefly technology.

Accurate localization of the tumor during robot-assisted laparoscopic surgery for rectal cancer is crucial. Several techniques have been described, but each has its shortcomings. We developed a new technique of near infrared ray-guided surgery (NIRGS) to localize the tumor accurately, using intra-operative colonoscopy and da Vinci Firefly technology. After clamping the oral side of the tumor, the colonoscope was inserted. In the normal visible light mode, we could not recognize the endoscopic light; however, after changing to the Firefly mode, the endoscopic light was seen clearly. Using this simple and new technique, we could locate the tumor easily and accurately. We performed this technique in 12 patients and detected the location of the tumor clearly in all, without any procedure-related complications. Based on these findings, NIRGS is a useful and safe technique for detecting tumor location during robot-assisted laparoscopic surgery for rectal cancer.

Diagnostic value of computed tomography (CT) and positron emission tomography (PET) for paraaortic lymph node metastasis from left-sided colon and rectal cancer.

BACKGROUND/OBJECTIVE: Paraaortic lymph node (PALN) metastasis influences treatment strategy for colorectal cancer. The aims of this study were to elucidate the diagnostic value of computed tomography (CT) and positron emission tomography (PET) for PALN metastasis from left-sided colorectal cancer. METHODS: A total of 108 patients who underwent radical surgery including PALN dissection were included. Size and morphology of PALN were evaluated using CT, and presence of higher FDG uptake was evaluated using PET. Findings of CT and PET were compared with pathological status. RESULTS: The largest major axis ≥11 mm and heterogeneous internal density were predictive factors on multivariate analysis. Eighty five percent of the PALNs ≥11 mm with heterogeneous internal density were pathologically metastatic, whereas 94.1% without them were not metastatic. PET had an accuracy, sensitivity, and specificity of 85.7%, 66.7%, and 94.1%, respectively. In patients with PALNs <11 mm without heterogeneous internal density, the accuracy and specificity of PET improved to 93.8% and 96.6%, respectively. Conversely, in patients with some predictive CT findings, although the positive predictive value of PET increased from 83.3% to 88.9%, the accuracy and sensitivity remained at 70.6% and 66.7%, respectively, and 50.0% were false-negatives. CONCLUSION: CT had high NPV and relatively high PPV. PET had high specificity but low sensitivity. The addition of PET could be useful to confirm no PALN metastasis in patients with no predictive CT findings. Conversely, the improvement of diagnostic ability was limited in patients with some predictive CT findings.

[Review of High-Risk Factors and Adjuvant Chemotherapy Indication in T4-pStage â ¡ Colon Cancer].

BACKGROUND: T4 is one of the high-risk factors, but the efficacy of adjuvant chemotherapy for T4-Stage Ⅱ colon cancer are unclear. METHOD: We retrospectively reviewed 211 patients with primary pStage Ⅱ colon cancer who underwent radical resection between 2004 and 2015. RESULTS: The 5-year overall survival rate(OS)of Stage ⅡA/ⅡB/ⅡC were 90.2/83.4/ 59.2%, and the 5-year recurrence-free survival rate(RFS)were 87.3/73.3/42.8%. Multivariate analysis of OS as a high-risk factor of T4 revealed male, ly2/3, no adjuvant chemotherapy, and in RFS, male, ly2/3. However, compared the cases with or without adjuvant chemotherapy, 5-year OS was no difference. There were no cases used oxaliplatin-based adjuvant chemotherapy. CONCLUSION: An adjuvant chemotherapy without oxaliplatin were not enough to improve the prognoses of T4-Stage Ⅱcolon cancer, so the oxaliplatin based regimen might be recommended.