Transanal minimally invasive surgery for rectal neuroendocrine tumors.

BACKGROUND: There is no literature that mainly searched for rectal neuroendocrine tumor (rNET) using transanal minimal invasive surgery (TAMIS). We report our clinical experiences of TAMIS for rectal neuroendocrine tumors to evaluate the feasibility and safety. METHODS: Between December 2010 and March 2020, the 25 consecutive patients with rectal neoplasma underwent the TAMIS procedure performed by single laparoscopic surgeon at the two hospitals. Of these, ten patients with rectal neuroendocrine tumors were reviewed retrospectively. The full-thickness excision down to the outer fatty tissues was completed using TAMIS technique. Clinicopathological findings, perioperative and postoperative complications were recorded. RESULTS: TAMIS for small rNET was successfully completed in all cases. There were seven cases with a tumor size of less than 10 mm, and three cases with a tumor size between 10 and 15 mm. Six patients underwent the primary tumor excision; the remaining four patients underwent resection for the scar after endoscopic procedure. The median surgical duration was 80.5 (53-124) minutes and the median blood loss was 1 (1-12) ml. All removed tumors in the 6 primary excisions were diagnosed as neuroendocrine tumor G1. The margins of specimens were completely free in all cases. Among the four patients after endoscopic procedure, all had no histological evidence of residual tumor. The median length of hospital stay was 7 days postoperatively. There was no post-operative mortality or severe complication. The median length of observation was 54 months. No recurrence, no local or distant metastasis and no mortality of all patients were observed. CONCLUSIONS: TAMIS is safety and feasible procedure for small rNET. Further experience and clinical trials are needed to fully define the advantages, disadvantages, and indications of TAMIS for rNET.

Urinary bladder fistula following laparoscopic inguinal hernioplasty: a case report.

BACKGROUND: Fistula formation due to mesh erosion into hollow viscera, such as the urinary bladder, is uncommon. To date, there have been no reports of fistula formation into the urinary bladder without evidence of mesh erosion after hernioplasty; herein, we report one such rare case, in which the clinical symptoms improved without any surgical intervention. CASE PRESENTATION: A 73-year-old man underwent a trans-abdominal preperitoneal repair for bilateral direct inguinal hernia. One month later, the patient experienced a painful induration in the right inguinal region, and computed tomography revealed fluid collection in this region. A culture of the aspirated fluid yielded no bacteria. Seven months later, he experienced another episode of painful induration in the same region. However, blood examination revealed a normal white blood cell count and C-reactive protein level. Moreover, no organisms were detected by aspirated fluid culture. Although the painful induration subsided after aspiration of the fluid collection, he developed gross hematuria and dysuria a month later. Cystoscopy revealed a fistula in the right wall of the urinary bladder that discharged a purulent fluid. Culture of the fluid revealed no bacteria, and there was no evidence of mesh erosion. Hematuria improved without therapeutic or surgical intervention. The patient's clinical symptoms improved without mesh removal. Moreover, cystoscopy revealed that the fistula was scarred 12 months after the initial appearance of urinary symptoms. No further complications were observed during a 42-month follow-up period. CONCLUSIONS: We report a rare case of a fistula in the urinary bladder without evidence of mesh erosion after laparoscopic hernioplasty. The patient's condition improved without mesh removal. Fluid collection due to foreign body reaction to meshes can cause fistula formation in the urinary bladder without direct mesh contact.

Lymph Node Positivity in One-Step Nucleic Acid Amplification is a Prognostic Factor for Postoperative Cancer Recurrence in Patients with Stage II Colorectal Cancer: A Prospective, Multicenter Study.

BACKGROUND: For colorectal cancer (CRC) patients, the standard histological lymph node (LN) evaluation has low sensitivity. Our previously developed one-step nucleic acid amplification (OSNA™) assay measures cytokeratin 19 gene expression in whole LNs. We recently showed that 17.6% of pN0 stage II CRC patients were OSNA positive, suggesting a correlation between OSNA results and disease recurrence. This multicenter, prospective study investigateed the prognostic value of the OSNA assay for pStage II CRC patients. METHODS: We examined 204 CRC patients who were preoperatively diagnosed as cN0 and cN1 and surgically treated at 11 medical institutions across Japan. Nine patients were excluded, and 195 patients (Stage I: n = 50, Stage II: n = 70, Stage III: n = 75) were examined. All LNs, harvested from patients, were examined histopathologically using one-slice hematoxylin-eosin staining. Furthermore, half of the LNs was examined by the OSNA assay. Patients were classified according to the UICC staging criteria and OSNA results, and the 3-year, disease-free survival (DFS) of each cohort was analyzed. RESULTS: Average 21.2 LNs/patient were subject to pathological examination. Approximately half of all harvested LNs (average, 9.4 LNs/patient) were suitable for the OSNA assay. Significantly lower 3-year DFS rates were observed in pStage (pathological Stage) II OSNA-positive patients than in OSNA-negative patients (p = 0.005). Among all assessed clinical and pathological parameters, only the OSNA result significantly affected 3-year DFS rates in pStage II CRC patients (p = 0.027). CONCLUSIONS: This study shows that OSNA positivity is a risk factor for recurrence of the patients with pStage II CRC.

OSNA-Assisted Molecular Staging in Colorectal Cancer: A Prospective Multicenter Trial in Japan.

BACKGROUND: We previously reported that the one-step nucleic acid amplification (OSNA) assay provided a judgment performance for colorectal cancer equivalent to a 2-mm-interval histopathological examination of lymph nodes (concordance 97.1 %, n = 385 lymph nodes). In this prospective multicenter study, we uncovered an OSNA-assisted pathology to detect lymph node metastasis. METHODS: A total of 204 (50 stage I, 74 stage II, and 80 stage III) colorectal cancer patients. All 4324 lymph nodes were examined by the standard histology (one-slice H&E staining) and 1925 lymph nodes (44.5 %) of them were also subject to the OSNA analysis. RESULTS: The concordance rate between 1 slice hematoxylin/eosin and OSNA assay was 95.7 % (1,842/1925 lymph nodes). The sensitivity and specificity of the OSNA assay were 86.2 % (125/145) and 96.5 % (1717/1780), respectively. Among 124 node-negative patients (pN0), the respective upstaging rates of pStages I, IIA, IIB, and IIC were 2.0 % (1/50), 17.7 % (11/62), 12.5 % (1/8), and 25 % (1/4). OSNA-positive patients had deeper invasion to the colonic wall and severe lymphatic invasion (P = 0.048 and P = 0.004, respectively). The sum of the quantitative results of OSNA and total tumor load increased as the number of metastasized lymph nodes increased: 1550 copies/µL in pN0, 24,050 copies/µL in pN1, and 90,600 copies/µL in pN2. CONCLUSIONS: The present study on colorectal cancer provided fundamental data regarding OSNA-assisted pathology of lymph node metastasis in Japan.

Prevention of postoperative small bowel obstruction in gastric cancer.

Postoperative adhesion is a frequent problem in patients undergoing surgery. In particular, gastrectomy is associated with a high risk of bowel obstruction. However, there are few reports of small bowel obstruction (SBO) after gastrectomy in the English-language literature. We reviewed the literature to assess the effectiveness of various techniques for preventing adhesion in patients treated with gastrectomy. We assumed that strategies used to prevent postoperative adhesion associated with colorectal surgery, cholecystectomy, appendectomy and gynecologic procedures are similar to those used in gastrectomy. We therefore reviewed reports on the prevention of postoperative SBO in any abdominal surgical procedure, focusing especially on gastrectomy. General intraoperative preventive techniques, such as the use of starch-free gloves, saline irrigation at a temperature below 37 °C and laparoscopic techniques whenever possible, may reduce the incidence of SBO in patients with gastric cancer who undergo gastrectomy. If preserving the omentum is unrelated to the survival rate of patients with gastric cancer, this technique should be recommended for preventing postoperative SBO. The use of hyaluronic acid/carboxymethylcellulose bioabsorbable membranes should also be considered in patients undergoing gastrectomy. However, demonstrating the advantages of bioabsorbable membranes would require larger randomized studies with a longer follow-up period.

Evaluation of three types of platforms in single-incision laparoscopic surgery for performing transanal endoscopic microsurgery (SILSTEM).

BACKGROUND/AIMS: Transanal endoscopic microsurgery using a platform for single-incision laparoscopic surgery (SILSTEM) is safe for excising rectal lesions. We tested three types of platforms. METHODOLOGY: Nine patients underwent SILSTEM by one surgeon. Tumors located 5­15 cm from the anal verge were eligible. After measuring their dimensions, length, and trocar channels, the platforms tested were the SILSTM port (SP), EZTM access (EA), and GelPOINTTM Path (GP). Clinicopathology, intraoperative parameters, and postoperative outcomes were recorded. RESULTS: Six men and three women (median age 63 years) underwent SILSTEM using platform SP in three patients, EA in four, GP in two. Median operation time was 128 min (range 71­313). Median blood loss was 3 ml (range 1­71). Pathology confirmed adenocarcinoma in five patients, adenoma in three, and carcinoid in one. Patients were discharged within 2­13 days postoperatively. There was no postoperative fecal incontinence or soiling. Overall median follow-up was 13.3 months (range 1.3­27.2). There were no recurrences. CONCLUSION: SILSTEM can effectively resect rectal tumors using any of three platforms. Large prospective trials are needed to define the advantages, disadvantages, and indications for each platform and to draw conclusions regarding operation time, anorectal function, and costs.

Single-incision laparoscopic surgery used to perform transanal endoscopic microsurgery (SILSTEM) for T1 rectal cancer under spinal anesthesia: report of a case.

Transanal endoscopic surgery has slowly gained widespread acceptance among colorectal surgeons, despite the need for specific training and the high costs of specialized instrumentation. At the other extreme, some laparoscopic surgeons recommend single port access surgery using a single-incision laparoscopic surgery port. Single-incision laparoscopic surgery was applied to perform transanal endoscopic microsurgery in a patient with T1 rectal cancer under spinal anesthesia. The patient was a 74-year-old man who presented with a 2-cm elevated lesion in the right anterior portion of the rectum. Ordinary laparoscopic instruments were used to perform submucosal resection. The tumor was completely excised from the rectal wall with the use of an ultrasonic surgical scissors. The patient recovered uneventfully and was discharged 4 days after the operation. There was no fecal incontinence or soiling during the postoperative follow-up. Colonoscopy at 4 months after the operation showed no recurrence of either adenocarcinoma or adenoma.

Comparison of Short-Term Outcomes Between Hand-assisted Laparoscopic Distal Gastrectomy and Laparoscopy-assisted Distal Gastrectomy in Gastric Cancer.

Hand-assisted laparoscopic surgery is considered to provide the benefits of laparoscopic surgery in various diseases. However, limited information is available regarding the feasibility of hand-assisted laparoscopic distal gastrectomy (HALDG)-a subset of hand-assisted laparoscopic surgery-as a gastric cancer treatment. This study aimed to evaluate the usefulness of HALDG compared with laparoscopy-assisted distal gastrectomy (LADG). Consecutive patients who underwent HALDG (n=58) or LADG (n=90) for stage I gastric cancer between 2005 and 2016 were eligible. Operative time was significantly shorter and blood loss was significantly higher in HALDG than in LADG (P<0.001, both). Postoperative aminotransferase levels were significantly lower in HALDG than in LADG (P<0.001). There was no significant difference in perioperative complications, a number of analgesics, postoperative C-reactive protein levels, and 3-year relapse-free and overall survival rates between the groups. This study suggests that HALDG is a safe and feasible approach and could become an effective option for stage I gastric cancer treatment.

Bioresorbable membrane to reduce postoperative small bowel obstruction in patients with gastric cancer: a randomized clinical trial.

OBJECTIVE: This randomized controlled trial was designed to assess whether the use of a sodium hyaluronate-based bioresorbable membrane reduces small bowel obstruction after gastrectomy for gastric cancer. SUMMARY BACKGROUND DATA: Clinical studies have reported that a bioresorbable membrane significantly reduces the incidence and severity of adhesion after abdominopelvic surgery. METHODS: Between 2003 and 2006, a total of 150 patients with gastric cancer who were scheduled to undergo gastrectomy were randomly assigned to a sodium hyaluronate-based bioresorbable membrane (Seprafilm) group or to a control group. Before closing the abdominal incision, 2 sheets of Seprafilm membrane were applied to the surface of the small intestine under the middle abdominal wound in the Seprafilm group. The primary end point was the incidence of bowel obstruction. Secondary end points were intraoperative and postoperative morbidity and mortality. We registered with Clinical Trials.gov using the Protocol Registration System (ID-NCT00529412). RESULTS: We evaluated a total of 144 patients: 70 in the Seprafilm group and 74 in the control group. The overall incidence (Seprafilm group, 5.7% vs. control group, 9.5%; P = 0.534) and the cumulative incidence of small bowel obstruction (6.2% vs. 12.2% at 36 months; P = 0.3789) were slightly but not significantly lower in the Seprafilm group. The incidence of postoperative complications was similar in the groups (32.9% vs. 29.7%; P = 0.722). Seprafilm did not adversely affect bowel, liver, or renal functions. CONCLUSIONS: The use of Seprafilm does not significantly reduce the incidence of small bowel obstruction in patients undergoing gastrectomy for gastric cancer.

Spontaneous Development of Acute Obstructive Suppurative Pancreatic Ductitis Associated with Pancreatic Carcinoma: A First Case Report.

A 68-year-old man with a history of diabetes mellitus was admitted to our hospital with a diagnosis of acute pancreatitis. Abdominal computed tomography revealed a suspicious tumor in the body of the pancreas, along with a dilated main pancreatic duct and edema of the pancreatic tail. Endoscopic retrograde pancreatography was performed after treating the patient's pancreatitis. When a cannula tip was advanced beyond the stenosis, deep into the distal pancreatic duct, thick white pus was evacuated. A bacteriological examination of the aspirated pancreatic juice revealed Enterobacter cloacae, and a cytological examination revealed adenocarcinoma. The diagnosis was acute obstructive suppurative pancreatic ductitis associated with pancreatic carcinoma.

[Remarkable response of simultaneous advanced esophageal and gastric cancer to combined chemotherapy with weekday-on/Weekend-off TS-1 plus biweekly cisplatin].

A 66-year-old man was found to have both advanced cancer of the middle thoracic esophagus and advanced cancer of the middle third of the stomach with paraaortic lymph node metastases. The prognosis was poor because of local advanced disease and distant metastasis. The patient was therefore given combined chemotherapy with TS-1 and cisplatin. TS-1 (80 mg/day) was administered on days 1 to 5, 8 to 12, 15 to 19, and 22 to 26 (weekday-on/weekend-off schedule), and cisplatin (70 mg/m2 intravenously over the course of 2 hours) was administered on days 1 and 15 of a 28-day cycle. After 2 courses of chemotherapy the esophageal lesion had a complete response, and the gastric lesion had a partial response (reduction ratio, 71.4%). However, stomatitis and anorexia of grade 2 (NCI-CTC) occurred. Two courses of TS-1 alone (80 mg/m2) were therefore given. The esophageal lesion continued to show a complete response and the gastric lesion a partial response (reduction ratio, 85.7%). There was no change in the para-aortic lymph node metastasis (No. 16a2 latero). No adverse reaction to chemotherapy was severer than grade 3, and a good response was obtained. These findings indicate that chemotherapy with a combination of TS-1 and cisplatin is effective against advanced esophageal cancer and advanced gastric cancer.

[A case of long survival with UFT and lentinan treatment in a patient with peritoneal metastasis of gastric carcinoma].

The patient was a 50-year-old female with peritoneal metastasis of Type 4 gastric cancer. She underwent a relative curative resection with total gastrectomy and peritonectomy. Postoperative chemotherapy with 5'-DFUR following 5-FU and CDDP was performed. Thirteen months after surgery, cancer recurrence was suspected due to elevated levels of the serum tumor markers carcinoembryonic antigen (8.9 ng/ml) and alpha fetoprotein (85.8 ng/ml). She was additionally treated with UFT 300 mg/day and Lentinan 2 mg/week. The serum tumor markers decreased gradually returned to normal levels. At 5 years and 8 months after surgery, she is alive without any sign of recurrence.

[A case of advanced gastric cancer with simultaneous multiple bone metastases and double occurrence of disseminated intravascular coagulation successfully controlled with combined chemotherapy].

A 41-year-old man was found to have advanced gastric cancer with simultaneous multiple bone metastases when pyloric stenosis was being diagnosed in our hospital. We performed gastrojejunostomy from the lower third of the stomach to the upper third of the duodenum to relieve the obstruction. However, at 8 days after surgery, disseminated intra-vascular coagulation (DIC) occurred. Therefore, the patient was administered combined chemotherapy with TS-1 plus low-dose cisplatin in addition to anti-DIC therapy. TS-1 (150 mg/day) and cisplatin (10 mg/body intravenously over the course of 30 minutes) were administered on days 1 to 5, 8 to 12, and 15 to 19 (weekday-on/weekend-off schedule). There was remarkable response to this chemotherapy, and the patient was shifted from inpatient to outpatient treatment. The treatment course was repeated for 4 cycles until remission was observed. Because of hematologic relapse due to DIC at 6 months after the first treatment, he was readmitted for administration of combined chemotherapy. Fortunately, DIC once again responded to the same chemotherapy regimen. In this pathologic condition, combined chemotherapy is unavoidable when DIC occurs with cancer. Accordingly, it is necessary that an effective combined chemotherapy with mild bone marrow suppression be chosen. A companion drug should be chosen in consideration of delayed homo-toxicity and of the possibility of relapse into DIC in the drug withdrawal period. In addition, it is indispensable that careful consideration be given to the most favorable dose and regimen.