Anterior versus posterior mediastinal reconstruction after esophagectomy in esophageal cancer patients: a systematic review and meta-analysis.

PURPOSE: Esophagectomy is the primary surgical treatment for esophageal cancer, although other treatment approaches are often incorporated, including preoperative chemotherapy and chemoradiotherapy. The two major routes of esophageal reconstruction after esophagectomy are the anterior mediastinal (retrosternal, heterotopic) and posterior mediastinal (prevertebral, orthotopic) routes. However, which of these two routes of reconstruction is the most appropriate remains controversial. This systematic review aimed to compare the efficacy and safety of anterior mediastinal reconstruction with those of posterior mediastinal reconstruction after esophagectomy in esophageal cancer. METHODS: In January 2022, a literature search of the CENTRAL, MEDLINE, and EMBASE databases was conducted to identify all published and unpublished randomized controlled trials, regardless of language. Eight studies were included for quantitative synthesis. RESULTS: Postoperative death (9/129 and 4/125, risk ratio [RR]: 2.07, 95% confidence interval [CI]: 0.65-6.64) and incidence of anastomotic leak (24/208 and 26/208, RR: 0.95, 95% CI: 0.56-1.62) were not significantly different between the two mediastinal reconstructions. We could not perform a meta-analysis for quality of life, loss of body weight, or postoperative hospital stay due to data limitations. CONCLUSION: Overall, there was low-quality evidence to suggest that the outcomes of the anterior and posterior mediastinal routes of reconstruction are not significantly different in patients with esophageal cancer.

Impact of the coronavirus disease 2019 pandemic on gastric and colorectal cancer surgeries: a multicenter epidemiologic study from the Kinki region of Japan.

The coronavirus disease 2019 pandemic affected cancer surgeries and advanced cancer diagnoses; however, the trends in patient characteristics in medical institutions during this time, and the surgical approaches used are unclear. We investigated the impact of the pandemic on gastric and colorectal cancer surgeries in the Kinki region of Japan. We grouped 1688 gastric and 3493 colorectal cancer surgeries into three periods: "pre-pandemic" (April 2019-March 2020), "pandemic 1" (April 2020-March 2021), and "pandemic 2" (April 2021-September 2021), to investigate changes in the number of surgeries, patient characteristics, surgical approaches, and cancer progression after surgery. Gastric and colorectal cancer surgeries decreased from the pre-pandemic levels, by 20% and 4%, respectively, in pandemic 1, and by 31% and 19%, respectively, in pandemic 2. This decrease had not recovered to pre-pandemic levels by September, 2021. Patient characteristics, surgical approaches, and cancer progression of gastric and colorectal surgeries did not change remarkably as a result of the coronavirus disease 2019 pandemic.

Comparison of Minimally Invasive Surgery with Open Surgery for Remnant Gastric Cancer: A Multi-institutional Cohort Study.

BACKGROUND: Despite growing evidence of the effectiveness of minimally invasive surgery (MIS) for primary gastric cancer, MIS for remnant gastric cancer (RGC) remains controversial due to the rarity of the disease. This study aimed to evaluate the surgical and oncological outcomes of MIS for radical resection of RGC. PATIENTS AND METHODS: Patients with RGC who underwent surgery between 2005 and 2020 at 17 institutions were included, and a propensity score matching analysis was performed to compare the short- and long-term outcomes of MIS with open surgery. RESULTS: A total of 327 patients were included in this study and 186 patients were analyzed after matching. The risk ratios for overall and severe complications were 0.76 [95% confidence interval (CI): 0.45, 1.27] and 0.65 (95% CI: 0.32, 1.29), respectively. The MIS group had significantly less blood loss [mean difference (MD), -409 mL; 95% CI: -538, -281] and a shorter hospital stay (MD, -6.5 days; 95% CI: -13.1, 0.1) than the open surgery group. The median follow-up duration of this cohort was 4.6 years, and the 3-year overall survival were 77.9% and 76.2% in the MIS and open surgery groups, respectively [hazard ratio (HR), 0.78; 95% CI: 0.45, 1.36]. The 3-year relapse-free survival were 71.9% and 62.2% in the MIS and open surgery groups, respectively (HR, 0.71; 95% CI: 0.44, 1.16). CONCLUSIONS: MIS for RGC showed favorable short- and long-term outcomes compared to open surgery. MIS is a promising option for radical surgery for RGC.

Employment Status of Patients With Colorectal Cancer After Surgery: A Multicenter Prospective Cohort Study in Japan.

BACKGROUND: Because of improved survival rates, patients with colorectal cancer may try to return to work. Many countries, however, have limited knowledge of the employment status of these patients. OBJECTIVE: To explore the employment status of patients with colorectal cancer after surgery in Japan and the risk factors affecting the same. DESIGN: This is a prospective multicenter cohort study that used self-administered questionnaires. Patients were recruited from June 2019 to August 2020 and were followed up for 12 months after surgery. SETTING: Six community hospitals and 1 university hospital in Japan. PATIENTS: Patients with clinical stages I to III colorectal cancer, employed at the time of diagnosis. INTERVENTIONS: Patients who underwent surgical resection between June 2019 and August 2020. MAIN OUTCOME MEASUREMENTS: The time it takes patients to return to work after surgery and the proportion of working patients 12 months after surgery were collected using self-administered questionnaires. RESULTS: A total of 129 patients were included in the analyses. The median time to return-to-work was 1.1 months, and the proportion of working patients at 12 months after surgery was 79%. Risk factors for delayed return-to-work after surgery were an advanced tumor stage, stoma, severe postoperative complications, shorter years of service at the workplace, and lower willingness to return-to-work. Risk factors for not working 12 months after surgery were stoma, lower willingness to return-to-work, nonregular employee status, lower income, national health insurance, and no private medical insurance. LIMITATIONS: This study is limited by its short-term follow-up and small sample size. CONCLUSIONS: This study revealed that Japanese patients with stages I to III colorectal cancer found favorable employment outcomes in the 12 months after surgery. These results may help health care providers better understand the employment status of patients with colorectal cancer and encourage them to consider returning to work after surgery. SITUACIN LABORAL DE LOS PACIENTES CON CNCER COLORRECTAL DESPUS DE LA CIRUGA UN ESTUDIO DE COHORTE PROSPECTIVO MULTICNTRICO EN JAPN: ANTECEDENTES:Debido a las mejores tasas de supervivencia, los pacientes con cáncer colorrectal pueden intentar volver al trabajo. Muchos países, sin embargo, tienen un conocimiento limitado de su situación laboral.OBJETIVO:Explorar la situación laboral de los pacientes con cáncer colorrectal después de la cirugía en Japón y los factores de riesgo que afectan a la misma.DISEÑO:Este es un estudio prospectivo de cohortes multicéntrico que utiliza cuestionarios autoadministrados. Los pacientes fueron reclutados desde junio de 2019 hasta agosto de 2020 y fueron seguidos durante 12 meses después de la cirugía.ENTORNO CLINICO:Seis hospitales comunitarios y un hospital universitario en Japón.PACIENTES:Pacientes con estadios clínicos I-III de cáncer colorrectal, trabajando en el momento del diagnóstico.INTERVENCIONES:Pacientes que recibieron resección quirúrgica desde junio de 2019 hasta agosto de 2020.PRINCIPALES MEDIDAS DE RESULTADO:El tiempo que tardan los pacientes en volver al trabajo después de la cirugía y la proporción de pacientes que trabajan 12 meses después de la cirugía se recogieron mediante cuestionarios autoadministrados.RESULTADOS:Un total de 129 pacientes fueron incluidos en los análisis. La mediana de tiempo de reincorporación al trabajo fue de 1,1 meses y la proporción de pacientes que trabajaban a los 12 meses de la cirugía fue del 79%. Los factores de riesgo para el retraso en el regreso al trabajo después de la cirugía fueron un estadio avanzado del tumor, estoma, complicaciones postoperatorias graves, menos años de servicio en el lugar de trabajo y menor disposición para volver al trabajo. Los factores de riesgo para no trabajar 12 meses después de la cirugía fueron estoma, menor voluntad de volver al trabajo, condición de empleado no regular, ingresos más bajos, seguro nacional de salud y la falta de seguro médico privado.LIMITACIONES:Este estudio está limitado por su seguimiento a corto plazo y tamaño de muestra pequeño.CONCLUSIONES:Este estudio reveló que los pacientes japoneses con cáncer colorrectal en estadios I-III obtuvieron resultados laborales favorables en los 12 meses posteriores a la cirugía. Estos resultados pueden ayudar a los proveedores de atención médica a comprender mejor la situación laboral de los pacientes con cáncer colorrectal y alentarlos a considerar regresar al trabajo después de la cirugía. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Postoperative recurrence in locally advanced rectal cancer: how does neoadjuvant treatment affect recurrence pattern?

BACKGROUND: The treatment strategy for locally advanced rectal cancer (LARC) has recently expanded from total mesorectal excision to additional neoadjuvant chemoradiotherapy (nCRT) and/or systemic chemotherapy (NAC). Data on disease recurrence after each treatment strategy are limited. METHODS: Clinical stage II to III rectal cancer patients who underwent curative surgery between July 2005 and February 2021 were analyzed. The cumulative incidence and site of first recurrence were assessed. The median follow-up duration was 4.6 years. RESULTS: Among the 332 patients, we performed nCRT and NAC in 15.4% (N=51) and 14.8% (N=49), respectively. The overall recurrence rate was 23.5% (N=78). Although several differences in tumor stage or location were observed, there was no significant difference in the rate among the surgery alone (N=54, 23.3%), nCRT (N=11, 21.6%), and NAC (N=13, 26.5%) groups. In this cohort, the local recurrence rate (18.4%) was higher than the rate of distant metastasis in the NAC group (14.3%). All patients with recurrence in the nCRT group had distant metastases (N=11: one patient had distant and local recurrences simultaneously). For pathological stage 0-I, the recurrence rate was higher in the nCRT and NAC groups than in the surgery-alone group (nCRT, 10.0%; NAC, 15.4%; and surgery-alone, 2.0%). Curative-intent resection of distant-only recurrences significantly improved patients' overall survival (hazard ratio [95% confidence interval], 0.34 [0.14-0.84]), which was consistent even when stratified according to neoadjuvant treatment. Regardless of neoadjuvant treatment, >80% of recurrences occurred in the first 2.2 years, and 98.7% within 5 years after surgery. CONCLUSION: Regardless of neoadjuvant treatment, detecting distant metastases with intensive surveillance, particularly in the first 2 years after surgery, is important. Also, even if neoadjuvant treatment can downstage LARC to pathological stage 0-I, careful follow-up is needed.

Prophylactic supraclavicular lymph node dissection for esophageal squamous cell carcinoma: a systematic review and meta-analysis.

The supraclavicular lymph nodes (SCLNs) have been regarded as regional nodes for esophageal squamous cell carcinoma (ESCC) in Japan and eastern Asian countries, whereas their involvement has been regarded as distant metastasis in Western countries. The importance of thorough dissection of the lymphatic chain along the recurrent laryngeal nerve, including the cervical paraesophageal nodes, has become well understood; therefore, the contemporary clinical question is whether prophylactic SCLN dissection (SLND) in addition to cervical paraesophageal node dissection is beneficial for patients with ESCC. We analyzed studies comparing esophagectomy with SLND vs. esophagectomy without SLND, in both of which cervical paraesophageal node dissection had been completed, based on a comprehensive literature search of the PubMed, Scopus, and Cochrane databases. Our meta-analysis focused on two long-term outcomes: 3-year and 5-year overall survival (OS) rates; and three short-term outcomes: pneumonia, recurrent nerve palsy, and anastomotic leakage. Four studies, with a collective total of 1584 patients were included in the review. No significant differences were found between esophagectomy with SLND vs. esophagectomy without SLND in the meta-analysis of both long-term (3-year and 5-year OS; risk ratio 1.09, 95% CI 0.94-1.26, P = 0.28, and risk ratio 1.14, 95% CI 0.96-1.35, P = 0.15, respectively) and short-term outcomes. Based on our analysis, no clear data support prophylactic SLND on the cervical paraesophageal node dissection.

Identification of high-risk stage I colon and rectal cancer patients: a retrospective analysis of a large Japanese cohort.

PURPOSE: Data regarding risk factors for recurrence in stage I colorectal cancer patients are limited. The aim of this study was to clarify the existence of a high-recurrence-risk population among stage I colorectal cancer patients. METHODS: This analysis included 7,539 stage I colorectal cancer patients treated between 1997 and 2012 at 24 leading hospitals in Japan. Risk factors for time to recurrence were evaluated using a Cox proportional hazards model, and a high-risk group for recurrence was identified. Prognostic outcomes of high-risk stage I colorectal cancer patients were compared with those of low-risk stage I and stage II patients. RESULTS: Multivariable analyses identified left-sided location (hazard ratio [HR]: 1.65, 95% confidence interval [CI]: 1.09-2.58), T2 tumors (HR: 1.80, 95% CI: 1.21-2.66), and lymphatic invasion (HR: 1.55, 95% CI: 1.05-2.28) as risk factors for recurrence in stage I colon cancer, and patients with these three risk factors were classified as high risk. For stage I rectal cancer, patients with poor differentiation (HR: 2.86, 95% CI: 1.21-5.69), T2 tumors (HR: 1.53, 95% CI: 1.07-2.23), and venous invasion (HR: 1.51, 95% CI: 1.08-2.13) were identified as high risk. The Kaplan-Meier analysis of cumulative recurrence rate and recurrence-free survival revealed that the high-risk stage I colorectal cancer patients have poorer clinical outcomes than the low-risk patients. CONCLUSION: Although stage I colorectal cancer patients generally have a favorable prognosis after curative surgery, poorer prognosis was observed in high-risk stage I colorectal cancer patients than in low-risk patients.

Relationship between diverting stoma and adjuvant chemotherapy in patients with rectal cancer: a nationwide study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan.

BACKGROUND: Patients at risk of recurrence after curative surgery for rectal cancer usually receive adjuvant chemotherapy. Postoperative recovery after low anterior resection (LAR) for rectal cancer can be improved by placement of a diverting stoma to reduce anastomotic leakage. However, it remains unclear how a diverting stoma affects administration of adjuvant chemotherapy in these patients. METHODS: We identified Japanese patients with rectal cancer who underwent LAR in 2014 and received adjuvant chemotherapy within 12 months of surgery in the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Doses of five types of chemotherapy administered (tegafur/uracil, tegafur/gimeracil/oteracil potassium, capecitabine, 5-fluorouracil, and oxaliplatin) were assessed according to the presence or absence of diverting stoma and the timing of stoma closure. RESULTS: There was no significant difference in the cumulative doses of chemotherapy administered in the 12 months after LAR between patients with and without diverting stoma, but more doses were administered in the early postoperative period (0-2 months after LAR) in patients without diverting stoma. Also, more doses of chemotherapy, regardless of type, were administered in the late closure group (7-12 months after LAR) than in the early closure (≤ 6 months) and no closure groups. CONCLUSION: Presence of a diverting stoma did not influence the dose of adjuvant chemotherapy administered within 12 months after LAR but could have delayed the start of adjuvant chemotherapy. Patients with late closure of a diverting stoma received more doses of adjuvant chemotherapy administered over 12 months.

Establishment and validation of a nomogram for predicting potential lateral pelvic lymph node metastasis in low rectal cancer.

BACKGROUND: Identifying lateral pelvic lymph node (LPN) metastasis in low rectal cancer is crucial before treatment. Several risk factors and prediction models for LPN metastasis have been reported. However, there is no useful tool to accurately predict LPN metastasis. Therefore, we aimed to construct a nomogram for predicting LPN metastasis in rectal cancer. METHODS: We analyzed the risk factors for potential LPN metastasis by logistic regression analysis in 705 patients who underwent primary resection of low rectal cancer. We included patients at 49 institutes of the Japan Society of Laparoscopic Colorectal Surgery between June 2010 and February 2012. Clinicopathological factors and magnetic resonance imaging findings were evaluated. The nomogram performance was assessed using the c-index and calibration plots, and the nomogram was validated using an external cohort. RESULTS: In the univariable logistic regression analysis, age, sex, carcinoembryonic antigen, tumor location, clinical T stage, tumor size, circumferential resection margin (CRM), extramural vascular invasion (EMVI), and the short and long axes of LPN and perirectal lymph node (PRLN) were nominated as risk factors for potential LPN metastasis. We identified a combination of the short axis of LPN, tumor location, EMVI, and short axis of PRLN as optimal for predicting potential LPN metastasis and developed a nomogram using these factors. This model had a c-index of 0.74 and was moderately calibrated and well-validated. CONCLUSIONS: This is the first study to construct a well-validated nomogram for predicting potential LPN metastasis in rectal cancer, and its performance was high.

Roux-en-Y versus Billroth-I reconstruction after distal gastrectomy for gastric cancer.

BACKGROUND: Gastric cancer is the fifth most common cancer diagnosed worldwide. Due to improved early detection rates of gastric cancer and technological advances in treatments, a significant improvement in survival rates has been achieved in people with cancer undergoing gastrectomy. Subsequently, there has been increasing emphasis on postgastrectomy syndrome (e.g. fullness, delayed emptying, and cold sweat, amongst others) and quality of life postsurgery. However, it is uncertain which types of reconstruction result in better outcomes postsurgery. OBJECTIVES: To assess the evidence on health-related quality of life and safety outcomes of Roux-en-Y and Billroth-I reconstructions after distal gastrectomy for people with gastric cancer. SEARCH METHODS: We searched the Cochrane Library and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 4 May 2021. We checked the reference lists of the included studies and contacted manufacturers and professionals in the field. There were no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) allocating participants to Roux-en-Y reconstruction or Billroth-I reconstruction after distal gastrectomy for gastric cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies identified by the search for eligibility and extracted data. The primary outcomes were health-related quality of life after surgery and incidence of anastomotic leakage. The secondary outcomes included body weight loss, incidence of bile reflux, length of hospital stay, and overall morbidity. We used a random-effects model to conduct meta-analyses. We assessed risk of bias of the included studies in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included eight RCTs (942 participants) in the review. One study included both cancer patients and benign disease patients such as stomach ulcers. Two studies compared Roux-en-Y, Billroth-I, and Billroth-II reconstructions, whilst the other studies compared Roux-en-Y and Billroth-I directly.  For the primary outcomes, the evidence suggests that there may be little to no difference in health-related quality of life between Roux-en-Y and Billroth-I reconstruction (standardised mean difference 0.04, 95% confidence interval (CI) -0.11 to 0.18; I² = 0%; 6 studies; 695 participants; low-certainty evidence due to study limitations and imprecision). The evidence for the effect of Roux-en-Y versus Billroth-I reconstruction on the incidence of anastomotic leakage is very uncertain (risk ratio (RR) 0.63, 95% CI 0.16 to 2.53; I² = 0%; 5 studies; 711 participants; very low-certainty evidence). The incidence of anastomotic leakage was 0.6% and 1.4% in the Roux-en-Y and Billroth-I groups, respectively. For the secondary outcomes, the evidence suggests that Billroth-I reconstruction may result in little to no difference in loss of body weight compared to Roux-en-Y reconstruction (mean difference (MD) 0.41, 95% CI -0.77 to 1.59; I² = 0%; 4 studies; 541 participants; low-certainty evidence). Roux-en-Y reconstruction probably reduces the incidence of bile reflux compared to Billroth-I reconstruction (RR 0.40, 95% CI 0.25 to 0.63; I² = 22%; 4 studies; 399 participants; moderate-certainty evidence). Billroth-I reconstruction may shorten postoperative hospital stay, but the evidence for this outcome is very uncertain (MD 0.96, 95% CI 0.16 to 1.76; I² = 56%; 7 studies; 894 participants; very low-certainty evidence). Billroth-I reconstruction may reduce postoperative overall morbidity compared to Roux-en-Y reconstruction (RR 1.47, 95% CI 1.02 to 2.11; I² = 0%; 7 studies; 891 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: The evidence suggests that there is little to no difference between Roux-en-Y and Billroth-I reconstruction for the outcome health-related quality of life. The evidence for the effect of Roux-en-Y versus Billroth-I reconstruction on the incidence of anastomotic leakage is very uncertain as the incidence of this outcome was low. Although the certainty of evidence was low, we found some possibly clinically meaningful differences between Roux-en-Y and Billroth-I reconstruction for short-term outcomes. Roux-en-Y reconstruction probably reduces the incidence of bile reflux into the remnant stomach compared to Billroth-I reconstruction. Billroth-I reconstruction may shorten postoperative hospital stay compared to Roux-en-Y reconstruction, but the evidence is very uncertain. Billroth-I reconstruction may reduce postoperative overall morbidity compared to Roux-en-Y reconstruction. Future trials should include long-term follow-up of health-related quality of life and body weight loss.

Survival benefit of adjuvant chemotherapy in elderly patients with colon cancer: a systematic review and meta-analysis.

BACKGROUND: Adjuvant chemotherapy after curative resection is established as a standard therapy for colon and rectal cancer. Although the efficacy of adjuvant chemotherapy has been shown by pooled analyses from randomized controlled trials, elderly patients still receive adjuvant chemotherapy less frequently than younger patients. In this systematic review and meta-analysis, we aimed to assess the survival benefit of adjuvant chemotherapy in elderly patients based on observational studies in which the elderly patients would likely be representative of those encountered in real-world clinical settings. METHODS: A comprehensive literature search was conducted using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials. Observational studies that investigated the survival benefit of adjuvant chemotherapy after curative resection in elderly patients (age ≥ 70 years) with colon or rectal cancer were included. The 5-year overall survival (OS) rate and OS were assessed. Risk of bias was assessed using the ROBINS-I tool. RESULTS: Eleven studies in elderly patients with colon cancer were included. No relevant study was identified for rectal cancer. Elderly patients who received adjuvant chemotherapy had a significantly higher 5-year OS rate than those who did not (risk ratio 1.51, 95% confidence interval 1.29-1.76, P < 0.001). There was also a significant improvement in OS in elderly patients who received adjuvant chemotherapy (hazard ratio 0.59, 95% confidence interval 0.53-0.66, P < 0.001). The overall risk of bias was judged to be critical for both outcomes. CONCLUSION: Adjuvant chemotherapy provides a survival benefit for elderly patients with colon cancer, although the quality of evidence is low.

Changes in the sexual function of male patients with rectal cancer over a 2-year period from diagnosis to 24-month follow-up: A prospective, multicenter, cohort study.

BACKGROUND AND OBJECTIVES: This prospective study aimed to identify long-term changes in sexual function of men with rectal cancer from point of diagnosis to 24 months postoperatively. METHODS: Male patients undergoing laparoscopic rectal cancer surgery were prospectively enrolled. International Index of Erectile Function (IIEF) Questionnaire scores were collected at diagnosis; first follow-up; and 6, 12, and 24 months postoperatively. Missing values were managed via multiple imputations using the propensity score method. Paired t tests were applied to examine changes in IIEF scores over time. RESULTS: This study analyzed 115 patients. For erectile function, there were no significant changes in scores from the point of diagnosis to first treatment (9.4 vs. 9.8 as mean scores; p = .227). Scores deteriorated postoperatively and recovered until 12 months post-surgery, but did not improve significantly from 12 months to 24 months post-surgery (8.7 vs. 8.2 as mean scores; p = .440). This pattern of change was observed in all other domains: orgasmic function, sexual desire, orgasmic satisfaction, and overall satisfaction. CONCLUSIONS: Sexual function was not influenced by a rectal cancer diagnosis. Sexual function deteriorated following surgery and recovered until 12 months post-surgery; however, it did not significantly improve from 12 months to 24 months postoperatively.

Linear or circular stapler? A propensity score-matched, multicenter analysis of intracorporeal esophagojejunostomy following totally laparoscopic total gastrectomy.

BACKGROUND: Presently, there is no consensus as to what procedure of intracorporeal esophagojejunostomy (EJS) in totally laparoscopic total gastrectomy (TLTG) is best to reduce postoperative complications. The aim of this study was to demonstrate the superiority of linear stapled reconstruction in terms of anastomotic-related complications for EJS in TLTG. METHODS: We collected data on 829 consecutive gastric cancer patients who underwent TLTG reconstructed by the Roux-en-Y method with radical lymphadenectomy between January 2010 and December 2016 in 13 hospitals. The patients were divided into two groups according to reconstruction method and matched by propensity score. Postoperative EJS-related complications were compared between the linear stapler (LS) and the circular stapler (CS) groups. RESULTS: After matching, data from 196 patients in each group were analyzed. The overall incidence of EJS-related complications was significantly lower in the LS group than in the CS group (4.1% vs. 11.7%, p = 0.008). The incidence of EJS anastomotic stenosis during the first year after surgery was significantly lower in the LS group than in the CS group (1.5% vs. 7.1%, p = 0.011). The incidence of EJS bleeding did not differ significantly between the groups, although no bleeding was observed in the LS group (0% vs. 2.0%, p = 0.123). The incidence of EJS leakage did not differ significantly between the groups (2.6% vs. 3.6%, p = 0.771). CONCLUSION: The use of linear stapled reconstruction is safer than the use of circular stapled reconstruction for intracorporeal EJS in TLTG because of its lower risks of stenosis.

Daikenchuto for reducing postoperative ileus in patients undergoing elective abdominal surgery.

Reason for withdrawal: Serious breach of Cochrane's conflict of interest policy. A ruling by Cochrane's Funding Arbiters that a Cochrane Review has seriously breached Cochrane's conflict of interest policy.

Chemotherapy for patients with unresectable or metastatic small bowel adenocarcinoma: a systematic review.

BACKGROUND: There is no standard chemotherapy available for unresectable or metastatic small bowel adenocarcinoma (SBA) because of its rarity. This systematic review aims to assess the efficacy and safety of chemotherapy for patients with unresectable or metastatic SBA. METHODS: In accordance with the PRISMA statements, literature search was conducted using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials. The included studies were prospective randomized, nonrandomized, or observational studies. Risk of bias was assessed the ROBINS-I tool. RESULTS: Seven prospective single-arm Phase II studies were included in this review. Six of them were assessed as having a moderate risk of bias and one as having a serious risk of bias. A meta-analysis was not performed, because the studies were single-arm. Systemic chemotherapy based on fluoropyrimidine regimens achieved favorable outcomes with acceptable adverse effects as a first therapy; however, the regimens differed in each study. The object response rate was 18-50%, and the disease control rate was 29-87%. With 5-fluorouracil, adriamycin, and mitomycin-C regimen, one treatment-related death occurred. A second line of therapy including chemotherapy with nab-paclitaxel also showed favorable efficacy. The object response rate was 20%, and the disease control rate was 50%. CONCLUSIONS: Systemic chemotherapy based on fluoropyrimidine regimens was mainly used for unresectable or metastatic SBA. While it may achieve favorable outcomes with acceptable adverse effects, further evidence is needed.

A Phase 2 Study of Induction Chemotherapy Using Docetaxel, Cisplatin, and S-1 for Gastric Cancer with Peritoneal Metastasis (KUGC06).

BACKGROUND: The authors previously showed the significant efficacy of S-1 plus cisplatin for gastric cancer with limited peritoneal metastasis. They conducted a phase 2 study to evaluate the safety and efficacy of induction chemotherapy using a docetaxel, cisplatin, and S-1 (DCS) triplet regimen to treat gastric cancer with peritoneal metastasis. METHODS: The key eligibility criteria were gastric cancer with peritoneal metastasis or positive peritoneal cytology but no other distant metastases and capability of oral administration. The patients received three 28-day cycles of DCS (60 mg/m2 of cisplatin, 40 mg/m2 of docetaxel on day 1, and 80 mg/m2 of S-1 from day 1 to day 14), then underwent D2 gastrectomy if R0 was possible. The primary end point was the R0 resection rate. The sample size was determined to have 80% power for detecting a 20% improvement in the R0 resection rate over a 45% baseline for a one-tailed alpha of 0.1. RESULTS: Among 30 enrolled patients, 24 completed three cycles of DCS. The most frequent grade 3 or 4 toxicity was neutropenia (60%). A complete response of peritoneal metastasis was observed in 16 patients, and 14 patients achieved R0 resection (47%; 95% confidence interval 28-66%). When the extent of peritoneal metastasis was classified as P0CY1, P1, P2, and P3 according to the Japanese classification, the R0 resection rates were respectively 63%, 60%, 46% and 0%. CONCLUSIONS: Induction chemotherapy with DCS is safe and can achieve R0 resection for some patients with limited peritoneal metastasis or positive peritoneal cytology. The efficacy, however, appears similar to that of S-1 plus cisplatin.

Short-term outcomes of laparoscopic surgery for colorectal cancer in the elderly versus non-elderly: a systematic review and meta-analysis.

PURPOSE: Laparoscopic surgery for colorectal cancer has spread globally. The usefulness of laparoscopic surgery for elderly patients was initially indicated by comparison with open surgery. However, whether the procedure is safe for elderly as well as non-elderly patients with colorectal cancer remains unclear. METHODS: In this review, patients aged ≥ 75 were defined as elderly. We conducted literature searches using PubMed, Scopus, and the Cochrane Central Register of Clinical Trials. Two authors independently reviewed resultant articles to identify relevant observational studies. Data synthesis was performed with a random-effects model. Heterogeneity was investigated by using forest plots and I2 statistics. Risk of bias of included studies was assessed by the Risk of Bias Assessment Tool for Nonrandomized Studies. Publication bias was assessed by funnel plots. RESULTS: Twenty-two studies were included. The incidence of overall complications was slightly higher in elderly patients than in non-elderly patients, with statistical significance (risk ratio (RR) 1.20, 95% confidence interval (CI) 1.08-1.34). There was no difference between them in the incidence of anastomotic leakage (RR 1.24, 95% CI 0.86-1.80) and mortality (risk difference 0.00, 95% CI - 0.01 to 0.01). CONCLUSIONS: Laparoscopic surgery for colorectal cancer is mostly safe for elderly patients as well as non-elderly patients. Preoperative comorbidities or poor physical capacity should be cared for in the elderly.

Diagnostic accuracy of magnetic resonance imaging and computed tomography for lateral lymph node metastasis in rectal cancer: a systematic review and meta-analysis.

PURPOSE: Accurate diagnosis of lateral lymph node metastasis is a major concern in rectal cancer. Metastasis is not only a poor prognostic factor, but it can also affect decisions about treatment options, such as preoperative chemoradiotherapy and lateral lymph node dissection. The purpose of this review was to assess the diagnostic performance of magnetic resonance imaging and computed tomography for lateral lymph node metastasis in rectal cancer. METHODS: A literature search was systematically performed using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials. All studies in which preoperative magnetic resonance imaging or computed tomography findings involving the lateral lymph nodes were compared with pathologic findings were included. Two authors independently assessed the literature and extracted the data, and any disagreement was resolved by discussion. Pooled sensitivity, specificity, and diagnostic odds ratios were estimated using hierarchical summary receiver-operating characteristic curve analysis. The methodologic quality of the included studies was assessed using the QUADAS-2 tool. RESULTS: Nine studies were included in the meta-analysis of magnetic resonance imaging. The pooled sensitivity, specificity, and diagnostic odds ratio for magnetic resonance imaging were 0.72 [95% confidence interval (CI) 0.66-0.78], 0.80 (95% CI 0.73-0.85), and 10.2 (95% CI 6.4-16.3), respectively. Pooled analyses were not conducted for computed tomography because of the small number of studies (only three could be identified) and the wide range in diagnostic performance between these studies. CONCLUSIONS: Magnetic resonance imaging was useful to diagnose lateral lymph node metastasis in rectal cancer, especially due to high specificity.

The effects of intraoperative ICG fluorescence angiography in laparoscopic low anterior resection: a propensity score-matched study.

BACKGROUND: It remains unclear whether indocyanine green (ICG) angiography could reduce the rate of postoperative anastomotic leakage (AL) following rectal surgery. The aim was to determine whether intraoperative ICG angiography could decrease symptomatic AL following laparoscopic low anterior resection (LAR). METHODS: This is a retrospective study of 149 patients with rectal cancer who underwent laparoscopic LAR at a single institution. Propensity score matching (PSM) was employed to compare groups with and without ICG angiography. RESULTS: Before PSM, the symptomatic AL rate was 10.4% (5/48) in patients with ICG angiography, compared with 6.9% (7/101) in cases without ICG angiography (P = 0.52). In patients with ICG angiography, poor perfusion of the proximal colon judged by ICG angiography led to additional colon resection in 27.1% (13/48). Symptomatic AL occurred in 30.8% (4/13) of the patients who had revision of the transection site, whereas it occurred in only 2.9% (1/35) of the patients who did not need revision of the transection site (P = 0.015). After PSM, the symptomatic AL rate was 8.8% (3/34) in patients with ICG angiography, compared with 14.7% (5/34) in cases without ICG angiography (P = 0.71). In univariate analysis, high BMI, preoperative chemotherapy, and lateral lymph node dissection were significantly associated with symptomatic AL. Multivariate analysis indicated that only lateral lymph node dissection remained significantly associated with AL (odds ratio, 10.05; 95% confidence interval, 1.75-58.61; P = 0.011). CONCLUSIONS: Intraoperative ICG angiography is useful for prediction of AL following laparoscopic LAR.

Robotic versus laparoscopic surgery for rectal cancer: an overview of systematic reviews with quality assessment of current evidence.

PURPOSE: The clinical benefits of robotic surgery for patients with rectal cancer have been reported and many systematic reviews have been published. However, they have investigated a variety of outcomes and differ remarkably in quality. In this overview, we summarize the findings of these reviews and evaluate their quality. METHODS: The PubMed, Scopus, and Cochrane Central Register of Controlled Trials databases were comprehensively searched to identify systematic reviews and meta-analyses that compared robotic and laparoscopic surgery. We assessed the quality of the reviews using the AMSTAR-2 tool. RESULTS: The literature search identified 17 eligible reviews, all of which reported that the incidence of conversion to open surgery was lower for robotic surgery than for laparoscopic surgery. Most of the reviews reported no difference in the other outcomes between robotic surgery and laparoscopic surgery. However, the quality of the reviews was judged to be low or critically low. CONCLUSIONS: Critically low quality evidence suggests that robotic surgery for rectal cancer decreases the likelihood of conversion to open surgery, but other clinical benefits remain unclear. High-quality systematic reviews in which selection of high-quality studies is combined with adequate methodology are needed to clarify the true efficacy of robotic surgery for rectal cancer.