Conscientiousness Counts: How Personality Traits Impact Laparoscopic Surgical Skill Improvement in Medical Students.

OBJECTIVE: Studies have shown that personality traits affect cognitive performance; however, little is known about their influence on surgical performance. This study aimed to assess the impact of the Big Five personality traits on medical students' laparoscopic surgical skills. DESIGN: In this prospective study, medical students' laparoscopic surgical skills were assessed using the Hiroshima University Laparoscopic Surgical Assessment Device (HUESAD). The participants performed the HUESAD tasks 10 times before they underwent training. After completing the simulator training, they performed the tasks 10 times. Thereafter, they answered Big Five personality trait questionnaires (Extraversion, Neuroticism, Openness to experience, Conscientiousness, and Agreeableness). SETTING: Academic medical centers. PARTICIPANTS: Forty medical students (10 women) were recruited. The selection criterion was a lack of simulations or clinical experience in laparoscopic procedures. RESULTS: No significant correlations were found between personality traits and HUESAD assessment scores before training. Laparoscopic surgical skills improved significantly after the training (p < 0.001). The Big Five personality traits were correlated with improved laparoscopic surgical performance after training (r = -0.44, p < 0.05). Moreover, statistically significant positive correlations were observed between Conscientiousness and improvement rates (r = 0.36, p < 0.05). CONCLUSIONS: The results suggest that medical students scoring high on Conscientiousness were more likely to have improved laparoscopic surgical skills, regardless of their initial skills. The ability to predict laparoscopic surgical skills would be useful in designing tailor-made training programs for safe and high-quality operations.

Efficacy of Coagulofibrinolytic Markers for Postoperative Prediction of Venous Thromboembolism in Colorectal Surgery Patients: A Retrospective Observational Study.

Objectives: A low rate of the incidence of venous thromboembolism (VTE) after surgeries that are preoperatively classified as having high risk of VTE has been reported in recent years. We seek to identify the optimal cases to receive perioperative pharmacologic thromboprophylaxis. In this study, we evaluated the incidence rate of VTE among patients undergoing colorectal surgery who did not receive perioperative pharmacologic thromboprophylaxis, and the ability of coagulofibrinolytic markers to predict the postoperative development of VTE. Methods: We retrospectively analyzed the rate of postoperative development of VTE in 70 patients undergoing elective colorectal surgery without perioperative pharmacologic thromboprophylaxis and the ability of coagulofibrinolytic markers to predict the development of VTE. Results: The incidence of VTE was observed in 11 patients (15.7%); all cases were asymptomatic and distal-type deep vein thrombosis (DVT). Comparisons of time course changes in perioperative coagulofibrinolytic markers between patients with and without DVT revealed significant differences in soluble fibrin (SF), thrombin-antithrombin complex (TAT), fibrin/fibrinogen degradation product (FDP) and D-dimer. Dynamic postoperative physiological coagulofibrinolytic responses were shown, but all four markers at each postoperative point demonstrated moderate accuracy (median area under the curve [AUC]: 0.788, median sensitivity: 0.865, median specificity: 0.644) for predicting the development of DVT. Conclusions: The incidence of postoperative VTE was low in patients with colorectal surgery even in those who did not receive perioperative pharmacologic thromboprophylaxis. SF, TAT, FDP and D-dimer were useful for predicting the development of DVT when we set cut-off values taking the physiological perioperative coagulofibrinolytic responses into consideration.

Imaging Classification of Constipation.

Objectives: The diagnosis of patients with chronic constipation is very complicated. This study aimed to develop a simple imaging classification for the diagnosis of chronic constipation by abdominal computed tomography (CT). Methods: Sixty-two patients who underwent abdominal CT in our hospital between January and June 2022 were enrolled. The CT values of the stool in the rectum and cecum were measured in patients with chronic constipation (C group) and in those without (non-C group). Results: A strong correlation was observed between the Bristol Stool Form Scale (BSFS) and the CT value of rectal stool. Furthermore, the rectal stool CT value was significantly higher in patients with chronic constipation than in those without. The CT value of cecal stool did not differ between the two groups. The cecal stool CT value was significantly higher in patients with severe constipation (BSFS 1) than in those with BSFS 2-6. A cutoff CT value of 100 was selected as the optimal value for indicating chronic constipation. Conclusions: Abdominal CT was useful in the diagnosis of chronic constipation. If the patient had constipation, the optimal cutoff CT value was 100.

Cadaveric and CT angiography study of vessels around the transverse colon mesentery.

BACKGROUND: Laparoscopic and robotic surgery for transverse colon cancer are difficult due to complex fusion of the foregut and midgut and variation of the vessels of the transverse colon. Although the vessels of the right colon have been investigated, middle colic artery (MCA) variation and the relationship with vessels around the transvers colon are unknown. We investigated variation of the MCA using computed tomography angiography (CTA) and cadaver specimen and the relationship between the superior mesenteric vein (SMV) and MCA using CTA. The classification of vessels around the transverse colon may lead to safer and reliable surgery. METHODS: This study included 505 consecutive patients who underwent CTA in our institution from 2014 to 2020 and 44 cadaver specimens. Vascular anatomical classifications and relationships were analyzed using CT images. RESULTS: The MCA was defined as the arteries arising from the superior mesenteric artery (SMA) that flowed into the transverse colon at the distal ends. The classifications were as follows: type I, branching right and left from common trunk; type II, the right and left branches bifurcated separately from the SMA; and type III, the MCA branched from a vessel other than the SMA. Type II was subclassified into two subtypes, type IIa with one left branch and type IIb with two or more left branches from SMA. In the CTA and cadaver studies, respectively, the classifications were as follows: type I, n = 290 and n = 31; type IIa, n = 211 and n = 13; type IIb, n = 3 and n = 0; and type III, n = 1 and n = 0. We classified the relationship between the MCA and left side of the SMV into three types: type A, a common trunk runs along the left edge of the SMV (n = 173; 59.7%); type B, a right branch of the MCA runs along the left edge of the SMV (n = 116; 40.0%); and type C, the MCA runs dorsal of the SMV (n = 1; 0.3%). CONCLUSIONS: This study revealed that The MCA branching classifications and relationship between the SMV and MCA. Preoperative CT angiography may be able to reliably identify vessel variation, which may be useful in clinical practice.

Clinical efficacy of Daikenchuto (DKT: TJ-100) for gastrointestinal symptoms in patients with a history of colon and rectosigmoid cancer surgery: a randomized crossover study.

PURPOSE: This randomized crossover trial investigated the effects of Daikenchuto (DKT: TJ-100) on gastrointestinal symptoms of patients after colon and rectosigmoid cancer surgery. METHODS: Among patients who had completed surgery for colon cancer, including rectosigmoid cancer, over 6 months ago, 20 who complained of gastrointestinal symptoms were enrolled. Subjects were randomly assigned to two sequences: sequences: A and B. In period 1, sequence A subjects were orally administered DKT, whereas sequence B subjects were untreated for 28 days. After a 5-day interval, in period 2, sequences A and B were reversed. Quality-of-life markers (GSRS and VAS), the Sitzmark transit study, the orocecal transit time (lactulose hydrogen breath test) and Gas volume score were evaluated before and after each period with findings compared between the presence of absence of DKT administration. RESULTS: Between sequences, there were no significant differences in clinicopathological characters or any evaluations before randomization. There was no carryover effect in this crossover trial. The administration of DKT significantly ameliorated the GSRS in total, indigestion, and diarrhea, although the planned number of subjects for inclusion in this trial was not reached. CONCLUSIONS: DKT may ameliorate subjective symptoms for postoperative patients who complain of gastrointestinal symptoms.

Clinical Phase I Study of TAS102/Irinotecan/Bevacizumab Combination Therapy in Japanese Patients With Unresectable Metastatic Colorectal Cancer (mCRC).

BACKGROUND: In this phase I study, we aimed to examine the safety of a triple combination (TAS-102/irinotecan/bevacizumab) therapy in patients with previously treated metastatic colorectal cancer (mCRC). METHODS: In the TAS-102 dose-escalation phase, we determined dose-limiting toxicity (DLT), estimated the maximum tolerated dose (MTD), and determined the recommended dose (RD); in the expansion phase, we evaluated safety. The RD was administered in advance for 10 patients. The TAS-102 dose was increased to 25-35 mg/m2 and administered orally twice on days 1-5 and 8-12. Irinotecan (100 mg/m2) and bevacizumab (5 mg/m2) were administered on days 1 and 15 of the treatment, respectively. RESULTS: Fifteen patients were enrolled in dose-escalation Levels 1-3, and ten in the expansion phase. A 30 mg/m2 TAS-102 dose at Level 2 was administered to three patients, with one presenting grade 4 neutropenia. A 35 mg/m2 TAS-102 dose at Level 3 was administered to five patients, with three patients presenting grade 4 neutropenia and grade 3 DLTs. We added three patients at Level 2 and set the MTD at 30 mg/m2, with no DLTs. The RD was fixed at 25 mg/m2, with no DLTs (N = 10) or treatment-related deaths. One patient showed complete response at Level 2, four presented partial response, and eleven individuals maintained stable disease for over four months. The median progression-free survival duration was 7.6 months, while the median overall survival period was 16.9 months. CONCLUSION: The TAS-102/irinotecan/bevacizumab combination therapy was safe, effective, and well-tolerated in patients previously treated with mCRC.

Long-term prognosis of laparoscopic gastrectomy for patients on antithrombotic therapy: a retrospective cohort study.

PURPOSE: Few studies have reported on the interactions between gastrectomy and antithrombotic therapy, especially the long-term prognosis. We aimed to clarify the short- and long-term prognosis of gastrectomy for patients on antithrombotic therapy. METHODS: We reviewed the perioperative data and survival rate of patients who underwent laparoscopic distal gastrectomy (LDG) at our institute between 2010 and 2013. RESULTS: There were 119 patients enrolled in this retrospective study: 31 who were taking antithrombotic drugs (antithrombotic therapy (ATT) group), and 88 who were not (non-ATT group). The mean age was significantly higher in the ATT group than in the non-ATT group. No significant differences were observed in the amount of intraoperative bleeding or blood hemoglobin level after surgery between the groups. Bleeding complications occurred in only one patient from the ATT group, and the postoperative complication rate was comparable between the groups. During follow-up, cerebrovascular or cardiovascular events developed in 19.4% of the ATT group patients and 4.5% of the non-ATT group patients; however, there were no significant differences in the 5-year overall survival rates between the groups (ATT group, 76.9%; non-ATT group, 82.9%). CONCLUSIONS: Antithrombotic therapy did not affect the short-term or long-term prognosis of patients after LDG.

Prediction of anastomotic leakage after left-sided colorectal cancer surgery: a pilot study utilizing quantitative near-infrared spectroscopy.

BACKGROUND: Anastomotic leakage (AL) occurs with some frequency in all types of colorectal cancer surgery and is associated with increased morbidity, mortality and recurrence rates. Complications might be prevented by monitoring intra-operative bowel perfusion at the anastomotic site. A pilot study concerning the objective and quantitative measurement of tissue perfusion by monitoring regional tissue saturation of oxygen (rSO2) was conducted, using the In Vivo Optical Spectroscopy (INVOS™) system (Medtronic, Minneapolis, MN, USA). METHODS: This study evaluated the ability of the INVOS™ system to predict AL after left-sided colorectal cancer surgery. rSO2 measurements of the oral side of the site of bowel anastomosis were taken before anastomosis in 73 patients. Clinical factors, including rSO2, were analyzed to identify risk factors for AL. RESULTS: Among 73 patients, 6 (8.2%) experienced AL. The rSO2 values of the oral anastomotic site were significantly lower in AL patients than in non-AL patients. In the multivariate analysis, the rSO2 value of the oral anastomotic site was an independent risk factor for AL. CONCLUSION: Monitoring the rSO2 at the anastomotic site enabled the prediction of AL. A prospective study to evaluate the efficacy of the INVOS™ system for monitoring intestinal rSO2 is in progress.

A case of successful laparoscopic intraperitoneal onlay mesh plus technique repair for perineal hernia after laparoscopic abdominoperineal resection.

The frequency of secondary perineal hernia after abdominoperineal resection has been reported as 0.83%-26%. The optimal surgery for secondary perineal hernia and surgical indication remains controversial. An 87-year-old woman diagnosed with lower rectal cancer underwent laparoscopic abdominoperineal resection. Follow-up computed tomography at 6 months postoperatively revealed secondary perineal hernia. She reported no discomfort and no incarceration was apparent, but she complained of perineal discomfort 3 months later. Laparoscopic repair surgery was performed using an intraperitoneal onlay mesh plus technique with VENTRALIGHT® ST mesh (Medicon, Osaka, Japan), a non-absorbable mesh with a biodegradable coating. No recurrence of peritoneal hernia was seen as of 3 months postoperatively. A time lag can exist between imaging findings and symptom appearance. This laparoscopic intraperitoneal onlay mesh plus technique might become the optimal treatment for perineal hernia.

Perioperative coagulofibrinolytic responses in colorectal surgery patients without chemical thromboprophylaxis: a retrospective observational study.

PURPOSE: During the perioperative period, coagulofibrinolytic activation occurs, which occasionally results in thromboembolic complications. However, natural perioperative coagulofibrinolytic responses have not been well investigated. The present study examined perioperative coagulofibrinolytic changes and their association with the development of venous thromboembolism (VTE). METHODS: We retrospectively analyzed the changes in coagulofibrinolytic markers for 7 days in 70 patients undergoing elective colorectal surgery. To explore the natural coagulofibrinolytic response, we investigated patients not undergoing perioperative chemical thromboprophylaxis. RESULTS: Coagulation activation occurred from just after surgery to postoperative day (POD) 1, followed by a gradual decrease, but persisted to even POD 7. Fibrinolytic activity showed a tri-phasic response: activation, shutdown and reactivation. Consequently, fibrin/fibrinogen degradation product (FDP) and D-dimer levels continued to increase until POD 7. The development of deep vein thrombosis (DVT) was observed in 11 patients (15.7%). Postoperative sustained hyper-coagulation [soluble fibrin (SF) or thrombin-antithrombin complex (TAT) values on POD 7 > their normal limits] was significantly associated with the development of DVT (SF, p < 0.001; TAT, p = 0.001). CONCLUSION: We found initial coagulation activation and a tri-phasic response of fibrinolytic activity after colorectal surgery. Thus, physicians need to pay attention to these responses when attempting to prevent or treat VTE.

The arrival time of indocyanine green in tissues can be a quantitative index because of its correlation with tissue oxygen saturation: A clinical pilot study.

Indocyanine green (ICG) fluorescence angiography has recently been reported useful as a method for predicting intestinal blood flow and may reduce anastomotic leakage. However, the quantification method for ICG fluorescence angiography has not been established. We usually measure the tissue oxygen saturation (StO2 ) in the intestinal tract via near-infrared spectroscopy, as it is able to measure the oxygen concentration accurately and immediately shows objective data. In this study, we propose that the time to reach the anastomotic site after intravenous ICG injection is an effective parameter for quantifying ICG fluorescence angiography from the comparison to the data of StO2 in the intestinal tract.

The characteristics of residual pneumoperitoneum after laparoscopic colorectal surgery.

INTRODUCTION: Despite the popularity of laparoscopic surgery, it remains unclear whether residual pneumoperitoneum influences the patient's postoperative course. This study aimed to evaluate the characteristics of residual pneumoperitoneum. METHODS: This retrospective study included 201 Japanese patients who had undergone elective laparoscopic colorectal surgery. The patients were divided into groups, with and without anastomotic failure; the non-anastomotic failure group was further divided into subgroups, with and without residual pneumoperitoneum. Patient characteristics were compared between the various groups. RESULTS: The group with residual pneumoperitoneum included 57 patients (30.3%). Percutaneous drainage was required for one patient with residual pneumoperitoneum. Univariate analyses revealed that residual pneumoperitoneum was associated with low values for body mass index (BMI) and subcutaneous fat area (SFA). Furthermore, relative to the group with anastomotic failure, the group without anastomotic failure but with residual pneumoperitoneum had lower values for inflammatory markers. CONCLUSION: Low BMI and SFA values were identified as risk factors for residual pneumoperitoneum. Inflammatory markers may be useful as indicators for avoiding emergent surgery when it is difficult to differentiate between asymptomatic residual pneumoperitoneum and free air related to anastomotic failure.

Omnidirectional camera and head-mount display contribute to the safety of laparoscopic surgery.

BACKGROUND: We focused on the availability of an omnidirectional camera and head-mount display (HMD). If the laparoscope is an omnidirectional camera, captured images are sent to the HMD worn by the operator in real time. The operator can thus view the image as they like without moving the camera and obtain a 360° view intuitively. However, the surgical system that can be used for actual laparoscopic operations has not yet been developed. In this study, we aimed to show that an omnidirectional camera and HMD would be useful in laparoscopic surgery. MATERIAL AND METHODS: Eleven medical students and twelve surgical residents (Surgeons group) participated in this study. We created an experimental box with five marks randomly attached inside the box, and the inside cannot be seen from the outside. We measured the time it took to identify all marks between conventional laparoscope and substitute system in each group. RESULTS: In the substitute system, the time required for the task was significantly shorter than with conventional laparoscopy in each group. CONCLUSION: An omnidirectional camera and HMD may be a useful new device for laparoscopic surgery. This system may help improve the safety of laparoscopic surgery.

Identification of patient subgroups with unfavorable long-term outcomes associated with laparoscopic surgery in a randomized controlled trial comparing open and laparoscopic surgery for colon cancer (Japan Clinical Oncology Group Study JCOG0404).

BACKGROUND: Previously, we conducted a randomized controlled trial (JCOG0404) for stage II/III colon cancer patients and reported that the long-term survival after open surgery (OP) and laparoscopic surgery (LAP) were almost identical; however, JCOG0404 suggested that survival of patients after LAP with tumors located in the rectosigmoid colon, cT4 or cN2 tumors, and high body mass index (BMI) might be unfavorable. AIM: To identify the patient subgroups associated with poor long-term survival in the LAP arm compared with the OP arm. METHODS: Patients aged 20-75, clinical T3 or deeper lesion without involvement of other organs, clinical N0-2 and M0 were included. The patients with pathological stage IV and R2 resection were excluded from the current analysis. In each subgroup, the hazard ratio for LAP (vs. OP) in overall survival (OS) from surgery was estimated using a multivariable Cox regression model adjusted for the clinical and pathological factors. RESULTS: In total, 1025 patients (OP, 511 and LAP, 514) were included in the current analysis. Adjusted hazards ratios for OS of patients with high BMI (>25 kg/m2), pT4, and pN2 in LAP were 3.37 (95% confidence interval [CI], 1.24-9.19), 1.33 (0.73-2.41), and 1.74 (0.76-3.97), respectively. In contrast, that of rectosigmoid colon tumors was 0.98 (0.46-2.09). CONCLUSIONS: Although LAP is an acceptable optional treatment for stage II/III colon cancer, the present subgroup analysis suggests that high BMI (>25 kg/m2), pT4, and pN2 except for RS were factors associated with unfavorable long-term outcomes of LAP in patients with colon cancer who underwent curative resection. (JCOG 0404: NCT00147134/UMIN-CTR: C000000105.).

Risk Factors for Anastomotic Leakage after Colorectal Surgery with Double-staple Technique Anastomosis: Impact of the Agatston Score.

OBJECTIVES: Anastomotic leakage is associated with severe morbidity, mortality, and functional defects. Its risk factors remain unclear. However, blood perfusion may be a potential major risk factor. It has been reported that the Agatston score is an index for blood flow perfusion evaluation. Therefore, we evaluated the clinical indicators associated with anastomotic leakage, including the Agatston score, in patients who underwent colorectal surgery. METHODS: We retrospectively analyzed 147 patients who underwent elective colorectal surgery with the double-staple technique anastomosis for colorectal cancer between April 2015 and March 2020. The primary outcome was the presence or absence of anastomotic leakage. Univariate and multivariate analyses were employed to identify pre- and intraoperative risk factors. RESULTS: Of the 147 patients analyzed, anastomotic leakage occurred in 12 (8.16%). Male gender, history of angina and myocardial infarction, preoperative white blood cell count, the Agatston score, extent of bleeding, operation time, and intraoperative fluid volume were significantly related to a higher incidence of anastomotic leakage in univariate analysis. Multivariate analysis demonstrated that the incidence of anastomotic leakage was high in patients with a high Agatston score. CONCLUSIONS: The Agatston score can predict the incidence of anastomotic leakage in patients following colorectal surgery. Thus, perioperative measures to prevent anastomotic leakage are recommended when a high Agatston score is observed. A prospective trial is required to demonstrate, with a high level of evidence, that the Agatston score can be useful as a risk score for anastomotic leakage following colorectal surgery.

KIFC1 regulates ZWINT to promote tumor progression and spheroid formation in colorectal cancer.

Colorectal cancer (CRC) is the second leading cause of cancer-related mortality worldwide. Kinesin Family Member C1 (KIFC1) has been proposed as a promising therapeutic target due to its pivotal role in centrosome clustering to mediate cancer cell progression. This study aimed to analyze the expression and biological function of KIFC1 in CRC. Immunohistochemically, 67 (52%) of 129 CRC cases were positive for KIFC1 and statistically associated with poorer overall survival. KIFC1 small interfering RNA (siRNA)-transfected cells demonstrated lower cell proliferation as compared to the negative control cells. A specific KIFC1 inhibitor, kolavenic acid analog (KAA) drastically inhibited CRC cell proliferation. Microarray analysis revealed that KAA-treated CRC cells presented reduced ZW10 interacting kinetochore protein (ZWINT) expression as compared to control cells. Immunohistochemical analysis demonstrated that 61 (47%) of 129 CRC cases were positive for ZWINT and ZWINT expression was significantly correlated with KIFC1 expression. ZWINT-positive cases exhibited significantly worse overall survival. KIFC1 siRNA-transfected cells showed reduced ZWINT expression while ZWINT siRNA-transfected cells decreased cell proliferation. Both KIFC1 and ZWINT knockdown cells attenuated spheroid formation ability. This study provides new insights into KIFC1 regulating ZWINT in CRC progression and its potential as a therapeutic target.

Tumor budding as a predictive marker for 5-fluorouracil response in adjuvant-treated stage III colorectal cancer.

BACKGROUND: Tumor budding (TB) has been described as an adverse prognostic marker for operable colorectal cancer (CRC); however, a limited number of studies have demonstrated the prognostic significance of TB in patients with drug therapy. This study was conducted to determine the predictive power of TB in stage III CRC patients who received adjuvant chemotherapy. METHODS: We retrospectively collected clinicopathological data including TB of 237 stage III colorectal cancer patients at Hiroshima University Hospital between July 1, 2006 and June 31, 2019. Differential disease-free survival (DFS) was investigated according to TB status. RESULTS: This study included 237 patients with a median age of 67 years, comprising patients who underwent surgery alone (n = 65), 5-fluorouracil (5-FU) monotherapy (n = 129), and oxaliplatin-based chemotherapy (n = 43). Overall, 81 patients developed disease recurrence, and 33 patients died of cancer-related causes. The TB status was categorized into two groups: 99 with low budding (< 5 buds) and 138 with high budding (≥ 5 buds). Overall, the low budding cases demonstrated significantly better DFS. In the 5-FU monotherapy group, low-risk patients (T1, T2, or T3 and N1) with low budding showed a remarkably higher 3-year DFS (91%) compared to high budding (55%). CONCLUSION: Our results indicate that TB could play a subsidiary role in selecting patients who could maintain a favorable prognosis with 5-FU monotherapy in stage III CRC.

Anomalous origin of the middle colic artery from the ileocecal artery affecting laparoscopic ascending colon cancer resection.

The anomalies of the middle colic artery have rarely been reported and reviewed in literature. However, in case such anomalies are observed in clinical practice, surgery must still be performed safely. This report presents the case of a 78-years-old female who underwent ileocecal resection and hepatectomy due to ascending colon cancer with liver metastasis. Preoperative abdominal contrast-enhanced computed tomography showed an anomaly of the middle colic artery. Since such anomaly is extremely rare, preoperative evaluation of vascular structure is important for safely performing the surgery.