Intraluminal lavage to remove exfoliated tumor cells after colorectal endoscopic submucosal dissection.

BACKGROUND: Endoscopic submucosal dissection (ESD) involves dissection of tumors and manipulation of them in an exposed condition for prolonged periods. A large number of tumor cells are exfoliated into the intestinal lumen after colorectal ESD. The aim of this study was to determine whether lavage volume has an influence on tumor cell clearance after colorectal ESD. METHODS: Twenty patients who underwent colorectal ESD at our hospital between July 2013 and December 2014 were studied. Cytological examination of intraluminal lavage samples associated incremental increases in lavage volume was collected. This prospective study was approved by the ethics committee of our hospital. RESULTS: No patients had exfoliated tumor cells in their samples before ESD. Four patients (20 %) had exfoliated tumor cells in their samples after lavage with 500 ml, while one patient (5 %) had exfoliated tumor cells after lavage with 1000 or 1500 ml. CONCLUSION: Tumor cells are exfoliated into the intestinal lumen by tumor manipulation during colorectal ESD. There seems to be a risk for implantation after ESD, as well as rectal surgery. Sufficient intraluminal lavage of more than 1000 ml may be desirable to remove exfoliated tumor cells after colorectal ESD.

Exfoliated Tumor Cells in Intraluminal Lavage Samples after Colorectal Endoscopic Submucosal Dissection: A Pilot Study.

Endoscopic submucosal dissection involves dissecting manipulation performed with tumors in an exposed condition for a long period of time. Thus, there is a risk for implantation of tumor cells. The objectives of this study were to examine exfoliated tumor cells after colorectal endoscopic submucosal dissection and to elucidate the effectiveness of intraluminal lavage to remove these cells. The subjects were 8 patients who had undergone colorectal endoscopic submucosal dissection at our hospital between September and December 2012. A retrospective study was conducted on the cytological findings of intraluminal lavage samples in these patients. Seven of the 8 patients (88%) had exfoliated tumor cells in the lavage samples at the beginning of lavage. Only 3 patients (3 8%) had exfoliated tumor cells after lavage with 300 ml of water. A large number of tumor cells were thought to have exfoliated into the intestinal lumen after endoscopic submucosal dissection. Sufficient intraluminal lavage after colorectal endoscopic submucosal dissection is necessary to remove exfoliated tumor cells.

Prophylactic laparoscopic lateral pelvic lymph node dissection for lower rectal cancer: remarking on the vesicohypogastric fascia.

OBJECTIVE: To introduce the prophylactic laparoscopic lateral pelvic lymph node dissection performing by remarking the vesicohypogastric fascia following total mesorectal excision for patients with advanced lower rectal cancer without radiological evidence of lymph node involvement. SURGICAL METHOD: We set 5 ports for conventional laparoscopic rectal surgery. During the prophylactic laparoscopic lateral pelvic lymph node dissection, we retrieved the lymph nodes from the internal iliac area and obturator area. We recognized the pelvic nerve plexus, vesicohypogastric fascia (including internal iliac vessels), and parietal fascia (psoas muscle fascia, pubic bone and internal obturator muscle fascia) as the dissection borders from internal to external. Of note, the vesicohypogastric fascia can be recognized under magnified clear vision, and can be preserved by precise dissection, resulting in reduced hemorrhage from the internal iliac vessels and complications such as urinary dysfunction. CONCLUSION: Prophylactic laparoscopic lateral pelvic lymph node dissection after remarking on the vesicohypogastric fascia may contribute to a less invasive surgery compared with conventional laparoscopic lateral pelvic lymph node dissection.

Mucinous adenocarcinoma associated with a chronic perianal fistula - a review of cases from a single institution.

PURPOSE: The purpose of this study was to evaluate the clinicopathological features of mucinous adenocarcinoma associated with perianal fistulas (MAF), to assess the importance of preoperative MRI analysis, and to determine the optimal surgery. METHODS: We performed a retrospective analysis of the data from seven patients with MAF treated at our hospital between 2000 and 2013, and herein discuss the importance of preoperative magnetic resonance imaging (MRI) and of radical surgery. RESULTS: The male to female ratio was 5:2, and the mean age of the patients was 63 years old (28-70). The median duration of chronic fistulation was 16 years (5-40). The tumor extension was classified as II+III+IV in five patients and as II+III in 2 patients according to the Sumikoshi classification, as determned by pelvic MRI. The performed surgeries were 3 abdominoperineal resections with sacral resection and 4 pelvic exenterations with sacral resection. Two local recurrences developed in patients with R1 resection, and 1 distant metastasis occurred in 1 patient with R0 resection. CONCLUSION: For patients with MAF, a curative surgical resection is the only definitive treatment that can be expected to provide a good prognosis. The application of the Sumikoshi classification using MRI may provide a precise assessment of the extension of MAF, which can allow the appropriate surgery to be selected for the patients with MAF.

[A case of multiple gastrointestinal stromal tumors of the small intestine associated with von Recklinghausen disease].

A 63-year-old woman was admitted to our hospital because of tarry stool several years previously. At the time, café-au-lait spots and dermal nodules were found on her entire body, and a diagnosis of von Recklinghausen disease was established. Small bowel endoscopy revealed a submucosal tumor in the jejunum. Laparotomy was therefore performed on the suspicion of intestinal GIST. Numerous extramural tumors with a diameter of 3-5mm were observed along the jejunum and ileum, in addition to the primary tumor. Partial resection of the jejunum, including the primary tumor and only one small nodule was performed to prevent short bowel syndrome. Immunopathological studies of the tumors were positive for KIT and CD34 and we diagnosed multiple intestinal GISTs. Imatinib mesylate was not administered, but no growth of the residual tumors have been recognized for 10 months after surgery.

Prognostic value of immunohistochemical analysis of tumor budding in colorectal carcinoma.

BACKGROUND: Tumor 'budding' of colorectal carcinoma along the invasive margin has been associated with increased malignant potential. This study investigated the possible prognostic significance of budding in invasive colorectal carcinoma. PATIENTS AND METHODS: Specimens resected from 149 patients who underwent potentially curative surgery for invasive colorectal carcinoma were studied. Budding was defined according to Ueno's criteria; budding intensity was assessed by examination of hematoxylin-eosin (HE)-stained specimens and immunohistochemical (IHC)-stained specimens using anti-cytokeratin antibody and anti-lymphatic vessel antibody. RESULTS: Immunohistochemical analysis identified many more budding foci that were not detectable by examination of HE-stained specimens. Multivariate analyses revealed that budding identified using immunohistochemical staining was a significant prognostic marker for disease-free survival and there was significant correlation between budding and microlymphatic vessel infiltration at the invasive tumor front. CONCLUSION: Budding, particularly as assessed with immunohistochemical staining, is a useful predictor of poor prognosis in patients with invasive colorectal carcinoma.

Rectourethralis muscle and pitfalls of anterior perineal dissection in abdominoperineal resection and intersphincteric resection for rectal cancer.

When performing nerve-sparing abdominoperitoneal resection or intersphincteric resection of lower rectal cancer, difficulty is sometimes encountered during dissection, separation and treatment in the area anterior to the anorectum passing through the levator hiatus between the bilateral levator ani slings owing to missing the surgical plane or venous bleeding. The rectourethralis muscle, which is a mass of smooth muscle, occupies the levator hiatus. The present histological study using nine male cadaveric specimens demonstrated that: (i) the external anal sphincter is likely to be tightly connected to the rectourethralis muscle; (ii) the rectal muscularis propria communicates with the rectourethralis muscle; (iii) the anorectal veins take a tortuous course across the rectourethralis muscle; (iv) Denonvilliers' fascia ends at the rectourethralis muscle; and (v) the rectourethralis muscle provides posterior attachment for the rhabdosphincter. Moreover, the cavernous nerve has been reported to penetrate the rectourethralis muscle. Therefore, careful treatment of the muscle seems to be necessary to avoid male sexual dysfunction. Owing to muscle fiber communications between the rectal muscularis propria and the rectourethralis muscle, and the fact that Denonvilliers' fascia terminates in the rectourethralis muscle, the surgical plane would tend to deeply penetrate the muscle mass. However, mass ligation of the anterior tissues for control of venous bleeding should be avoided. When the tumor is non-anterior, an abdominal surgical plane behind Denonvilliers' fascia is recommended to avoid excess invasion into the rectourethralis muscle.

D2-40 positive lymphatic endothelial cell density is much higher in and along the mammary glandular tissues than in subcutaneous tissue: case report of a 20-year-old donated female cadaver.

Sappey's demonstration of the breast lymphatic vessels, showing the presence of a subareolar lymphatic plexus and few thick vessels originating from the breast itself, is famous. However, with the exception of such studies performed by injection methods, to the best of our knowledge there has been no demonstration of the entire distribution of the breast lymphatic vessels. D2-40 immunohistochemistry of semiserial sections (at 0.1-mm intervals) taken from the healthy breast of a 20-year-old female cadaver revealed that the lymphatic endothelial density was much higher in and along the mammary glandular tissues than in the overlying subcutaneous and deep fascial tissues. Thus, the extent of the subareolar lymphatic plexus is likely to have been overestimated by the injection method. Instead, networks of lymphatic vessels around the mammary glands were evident in the physiological state.

Local recurrence after rectal endoscopic submucosal dissection: a case of tumor cell implantation.

We report a case of local recurrence of cancer after rectal endoscopic submucosal dissection (ESD). A 52-year-old male underwent a curative resection with ESD for rectal intramucosal cancer. Seventy-four months after ESD, surveillance colonoscopy showed an elevated lesion on the ESD scar, suspicious of a recurrence. The patient subsequently underwent a low anterior resection (intersphincteric) with lymph node dissection. Pathology revealed a well-differentiated adenocarcinoma, similar to the ESD specimen. We suspected that the local recurrence was caused by implantation of tumor cells during the ESD, due to surgical manipulation performed with the tumor in an exposed setting for a long period of time.

Sigmoidectomy for radiation-induced sigmoid colonic dysplasia 35 years after radiotherapy for cervical cancer.

Although radiation-induced colonic cancer is thought to arise from dysplasia, no guidelines exist for the treatment of such dysplasia. Therefore, clinicians must make treatment decisions for this condition on a case-by-case basis. Especially when the operative procedure is being decided, it is necessary to consider postoperative quality of life for advanced age. We report a patient who underwent sigmoidectomy for sigmoid colonic dysplasia that developed 35 years after radiation therapy. A 73-year-old woman who had undergone total hysterectomy and chemoradiotherapy for cervical cancer 35 years previously presented following a positive fecal occult blood test. Colonoscopy revealed sigmoid colonic dysplasia. To ensure reliable removal of the lesion, we elected to perform surgical resection. Given the patient's age, we performed sigmoidectomy rather than resecting the entire irradiated intestinal tract. The diagnosis of dysplasia was confirmed based on pathological findings, which included duct proliferation with partial structural atypia.

Operating behind Denonvilliers' fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models.

PURPOSE: Little is known about which urogenital nerves are liable to be injured along surgical planes in front of or behind Denonvilliers' fascia. METHODS AND RESULTS: Using semiserial histology for five fixed male pelves, we demonstrated that: 1) left/right communicating branches of bilateral pelvic plexuses run immediately in front of Denonvilliers' fascia; and 2) a lateral continuation of Denonvilliers' fascia separates the urogenital neurovascular bundle from the mesorectum. Notably, the mesorectum contains no or few extramural ganglion cells. At the level of the seminal vesicles, incision in front of Denonvilliers' fascia seems likely to injure superior parts of the pelvic plexus and the left/right communication. Moreover, at the prostate level, this incision misleads the surgical plane into the neurovascular bundle. Fresh cadaveric dissections of five unfixed male pelves confirmed that the surgical plane in front of Denonvilliers' fascia continues to a fascial space for the pelvic plexus containing ganglion cell clusters lateral and/or inferior to the seminal vesicles. CONCLUSIONS: To preserve all autonomic nerves for urogenital function, optimal total mesorectal excision for rectal cancer requires dissection behind Denonvilliers' fascia.