Validation of the histone methyltransferase EZH2 as a therapeutic target for various types of human cancer and as a prognostic marker.

The emphasis in anticancer drug discovery has always been on finding a drug with great antitumor potential but few side-effects. This can be achieved if the drug is specific for a molecular site found only in tumor cells. Here, we find the enhancer of zeste homolog 2 (EZH2) to be highly overexpressed in lung and other cancers, and show that EZH2 is integral to proliferation in cancer cells. Quantitative real-time PCR analysis revealed higher expression of EZH2 in clinical bladder cancer tissues than in corresponding non-neoplastic tissues (P < 0.0001), and we confirmed that a wide range of cancers also overexpress EZH2, using cDNA microarray analysis. Immunohistochemical analysis showed positive staining for EZH2 in 14 of 29 cases of bladder cancer, 135 of 292 cases of non-small-cell lung cancer (NSCLC), and 214 of 245 cases of colorectal cancer, whereas no significant staining was observed in various normal tissues. We found elevated expression of EZH2 to be associated with poor prognosis for patients with NSCLC (P = 0.0239). In lung and bladder cancer cells overexpressing EZH2, suppression of EZH2 using specific siRNAs inhibited incorporation of BrdU and resulted in significant suppression of cell growth, even though no significant effect was observed in the normal cell strain CCD-18Co, which has undetectable EZH2. Because EZH2 expression was scarcely detectable in all normal tissues we examined, EZH2 shows promise as a tumor-specific therapeutic target. Furthermore, as elevated levels of EZH2 are associated with poor prognosis of patients with NSCLC, its overexpression in resected specimens could prove a useful molecular marker, indicating the necessity for a more extensive follow-up in some lung cancer patients after surgical treatment.

Which is the preference of choice either life with a stoma or evacuatory disorder following rectal cancer surgery?

BACKGROUND/AIMS: Low anastomosis with covering stoma is the standard operation for low rectal carcinoma. Some patients experience severe anorectal disorder, which makes us consider whether stoma closure should be performed or not. There was no comparative study between life with a stoma and life with evacuatory disorder. METHODOLOGY: Covering stoma was closed at 4 to 6 months after ultra-low anterior resection. Forty-five patients were evaluated by questionnaire in terms of their bowel evacuation and anorectal manometry before ultra-low anterior resection and 6 months after stoma closure. They were also questioned about their subjective preference regarding the life before and after stoma closure. RESULTS: After stoma closure, frequency of daily bowel movement was significantly increased up to 5 times (range 2-15). Incontinence score was also significantly worsened from 0 to 8, postoperatively. All patients complained of any influence in their social life. Ninety-three percent (42/45) of the cases were dissatisfied with evacuation, postoperatively. Eighty-nine percent (40/45) of the cases had postoperative evacuatory disorder defined by the present study. Under these backgrounds, all patients replied that evacuation from the anus was superior to life with a stoma even during postoperative evacuatory disorder status. CONCLUSION: Even when patients had evacuatory disorder, they preferred life without a stoma according to their subjective opinion.

Neurophysiologic investigation of anal function following double stapling anastomosis.

BACKGROUND AND AIM: Manual dilatation of the anal sphincter and transanal introduction of the circular stapling device are required for intraluminal stapling anastomosis. This procedure has been regarded as one of the causes of postoperative evacuatory disorder in low anterior resection. However, there has been no evidence of this matter. Therefore, we conducted this study to clarify the impact of the procedure of stapling anastomosis on postoperative anal function. METHODS: Twenty-five cases with sigmoid colon cancer underwent potentially curative sigmoid colectomy with stapling anastomosis (ST group) and 20 cases with hand-sewn anastomosis (non-ST group). The patients were questioned regarding the daily frequency of bowel movement, the presence of urgency and soiling, and Wexner's incontinence score. Anorectal manomatry and pudendal nerve terminal motor latency were also evaluated. The patients' questionnaire and physiologic examinations were prospectively obtained before, and 1 and 6 months after the operation. RESULTS: Postoperative bowel habit was graded as satisfied in 92% (23/25 patients) in the ST group and 90% (18/20 patients) in the non-ST group. There was no significant difference between the 2 groups in terms of presence of fecal incontinence, discrimination of gas and stool, and daily frequency of bowel movement. In anal manometry, there was no significant difference between the 2 groups regarding the resting and squeezing anal canal sphincter pressures at 1 and 6 months postoperatively. Pudendal nerve terminal motor latency showed their latency from 2.0 to 2.5 ms throughout the periods, and there was no difference between the 2 groups before, and 1 and 6 months after the operation. CONCLUSION: Stapling anastomosis does not affect anal function in the early postoperative period.

Quality assurance of pelvic autonomic nerve-preserving surgery for advanced lower rectal cancer--preliminary results of a randomized controlled trial.

BACKGROUND: Pelvic autonomic nerve-preserving (PANP) lateral node dissection (LLND) has been introduced in rectal cancer surgery in Japan, but quality assurance of this approach has not been tested by randomized controlled trials. METHODS: Patients with advanced lower rectal cancer were randomized either to complete PANP + LLND surgery combined with intraoperative radiotherapy (preserved group; n = 28) or to pelvic autonomic nerve resection + LLND surgery (resected group; n = 27). Operation-related parameters were compared statistically. RESULTS: Patient and tumor characteristics were well comparable. The incidence of anastomotic breakdown, intrapelvic abscess, and small bowel obstruction was not different between the two groups. In the preserved group, no patients had ureteral stenosis, pelvic bone fractures, or peripheral neuropathy due to intraoperative radiotherapy. Sphincter-preserving operation was possible with similar ratio in both groups. Adjuvant chemotherapy was given with similar ratio in both groups. The average operation time was 513 minutes in the preserved group and 409 minutes in the resected group, with a significant difference between the two groups. The average amount of hemorrhage was not different significantly between the preserved group (996 ml) and the resected group (970 ml). Circumferential resection margin status and operative curability were similar between the two groups. The average number of harvested and metastatic nodes in the mesentery and pelvic sidewall was not different significantly between the two groups. CONCLUSIONS: This study revealed, for the first time, that the surgical quality of PANP + LLND is the same as pelvic autonomic nerve resection + LLND.

Rationale of pelvic autonomic nerve preservation in rectal cancer surgery based on immunohistochemical study.

PURPOSE: Previous studies revealed that the incidence of cancer cell involvement along the pelvic autonomic nerves ranged from 4 to 14%. However, patients' profiles and methodologies differed among the studies. This study was conducted to clarify the incidence of cancer cell involvement in and around the pelvic autonomic nerves immunohistochemically. METHODS: Immunohistochemical staining was performed on pelvic autonomic nerve specimens resected from 17 patients with p-Stage I-III lower rectal cancers. Antibodies used were pan-cytokeratin (AE1/AE3) for staining cancer cells, S-100 for autonomic nerves, and D2-40 for lymphatic vessels. Lymphatic permeation around the pelvic autonomic nerves was defined as present when AE1/AE3-positive cells were detected in D2-40-stained lymphatic vessels. The presence of metastasis to the interstitial tissue or contaminants was also recorded. RESULTS: TNM staging was stage I in 1, stage II in 5, and stage III in 11 cases, respectively. No cases had lymphatic permeation or metastasis to the interstitial tissue in and around the pelvic autonomic nerves. Cancer cell contaminants were seen in four cases (23%). In three cases (18%), metastatic nodes were located at the root of the middle rectal artery, very close to the pelvic autonomic nerves. CONCLUSIONS: Cancer cell involvement was not seen in and around the pelvic autonomic nerves, suggesting that complete pelvic autonomic nerve preservation may be feasible, unless nerves are invaded by the tumor. In some cases, however, metastatic nodes were seen very close to the nerves. Meticulous lymph node dissection along the pelvic autonomic nerves is mandatory.

Comparison of functional and clinical outcomes: colonic J-pouch vs. coloplasty in patients with low rectal cancer.

BACKGROUND/AIMS: Coloplasty has been reported as substitution to colonic J-pouch when it is difficult to fashion. However, previous studies showed conflicting results with reference to functional outcome. METHODOLOGY: Forty-seven patients with low rectal cancer were involved in this study from July 2000 to December 2006. Coloplasty was performed when colonic J-pouch was hard to construct due to technical difficulty such as short masenterium and narrow pelvis. Clinical and functional evaluations were performed before the operation and 12 months after stoma closure. RESULTS: Colonic J-pouch was abandoned in 12 of 37 cases (26%) due to short colon and mesenterium in 8 cases and narrow pelvis in 4 cases. Frequency of daily bowel movement was significantly increased in both groups but no difference between the groups. Anal sphincter tones were maintained even after the operation. Moreover, no difference was noted between the groups. Anal canal length and sensory factor were also maintained. Volumetric factors such as maximum tolerable volume and neo-rectal capacity showed significant changing before and after the operation. However, there was no significant difference between the groups. CONCLUSIONS: Coloplasty could be a possible substitution to colonic J-pouch in patients with low rectal cancer from functional point of view.

Advanced ampullary carcinoma showing complete response to S-1: report of a case.

We report a case of advanced ampullary carcinoma with para-aortic lymph node metastasis, which showed a complete response to S-1. The patient underwent cholecystectomy and Roux-en-Y choledochojejunostomy, and was then given S-1 orally 80 mg daily for 14 days, followed by 7 days of rest. After four cycles of the S-1 chemotherapy, both the tumor and the swollen paraaortic lymph node had completely disappeared. An additional six cycles were given at the request of the patient. No adverse effects were seen during the S-1 chemotherapy, and the patient has been free of the disease for the 27 months since its completion. Thus, S-1 monotherapy may be considered as a chemotherapeutic strategy for unresectable ampullary carcinoma, although large-scale studies will be required to confirm its true efficacy.

Surgical indications and procedures for bleeding peptic ulcer.

Recent important insights into the surgical treatment of bleeding peptic ulcer are reviewed in this article. Although the widespread use of endoscopic treatment and interventional radiology has reduced the number of surgical cases, surgery still plays a pivotal role in managing bleeding peptic ulcer. Failure to stop the bleeding by endoscopy and/or interventional radiology is the most important indication for emergency surgery. An early elective/planned surgery after the initial endoscopic control to prevent life-threatening rebleeding seems justified in patients who have risk factors for rebleeding, although its true efficacy still remains controversial. The surgical procedures in emergency situations should be limited to safe hemostasis. The addition of acid-reduction surgery may be unnecessary as a result of the increasing utilization of proton pump inhibitors. Angiographic embolization may be a less invasive alternative to surgery, and may further enhance endoscopic hemostasis.

Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor.

BACKGROUND AND OBJECTIVE: Laparoscopic wedge resection using a linear stapler is widely accepted as a treatment for gastric submucosal tumor (SMT). Although this surgery is simple, it can lead to excessive normal tissue removal. To avoid the latter, we have introduced endoscopic full-thickness resection with laparoscopic assistance, known as laparoscopy-assisted endoscopic full-thickness resection (LAEFR). Herein, we present the preliminary results of LAEFR for gastric SMT patients. METHODS: Four patients with gastric SMT underwent LAEFR. LAEFR consists of four major procedures: (1) a circumferential incision as deep as the submucosal layer around the lesion by the endoscopic submucosal dissection technique, (2) endoscopic full-thickness (from the muscle layer to the serosal layer) incision around the three-fourths or two-thirds circumference on the above-mentioned submucosal incision under laparoscopic supervision, (3) completion of the full-thickness incision laparoscopically from inside the peritoneal cavity, and (4) handsewn closure of the gastric-wall defect. RESULTS: LAEFR was successfully carried out without any intraoperative or postoperative adverse events. Mean operating time and estimated blood loss were 201 min and 27 mL, respectively. Contrast roentgenography on postoperative day 3 showed neither gastric deformity nor disturbance of gastric emptying in all the patients. CONCLUSIONS: LAEFR may be considered one of the so-called hybrid natural orifice transluminal endoscopic surgery (NOTES) techniques because a peroral endoscope advances into the peritoneal cavity. LAEFR enabled whole-layer excision as small as possible with an adequate margin. LAEFR is a safe and minimally invasive treatment for patients with gastric SMT, and could be a more reasonable and economical alternative to other laparoscopic procedures.

Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels.

BACKGROUND/PURPOSE: Pancreatic fistula, which is one of the main causes of late postpancreatectomy hemorrhage (PPH), is a common complication of pancreatoduodenectomy (PD). It may erode the anastomosis site and vascular wall in its vicinity, resulting in pseudoaneurysm formation and/or the rupture of major vessels. To protect the vessels near the area for pancreaticojejunostomy from potential pancreatic fistula, we have adopted a surgical option by which such vessels are separated from the pancreaticojejunostomy using a pedicled falciform ligament. We reviewed 36 patients who underwent PD that included this option. METHODS: After the PD was completed (before reconstructions), the pedicled falciform ligament was spread widely on the major vessels exposed during resection, and was fixed to the surrounding retroperitoneal connective tissue. These procedures enabled the complete separation of these vessels from the pancreaticojejunostomy. RESULTS: The mobilization and placement of the falciform ligament in the space between the pancreaticojejunostomy and the major vessels were successfully carried out without any complications. Although ten (28%) patients developed pancreatic fistula and three (8%) developed intraabdominal infection, none of the patients developed late PPH. CONCLUSIONS: The present surgical option is technically simple and easy, and may be an effective prophylactic measure against late PPH following PD.

Modified liver hanging maneuver with extraparenchymal isolation of the middle hepatic vein in left hepatectomy.

BACKGROUND/PURPOSE: The liver hanging maneuver has been employed mostly for right hepatectomy. After the space between the inferior vena cava and the liver parenchyma is bluntly dissected, a tape is passed through the space, with the upper end of the tape between the right hepatic vein and middle hepatic vein (MHV). We devised a modified maneuver with tape repositioning between the MHV and left hepatic vein (LHV) after extraparenchymal isolation of the MHV, in left hepatectomy with the caudate lobe and without the MHV. METHODS: The ligamentum venosum is divided. Traction of the cranial stump of the ligament in the cranial and left direction shows an avascular plane between the LHV and MHV, and enables the taping of each MHV and LHV. Finally, the upper end of the hanging tape is repositioned. RESULTS: This maneuver was successfully performed in three patients. CONCLUSIONS: The present maneuver is feasible and useful in left hepatectomy.

Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes.

OBJECTIVE: This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy. METHODS: Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope. RESULTS: A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1). CONCLUSION: This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.

Single-port endoscopic cholecystectomy: a bridge between laparoscopic and translumenal endoscopic surgery.

BACKGROUND AND OBJECTIVE: The intentional puncture of the normal viscera is likely the most important issue limiting the widespread use of natural orifice translumenal endoscopic surgery (NOTES). We developed a new procedure for cholecystectomy using a flexible endoscope via a single port placed in the abdominal wall without visceral puncture (single-port endoscopic cholecystectomy; SPEC) as a bridge between laparoscopic surgery and NOTES. This study aimed to evaluate the technical feasibility of SPEC. METHODS: Five pigs were subjected to SPEC. An endoscope was inserted through a 12-mm port placed in the right upper abdomen. After grasping and retracting the gallbladder using a 2-mm retractor that was directly introduced into the peritoneal cavity, gallbladder excision with ligation of the cystic artery and duct using endoclips was carried out. RESULTS: A complete gallbladder excision was carried out easily and safely in all cases. No major adverse events occurred. The mean operating time was 67 min (range 52-84 min). CONCLUSIONS: SPEC is a technically feasible procedure. It is simpler, easier, and safer than NOTES cholecystectomy. SPEC could be a less invasive alternative to the conventional four-port laparoscopic cholecystectomy.

Microscopic cancer cell spread in gastric cancer: whole-section analysis of mesogastrium.

PURPOSE: Cancer cells are often found in adipose connective tissue separate from the primary lesion and outside lymph nodes on routine pathologic examination of resected gastric cancer specimens. To identify the anatomical relationship between such cancer cell spread and lymph nodes, we investigated the microscopic cancer cell spread in the mesogastrium (CSM) by the whole-section analysis of the mesogastrium. METHOD: One thousand five hundred fifty-two sections of the mesogastrium obtained from 37 patients with gastric cancer were subjected. CSM is defined as the existence of cancer cell spread in the mesogastrium separate from the primary lesion. RESULTS: CSM was detected in three (8%) of the 37 patients. CSM was classified into three types. CSM was found in three of the 12 patients with advanced cancer, but not in 25 patients with early cancer. CONCLUSIONS: CSM may occur in the mesogastrium separate from metastatic lymph nodes; therefore, we should pay particular attention to the potential existence of CSM in surgery for gastric cancer.

Morphological criteria for metastatic mesorectal lymph nodes in rectal cancer.

BACKGROUND/AIMS: Preoperative diagnostic criteria for mesorectal lymph node metastasis in rectal cancer patients were not consistent in previous reports. This study was conducted to get conclusions on this controversial issue by detailed histological examination. METHODOLOGY: Fifty-eight patients with rectal carcinoma who underwent total mesorectal excision were studied. The total number of lymph nodes evaluated was 538. Parameters of lymph nodes evaluated were size, shape and texture of internal structure. Size was evaluated using long and short axis diameter. Shape was categorized into ovoid or irregular. Heterogeneity of internal structure was categorized into 4 groups (none, less than half, half or over, and whole) according to the tumor volume in the lymph node. RESULTS: Of 538 lymph nodes, 118 lymph nodes were found to have metastasis. There was a significant difference in terms of long (6.6 vs. 3.5 mm: p < 0.05) and short axis diameters (5.1 vs. 2.6 mm: p < 0.05) between metastatic and non-metastatic lymph nodes. Shape showed significantly higher proportion of irregularity (26% vs. 11%) in the metastasis group, while ovoid shape was still the majority in both groups. Heterogeneity of internal structure was significantly more frequent in the metastasis group. In the ROC curve analysis, heterogeneity of internal structure showed the highest diagnostic accuracy (Area under ROC curve, AUC: 0.998), followed by long axis diameter (AUC: 0.794), short axis diameter (AUC: 0.821) and shape of lymph nodes (AUC: 0.570). Multivariate analysis showed that presence of heterogeneity (odds ratio 1.442, p < 0.00001), long axis diameter (odds ratio 1.082, p = 0.001) and short axis diameter (odds ratio 1.068, p = 0.037) were the independent signs of lymph node metastasis. CONCLUSION: The current histological study confirmed that presence of heterogeneity of internal structure, long axis diameter, and short axis diameter were the independent findings for mesorectal lympnode metastasis in rectal cancer patient.

Impact of intra-operative radiotherapy on evacuatory function following ultra-low anterior resection. A preliminary result of prospective randomized trial.

BACKGROUND/AIMS: Preoperative radiotherapy and/or chemotherapy have been reported as effective treatment for locally advanced low rectal carcinoma. However, recent follow-up studies represented severe postoperative evacuatory disorder, which annoys patients' quality of life. METHODOLOGY: The present study was a part of a randomized trial protocol comparing between intraoperative radiotherapy with pelvic autonomic nerve preservation and control group without radiation. Of these, 24 patients having sphincter preservation were followed in terms of their bowel function with questionnaire and anorectal manometry. RESULTS: In terms of background, patients' age, gender, depth of the tumor invasion and lymph node metastasis showed no significant difference between the groups. After stoma closure, frequency of bowel movement was increased and incontinence scores worsened in both groups. However, no significant difference was noted between the groups, postoperatively. Regarding anorectal manometry, postoperative anal sphincter tones were stable compared even to pre-operative findings and no difference was noted between the groups postoperatively. Anal canal length and sensory factor were stable and no difference between the groups. Volumetric factors such as rectal capacity and maximum tolerable volume were also stable even after ultra-low anterior resection. CONCLUSIONS: Intraoperative radiotherapy did not affect adversely on evacuatory function following ultra-low anterior resection in the early postoperative period. Long-term follow-up is warranted.

Autophagy is activated in colorectal cancer cells and contributes to the tolerance to nutrient deprivation.

Several types of cancer cells, including colorectal cancer-derived cell lines, show austerity, the resistance to nutrient starvation, but exactly how cancer cells obtain energy sources under conditions in which their external nutrient supply is extremely limited remains to be clarified. Because autophagy is a catabolic process by which cells supply amino acids from self-digested organelles, cancer cells are likely to use autophagy to obtain amino acids as alternative energy sources. Amino acid deprivation-induced autophagy was assessed in DLD-1 and other colorectal cancer-derived cell lines. The autophagosome-incorporated LC3-II protein level increased after treatment with a combination of autolysosome inhibitors, which interferes with the consumption of autophagosomes. Autophagosome formation was also morphologically confirmed using ectopically expressed green fluorescent protein-LC3 fusion proteins in DLD-1 and SW480 cells. These data suggest that autophagosomes were actively produced and promptly consumed in colorectal cancer cells under nutrient starvation. Autolysosome inhibitors and 3-methyl adenine, which suppresses autophagosome formation, remarkably enhanced apoptosis under amino acid-deprived and glucose-deprived condition. Similar results were obtained in the cells with decreased ATG7 level by the RNA interference. These data suggest that autophagy is pivotal for the survival of colorectal cancer cells that have acquired austerity. Furthermore, autophagosome formation was seen only in the tumor cells but not in the adjacent noncancerous epithelial cells of colorectal cancer specimens. Taken together, autophagy is activated in colorectal cancers in vitro and in vivo, and autophagy may contribute to the survival of the cancer cells in their microenvironment.

Management of intraductal papillary mucinous neoplasm of the pancreas.

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a distinct entity characterized by papillary proliferations of mucin-producing epithelial cells with excessive mucus production and cystic dilatation of the pancreatic ducts. IPMNs have malignant potential and exhibit a broad histologic spectrum, ranging from adenoma to invasive carcinoma. IPMNs are classified into main duct and branch duct types, based on the site of tumor involvement. IPMN patients have a favorable prognosis if appropriately treated. The postoperative 5-year survival rate is nearly 100% for benign tumors and noninvasive carcinoma, and approximately 60% for invasive carcinoma. A main duct type IPMN should be resected. Surgical treatment is indicated for a branch duct IPMN with suspected malignancy (tumor diameter > or = 30 mm, mural nodules, dilated main pancreatic duct, or positive cytology) or positive symptoms. Malignant IPMNs necessitate lymph node dissection (D1). IPMNs are associated with a high incidence of extrapancreatic malignancies and pancreatic ductal carcinoma.

Intraoperative radiotherapy for oncological and function-preserving surgery in patients with advanced lower rectal cancer.

BACKGROUND: Pelvic autonomic nerve preservation (PANP) with lateral lymph node dissection (LLND) has been introduced in rectal cancer surgery in Japan; however, its indication has not been standardized yet. MATERIALS AND METHODS: Forty-four patients with advanced lower rectal cancer were randomized to either the standard treatment group (control group) or the intraoperative radiotherapy (IORT) group. All patients underwent potentially curative resection of the rectum with total mesorectal excision. The control group underwent bilateral LLND and limited PANP. The IORT group underwent bilateral LLND, complete PANP, and IORT. Patients allocated to the IORT group received IORT to the bilateral preserved pelvic nerve plexuses. Patients' clinicopathologic parameters, postoperative complications, voiding function, and prognosis were compared between the two groups. RESULTS: Among 44 patients enrolled, three patients were excluded from the analysis, resulting in 19 patients in the IORT group and 22 patients in the control group. Patients' demographic and pathological parameters and postoperative complications were well balanced between the two groups. Oncological outcomes including overall and disease-free survival were also similar. Local recurrence was observed in one patient in each group. Among the 34 patients not complicated with intrapelvic abscess, the mean duration of urinary catheter indwelling was 8 days in the IORT group and 13 days in the control group (p = 0.055). In the long term, medication for urination was necessitated in four patients in the control group, whereas in none in the IORT group (p = 0.059). DISCUSSIONS: Oncological outcomes in the IORT group are equal to those in the control group, and voiding functions in the IORT group are superior to those in the control group. These results suggest that IORT may be useful to expand the indication of complete PANP with LLND for advanced lower rectal cancer.

Magnetic resonance imaging for diagnosing chronic pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is highly sensitive for detecting chronic pancreatitis, even when mild, but it is invasive. Magnetic resonance cholangiopancreatography (MRCP), a noninvasive modality, well demonstrates dilatation, stricture, and irregularity of the main pancreatic duct as well as filling defects due to pancreatic stones and protein plugs in chronic pancreatitis. MRCP well visualizes the pancreatic ducts distal to the sites of complete obstruction and noncommunicating pseudocysts, in contrast to ERCP. MRCP is sensitive for detecting moderate to severe pancreatitis but not for mild pancreatitis. However, secretin-stimulated MRCP and technological innovations in magnetic resonance may improve diagnostic accuracy. A recently developed technique, secretin-stimulated diffusion-weighted magnetic resonance imaging (DW-MRI), noninvasively and accurately evaluates pancreatic exocrine function. In conclusion, MRCP can most likely replace ERCP for evaluation of moderate to severe chronic pancreatitis. Secretin-stimulated DW-MRI may help to detect mild or early pancreatitis.