Medium-term oncological outcomes of totally laparoscopic colectomy with intracorporeal anastomosis for right-sided and left-sided colon cancer: propensity score matching analysis.

BACKGROUND: This retrospective study aimed to compare long-term oncological outcomes between laparoscopic-assisted colectomy (LAC) with extracorporeal anastomosis (EA) and totally laparoscopic colectomy (TLC) with intracorporeal anastomosis (IA) for colon cancers, including right- and left-sided colon cancers. METHODS: Patients with stage I-III colon cancers who underwent elective laparoscopic colectomy between January 2013 and December 2017 were analyzed retrospectively. Patients converted from laparoscopic to open surgery and R1/R2 resection were excluded. Propensity score matching (PSM) analysis (1:1) was performed to overcome patient selection bias. RESULTS: A total of 388 patients were reviewed. After PSM, 83 patients in the EA group and 83 patients in the IA group were compared. Median follow-up was 56.5 months in the EA group and 55.5 months in the IA group. Estimated 3-year overall survival (OS) did not differ significantly between the EA group (86.6%; 95% confidence interval (CI), 77.4-92.4%) and IA group (84.8%; 95%CI, 75.0-91.1%; P = 0.68). Estimated 3-year disease-free survival (DFS) likewise did not differ significantly between the EA group (76.4%; 95%CI, 65.9-84.4%) and IA group (81.0%; 95%CI, 70.1-88.2%; P = 0.12). CONCLUSION: TLC with IA was comparable to LAC with EA in terms of 3-year OS and DFS. TLC with IA thus appears to offer an oncologically feasible procedure.

Closure of enterotomy after side-to-side ileocolic anastomosis with two barbed sutures in totally laparoscopic colectomy for right-sided colon cancer.

Good short-term outcomes of intracorporeal ileocolic anastomosis (IIA) in totally laparoscopic colectomy for right-sided colon cancer (TLRC) have been shown in many reports, but no standardized technique for enterotomy closure after stapled side-to-side ileocolic anastomosis has so far been established. We retrospectively compared the short-term outcomes between 13 consecutive patients receiving either TLRC with IIA by conventional enterotomy closure (n = 6) or closure of the enterotomy using two barbed sutures (CEBAS) (n = 7) from July 2019 to April 2020. No anastomotic bleeding or leakage was observed in either group. Time to enterotomy closure was significantly shorter with the CEBAS method (16.5 ± 3.7 min) than with the conventional method (24.5 ± 4.7 min, p = 0.0059). The CEBAS method in TLRC with IIA was thus found to be technically feasible and it might reduce the stress associated with intracorporeal enterotomy closure.

Male sex and anterior wall tumor location as risk factors for urinary dysfunction after laparoscopic rectal surgery.

BACKGROUND: Total mesorectal excision (TME) has decreased the local recurrence rate and improved the overall survival of rectal cancer patients. However, urinary dysfunction remains a clinical problem after rectal cancer surgery. The aim was to assess the risk factors for postoperative urinary dysfunction. METHODS: This study was a single-center, retrospective analysis of 104 patients who underwent laparoscopic rectal surgery between November 2016 and October 2017. Postoperative urinary dysfunction was defined as the need for urinary catheter re-insertion or the presence of residual urine (≥ 150 mL) postoperatively. RESULTS: Postoperative urinary dysfunction was seen in 18 patients (17%). Multivariate analysis showed that male sex (odds ratio 3.89, p = 0.034) and anterior wall tumor location (odds ratio = 4.07, p = 0.037) were the predictors of postoperative urinary dysfunction. Compared with patients without risk factors, those with the two risk factors needed longer hospital stays (16 days vs. 30 days, p = 0.0022). CONCLUSION: Male sex and anterior wall tumor location were the risk factors for urinary dysfunction after laparoscopic rectal surgery.

The Management of Recurrence within Six Months after Hepatic Resection for Colorectal Liver Metastasis.

BACKGROUND: Hepatectomy is currently recommended as the most reliable treatment for colorectal liver metastases. However, the association between the choice of treatment for recurrence and the timing of recurrence remains controversial. METHODS: Two-hundred ninety-five patients who underwent hepatectomy were retrospectively analyzed for the risk factors and the outcomes for early recurrence within 6 months. The remnant liver volumes (RLVs) and laboratory data were measured postoperatively using multidetector computed tomography on days 7 and months 1, 2, and 5 after the operation. RESULTS: Early recurrence developed in 88/295 patients (29.8%). Colorectal cancer lymph node metastasis, synchronous liver metastasis, and multiple liver metastases were independent risk factors for the occurrence of early recurrence (p < 0.001, 0.032, and 0.019, respectively). Patients with early recurrence had a poorer prognosis than did patients who developed later recurrence (p < 0.001). Patients who underwent surgery or other local treatment had better outcomes. The changes in RLV and laboratory data after postoperative month 2 were not significantly different between the 2 groups. CONCLUSION: Patients with early recurrence within 6 months had a poorer prognosis than did patients who developed later recurrence. However, patients who underwent repeat hepatectomy for recurrence had a better prognosis than did those who underwent other treatments, with good prospects for long-term survival.

Clinical impact of single-incision laparoscopic right hemicolectomy with intracorporeal resection for advanced colon cancer: propensity score matching analysis.

BACKGROUND: Laparoscopic right hemicolectomy has become an acceptable treatment for right-sided colon cancer. Most centers use multiport laparoscopic right hemicolectomy extracorporeally (MRHE), whereas single-incision laparoscopic right hemicolectomy intracorporeally (SRHI) remains controversial. The aim of this study was to compare these two techniques using propensity score matching analysis. METHODS: We analyzed the data from 111 patients who underwent laparoscopic right hemicolectomy between December 2015 and December 2016. The propensity score was calculated according to age, gender, body mass index, the American Society of Anesthesiologists score, previous abdominal surgery, and D3 lymph node dissection. Postoperative pain was evaluated using a visual analogue scale (VAS) and postoperative analgesic use was an outcome measure. RESULTS: The length of skin incision in SRHI was significantly shorter than in MRHE [3 (3.5-6) versus 4 (3-6) cm, respectively; P = 0.007]. The VAS score on day 1 and day 2 after surgery was significantly less in SRHI than in MRHE [30 (10-50) versus 50 (20-69) on day 1, P = 0.037; 10 (0-50) versus 30 (0-70) on day 2, P = 0.029]. Significantly fewer patients required analgesia after SRHI on day 1 and day 2 after surgery [1 (0-3) versus 2 (0-4) on day 1, P = 0.024; 1 (0-2) versus 1 (0-4) on day 2, P = 0.035]. There were no significant differences in operative time, intraoperative blood loss, number of lymph nodes removed, and postoperative course between groups. CONCLUSIONS: SRHI appears to be safe and technically feasible. Moreover, SRHI reduces the length of the skin incision and postoperative pain compared with MRHE.

Surgical Outcome and Hepatic Regeneration after Hepatic Resection for Hepatocellular Carcinoma in Elderly Patients.

INTRODUCTION: The rising proportion of elderly patients (aged 80 yearsor above) in our population means that more elderly patients are undergoing hepatectomy. METHODS: Five-hundred and thirty patients who underwent hepatectomy for hepatocellular carcinoma (HCC) were retrospectively analyzed with respect to their preoperative status and perioperative results, including remnant liver regeneration. The remnant liver volume was postoperatively measured with multidetector CT on postoperative day 7 and 1, 2, 5, and 12 months after surgery. An elderly group (aged 80 or older) was compared with a non-elderly group (aged less than 80 years). RESULTS: Underlying diseases of the cardiovascular system were significantly more common in the elderly group (57.8%, p = 0.0008). The postoperative incidence of Clavien-Dindo Grade IIIa or higher complications was 20.0% in the elderly group and 24.3% in the non-elderly group, and this difference was not significant. As for regeneration of the remnant liver after resection, this was not morphologically delayed compared to the non-elderly group. CONCLUSIONS: In this study, we have demonstrated that safe, radical hepatectomy, similar to procedures performed on non-elderly patients, can be performed on patients with HCC aged 80 and older with sufficient perioperative care.

Totally extraperitoneal approach to laparoscopic lateral lymph node dissection for patients with recurrent lateral pelvic lymph nodes after rectal cancer surgery: a novel technique-M TEP LLND.

Lateral lymph node dissection (LLND) for recurrence of lateral pelvic lymph node metastasis after rectal cancer surgery is technically demanding because of the need for re-do surgery. We herein report a novel technique of laparoscopic LLND via a totally extraperitoneal (TEP) approach. Since October 2018, we have performed LLND based on a TEP approach, called "M TEP LLND", with two cases treated. By peeling in the caudal direction in the dorsal layer of the rectus abdominis muscle, a working space is created once the extraperitoneal space is reached, and LLND is performed. All lateral pelvic lymph node dissection procedures have been successfully completed, and there have been no intraoperative or postoperative complications. This procedure allows TEP-experienced colorectal surgeons to perform safe and complete LLND without any influence of intraperitoneal adhesion or intestinal obstruction. M TEP LLND is less invasive than the conventional intraperitoneal approach and appears to be useful, particularly for recurrence of lateral pelvic lymph node metastasis.

The impact of preoperative carbohydrate loading on intraoperative body temperature: a randomized controlled clinical trial.

BACKGROUND: Preoperative carbohydrate loading (CHO) is one element of the enhanced recovery after surgery protocol. No clinical trial has investigated the impact of preoperative CHO on intraoperative body temperature. METHODS: This study was a single-center, prospective, randomized controlled clinical trial involving patients undergoing laparoscopic colon cancer surgery. The primary end point was the intraoperative core temperature during surgery, which was measured at 30-min intervals for 150 min after starting surgery. The secondary end points were short-term outcomes and body composition changes. RESULTS: From July 2013 to May 2014, we randomized 70 patients into the control group (n = 33) or CHO group (n = 31); six patients were excluded. The core temperature of the CHO group 90, 120, and 150 min after starting surgery was significantly lower than that of the control group (control vs. CHO, respectively: 90 min; 36.26 ± 0.41 vs. 36.05 ± 0.43 °C, p = 0.0233, 120 min; 36.30 ± 0.44 vs. 36.06 ± 0.50 °C, p = 0.0283, 150 min; 36.33 ± 0.50 vs. 36.01 ± 0.56 °C, p = 0.0186). We also found a significant difference in body weight loss (control vs. CHO, respectively: - 1.6 ± 0.8 vs. - 0.9 ± 1.4 kg, p = 0.0304) and loss of lower limb muscle mass (- 0.7 ± 0.7 vs. - 0.3 ± 0.6 kg, p = 0.0110) between the control and CHO groups, respectively. CONCLUSION: CHO had no effect on raising the intraoperative core temperature, and no negative impact on the perioperative outcome. CHO prevented the loss of lower limb muscle mass, which may lead to better postoperative recovery.

Preoperative Chemotherapy May Not Influence the Remnant Liver Regenerations and Outcomes After Hepatectomy for Colorectal Liver Metastasis.

BACKGROUND: Various chemotherapy regimens have been shown to improve outcomes when administered before tumor excision surgery. However, there is no consensus on the utility of multidisciplinary treatment with preoperative chemotherapy for treating colorectal liver metastasis (CLM). MATERIALS AND METHODS: Two hundred-fifty patients who underwent hepatectomy were retrospectively analyzed using propensity score matching. Postoperative outcomes were evaluated with a focus on the effect of pre-hepatectomy chemotherapy on regeneration of the remnant liver in patients with CLM. The remnant liver volumes (RLVs) were postoperatively measured with multidetector computed tomography on days 7 and months 1, 2, 5, and 12 after the operation. RESULTS: RLV regeneration and blood test results did not significantly differ between patients who underwent preoperative chemotherapy versus those who did not immediately after surgery or at any time point from postoperative day 7 to postoperative month 12. The 1-, 2-, and 3-year overall survival (OS) rates for all patients were 94.6, 86.2, and 79.9%, respectively; the corresponding disease-free survival (RFS) rates were 49.3, 38.6, and 33.7%, respectively. There were no significant differences in OS and RFS between the two groups after hepatic resection. The recurrence rates, including marginal and intrahepatic recurrences, as well as resection frequency of the remnant liver were not significantly different between the two groups. CONCLUSION: Preoperative chemotherapy may have no appreciable benefit for patients with CLM in terms of perioperative and long-term outcomes.

The utility of the subcuticular suture in hepatic resection.

AIM OF THE STUDY: Despite recent technical progress and advances in the perioperative management of liver surgery, postoperative surgical site infection (SSI) is still one of the most common complications that extends hospital stays and increases medical expenses following hepatic surgery. MATERIAL AND METHODS: From 2001 to 2017 a total of 1180 patients who underwent hepatic resection for liver tumours were retrospectively analysed with respect to the predictive factor of superficial incisional SSI, using a propensity score matching by procedure (subcuticular or mattress suture). RESULTS: The incidence of superficial and deep incisional SSIs was found to be 7.1% (84/1180). By propensity score matching (PSM), 121 of the 577 subcuticular suture group patients could be matched with 121 of the 603 mattress suture group patients. Multivariate analysis demonstrated wound closure technique as the only independent risk factor that correlated significantly with the occurrence of superficial incisional SSIs (p = 0.038). C-reactive protein (CRP) levels on postoperative day 4 were significantly higher in patients with incisional SSIs than in those without (p < 0.001). CONCLUSIONS: Wound closure technique with subcuticular continuous spiral suture using absorbable suture should be considered to minimise the incidence of incisional SSIs. Moreover, wounds should be carefully checked when CRP levels are high on postoperative day 4.

Chymase inhibitor prevents the development and progression of non-alcoholic steatohepatitis in rats fed a high-fat and high-cholesterol diet.

The effect of the chymase inhibitor TY-51469 on the development and progression of non-alcoholic steatohepatitis (NASH) was evaluated in rats fed a high-fat and high-cholesterol (HFC) diet. To evaluate the preventive effect of TY-51469 on the development of NASH, stroke-prone spontaneously hypertensive rat 5 (SHRSP5)/Dmcr rats were fed either a normal or HFC diet for 8 weeks, and concurrently administered either placebo or TY-51469 (1 mg/kg per day). To evaluate the effect of TY-51469 on the survival rate, TY-51469 was administered either concurrently with HFC diet (pretreated group) or 8 weeks after HFC diet at which point NASH had developed (posttreated group). Eight weeks after HFC diet, significant increases of steatosis, fibrosis and chymase-positive cells were observed in liver from the placebo-treated rats. Significant increases of myeloperoxidase, transforming growth factor-ß, matrix metalloproteinase-9, and collagen I mRNA levels were also observed. However, all parameters were significantly attenuated in the TY-51469-treated group. A survival rate of the placebo-treated group fed the HFC diet was 0% at 14 weeks. In comparison, the rates of TY-51469-pretreated and TY-51469-posttreated groups were 100% and 50% at 14 weeks, respectively. Chymase inhibitor may be applicable to preventing the development and progression of NASH.

Effect of previous abdominal surgery on outcomes following laparoscopic colorectal surgery.

OBJECTIVE: The impact of previous abdominal surgeries on the need for conversion to open surgery and on short-term outcomes during/after laparoscopic colectomy was retrospectively investigated. DESIGN: This retrospective cohort study was conducted from December 1996 through December 2009. SETTING: This study was conducted at Osaka Medical College Hospital. PATIENTS: A total of 1701 consecutive patients who had undergone laparoscopic resection of the colon and rectum were classified as not having previous abdominal surgery (n = 1121) or as having previous abdominal surgery (n = 580). MAIN OUTCOME MEASURES: Short-term outcomes were recorded, and risk factors for conversion to open surgery were analyzed. RESULTS: There were no significant differences in operative time, blood loss, number of lymph nodes removed, or conversion rate between the groups. The rate of inadvertent enterotomy was significantly higher in the previous abdominal surgery group than in the not having previous abdominal surgery group (0.9% versus 0.1%; p = 0.03), and the postoperative recovery time was significantly longer in the previous abdominal surgery group than in the not having previous abdominal surgery group. Ileus was more frequent in the previous abdominal surgery group than in the not having previous abdominal surgery group (3.8% versus 2.1%; p = 0.04). Significant risk factors for conversion to open surgery were T stage ≥3 (OR, 2.81; 95% CI, 1.89-3.75), median incision (OR, 4.34; 95% CI, 1.23-9.41), upper median incision (OR, 2.78; 95% CI, 1.29-5.42), lower median incision (OR, 1.82; 95% CI, 1.09-3.12), and transverse colectomy (OR, 1.76; 95% CI, 1.29-2.41). CONCLUSION: The incidence of successfully completed laparoscopic colectomy after previous abdominal surgery remains high, and the short-term outcomes are acceptable.

Chymase inhibitor ameliorates hepatic steatosis and fibrosis on established non-alcoholic steatohepatitis in hamsters fed a methionine- and choline-deficient diet.

AIM: Chymase plays a role in the augmentation of angiotensin II formation, which is involved in liver fibrosis. The therapeutic effects of a chymase inhibitor, TY-51469, on established hepatic steatosis and fibrosis were investigated in a model of developed non-alcoholic steatohepatitis. METHODS: Hamsters were fed a normal diet or methionine- and choline-deficient (MCD) diet for 12 weeks. Then, treatment with TY-51469 (1 mg/kg per day) or placebo was initiated, and the treatment was continued concurrently with the MCD diet for an additional 12 weeks. RESULTS: At 12 weeks after initiating the MCD diet, marked hepatic steatosis and fibrosis were observed in MCD diet-fed hamsters. Malondialdehyde and gene expression levels of collagen I, collagen III, α-smooth muscle actin (α-SMA) and Rac-1 in liver extracts were also increased in the MCD-diet-fed hamsters at 12 weeks. At 24 weeks, hepatic steatosis and fibrosis were more prominent in the placebo-treated hamsters that were fed the MCD-diet for 24 weeks versus 12 weeks. Hamsters treated with TY-51469 for 12 weeks after being on a 12-week MCD diet had significant ameliorations in both hepatic steatosis and fibrosis, and there were no significant differences compared to normal diet-fed hamsters. There were significant augmentations in angiotensin II and malondialdehyde, and gene expressions of collagen I, collagen III, α-SMA and Rac-1 in the placebo-treated hamsters at 24 weeks; however, these levels were reduced to normal levels in the TY-51469-treated hamsters. CONCLUSION: TY-51469 not only prevented the progression of hepatic steatosis and fibrosis, but also ameliorated hepatic steatosis and fibrosis.

Internal hernia projecting through a mesenteric defect to the lesser omental cleft following laparoscopic-assisted partial resection of the transverse colon: report of a case.

We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy to the lesser omental cleft in a 61-year-old female. We performed laparoscopic-assisted partial resection of the transverse colon to treat transverse colon cancer. Three years and 6 months after the operation, the patient developed a bowel obstruction requiring surgical intervention. When we observed the intraperitoneal space under laparoscopy, we determined that the small intestine had passed into the bursa omentalis through the mesenteric defect. Additionally, an abnormal opening of the lesser omentum was present with a portion of the small intestine escaping into the space inferior to the liver. We performed reintegration of the escaped bowel and closed the mesenteric defect laparoscopically. This is the first case of an internal hernia projecting through a mesenteric defect following laparoscopic-assisted colectomy that we have experienced out of more than 2400 cases. Further research is needed to identify the patients who would benefit from the closure of mesenteric defects during laparoscopic-assisted colectomy.

Successful Laparoscopic Treatment of Pancreatic Metastasis From Sigmoid Colon Cancer: A Case Report.

Progressive colorectal cancer frequently presents with various manifestations, including hepatic, pulmonary, and peritoneal metastases, as well as local and anastomotic site recurrences. However, pancreatic metastasis is extremely rare. Complete surgical resection is currently considered the most effective and only potentially curative treatment for colorectal cancer with distant metastases. We report the successful laparoscopic treatment of a patient with pancreatic metastasis after initial surgery for Stage IV sigmoid colon cancer with pulmonary metastasis. An 84-year-old man was initially diagnosed with sigmoid colon cancer and pulmonary metastasis. Laparoscopic sigmoidectomy and thoracoscopic partial resection of the right lung were performed in 2017. After 8 months, an approximately 20-mm tumor was detected in the pancreatic tail during imaging investigations. We performed laparoscopic distal pancreatectomy without lymph node dissection at 1 year after the initial operation. The histopathological findings suggested metachronous pancreatic metastasis from the sigmoid colon cancer. The patient has had an uneventful postoperative course with no signs of recurrent disease during 29 months of follow-up after the pancreatic surgery. After prior surgery for Stage IV sigmoid colon cancer with pulmonary metastasis, curative resection was performed for pancreatic metastasis. We believe that curative resection may be useful for pancreatic tumors that involve hematogenous metastasis.

The Management of Recurrence of Hepatocellular Carcinoma Occurring Within 6 Months After Hepatic Resection: A Comparative Study Using a Propensity Score Matching Analysis.

BACKGROUND: Hepatectomy is currently recommended as the most reliable treatment for hepatocellular carcinoma. However, the association between the choice of treatment for recurrence and the timing of recurrence remains controversial. METHODS: Three-hundred thirty-nine patients who underwent hepatectomy were retrospectively analyzed using a propensity score matching analysis for the risk factors and outcomes for early recurrences within 6 months. The remnant liver volumes and laboratory data were measured postoperatively using multidetector computed tomography on days 7 and months 1, 2, and 5 after surgery. The Student's t test and chi-square test, the likelihood-ratio test, Fisher's exact test, Mann-Whitney U test, or Wilcoxon signed-rank test were used in the statistical analyses. RESULTS: Early recurrence developed in 41/312 patients (13.1%). Vascular invasion and non-curative resection were independent risk factors for the occurrence of early recurrence (P < 0.001 and < 0.001, respectively). Patients with early recurrence had a poorer prognosis than patients who developed later recurrences (P < 0.001). Patients who underwent surgery or other local treatments had better outcomes (P < 0.001). The changes in remnant liver volumes and laboratory data after postoperative month 2 were not significantly different between the two groups. CONCLUSION: Patients with early recurrence within 6 months had a poorer prognosis than patients who developed a later recurrence. However, patients who underwent repeat hepatectomy for recurrences had a better prognosis than did those who underwent other treatments, with good prospects for long-term survival.

Natural orifice specimen extraction in laparoscopic colorectal cancer surgery: A case series study.

INTRODUCTION: In recent years, natural orifice specimen extraction (NOSE) has been attracting attention as a further minimally invasive operation for colorectal cancer, and not only improvement of appearance, but also reduction of pain and wound-related complications due to abdominal wall destruction has been reported. However, NOSE is technically complicated and difficult, and it has not yet been widely used. The aim of this study was to confirm the feasibility, safety, and short-term outcomes of total laparoscopic colon cancer surgery with NOSE. CASE PRESENTATION: From May 2018 to October 2019, eight patients with stage 0 or I colon cancer underwent NOSE surgery in our hospital. Transanal specimen extraction was performed in six cases, and transvaginal specimen extraction was performed in two cases. All operations were successfully accomplished without conversion to open surgery. The anastomosis method was double stapling technique in three cases and overlap method in five cases. The median operative time was 224 min. The median blood loss was 10 mL. The median time to first flatus was 1 day, and the median time to first stool was 2 days. The median postoperative observation period was 18 months, but there was no recurrence. There were no postoperative complications in these cases. CONCLUSION: Total laparoscopic colon cancer surgery with NOSE appears to be feasible, safe, and show promising efficacy for selected patients.

Clinical experience with near-infrared ray catheter, a fluorescent ureteral catheter, on laparoscopic surgery for colon diverticulitis: A case report.

RATIONALE: As the world's population ages, the number of surgical cases of colovesical fistulas secondary to colon diverticulitis is also expected to increase. The key issue while performing laparoscopic surgery for these fistulas is the avoidance of iatrogenic ureteral injury. There are no reports of Near-infrared Ray Catheter being used in surgery for diverticulitis, which is one of the diseases with the highest risk of ureteral injury. We present a case of a male patient with colovesical fistulas secondary to sigmoid colon diverticulitis who underwent laparoscopic surgery with visualization of the ureter using a new surgical technique in laparoscopic surgery. PATIENTS CONCERN: An 82-year-old man presented to our urological department with general fatigue and air and fecal matter in the urine. DIAGNOSES: Cystography showed delineation of the sigmoid colon. Abdominal computed tomography findings revealed multiple sigmoid colon diverticula with thickened walls as well as large stones and a small amount of air in the bladder. He was diagnosed with a urinary tract infection with colovesical fistulas and bladder stones due to sigmoid diverticulitis. INTERVENTIONS: After the creation of a transverse colostomy, we scheduled a laparoscopic anterior resection and cystolith removal. OUTCOMES: Severe inflammatory adhesions around the sigmoid colon and a high risk of ureteral injury were expected preoperatively. After induction of anesthesia, we inserted a Near-infrared Ray Catheter, a fluorescent ureteral catheter, which allowed us to easily identify and visualize the ureter in real-time. This allowed bowel dissection without concerns of ureteral injury. The operative time for the gastrointestinal part of the procedure was 150 minutes, and the patient was in a good general condition after the operation and was discharged on postoperative day 7. LESSONS: The course of the ureter was easily and quickly identified by the green fluorescence from the ureteral catheter during laparoscopic surgery for fistulas associated with diverticulitis, where severe inflammation and dense fibrosis were present. Our technique is an easy and feasible approach that provides real-time urethral navigation during surgery for colovesical fistulas secondary to colon diverticulitis.

Preventing anastomotic leakage after laparoscopic intersphincteric resection without a diverting stoma: "pull-through/reborn".

INTRODUCTION: Patients with very low rectal cancer who undergo intersphincteric resection (ISR) often experience anastomotic leakage (AL), even with a diverting stoma. The aim of this study was to introduce a technique for anastomosis after laparoscopic ISR to avoid AL. MATERIALS AND SURGICAL TECHNIQUE: In the first ISR procedure, the rectum was mobilized, the mesorectum was excised, and total, subtotal, or partial internal sphincter incision was performed transanally. In the second surgery, the adhesions between the prolapsed colon and the anal canal were bluntly dissected only as needed for suturing. After sufficient blood flow was confirmed using indocyanine green fluorescence imaging, coloanal transanal anastomosis was performed without a diverting stoma. We call this method "pull-through/reborn". DISCUSSION: "Pull-through/reborn" method can prevent AL after laparoscopic ISR. However, more cases and more experience are necessary to analyze anal functions after this method is applied.

A new spray-type adhesion barrier (AdSpray) improves condition for surgical treatment in the reversal of Hartmann procedure: A case report.

RATIONALE: Hartmann procedure (HP) often causes severe postoperative adhesions in the pelvic space; therefore, the reversal of Hartmann procedure (RHP) is a challenging surgery. A new spray-type antiadhesion agent, AdSpray, has been reported to be useful in three-dimensional fields such as the liver. However, there are no reports of its use in HP. We present a case of a male patient with rectal cancer who underwent laparoscopic HP with AdSpray to prevent postoperative adhesions. PATIENT CONCERNS: A 52-year-old man presented with melena and constipation. DIAGNOSIS: Colonoscopy revealed an almost obstructive type II tumor at the rectosigmoid colon, and histopathological examination revealed moderately differentiated adenocarcinoma. Enhanced abdominal computed tomography revealed slightly enlarged regional lymph nodes but no ascites around the tumor, and there was no metastasis to the liver or lungs. Therefore, we diagnosed clinical stage T4aN1bM0 rectosigmoid colon cancer. Intraoperatively, a metastatic tumor of the liver surface and a high degree of valve retention in the oral colon were identified. INTERVENTIONS: After performing laparoscopic HP with AdSpray, we scheduled a laparoscopic RHP with staged hepatic surgery for synchronous liver metastasis from colorectal cancer 1 month later. OUTCOMES: No postoperative inflammatory adhesions were observed in the pelvis or around the rectal stump, allowing us to perform RHP by a single-incision laparoscopic surgery from the stoma site without any problem. The operation time for RHP was 80 minutes; the patient was in good general condition after the operation, and he was discharged on postoperative day 7. LESSONS: In laparoscopic HP, Adspray was easy to use for three-dimensional fields such as the pelvis and effectively prevented postoperative inflammatory adhesions. Thus, RHP may become less risky and be performed more as a minimally invasive surgery.