Randomized controlled trial comparing cosmetic results of midline incision versus off-midline incision for specimen extraction in laparoscopic colectomy.

PURPOSE: A notable advantage of laparoscopic colorectal surgery is that only a small incision at the extraction site is necessary, which is considered to be cosmetically beneficial. Meanwhile, the optimal extraction site for the resected specimen in laparoscopic colectomy is controversial in terms of cosmetic benefit. This randomized controlled trial compares midline and off-midline extraction sites in laparoscopic colectomy in patients with colon cancer, with consideration of cosmetic benefits as the primary endpoint. METHODS: Included were patients that underwent elective laparoscopic colectomy at WMUH between October 2014 and February 2017. Patients were randomly assigned to either midline incision group or off-midline incision group. Prospectively collected data included cosmetic results (patients and observer assessment scale) and complications including incidence of incisional hernia, SSI, and pain. This trial was registered with UMIN Clinical Trials (UMIN000028943). RESULTS: Finally, 98 patients with colorectal cancer were analyzed. No significant differences were found between the two groups in patient and observer assessment scales of cosmetic results (midline 8 ± 1.1 vs off-midline 11 ± 5.9 p = 0.16, midline 13.5 ± 6.6 vs off-midline 15 ± 11 p = 0.58, respectively) or in postoperative pain. However, incisional hernia occurred in four cases in the midline group (8%), which was significantly higher than that in the off-midline group (no cases, 0%). CONCLUSION: There was no significant difference in terms of cosmetic benefit, the primary endpoint, between the two groups. In this study, only the extraction site location was compared; future studies will examine differences depending on the incisional direction, including the incidence of incisional hernia.

New diagnostic strategy using narrow-band imaging (NBI) during laparoscopic surgery for patients with colorectal cancer.

BACKGROUND: Accurate tumor stage diagnosis during laparoscopic surgery remains difficult. We clarify the impact of new diagnostic strategy using narrow-band imaging (NBI) during laparoscopic surgery for colorectal cancer compared with other strategies. METHODS: We defined angiogenesis (Ag) and fibrosis (Fib) grades using NBI laparoscopy (lap-NBI), and assessed the clinicopathological features associated with these grades for 67 patients with colorectal cancer who underwent surgery. We assessed vessel density and gray scale with computer software. RESULTS: NBI-Ag-grade and NBI-Fib-grade of the serosal surface of cancer lesions and peritoneal nodules correlated with vessel density and gray scale of those assessed by Image J computer software. NBI-Fib-grades of liver nodules also correlated with gray scale. NBI-Ag- grade and Fib-grade of the serosal surface of cancer lesions correlated with pathological depth of invasion. These NBI grades of pathological metastatic peritoneal nodules were higher than those of pathologically benign peritoneal nodules. NBI- Fib grades of pathological metastatic liver nodules were higher than those of pathologically benign liver nodules. In multivariate analysis, lap-NBI was associated with different diagnosis for T3, T4 and non-T3, and non-T4. Moreover, lap-NBI was associated with different diagnosis for T4 and non-T4. Predictive value for T4 by lap-NBI showed high sensitivity (85%) specificity (87%), positive predictive value (74%), negative predictive value (93%), and overall accuracy (87%). Sensitivity and overall accuracy of lap-NBI was superior to that of other diagnostic modalities. CONCLUSION: We clarified the usefulness of the new diagnostic strategy using lap-NBI during laparoscopic surgery for colorectal cancer in comparison with other strategies.

Optimal Assessment of Frailty Predicts Postoperative Complications in Older Patients with Colorectal Cancer Surgery.

OBJECTIVES: The increasingly elderly worldwide population has affected the incidence of colorectal cancer. Establishment of reliable assessment of frailty and proposals for multi-disciplinary interventions are urgently required in oncology practices. Kihon Checklist (KCL) was published by the Japanese Ministry of Health, Labor and Welfare originally to identify individuals ≥ 65 years old at probable risk for requiring care or social support. We investigate the validity of KCL for frailty assessment to predict postoperative complication in older patients with colorectal cancer. METHODS: Consecutive colorectal cancer patients aged ≥ 65 (n = 500) were prospectively examined between May 2017 and December 2018. Preoperative frailty assessment was conducted by the G8 questionnaire and KCL. The main outcome measures were correlation between frailty, other clinical variables, and postoperative complications within 30 days after elective surgery. RESULTS: Of the 500 patients, 278 (55.6%) and 164 (32.8%) patients were classified as 'frail' by G8 and KCL, respectively. Overall complications counted among 97 patients (19.4%), and they were significantly associated with KCL ≥ 8-frail (46/164, p = 0.001), as opposed to G8 ≤ 14-frail (56/278, p = 0.531). Multivariate analysis showed that KCL ≥ 8 (hazard ratio 1.88, 95% confidence interval 1.16-3.04, p = 0.011) was an independent risk factor for these complications. CONCLUSIONS: KCL assessment can identify frail older patients likely to suffer from postoperative complications after colorectal cancer surgery. Preoperative screening of frailty, particularly by KCL, would help older patients prevent their worse outcomes in colorectal cancer. TRIAL REGISTRATION: UMIN000026689.

Endoscopic submucosal tunnel dissection versus conventional endoscopic submucosal dissection for early gastric cancers: outcomes of 799 consecutive cases in a single institution.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a standard treatment for early gastric cancers (EGCs), but because of the obscured view and difficulty in submucosal lifting it is time consuming and poses high risk of perforation and bleeding in large lesions. In endoscopic submucosal tunnel dissection (ESTD) technique, good visualization of the submucosal layer can be achieved in the tunnel, it is, therefore, easy to discern the muscularis propria and visualize the vessels in the submucosal area. This study aims to evaluate the technical feasibility, efficacy, and safety of ESTD in comparison with conventional ESD (cESD) technique for treatment of EGCs. METHODS: This is a single-center retrospective study of 799 consecutive patients with EGCs who underwent ESD. ESTD (n = 141) were performed between 2015 and 2018 and cESD (n = 658) were performed between 2003 and 2015. Using propensity scores to strictly balance the significant variables, we compared treatment outcomes. RESULTS: After matching, we enrolled 444 patients (n = 111 in ESTD group, n = 333 in cESD group). The resection speeds for lesions of the ESTD were faster than those of cESD (19.3 mm2/min versus 17.7 mm2/min, P = 0.009). There was no need to use additional countertraction by clip-with-line technique or snare for the submucosal dissection in the ESTD procedure. The incidence of perforation was significantly higher in the cESD group (6.0%) than in the ESTD group (0.9%) (P = 0.035). Among 799 patients, four patients who received non-curative ESD had recurrence of gastric cancer. CONCLUSION: ESTD technique is a safe and feasible treatment procedure for EGCs. It presents many theoretical advantages and may have definite benefits over cESD. ESTD may, therefore, be considered as the standard endoscopic treatment for EGCs.

Laparoscopic and endoscopic cooperative surgery is a feasible treatment procedure for intraluminal gastric gastrointestinal stromal tumors compared to endoscopic intragastric surgery.

BACKGROUND: Laparoscopic wedge resection of the stomach is an ideal procedure if the gastric gastrointestinal stromal tumors (GISTs) are located in the extraluminal stomach. When the tumor is located in the intraluminal stomach, two minimally invasive surgical procedures involving laparoscopic and endoscopic cooperative surgery (LECS) or endoscopic intragastric surgery (EIGS) are frequently performed. To date, there have been no comparative studies of LECS and EIGS in patients with intraluminal gastric GISTs regarding short-term and long-term outcomes. The aim of this study was to compare the safety and feasibility of LECS and EIGS in patients with intraluminal gastric GISTs. METHODS: This was a single-center retrospective study of 46 consecutive patients with intraluminal gastric GISTs who underwent minimally invasive surgery. LECS (n = 21) was performed between 2013 and 2015 and EIGS (n = 26) was performed between 2001 and 2013. RESULTS: The overall incidence of perioperative complications was significantly higher in the EIGS group than in the LECS group (40 vs 4.8%; P = 0.006). In the EIGS group, three patients with intraoperative gastric mucosal injury were followed-up throughout surgical repair (12%). An esophageal tear was found in one patient during oral removal of tumor (4%). Postoperative gastric hemorrhage occurred in three patients (12%) and superficial surgical site infection was observed in three patients (12%). In the LECS group, anastomotic leakage requiring additional drainage was observed in one patient (4.8%). EIGS had less favorable results regarding median time to resumption of first oral intake (2 vs 1 days; P = 0.005). Two of 46 patients (4.3%), including one patient who underwent LECS and one patient who underwent EIGS developed recurrence. No cause-specific deaths were observed. CONCLUSION: LECS is a feasible and safe procedure for intraluminal gastric GISTs with regard to both short-term surgical and long-term oncological outcomes. Registration number: UMIN000026631.

Perineural Invasion Is Associated with Poor Survival after Preoperative Chemoradiation Therapy for Advanced Lower Rectal Cancer.

BACKGROUND: Preoperative chemoradiation therapy (pCRT) is a standard procedure for patients with advanced lower rectal cancer. It has been reported that pCRT cannot prolong the survival of patients with advanced lower rectal cancer. The aim of this study is to address the controllable and uncontrollable pathological factors of pCRT in predicting local and distant recurrences. METHODS: One hundred two patients with stages 2 and 3 cancer were consecutively enrolled to the study. The first 51 patients (October 2008-August 2010) underwent curative resection without pCRT. The latter 51 patients (September 2010-May 2015) underwent curative resection after pCRT. Pathological factors of patients were evaluated to assess the association between local and distant recurrences. RESULTS: Multivariate analyses for local and distant recurrences of patients without pCRT revealed that the independent risk factors were tumor deposit and perineural invasion respectively. pCRT was able to diminish circumferential resection margin, tumor deposit, venous invasion, and lymphatic permeation but not neural invasion and lymph node involvement. Kaplan-Meier curve of local and distant recurrence-free survival of patients with pCRT illustrated that tumor deposit is controllable, whereas perineural invasion is uncontrollable by pCRT. CONCLUSION: pCRT-uncontrollable perineural invasion may be a factor for distant recurrence of advanced rectal cancer patients, leading to poor survival.

P4H9-detected molecule expression on spindle-shaped fibroblasts indicates malignant phenotype of colorectal cancer.

BACKGROUND: Our previous study using a mammary fat pad mouse model showed that P4H9, produced by the ß2 integrin epitope, detected a molecule on fibroblasts in response to carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1)-expressing cancer cells. P4H9-detected molecule (PDM) expression appeared to be associated with myofibroblast differentiation. In this study, we investigated whether PDM is expressed on fibroblasts and cancer cells in clinical tissue samples, and whether the presence of PDM-expressing colorectal cancer cells is correlated with clinicopathological features of patients. METHODS: Immunohistochemistry was conducted to detect P4H9 on clinical tissue samples from 156 patients with colorectal cancer. Risk factors for metastases and survival were calculated for clinical implication of PDM-expressing spindle-shaped fibroblasts. RESULTS: Multivariate analysis showed that PDM-expressing spindle-shaped fibroblasts were an independent risk factor for lymph node metastasis, hematogenous metastasis, and poor survival. A Kaplan-Meier survival curve indicated that PDM-expressing spindle-shaped fibroblasts were associated with shorter survival time (P<0.0001). Immunofluorescence showed PDM expression on CCD-18Co fibroblasts and two colorectal cancer cell lines (HCT116 and HCT-15). CONCLUSIONS: PDM-expressing spindle-shaped fibroblasts are associated with metastasis and shorter survival in colorectal cancer patients. PDM-expressing spindle-shaped fibroblasts may have a role in eliciting the malignant phenotype of colorectal cancer.

Clinical characteristics of anastomotic leakage after an anterior resection for rectal cancer by assessing of the international classification on anastomotic leakage.

PURPOSE: The International Study Group of Rectal Cancer (ISREC) has proposed a new definition of anastomotic leakage (AL) which was simply classified into three grades; however, these criteria have not been assessed well. The aims of this study are to assess the new definition and to show the clinical features of AL after an anterior resection for rectal cancer. METHODS: Fifty consecutive patients developed AL after an anterior resection for rectal cancer was retrospectively assessed. AL was defined by the ISREC criteria. RESULTS: Twenty-seven (54 %) patients with AL were diagnosed by drain contents. The postoperative day of diagnosis for AL was later in grade A versus grades B and C (p = 0.038 vs p = 0.006, respectively). Permanent stoma (PS) was significantly more frequent in patients with grade C but not grade B compared to the patients with no AL (p < 0.001 and p = 0.171, respectively). In patients without diverting stoma, there was more serious grade of AL (p < 0.001). CONCLUSIONS: Differences were observed in the postoperative day of diagnosis, the creation rate of PS, and impact on diverting stoma after AL between each grade of leakage. The new classification was easy and reasonable to evaluate AL. As a result, it should be widely used in future studies.

Evaluation of the health-related quality of life for patients following laparoscopic cholecystectomy.

PURPOSE: Laparoscopic cholecystectomy (LC) has become the standard procedure, and contributes to a shorter hospital stay. However, there have been no reports regarding when the patients can be discharged in terms of their health-related quality of life (HRQOL). METHODS: The HRQOL was evaluated by using the SF-8 health survey (SF-8) 24-hour version in 127 consecutive patients treated from May 2007 to December 2008. The HRQOL and a visual analogue scale (VAS) score were assessed on the day before surgery and on postoperative day (POD) 1, POD2 and POD7. RESULTS: All scores of the eight domains on POD1 were significantly decreased compared to the preoperative score (P < 0.05), and seven scores were still decreased on POD2, with the mental health (MH) domain showing an improvement. On POD7, the general health score improved to the preoperative level. The physical component summary 8 (PCS-8) was suppressed for all 7 days after LC. The mental health component summary 8 (MCS-8) was improved to the preoperative level on POD2, despite the significant suppression observed on POD1 (P < 0.05). The VAS score was higher in the low PCS-8 (PCS-8 < 42.4) and low MCS-8 (MCS-8 < 40.6) patients than in the high PCS-8 and high MCS-8 patients. CONCLUSION: The HRQOL score demonstrated the improvement of the MCS-8 on POD2, which might suggest that a discharge of LC patients is appropriate on POD2 in terms of the patients' point of view.

Is preoperative colonoscopy necessary for patients undergoing gastric cancer surgery?

PURPOSE: The aim of this study was to evaluate the necessity of preoperative colonoscopy (CS) in gastric cancer (GC) patients and to assess the outcomes of different treatments in patients with synchronous GC and colorectal neoplasms (CRN). We also determined the risk factors influencing the comorbidity of colorectal cancer (CRC) in patients with GC. METHODS: This retrospective study included 1891 consecutive GC patients who underwent CS before surgery from January 1, 1999, through June 30, 2012. RESULTS: There was a high prevalence of concurrent CRN (28.4 %) and CRC (3.2 %) in our patients with GC. Sixty-one patients with GC had synchronous CRC. Twenty-three of the 61 tumors were perioperatively treated by endoscopic resection. The other 38 tumors were treated by simultaneous surgery for the GC and CRC. Surgical complications were not found in either the endoscopic or surgical resection group. The multivariate logistic regression analysis indicated that the prevalence of synchronous CRC in patients with GC was significantly associated with the incidence of multiple GCs [P < 0.0001; odds ratio (OR) 15.3], having anemia (P = 0.002; OR 3.0), and having a smoking history (P = 0.021; OR 1.9). CONCLUSIONS: We recommend preoperative CS screening for GC patients. In particular, preoperative CS screening is indispensable for patients with multiple GCs. In addition, simultaneous treatments for patients with synchronous GC and CRN are safe and feasible procedures.

Endoscopic submucosal dissection for gastric tumors in various types of remnant stomach.

BACKGROUND AND STUDY AIMS: The aim of this study was to examine the clinical outcomes of endoscopic submucosal dissection (ESD) for gastric tumors in various types of remnant stomach. PATIENTS AND METHODS: Between January 2002 and March 2013, ESD was performed for 750 gastric tumors. Of these lesions, 49 were in a remnant stomach, and were included in the study. RESULTS: The en bloc resection rate was 100 %. The curative resection rate was 82 %. The rate of perforation was high in patients with gastric conduits (28.6 %). Perforation was significantly more common in patients with lesions located on the suture line (4.9 % vs. 50.0 %; P = 0.0043). CONCLUSION: ESD for gastric tumors in the remnant stomach can be considered feasible and safe in clinical practice. However, the procedure is technically more difficult in patients with a gastric conduit, due to the increased risk of perforation at the suture line.

Survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved.

PURPOSE: The effectiveness of lateral lymph node dissection for extending the survival of patients with advanced lower rectal cancer remains unclear. The purpose of this study was to clarify the survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved. METHODS: We reviewed 131 consecutive patients with advanced lower rectal cancer, who had undergone curative resection with total mesorectal excision plus extended lateral lymph node dissection at Wakayama Medical University Hospital. Twenty-six (19.1 %) of these patients had lateral lymph involvement. We performed univariate and multivariate analyses for the 3-year disease-free and overall survival of these patients. RESULTS: Multivariate analysis revealed that the number (>1) and the region (common iliac artery region or external iliac artery region) of lateral lymph node metastasis are independent predictive factors for recurrence and survival. The Kaplan-Meier analysis demonstrated that patients with one lymph node metastasis in the internal iliac artery or obturator region had better survival. CONCLUSIONS: Lateral lymph node dissection resulted in survival benefit for patients with single lateral lymph node involvement in the internal iliac artery region or the obturator region.

Impact of the post/preoperative serum CEA ratio on the survival of patients with rectal cancer.

PURPOSE: This study demonstrated the usefulness of the post/preoperative serum carcinoembryonic antigen (CEA) ratio as a predictor of survival after surgery for stage III rectal cancer patients. METHODS: One hundred and four patients with stage III rectal cancer who underwent surgery between 1991 and 2000 were enrolled. The ratio of the postoperative serum CEA value divided by the preoperative serum CEA value was defined as post/preoperative serum CEA ratio, and the patients were separated into two groups: post/preoperative serum CEA ratio ≤ 1 (n = 86) and >1 (n = 18). RESULTS: The multivariate analyses demonstrated that the intraoperative blood loss, lack of a sphincter-saving procedure and a post/preoperative serum CEA ratio >1 were independent factors predicting a poor prognosis for the overall and disease-free survival. The overall and disease-free survival rates among patients with a high preoperative serum CEA level (>5 ng/ml) or patients with a high postoperative serum CEA (>5 ng/ml) were longer in patients with a post/preoperative serum CEA ratio ≤ 1, in comparison to those with a post/preoperative serum CEA ratio >1. Liver metastasis was observed more frequently in patients with a post/preoperative serum CEA ratio >1. CONCLUSIONS: The post/preoperative serum CEA ratio may be a predictor of the prognosis after surgery for stage III rectal cancer patients.

Predicting lymph node metastasis in early colorectal cancer using the CITED1 expression.

BACKGROUND: The identification of molecular markers that are useful for predicting lymph node metastasis is urgently needed to determine treatment strategies for T1 colorectal cancer (CRC). We previously showed that 10 candidate genes are correlated with de-differentiation at the invasion front of CRC using a gene expression analysis. These 10 genes are potential markers that may predict lymph node metastasis by CRC. MATERIALS AND METHODS: Samples were obtained from 161 patients with CRC. Quantitative real-time reverse transcription-polymerase chain reaction assays were performed using 66 T3 samples in order to extract genes correlated with lymph node metastasis. Immunohistochemical studies of the extracted genes were performed on 66 T3 and 95 T1 samples. A univariate analysis followed by a multivariate logistic regression model was used to examine independent risk factors for lymph node metastasis. RESULTS: The CITED1 messenger RNA expression was found to be an independent risk factor for lymph node metastasis in T3 CRC patients (P = 0.040). A high CITED1 protein expression, as detected with immunohistochemistry, was also an independent risk factor in T3 CRC patients (P = 0.035). In T1 colorectal cancer patients, a high CITED1 protein expression was found to be an independent risk factor for lymph node metastasis (P = 0.010). The positive predictive and negative predictive values in the T1 colorectal cancer patients were 27.5% and 95.5%, respectively. CONCLUSIONS: The CITED1 expression is correlated with lymph node metastasis in patients with CRC. In T1 colorectal cancer patients, CITED1 has the potential ability to predict the presence of lymph node metastasis.

Clinical outcome of up-front surgery in patients with asymptomatic, incurable synchronous peritoneal carcinomatosis.

PURPOSES: The purpose of this study was to show the clinical features of up-front surgery of the primary tumor in asymptomatic patients with incurable colorectal PC. METHODS: Forty-six patients that were diagnosed between 1998 and 2007 with asymptomatic colorectal PC who could not be successfully cured by surgery were assessed retrospectively. RESULTS: A univariate analysis revealed the presence of liver metastases, without the use of oxaliplatin (OX)/irinotecan (IRI) and without a primary tumor resection to be poor prognostic factors for survival (p = 0.044, p = 0.030, p < 0.001, respectively). According to a multivariate analysis, no use of OX/IRI and no primary tumor resection, were found to be independent poor prognostic factors for survival (HR 2.57; p = 0.047, HR 6.62; p = 0.003, respectively). The median survival time of patients treated with and without OX/IRI was 18 and 7 months, respectively. The median survival time of patients with and without primary tumor resection was 10 and 2 months, respectively. The number of patients needing surgical intervention for intestinal obstruction after surgery significantly increased in patients treated with OX/IRI (p = 0.001). CONCLUSION: Improvement of survival may be related to widespread use of modern systemic chemotherapy and primary tumor resection. However, an increased number of patients that needed surgery for an intestinal obstruction were observed, even after up-front surgery, when patients were treated with modern systemic chemotherapy.

Laparoscopic-Assisted Total Resection and Endorectal Pull-Through Technique for Congenital Megarectum with Anorectal Malformation.

BACKGROUND/PURPOSE: Congenital megarectum (CMR) is sometimes associated with anorectal malformations (ARM), although there is no established therapeutic strategy. This study aims to clarify the clinical features of ARM with CMR, and to demonstrate the effectiveness of a surgical treatment, namely laparoscopic-assisted total resection and endorectal pull-through technique. METHODS: We conducted a review of the clinical records of the patients with ARM with CMR treated at our institution between January 2003 and December 2020. RESULTS: Seven of 33 cases of ARM (21.2%) were diagnosed with CMR, four males and three females. The types of ARM were 'intermediate' in four, and 'low' in three patients. Five of the seven patients (71.4%) required resection of megarectum for intractable constipation and underwent laparoscopic-assisted total resection and endorectal pull-through technique. Bowel function was improved after resection in all five cases. All five specimens showed hypertrophy of the circular fibers, and three of them showed abnormal location of ganglion cells within the circular muscle fibers. CONCLUSIONS: CMR often causes intractable constipation and requires resection of the dilated rectum. Laparoscopic-assisted total resection and endorectal pull-through technique for ARM with CMR considered to be an effective, minimally invasive treatment for intractable constipation. LEVEL OF EVIDENCE FOR CLINICAL RESEARCH PAPERS: Level Ⅳ. TYPE OF STUDY: Treatment study.

Primary anaplastic large cell lymphoma of the psoas muscle: a case report and literature review.

Primary anaplastic large cell lymphoma (ALCL) of skeletal muscle is very rare. We report a case of ALCL arising from the left psoas muscle. A 14-year-old girl presented with a large left inguinal tumor. She complained of a 2-month history of left leg pain, which had been exacerbated upon leg extension, and she had become aware of a rapidly growing left inguinal tumor 3 weeks before admission. CT scan and MRI revealed a large tumor arising from the left major psoas muscle and protruding into the inguinal region. In view of the tumor's location and the patient's age, soft tissue tumors such as rhabdomyosarcoma and primitive neuroectodermal tumor were initially considered. However, histopathological examination yielded a diagnosis of anaplastic lymphoma kinase-positive ALCL. The serum level of soluble interleukin-2 receptor was markedly elevated at 50,414 U/ml, and this also strongly suggested ALCL. Although rarely reported, ALCL is an important entity to consider in the differential diagnosis of skeletal muscle tumors in children and young adults.

Rectal transection using a curved cutter stapler with an endo-Satinsky clamp during a laparoscopic low anterior resection.

PURPOSE: A new rectal transaction method was developed using a combination of the curved cutter stapler and endo-Satinsky clamp because of the difficulty in performing rectal transection in the narrow pelvic cavity. METHODS: The endo-Satinsky clamp is inserted without a flexible trocar cannula by connecting the handle extra-abdominally with a shaft of the endo-Satinsky clamp through the left higher quadrant port via a retrograde course from a midline incision above the pubis symphysis. The endo-Satinsky clamp is used to clamp the rectal wall horizontally at the distal end of the tumor. The wrist of an elastic surgical glove fixed with the shaft of the curved cutter stapler is covered with a midline incision, and consequently, the stapler is inserted into the pelvic cavity. The curved head of the stapler is rotated to the left at the anal side of the endo-Satinsky clamp to insert the rectum between the jaws of the stapler. The stapler is closed and fired, and a rectal transection is thus performed with one firing using a single cartridge. RESULTS: This method was performed in 12 patients with rectal cancer. The median value and range of the tumor distance from the anal verge were 7.0 and 4.5-11.0 cm, respectively. The median duration of the operation was 252 min, and the median blood loss was 15 mL. Only one stapling cartridge was used for rectal transection in all cases, and no major complications were observed. CONCLUSIONS: We herein demonstrated a new transection method for rectal cancer.

The impact of abdominal shape index of patients on laparoscopy-assisted distal gastrectomy for early gastric cancer.

PURPOSE: The aim of this study was to explore the effects of the abdominal shape index on gastric cancer patients' short-term surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) in both genders. METHODS: This retrospective study included 231 consecutive patients with early gastric cancer who underwent LADG with Billroth I anastomosis between 1998 and 2009. The abdominal shape index of patients was calculated using preoperative abdominal computed tomography scans and the Fat Scan software program. RESULTS: In male patients, the duration of surgery was longer in patients with a body mass index ≥25 kg/m(2) (P = 0.016), with the anterior to posterior diameter ≥200 mm (P < 0.0001), with the transverse diameter (TD) ≥300 mm (P = 0.030), with the waist ≥85 cm (P = 0.039), and with the visceral fat area (VFA) ≥100 cm(2) (P = 0.029). The intraoperative blood loss was higher in the large TD group (P = 0.049), in the high waist group (P = 0.006), and in the large VFA group (P = 0.007). In female patients, the correlations between these surgical outcomes and this abdominal shape index were not found. No significant relationships between each body shape index and the number of lymph nodes retrieved were found in either gender. Postoperative complications were not associated with the fat volume and abdominal shape index. CONCLUSIONS: Accumulation of fat did not affect short-term surgical outcomes except for the duration of surgery and intraoperative blood loss in male patients.

Endoscopically observable white nodule caused by distal intramural lymphatic spread of rectal cancer: a case report.

This report describes a case of rectal cancer with endoscopically observable white nodules caused by distal intramural lymphatic spread. A 57-year-old female presented to our hospital with frequent diarrhea and hemorrhoids. Computed tomography showed bilateral ovarian masses and three hepatic tumors diagnosed as rectal cancer metastases, and also showed multiple lymph node involvement. The patient was preoperatively diagnosed with stage IV rectal cancer. Colonoscopy demonstrated that primary rectal cancer existed 15 cm from the anal verge and that there were multiple white small nodules on the anal side of the primary tumor extending to the dentate line. Biopsies of the white spots were performed, and they were identified as adenocarcinoma. The patient underwent Hartmann's procedure because of the locally advanced primary tumor. The white nodules were ultimately diagnosed as being caused by intramural lymphatic spreading because lymphatic permeation was strongly positive at the surrounding area. Small white nodules near a primary rectal cancer should be suspected of being intramural spreading. Endoscopic detection of white nodules may be useful for the diagnosis of distal intramural spread.