Laser speckle flowgraphy has comparable accuracy to indocyanine green fluorescence angiography in assessing bowel blood perfusion.

PURPOSE: To investigate the accuracy of laser speckle flowgraphy (LSFG), a noninvasive method for the quantitative evaluation of blood flow using mean blur rate (MBR) as a blood flow parameter in the assessment of bowel blood perfusion compared to indocyanine green fluorescence angiography (ICG-FA). METHODS: We enrolled 46 patients who underwent left-sided colorectal surgery. LSFG and ICG-FA were applied to assess blood bowel perfusion, with MBR and luminance as parameters, respectively. In both measurement methods, the position where the parameter suddenly decreased was defined as the blood flow boundary line. Subsequently, the blood flow boundaries created after processing the blood vessels flowing into the intestinal tract were determined using LSFG and ICG-FA, and concordance between the two was examined. Blood flow boundaries were visually identified using color tone changes on a color map created based on MBR in LSFG and using differences in luminance in ICG-FA. The distances between the transection line and blood flow boundaries determined using each method were compared. RESULTS: The location of blood flow boundaries matched in 65% (30/46) of cases. Although locations differed in the remaining 35% (16/46), all were located on the anal side near the transection line, and the difference was not clinically significant. The average distances between the transection line and blood flow boundary were 2.76 (SD = 3.25) and 3.71 (SD = 4.26) mm, respectively. There was no statistically significant difference between the two groups (p = 0.38). CONCLUSION: LSFG was shown to have comparable accuracy to ICG-FA, and may be useful for evaluating bowel perfusion.

Efficacy and safety of preoperative chemoradiotherapy with S-1 for advanced rectal cancer: a phase II study.

Background: Preoperative chemoradiotherapy (CRT) for patients with rectal cancer is not yet established in Japan. We aimed to evaluate the efficacy and safety of preoperative CRT with S-1, a fixed-dose combination of tegafur, gimeracil, and oteracil potassium. Materials and methods: We conducted a prospective, interventional, non-randomized single-center study. Radiotherapy was administered at a total dose of 45 Gy (1.8 Gy in 25 fractions) for five weeks. S-1 was administered orally for nine weeks (five weeks during and four weeks after radiotherapy) at a dose of 80 mg/m2/day. The endpoint was the pathological complete response (pCR) rate. Results: Twenty-eight patients were finally enrolled. The following patient characteristics were recorded: clinical Stage (II: n = 12, III: n = 16), median age (66 years, range 40-77 years), male/female ratio (20/8), and lesion site (Ra-Rb:3/Rb:23/Rb-P:2). Preoperative treatment was completed in 27 patients (96%). Treatment abandonment occurred because of diarrhea. Grade 3 or higher adverse events were observed in one (4%) patient with two events. No serious adverse events occurred in the ≥ 70 years group. The response rate was 68% in all patients and 68% among elderly patients. Radical resection was achieved in all patients, including 19 (68%) who underwent sphincter-preserving surgery. The pCR rate was 11% (three patients). The five-year disease-free survival rate was 68%, and the overall survival rate was 82%. Local recurrence occurred in only one patient five years after surgery. Conclusion: Preoperative CRT with S-1 alone may be a safe and acceptable regimen from the perspective of adverse events and oncological outcomes. Trial registration: UMIN Clinical Trial Registry: UMIN000013598. Registered 1 April 2014, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recpt-no=R000015887.

Which preoperative immunonutritional index best predicts postoperative mortality after palliative surgery for malignant bowel obstruction in patients with late-stage cancer? A single-center study in Japan comparing the modified Glasgow prognostic score (mGPS), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT).

PURPOSE: To compare the utility of preoperative immunonutritional parameter measures for predicting postoperative mortality following palliative surgery (PS) for malignant bowel obstruction (MBO) in patients with late-stage cancer. METHODS: The subjects of this retrospective study were 83 late-stage cancer patients with MBO who underwent PS between January, 2005 and December, 2018, at a single institution in Japan. We compared the modified Glasgow prognostic score (mGPS), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT) for predicting postoperative mortality following PS in these patients. RESULTS: The most prevalent cancer in the patients who underwent PS was colorectal cancer (54.2%), followed by gastric cancer (24.1%). Postoperative complications of Clavien-Dindo classification grade ≥ 2 developed in 32 (38.6%) patients and stoma-related complications developed in 26 (31.3%) patients. There were 15 (18.1%) patients with 60-day mortality, 22 (26.5%) with 90-day mortality, and 4 (4.8%) with 30-day mortality. Multivariable analysis identified only mGPS as being associated with 60-day mortality (odds ratio, 9.387; 95% confidence interval, 0.001-4.478; p = 0.049). The overall survival of patients with a mGPS score of 2 was significantly worse than that of those with a mGPS score of < 2 (p = 0.013). CONCLUSIONS: These results suggest that the mGPS is a good predictor not only of 60-day mortality, but also of the overall survival of patients with late-stage cancer and MBO.

[Treatment Strategy for Familial Adenomatous Polyposis Presenting with Obstructive Colorectal Cancer and Concurrent Liver Metastasis].

A 27-year-old man was referred to our hospital for a detailed examination of abdominal distention, bloody stool, anorectal pain, and weight loss. A colonoscopy revealed a circumferential type 2 tumor at 9 cm from the anal verge which was diagnosed as an adenocarcinoma based on biopsy. Contrast-enhanced CT of the abdomen showed an elevated perineal lipid concentration in the rectum(Ra)which was suspicious for clinical T4a stage, and simultaneous S7/8 liver metastasis. We strongly suspected familial adenomatous polyposis(FAP)because his mother had a past history of total proctocolectomy for FAP. We decided to first create a loop stoma at the transverse colon for the obstructive rectal cancer, and then administer neoadjuvant chemotherapy(mFOLFOX6 plus panitumumab). We performed total proctocolectomy with permanent stoma and S8 ventral resection for the liver metastasis after 5 courses of mFOLFOX6 plus panitumumab. As for clinicopathological findings, round 50 polyps were identified in the colon and rectum, and rectal cancer invaded into the muscularis propria. Finally, the patient was diagnosed as a clinically attenuated FAP with ypT2 rectal cancer.

[Successful Continuation of Treatment in Advanced Colorectal Cancer by Switching to a Prior Biologic Agent after Emergence of Bevacizumab Allergy to a Biosimilar Drug-A Case Report].

Biosimilar(BS)drugs have recently been introduced owing to concerns with healthcare economics. In this report, we present a case in which a patient discontinued bevacizumab treatment following an allergic reaction to a BS formulation of bevacizumab but was able to safely continue treatment by switching to an original bevacizumab formulation in the late-line setting. The patient was a 66-year-old man diagnosed with unresectable colorectal cancer with synchronous multiple liver metastases. After primary tumor resection, chemotherapy including the original bevacizumab formulation was initiated. Allergic reactions to the BS formulation of bevacizumab occurred during the second-line treatment; however, in the late-line setting, switching back to the original bevacizumab formulation enabled the safe continuation of therapy. Overall, our case study suggests that switching of biologic agents may contribute to the ongoing management of chemotherapy.

Transanal down-to-up dissection of the distal rectum as a viable approach to achieve total mesorectal excision in laparoscopic sphincter-preserving surgery for rectal cancer near the anus: a study of short- and long-term outcomes of 123 consecutive patients from a single Japanese institution.

BACKGROUND: In rectal cancer (RC) surgery, the complexity of total mesorectal excision (TME) in laparoscopic sphincter-preserving surgery (lap-SPS) for RC near the anus has been a critical issue. Recently, technical assistance via the anus for complete TME has been receiving attention. This study aimed at clarifying the transanal down-to-up dissection viability for achieving TME in lap-SPS for RC near the anus. METHODS: We evaluated surgical and oncological outcomes of a total of 123 consecutive patients undergoing either a transanal rectal dissection (TARD) under direct vision mobilizing the most difficult portion of TME via the anus or the transanal TME by using an endoscopic system (TaTME) for achieving TME in lap-SPS for RC near the anus between January 2006 and February 2021. RESULTS: A total of 123 consecutive patients (83 men) with a median age of 66 years (range 33-86 years) were included. TARD and TaTME were performed for 50 (40.7%) and for 73 (59.3%) patients, respectively. Preoperative treatment was performed for 40 (32.5%) patients, resulting in a complete pathological response in 5 (12.5%) patients. Intersphincteric resection was performed significantly more in the TARD group (p<0.001). Although the TaTME group needed a longer operative time at the transanal portion (p<0.001), the median blood loss was lower (p<0.001). Postoperative complications with the Clavien-Dindo classification grade ≧2 developed in 52 (42.3%) patients. Urinary dysfunction and stoma-related complications were found most frequently. More patients needing medication for urinary dysfunction were found in the TARD group, but a significant difference was not observed (10.0% vs. 6.8%, p=0.526). The quality of TME was good for almost all patients. Recurrence developed in 18 (14.6%) patients. The 5-year overall survival (OS) and relapse-free survival (RFS) rates in 123 patients were 95.8% and 88.8%, respectively. The 5-year OS and RFS between the two groups were comparable. CONCLUSIONS: Our data suggested that a transanal down-to-up dissection of the distal rectum might be a viable approach in lap-SPS for RC near the anus. Further studies are needed to examine the differences between TARD and TaTME.

Preoperative CRP(-)/CEA(-)/CA19-9(-)/non-T4 in Stage III Colorectal Cancer Is Favorable Risk for Recurrence.

Objectives: We evaluated the prognostic impact of a novel C-reactive protein (CRP) cut-off value (0.6 mg/dl) and carcinoembryonic antigen (CEA)/carbohydrate antigen 19-9 (CA19-9) in stage II/III colorectal cancer. Methods: Four hundred ninety-eight patients with stage II (n = 275) or stage III (n = 223) colorectal cancer, surgically treated between January 2010 and December 2016, were analyzed. The optimal CRP cut-off value was fixed at 0.6 mg/dl to predict recurrence based on the receiver operating characteristic curve. Prognostic factors, including CRP/CEA/CA19-9 status, for relapse-free survival (RFS) were evaluated by multivariate analysis. Results: Recurrent rates were 15% and 32% in stages II and III, respectively. In stage II, CRP, CEA, and CA19-9 were not significant prognostic factors for RFS. In stage III, the RFS of the low CRP group was significantly better than that of the high CRP group (p = 0.002). In stage III, the RFS of CRP(-)/CEA(-) or CRP(-)/CA19-9(-) was significantly better than the other group, as opposed to the RFS of the CEA(-)/CA19-9(-) group that was not. The CRP(-)/CEA(-)/CA19-9(-) group recurrence rate in stage III was significantly better than the CRP(+)/CEA(-)/CA19-9(-) group (20% vs. 50%, p = 0.006). Multivariate analysis revealed that CRP(-)/CEA(-)/CA19-9(-) (p = 0.04) and non-T4 (p < 0.001) were good independent prognostic factors in stage III. The CRP(-)/CEA(-)/CA19-9(-)/non-T4 group recurrence rate in stage III was 11% (8 out of 73). Conclusions: In stage III, the CRP(-)/CEA(-)/CA19-9(-)/non-T4 group is favorable risk for recurrence.

[Subarachnoid Hemorrhage Associated with Bevacizumab during Chemotherapy for Clinical Stage â £ Sigmoid Colon Cancer-A Case Report].

The case is a 59‒year‒old woman. A detailed examination of fecal occult blood revealed a diagnosis of cStage Ⅳ sigmoid colon cancer cT3N1M1b(liver H2, hilar liver and celiac artery lymph nodes). After excision of the primary lesion, decided to give chemotherapy. The gene test was RAS gene mutation negative and EGFR positive, and mFOLFOX6 plus panitumumab (pani)was started as the first‒line treatment. Imaging tests at the end of 13 courses showed that the maximum diameter of liver metastases was reduced from 54 mm to 16 mm, and CEA was normalized from 93.9 ng/mL. However, metastasis was found in the hilar lymph nodes, it was judged that hepatectomy is not indicated, radiofrequency ablation therapy was performed. But FOLFIRI plus pani was restarted because metastatic liver tumor relapsed on CT 5 months later. After 6 courses, she felt tired, so I consulted her and changed to TAS‒102 plus bevacizumab. Sudden headache and vomiting appear during 3 courses, head CT revealed subarachnoid hemorrhage. No brain metastases or organic lesions such as cerebral aneurysms and stenotic lesions, the relationship with bevacizumab was strongly suspected.

What is the recommended procedure for recurrent rectal prolapse? A retrospective cohort study in a single Japanese institution.

PURPOSE: The choice of surgical procedure for rectal prolapse (RP) is challenging because of the high recurrence and morbidity rates. We aimed to clarify whether laparoscopic suture rectopexy (lap-rectopexy) is suitable for Japanese patients with recurrent RP. METHODS: We retrospectively evaluated 77 recurrent RP patients who had been treated on average 1.5 times between June 2008 and April 2016. Forty-one patients underwent lap-rectopexy and 36 underwent perineal procedures. We compared surgical outcomes and recurrence rate following surgery between the two groups. The multivariable logistic regression analysis was performed to determine risk factors of recurrent RP. RESULTS: In patients' characteristics, significant differences were observed in the type of anesthesia (p < 0.01) and length of recurrent RP (p = 0.030). The mean operative time was significantly longer in the lap-rectopexy group (p < 0.001). Blood loss, length of hospitalization, and postoperative complications were similar. The recurrence rate was significantly lower in the lap-rectopexy group (17.1% vs. 38.9%, p = 0.032). Multivariate analysis showed that only the laparoscopic approach was significantly associated with a low recurrence following surgery (odds ratio 0.273, 95% CI - 2.568 to - 0.032). CONCLUSION: Lap-rectopexy is recommended for recurrent RP because its low recurrence rate and safety profile are similar to those of perineal procedures.

[Long-Term Suppression with Short-Term Dose Reduction of Imatinib for Metastatic Lateral Lymph Nodes after Resection of a Rectal Gastrointestinal Stromal Tumor-A Case Report].

CASE: An 83-year-old female. At 82 years of age, the patient sought evaluation with a complaint of rectal bleeding. A 35-mm rectal gastrointestinal stromal tumor(GIST)was treated by laparoscopic ultra-low rectal resection and transanal anastomosis following trans-anal rectal dissection by perineal manipulation. Approximately 1 year later, a 20-mm metastatic lymph node within the right lateral lymph node group at the pelvic cavity was detected. The patient was diagnosed with a recurrence of rectal GIST. The patient had no symptoms and did not wish to undergo surgery. After 7 weeks of treatment with an imatinib dose reduction(200 mg), the dosage was increased and the patient was admitted to the hospital with edema of the face and lower limbs, and pleural and pericardial effusions(grade 2). After discharge from the hospital, the medication was terminated early at the patient's request. One year later, the lymph nodes had decreased in size to 7.5 mm, indicating a partial response. The treatment-free period continued, and after 5 years at 89 years of age the lymph nodes had not enlarged, thus the patient was thought to be clinically cured. We report a rare case of long-term tumor suppression using short-term low-dose imatinib therapy.

Possible predictive significance of serum RalA autoantibodies on relapse-free survival in patients with colorectal cancer.

RalA protein, a member of the Ras superfamily of small GTPases, is a tumor antigen that induces serum RalA antibodies (s-RalA-Abs). The present study explored the clinicopathological and prognostic significance of s-RalA-Abs in patients with colorectal cancer. Serum samples were obtained from 314 patients with colorectal cancer at stage 0/I (n=71), stage II (n=86), stage III (n=78), stage IV (n=64) and recurrence (n=15). Samples were analyzed for the presence of s-RalA-Abs using ELISA. The cutoff optical density value was fixed at 0.324 (mean of heathy controls + 3 standard deviations). The overall positive rate for serum anti-RalA antibodies was 14%. The presence of s-RalA-Abs was not significantly associated with clinicopathological characteristic factors. Additionally, the s-RalA-Abs(+) group demonstrated significantly poor relapse-free survival rates. The s-RalA-Abs (+)/carcinoembryonic antigen (CEA)(+) group exhibited the worst prognosis and s-RalA-Abs(+)/CEA(+) was an independent risk factor for poor relapse-free survival. Although the positive rate was not high, s-RalA-Abs may be a useful predictor of poor relapse-free survival in patients with colorectal cancer.

Incisional negative pressure wound therapy to reduce perineal wound infection after abdominoperineal resection.

We explored the effects of incisional negative pressure wound therapy in perineal wound infections after abdominoperineal resection. We retrospectively evaluated 146 patients who underwent abdominal perineal resection from December 2004 to December 2019 and compared conventional gauze dressing (controls) with incisional negative pressure wound therapy. We compared patients' characteristics, surgical factors, and perineal infection rates between groups, and patients' characteristics, surgical factors, and negative pressure therapy use between perineal infection vs non-infection groups, as well as the risk factors for perineal infections. In the negative pressure therapy group, compared with controls, the number of men, smoking prevalence, blood transfusion, drainage via the perineal wound, and intraoperative blood loss were significantly lower (p < 0.05, p < 0.05, p < 0.05, p < 0.001, p < 0.01, respectively), and operation time was significantly longer (p < 0.05). Infections were significantly less common in the negative pressure group (p < 0.05). In the univariate analysis, the infection-positive group had significantly higher laparoscopic surgery (p < 0.01) and negative pressure wound therapy-free rates (p < 0.01), and significantly more intraoperative blood loss (p < 0.05). Multivariate analysis using these three factors and preoperative radiotherapy showed that incisional negative pressure wound therapy-free status was a risk factor for infection. Incisional negative pressure wound therapy was beneficial in managing perineal wound infections after abdominoperineal resection.

Noninvasive assessment of bowel blood perfusion using intraoperative laser speckle flowgraphy.

PURPOSE: Laser speckle flowgraphy (LSFG) is a noninvasive method for quantitative evaluation of blood flow using the mean blur rate (MBR) as the blood flow index. We investigated whether LSFG can intraoperatively detect the demarcation line after vessel dissection and reduce the incidence of anastomotic leakage (AL). METHODS: This study included 36 patients who underwent left-sided colorectal surgery. First, we compared the demarcation line (determined by LSFG) with the transection line (TL) at which the marginal vessels were divided. We then measured the MBR on both sides of the TL to determine where the MBR changed significantly. We investigated the presence or absence of significant differences between the MBR on the proximal side and that on the distal side of the TL. Finally, we retrospectively compared the patient characteristics and AL rates in the LSFG group (n = 36) and control group (n = 87). RESULTS: In total, 58.3% (21/36) of the demarcation lines determined by LSFG matched the TL. The median distance between the demarcation line determined by LSFG and the TL was 0.0 mm (0.0-12.1 mm). The MBR sharply decreased at the TL in 80.6% (29/36) of cases. The median MBR was significantly lower on the distal than proximal side. The AL rate was not significantly lower in the LSFG group than in the control group. CONCLUSION: LSFG accurately detected the demarcation line during surgery. However, LSFG did not reduce the incidence of AL.

What is the advantage of rectal amputation with an initial perineal approach for primary anorectal carcinoma?

BACKGROUND: Rectal amputation (RA) remains an important surgical procedure for salvage despite advances in sphincter-preserving resection, including intersphincteric resection. The aim of this study was to compare short- and long-term outcomes of RA with an initial perineal approach to those of RA with an initial abdominal approach (conventional abdominoperineal resection (APR)) for primary anorectal cancer. METHODS: We retrospectively analyzed the short- and long-term outcomes of 48 patients who underwent RA with an initial perineal approach (perineal group) and 21 patients who underwent RA with an initial abdominal approach (conventional group). RESULTS: For the perineal group, the operation time was shorter than that for the conventional group (313 vs. 388 min, p = 0.027). The postoperative complication rate was similar between the two groups (43.8 vs. 47.6%, p = 0.766). Perineal wound complications (PWCs) were significantly fewer in the perineal group than in the conventional group (22.9 vs. 57.1%, p = 0.006). All 69 patients underwent complete TME, but positive CRM was significantly higher in the conventional group than in the perineal group (0 vs. 19.0%, p = 0.011). There were no significant differences in the recurrence (43.8 vs. 47.6%, p = 0.689), 5-year disease-free survival (63.7% vs. 56.7%, p = 0.665) and 5-year overall survival rates (82.5% vs. 66.2%, p = 0.323) between the two groups. CONCLUSION: These data suggest that RA with an initial perineal approach for selective primary anorectal carcinoma is advantageous in minimizing PWCs and positive CRMs. Further investigations on the advantages of this approach are necessary.

Comparative outcomes between palliative ileostomy and colostomy in patients with malignant large bowel obstruction.

OBJECTIVES: Palliative stoma creation should be considered in patients at high risk of colonic metallic stent failure. However, it is unclear whether ileostomy or colostomy is superior. This study compared short-term outcomes between palliative ileostomy and colostomy. METHODS: We identified 82 patients with malignant large bowel obstruction, caused by various advanced cancers, between January 2005 and December 2016. We compared short-term outcomes between the ileostomy group (n = 33) and the colostomy group (n = 49). RESULTS: For all 82 patients, clinical success was achieved. Three patients with ileostomy died within 30 days of ostomy formation. The ileostomy group had statistically significant differences in median operative time (113 vs. 129 minutes, p = 0.045) and blood loss (8 vs. 40 g, p = 0.037) in comparison with the colostomy group. No statistically significant differences were observed in the surgical complications (30.3 vs. 38.8%, p = 0.431), in the median period to oral intake (3 vs. 4 days, p = 0.335) and in the hospital stay after surgery (32 vs. 27 days, p = 0.509) between the two groups. Overall stoma-related complications occurred in 27 (32.9%) patients. Stoma-related complications occurred more frequently in the ileostomy group (16/33 vs. 11/49 patients, p = 0.014). High output stoma (6 patients) and irritation (5 patients) occurred more frequently in the ileostomy group. CONCLUSIONS: Palliative colostomy is superior to ileostomy due to fewer stoma-related complications. When ileostomy is required, aggressive interventions for high output stomas should be implemented.

[A Case of Colitic Cancer with Ulcerative Colitis Emphasizing the Importance of Surveillance].

The patient was a 77-year-old woman who visited our hospital with a chief complaint of blood in the stool. The patient had a colonoscopy 2 years earlier, which led to suspicions of total colitis-type ulcerative colitis(UC). However, the histological findings did not lead to a definitive diagnosis. Upon the withdrawal of urine in an outpatient visit, fecaluria was noted. Based on various examinations, we diagnosed this patient with Rs, cT4b(bladder), cN0, cM0 adenocarcinoma. We then performed Hartmann operation with partial cystectomy. The pathological findings indicated colorectal cancer with ulcerative colitis (CAC)(low grade and high grade dysplasia and carcinoma). Postoperative examinations of the oral side of the colon revealed a flat squamous elevated lesion in the ascending colon, which was diagnosed as adenocarcinoma. Therefore, we waited for the improvement of performance status and performed additional total colectomy with resection of the anus and ileostomy. We experienced a case of progressive CAC due to the difficulty of histological diagnosis via biopsy and a lack of appropriate surveillance post clinical suspicions. In cases of colitis-type UC, appropriate surveillance by endoscopists and pathologists is important.

[Five-Year Local Control by Stereotactic Body Radiation Therapy(SBRT)for Liver Metastasis from Colorectal Cancer-A Case Report].

An 84-year-old woman presented with a 9mm sized solitary liver metastasis in liver S8 18 months after the surgery for sigmoid colon cancer. The patient was treated with stereotactic body radiation therapy(SBRT)for local control, because the patient chose not to undergo surgery or chemotherapeutic treatment for metastatic liver cancer. SBRT is a minimally invasive treatment with a very short treatment period. Therefore, it may be considered as an alternative treatment for patients who are not suitable for surgery.

Comparative study between colonic metallic stent and anal tube decompression for Japanese patients with left-sided malignant large bowel obstruction.

BACKGROUND: Surgical management of malignant bowel obstruction carries with high morbidity and mortality. Placement of a trans-anal decompression tube (TDT) has traditionally been used for malignant bowel obstruction as a bridge to surgery. Recently, colonic metallic stent (CMS) as a bridge to surgery for malignant bowel obstruction, particularly left-sided malignant large bowel obstruction (LMLBO) caused by colorectal cancer, has been reported to be both a safe and feasible option. The aim of this retrospective study is to evaluate the clinical effects of CMS for LMLBO as a bridge to surgery compared to TDT. METHODS: Between January 2000 and December 2015, we retrospectively evaluated outcomes of 59 patients with LMLBO. We compared the outcomes of 26 patients with CMS for LMLBO between 2013 and 2015 (CMS group) with those of 33 patients managed with TDT between 2003 and 2011 (TDT group) by the historical study. LMLBO was defined as a large bowel obstruction due to a colorectal cancer that was diagnosed by computed tomography and required emergent decompression. RESULTS: All patients in the CMS group were successfully decompressed (p = 0.03) and could initiate oral intake after the procedure (p <  0.01). Outcomes in the CMS group were superior to the TDT group in the following areas: duration of tube placement (p <  0.01), surgical approach (p <  0.01), operation time (p <  0.01), number of resected lymph nodes (p <  0.001), and rate of curative resection (p <  0.01). However, no significant differences were found in the overall postoperative complication rate (p = 0.151), surgical site infection rate (p = 0.685), hospital length of stay (p = 0.502), and the need for permanent ostomy (p = 0.745). The 3-year overall survival rate of patients in the CMS and TDT groups was 73.0% and 80.9%, respectively, and this was not significant (p = 0.423). CONCLUSIONS: Treatment with CMS for patients with LMLBO as a bridge to surgery is safe and demonstrated higher rates of resumption of solid food intake and temporary discharge prior to elective surgery compared to TDT. Oncological outcomes during mid-term were equivalent.

Severe Fournier's gangrene in a patient with rectal cancer: case report and literature review.

BACKGROUND: Fournier's gangrene in the setting of rectal cancer is rare. Treatment for Fournier's gangrene associated with rectal cancer is more complex than other cases of Fournier's gangrene. We report on a patient with severe Fournier's gangrene in the setting of locally advanced rectal cancer who was treated with a combined modality therapy. CASE PRESENTATION: A 65-year-old man presented with general fatigue and anal pain. The medical and surgical histories were unremarkable. A black spot on the perineal skin surrounded by erythema was found on physical examination, suspicious for Fournier's gangrene. Computed tomography scan showed a rectal tumor invading into the bladder (clinically T4bN2M0) and abscess formation with emphysema around the rectum. He was thus diagnosed with locally advanced rectal cancer and Fournier's gangrene with a severity index score of 12 points. We created a diverting loop colostomy of the transverse colon and performed extensive debridement of the perineum and perianal area. Fifty days later, the patient underwent radical total pelvic exenteration with sacrectomy. In addition, reconstruction of the soft tissue defect was performed using the rectus muscle, the gluteus maximus muscle, and the femoral muscle. Histopathological findings of the specimen were as follows: the tumor was a moderately adenocarcinoma with invasion to the bladder and the prostate (T4b), metastases to four resected lymph nodes (N2), and lymphovascular invasion. There were no major postoperative complications, and the patient was discharged 108 days postoperatively. CONCLUSIONS: We report a rare case of locally invasive rectal cancer associated with Fournier's gangrene. This case highlights a usual cause of Fournier's gangrene. Physicians should be cognizant not only of the more common condition but also of the rare presentations including those associated with rectal cancer.

[A Case of Aortoesophageal Fistula Rupture Due to Descending Thoracic Aortic Dissection with Recurrent Colon Cancer during Chemotherapy Containing Bevacizumab].

We report a case of aortoesophageal fistula rupture during the course of chemotherapy following colon cancer resection. The patient was a 77-year-old woman. Following recurrence of cancer of the sigmoid colon, the patient received a course of XELOX plus bevacizumab(Bmab)to treat peritoneal dissemination and lung metastases. She was brought by ambulance to our hospital's emergency department 55 days after the last dose of Bmab, with a chief complaint of hematemesis. Hematolo- gy results showed severe anemia with a hemoglobin level of 4.0 g/dL. Descending thoracic aortic dissection was noted on chest CT with contrast, and the patient was diagnosed with an aortoesophageal fistula rupture. She underwent emergent endovascular chest stent grafting to control the bleeding. Although the ruptured esophagus was a potential source of infection, the patient and family members chose palliative treatment. Therefore, conservative treatment was administered without removing the esophagus. The patient's postoperative course was good; instead of resuming oral intake, the patient was discharged on home IVH 59 days after surgery. Outpatient follow-up continued, but multiple metastases led to gradual worsening of the patient's general condition. She died 168 days after being admitted for surgery.