Successful ureteral stent placement with rendezvous technique for ureteral obstruction after urinary diversion: A case report.

Ureteral obstruction after urinary diversion is not a rare complication, and the treatment is generally the ureteral stent placement via antegrade approach via the nephrostomy. We present a case of 64-year-old man with history of total pelvic resection and urinary diversion for local recurrence of rectal cancer who presented bilateral ureteral obstruction due to postoperative adhesion. First, bilateral nephrostomies were performed. The antegrade approach via nephrostomy could not break through the obstruction in the left side. Therefore, antegrade and retrograde approaches were attempted, and the internal-external drainage catheter could be placed by the rendezvous technique using bilateral microcatheters and microguidewires. The patient was able to avoid a permanent nephrostomy and continues to undergo regular internal drainage catheter exchange. Permanent nephrostomy considerably reduces the patient's quality of life, and in cases of tight obstruction, rendezvous techniques can be used.

Artificial Intelligence Imaging Diagnosis Using Super-Resolution and Three-Dimensional Shape for Lymph Node Metastasis of Low Rectal Cancer: A Pilot Study From a Single Center.

BACKGROUND: Although accurate preoperative diagnosis of lymph node metastasis is essential for optimizing treatment strategies for low rectal cancer, the accuracy of present diagnostic modalities has room for improvement. OBJECTIVE: The study aimed to establish a high-precision diagnostic method for lymph node metastasis of low rectal cancer using artificial intelligence. DESIGN: A retrospective observational study. SETTINGS: A single cancer center and a college of engineering in Japan. PATIENTS: Patients with low rectal adenocarcinoma who underwent proctectomy, bilateral lateral pelvic lymph node dissection, and contrast-enhanced multidetector row CT (slice ≤1 mm) between July 2015 and August 2021 were included in the present study. All pelvic lymph nodes from the aortic bifurcation to the upper edge of the anal canal were extracted, regardless of whether within or beyond the total mesenteric excision area, and pathological diagnoses were annotated for training and validation. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. RESULTS: A total of 596 pathologically negative nodes and 43 positive nodes from 52 patients were extracted and annotated. Four diagnostic methods, with and without using super-resolution images and with and without using 3-dimensional shape data, were performed and compared. The super-resolution + 3-dimensional shape data method had the best diagnostic ability for the combination of sensitivity, negative predictive value, and accuracy (0.964, 0.966, and 0.968, respectively), whereas the super-resolution only method had the best diagnostic ability for the combination of specificity and positive predictive value (0.994 and 0.993, respectively). LIMITATIONS: Small number of patients at a single center and the lack of external validation. CONCLUSIONS: Our results enlightened the potential of artificial intelligence for the method to become another game changer in the diagnosis and treatment of low rectal cancer. See Video Abstract . DIAGNSTICO POR IMGENES CON INTELIGENCIA ARTIFICIAL MEDIANTE SUPERRESOLUCIN Y FORMA D PARA LA METSTASIS EN LOS GANGLIOS LINFTICOS DEL CNCER DE RECTO BAJO UN ESTUDIO PILOTO DE UN SOLO CENTRO: ANTECEDENTES:Aunque el diagnóstico preoperatorio preciso de metástasis en los ganglios linfáticos es esencial para optimizar las estrategias de tratamiento para el cáncer de recto bajo, la precisión de las modalidades de diagnóstico actuales tiene margen de mejora.OBJETIVO:Establecer un método de diagnóstico de alta precisión para las metástasis en los ganglios linfáticos del cáncer de recto bajo utilizando inteligencia artificial.DISEÑO:Un estudio observacional retrospectivo.AJUSTE:Un único centro oncológico y una facultad de ingeniería en Japón.PACIENTES:En el presente estudio se incluyeron pacientes con adenocarcinoma rectal bajo sometidos a proctectomía, disección bilateral de ganglios linfáticos pélvicos laterales y tomografía computarizada con múltiples detectores con contraste (corte ≤1 mm) entre julio de 2015 y agosto de 2021. Se resecaron todos los ganglios linfáticos pélvicos desde la bifurcación aórtica hasta el borde superior del canal anal, independientemente de si estaban dentro o más allá del área de escisión mesentérica total, y se registraron los diagnósticos patológicos para entrenamiento y validación.PRINCIPALES MEDIDAS DE RESULTADO:Sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo y precisión.RESULTADOS:Se extrajeron y registraron un total de 596 ganglios patológicamente negativos y 43 positivos de 52 pacientes. Se realizaron y compararon cuatro métodos de diagnóstico, con y sin imágenes de súper resolución y sin datos de imagen en 3D. El método de superresolución + datos de imagen en 3D tuvo la mejor capacidad de diagnóstico para la combinación de sensibilidad, valor predictivo negativo y precisión (0,964, 0,966 y 0,968, respectivamente), mientras que el método de súper resolución solo tuvo la mejor capacidad de diagnóstico para la combinación de especificidad y valor predictivo positivo (0,994 y 0,993, respectivamente).LIMITACIONES:Pequeño número de pacientes en un solo centro y falta de validación externa.CONCLUSIONES:Nuestros resultados iluminan el potencial de la inteligencia artificial para que el método se convierta en otro elemento de cambio en el diagnóstico y tratamiento del cáncer de recto bajo. (Traducción ---Dr. Fidel Ruiz Healy ).

Colorectal Cancer Recurrence Prediction Using a Tissue-Free Epigenomic Minimal Residual Disease Assay.

PURPOSE: Post-treatment detection of circulating tumor DNA (ctDNA) is strongly predictive of recurrence. Most molecular residual disease (MRD) assays require prior tissue testing to guide ctDNA analysis, resulting in lengthy time to initial results and unevaluable patients. PATIENTS AND METHODS: We assessed a tissue-free assay (Guardant Reveal) that bioinformatically evaluates >20,000 epigenomic regions for ctDNA detection in 1,977 longitudinally collected post-operative plasma samples from 342 patients with resected colorectal cancer (CRC). RESULTS: We observed sensitive and specific detection of MRD associated with clinically meaningful differences in recurrence-free interval at each timepoint evaluated with a median lead time of 5.3 months. Longitudinal sensitivity in stage II or higher colon cancer was 81%. Sensitivity increased with serial measurement and varied by recurrence site: higher for liver (100%) versus lung (53%) and peritoneal (40%). Sensitivity among rectal cancer patients was 60% owing to a high proportion of lung metastases. Specificity was 98.2% among 1,461 post-treatment samples (99.1% among those with follow-up longer than the upper interquartile range of the lead time observed in this study). CONCLUSIONS: Our data demonstrate the potential clinical utility of ctDNA as a tool to improve management of stage II and higher CRC with a methodology that is non-invasive, accessible, and allows for rapid evaluation to inform clinical decisions.

Risk factors affecting delay of initiating adjuvant chemotherapy for stage III colorectal cancer.

PURPOSE: Delay in initiating adjuvant chemotherapy (AC) after curative resection of colorectal cancer (CRC) has been reported to lead to poor prognosis, but few studies have looked at associated factors. This study aimed to identify risk factors for delay in initiating AC. METHODS: Data from 200 consecutive patients who underwent curative resection and AC for stage III CRC between 2013 and 2018 were retrospectively collected and analyzed. RESULTS: AC was initiated more than 8 weeks after surgery in 12.5% of patients (the delay group). Compared to those with no delay (the non-delay group), patients in the delay group had significantly higher rates of synchronous double cancers (2.3% vs. 16.0%, p = 0.001), preoperative bowel obstruction (10.3% vs. 32.0%, p = 0.003), laparotomy (56.0% vs. 80.0%, p = 0.02), concomitant resection (2.9% vs. 24.0%, p < 0.001), and postoperative complications (32.0% vs. 56.0%, p = 0.02), and a significantly longer length of hospital stay (median 12 vs. 30 days, p < 0.001). In multivariate analysis, synchronous double cancers (odds ratio 10.2, p = 0.008), preoperative bowel obstruction (odds ratio 4.6, p = 0.01), concomitant resection (odds ratio 5.2, p = 0.03), and postoperative complications of Clavien-Dindo grade ≥ IIIa (odds ratio 4.0, p = 0.03) were identified as independent risk factors for delay in initiating AC. CONCLUSION: Careful preoperative treatment planning for CRC patients with synchronous double cancers, preoperative bowel obstruction, and concomitant resection, and management for postoperative complication are necessary to avoid delay in initiating AC.

Combined Pubic Arch and Ischial Bone Resection for Metachronous and Frequent Local Recurrences of Rectal Cancer.

BACKGROUND/AIM: Complete surgical resection with negative margins remains the cornerstone for curative treatment of rectal cancer; however, local recurrence can pose a significant challenge. Herein, we aimed to introduce a novel surgical technique for combined resection of the pubic arch and ischial bone in the context of treating recurrent rectal cancer. CASE REPORT: We present a case of a patient with a fourth local recurrence of rectal cancer, with no evidence of distant metastasis. The tumor directly invaded the posterior wall of the pubic arch. To achieve complete tumor resection, an osteotomy was performed using a thread wire saw at the bilateral pubic rami and ischial bones. Intraoperative frozen section analysis (rapid tissue examination) was conducted on tissue samples from the lateral margins of the planned osteotomy line. Samples were negative for adenocarcinoma (cancerous cells). The combined resection of the pubic arch and ischial bone was successfully performed with negative margins for adenocarcinoma, as confirmed by frozen section analysis. CONCLUSION: Mastery of the surgical technique for combined resection of the pubic arch and ischial bone may be clinically significant for achieving complete resection in cases of multiple resections for locally recurrent rectal cancer.

Localized colorectal cancer database integrating 4 randomized controlled trials; (JCOG2310A).

Although phase III randomized controlled trials (RCTs) represent the most robust statistical approach for answering clinical questions, they require massive expenditures in terms of time, labor, and funding. Ancillary and supplementary analyses using RCTs are sometimes conducted as alternative approaches to answering clinical questions, but the available integrated databases of RCTs are limited. In this background, the Colorectal Cancer Study Group (CCSG) of the Japan Clinical Oncology Group (JCOG) established a database of ancillary studies integrating four phase III RCTs (JCOG0212, JCOG0404, JCOG0910 and JCOG1006) conducted by the CCSG to investigate specific clinicopathological factors in pStage II/III colorectal cancer (JCOG2310A). This database will be updated by adding another clinical trial data and accelerating several analyses that are clinically relevant in the management of localized colorectal cancer. This study describes the details of this database and planned and ongoing analyses as an initiative of JCOG cOlorectal Young investigators (JOY).

BARD1 deletion in a patient with suspected hereditary colorectal cancer.

Deleterious germline variants in the BRCA1-associated ring domain (BARD1) gene moderately elevate breast cancer risk; however, their potential association with other neoplasms remains unclear. Here, we present the case of a 43-year-old female patient diagnosed with sigmoid colon adenocarcinoma whose maternal family members met the Amsterdam Criteria II for Lynch syndrome. Comprehensive multigene panel testing revealed a heterozygous BARD1 exon 3 deletion.

[Tips and Outcomes of Safe Laparoscopic Rectal Resection with Adequate Lymph Node Dissection in Patients with Obesity].

BACKGROUND: This study aimed to describe the surgical procedures involved in laparoscopic rectal resection in patients with obesity and report the short-term outcomes. MATERIALS AND METHODS: A total of 194 consecutive patients who underwent laparoscopic rectal resection in our department from 2013 to 2018 were divided into non-obese(body mass index[BMI] <25 kg/m2; n=161)and obese groups(BMI≥25 kg/m2; n=33)and subsequently analyzed. RESULTS: The operative time was significantly longer in the obese group(225 vs 266 min; p=0.003)than in the non-obese group. No conversions to laparotomy occurred in either group, and no discernible differences in blood loss(1 vs 5 mL; p=0.582), number of harvested lymph nodes(20 vs 17; p=0.356), and postoperative complication rates(9.3 vs 6.1%; p=0.547)were observed. CONCLUSION: Establishing an appropriate operative field, clarifying landmarks, and standardizing the procedure are important to assure safe laparoscopic rectal resection with adequate lymph node dissection in patients with obesity.

Novel Repair Technique for Oral and Anal Side Stoma Prolapse of a Loop Colostomy With the Stapled Modified Altemeier Method Using Indocyanine Green Fluorescence Imaging.

BACKGROUND/AIM: Stoma prolapse is a common complication in the late phase after stoma creation. With advances in chemotherapy, a double-orifice colostomy or ileostomy and chemotherapy are used to treat primary unresectable colorectal cancer. Preoperative therapy with a double-orifice colostomy or ileostomy is performed to aid primary colorectal cancer miniaturization. Therefore, the number of stoma prolapses will likely increase in the future. Previous reports on the repair of stoma prolapse focused on unilateral stoma prolapse of loop colostomy, and there are no reports about the bilateral stoma prolapse of loop colostomy or ileostomy. CASE REPORT: We report a novel repair technique for oral and anal side (bilateral) stoma prolapse of a loop colostomy with the stapled modified Altemeier method using indocyanine green (ICG) fluorescence imaging considering the distribution of marginal artery in preventing marginal artery injury which has considerable clinical significance. CONCLUSION: Our novel technique for the oral and anal side prolapse of a loop colostomy is considered effective and safe.

How Does Omitting Additional Surgery After Local Excision Affect the Prognostic Outcome of Patients With High-risk T1 Colorectal Cancer?

OBJECTIVE: To investigate how omitting additional surgery after local excision (LE) affects patient outcomes in high-risk T1 colorectal cancer (CRC). BACKGROUND: It is debatable whether additional surgery should be performed for all patients with high-risk T1 CRC regardless of the tolerability of invasive procedures. METHODS: Patients who had received LE for T1 CRC at the Japanese Society for Cancer of the Colon and Rectum institutions between 2009 and 2016 were analyzed. Those who had received additional surgical resection and those who did not were matched one-on-one by the propensity score-matching method. A total of 401 propensity score-matched pairs were extracted from 1975 patients at 27 Japanese Society for Cancer of the Colon and Rectum institutions and were compared. RESULTS: Regional lymph node metastasis was observed in 31 (7.7%) patients in the LE + surgery group. Comparatively, the incidence of oncologic adverse events was low in the LE-alone group, such as the 5-year cumulative risk of local recurrence (4.1%) or overall recurrence (5.5%). In addition, the difference in the 5-year cancer-specific survival between the LE + surgery and LE-alone groups was only 1.8% (99.7% and 97.9%, respectively), whereas the 5-year overall survival was significantly lower in the LE-alone group than in the LE + surgery group [88.5% vs 94.5%, respectively ( P = 0.002)]. CONCLUSIONS: Those who had decided to omit additional surgery at the dedicated center for CRC treatment presented a small number of oncologic events and a satisfactory cancer-specific survival, which may suggest an important role of risk assessment regarding nononcologic adverse events to achieve a best practice for each individual with high-risk T1 tumors.

Prognostic Relevance of Primary Tumor Sidedness in Early-stage Colorectal Cancer: An Integrated Analysis of 4 Randomized Controlled Trials (JCOG2003A).

OBJECTIVE: The aim of this study was to determine the genuine prognostic relevance of primary tumor sidedness (PTS) in patients with early-stage colorectal cancer (CRC). BACKGROUND: The prognostic relevance of PTS in early-stage CRC remains a topic of debate. Several large epidemiological studies investigated survival only and did not consider the risk of recurrence so far. METHODS: Patients with stage II/III adenocarcinoma of the colon and upper rectum from 4 randomized controlled trials were analyzed. Survival outcomes were compared according to the tumor location: right-sided (cecum to transverse colon) or left-sided (descending colon to upper rectum). RESULTS: A total of 4113 patients were divided into a right-sided group (N=1349) and a left-sided group (N=2764). Relapse-free survival after primary surgery was not associated with PTS in all patients and each stage [hazard ratio (HR) adjusted =1.024 (95% CI: 0.886-1.183) in all patients; 1.327 (0.852-2.067) in stage II; and 0.990 (0.850-1.154) in stage III]. Also, overall survival after primary surgery was not associated with PTS in all patients and each stage [HR adjusted =0.879 (95% CI: 0.726-1.064) in all patients; 1.517 (0.738-3.115) in stage II; and 0.840 (0.689-1.024) in stage III]. In total, 795 patients (right-sided, N=257; left-sided, N=538) developed recurrence after primary surgery. PTS was significantly associated with overall survival after recurrence (HR adjusted =0.773, 95% CI: 0.627-0.954). CONCLUSIONS: PTS had no impact on the risk of recurrence for stage II/III CRC. Treatment stratification based on PTS is unnecessary for early-stage CRC.

A case of simultaneous breast cancer and ovarian cancer based on a hereditary breast and ovarian cancer syndrome.

We experienced a relatively rare case of synchronous breast and ovarian cancer in a patient with hereditary breast and ovarian cancer syndrome (HBOC). Here, we report the usefulness of laparoscopic examination to determine the subsequent treatment strategy in cases of suspected concurrent multiple carcinomas. Our patient was diagnosed with breast cancer following detection of a right breast mass. She was diagnosed with HBOC as she was found to be harboring a germline pathogenic variant of breast cancer susceptibility gene 1 (BRCA1). Preoperative images suggested the presence of neoplastic masses in the abdominal cavity, and the possibility of metastatic peritoneal dissemination of breast cancer or concurrent overlapping of gynecological malignancies was considered. We decided to employ laparoscopic examination, and if simultaneous overlapping of cancers was suspected, we planned to further evaluate whether primary debulking surgery (PDS) for gynecological cancer was possible or not. Laparoscopy revealed the presence of ovarian cancer with neoplastic lesions on the bilateral ovaries and disseminations in the pelvic and abdominal cavities. The total predictive index was 0; therefore, PDS was considered feasible. We performed a total mastectomy, followed by laparotomy, and optimal surgery was achieved. The final diagnosis was simultaneous stage IIB invasive ductal breast carcinoma and stage IIIC high-grade serous ovarian carcinoma. In this case of suspected concurrent multiple carcinomas, laparoscopy was beneficial for decision-making regarding subsequent surgical treatment. We believe that the use of laparoscopy will enable simultaneous surgery for breast cancer and ovarian cancer to become one of the treatment strategies in the future.

Three cases of open surgical procedures on ileal conduits for the repair of benign ureteroenteric anastomotic strictures after total pelvic exenteration of rectal tumors.

Ureteroenteric anastomotic strictures (UEAS) are typical complications after creating an ileal conduit for total pelvic exenteration (TPE) of rectal tumors. We report the ileal conduit for reconstruction in three patients, in the age-range of 47-73 years. Case 1 was when a left-sided UEAS had sufficient length of ureter for anastomosis, Case 2 was a right-sided UEAS with sufficient length of ureter for anastomosis, and Case 3 was a left-sided UEAS with insufficient length of ureter for anastomosis. There were no complications after operation and no recurrence of UEAS. It is important to learn the open surgical procedures for repair of a benign UEAS after TPE of rectal cancers. This has fewer complications and is safe in the long term.

Novel Ureteral Stent Catheterization Technique for Treating Hyperchloremic Metabolic Acidosis After Total Pelvic Exenteration.

BACKGROUND/AIM: Hyperchloremic metabolic acidosis after total pelvic exenteration (TPE) is relatively rare. Urinary diversion of the ileal conduit during TPE can result in increased urine reabsorption leading to hyperchloremic metabolic acidosis. We developed a new technique for the retrograde catheterization of a ureteral stent into an ileal conduit to treat hyperchloremic metabolic acidosis. CASE REPORT: A 70-year-old man underwent TPE for locally recurrent rectal cancer. Multiple episodes of complications, such as hyperchloremia and metabolic acidosis, occurred. Effective drainage of urine from the ileal conduit is crucial. With collaboration between an endoscopist and a radiologist, we developed a novel method for retrograde catheterization of the ureteral stent into an ileal conduit for hyperchloremic metabolic acidosis after TPE. The patient's condition quickly improved after the procedure. CONCLUSION: Our novel technique of retrograde catheterization of a ureteral stent into an ileal conduit for hyperchloremic metabolic acidosis could be adopted worldwide, as it is effective and safe.

A multicenter prospective observational study of lymph node metastasis patterns and short-term outcomes of extended lymphadenectomy in right-sided colon cancer.

Background: The lymph node metastasis rate in right-sided colon cancer is unknown, and the optimal central vascular ligation level remains controversial. We aimed to determine the lymph node metastasis rate and short-term results of radical surgery with extended lymph node dissection in right-sided colon cancer. Methods: This prospective multicenter observational study included patients with stage II/III right-sided colon cancer from five cancer hospitals. The metastasis rate of each node station was analyzed according to tumor location and main feeding artery. Results: Between April 2018 and August 2021, 208 patients underwent dissection around the superior mesenteric artery (SMA) and vein (SMV). In transverse colon cancer, 7.5% and 2.5% of metastases occurred around the SMV and SMA at the root of the middle colic artery (MCA), respectively; 6.7% and 6.7% at the root of the right colic artery. In caecal cancer, 1.9% of metastases occurred around the SMV and 1.9% around the SMA. In ascending colon cancer, the rate was 1.1% around the SMV. Of the tumors, 17% fed mainly by the ileocolic artery had node metastases along the middle or right colic artery, as did 66.7% fed mainly by the right colic artery and 41.2% fed by the MCA (p = 0.01). Postoperative complications occurred in 42 patients (20.2%). Conclusion: Routine prophylactic extended lymphadenectomy around the SMA might not be necessary in caecum and ascending colon cancer. Dissection around the SMA may be necessary in cases of transverse colon cancer or when the feeding artery is the MCA.

How many times can patients tolerate reoperation for the local recurrence of colorectal cancer in terms of complications?

The frequency of resection for the recurrence of colorectal cancer has not been investigated in previous studies. Likewise, the related postoperative complications and the limit for indicating surgical resection has not been reported. Herein, we reported the complications of a highly frequent surgical approach for rectal cancer recurrence, i.e., exceeding three reoperations, based on our clinical experience. We included 15 cases exceeding two operations for the local recurrence of colorectal cancer from 2014 to 2019. We examined the postoperative complications classified as Clavien?Dindo IIIb. The positive rates of the complications were 0 (0.0%), 0 (0.0%), 2 (13.3%), 3 (37.5%), and 0 (0.0%) for the primary, 1st recurrent, 2nd recurrent, 3rd recurrent, and 4th recurrent operation group (p=0.027), respectively. It is important to exercise caution in handling cases exceeding two reoperations (exceeding three reoperations including the primary operation). J. Med. Invest. 70 : 369-376, August, 2023.

Clinical Impact of Radical Resection of Synchronous and Metachronous Peritoneal Metastases from Colorectal Cancer.

BACKGROUND: According to some case series, patients with colorectal cancer (CRC) who underwent radical resection of synchronous peritoneal metastases (PM) with the primary tumor had better survival than patients who underwent non-surgical treatment. However, little evidence exists regarding the significance of radical resection for metachronous PM. OBJECTIVE: This study aimed to evaluate the clinical significance of surgical intervention for isolated PM from CRC, with a particular focus on time to PM. METHODS: A total of 74 consecutive patients with isolated PM from CRC, including 40 and 34 patients with synchronous and metachronous PM, respectively, treated between 2007 and 2018 were retrospectively analyzed. The primary outcome measure was overall survival (OS) from diagnosis, and the OS was compared between radical resection and palliative chemotherapy. RESULTS: Five-year OS was 39.7% for all patients. Patients with radical resection had significantly better 5-year OS compared with those with palliative chemotherapy (62.8% vs. 11.0%; p < 0.0001). According to time to PM, patients with radical resection had significantly better 5-year OS compared with those with palliative chemotherapy for both synchronous PM (47.6% vs. 0%; p = 0.019) and metachronous PM (77.2% vs. 15.2%; p < 0.0001). Multivariable analysis stratified by time to PM revealed that surgical intervention is a significant favorable prognostic factor only in patients with metachronous PM (hazard ratio 0.117, 95% confidence interval 0.020-0.678; p = 0.017). CONCLUSIONS: Patients with radical resection of PM had good survival compared with those with chemotherapy alone, especially for metachronous PM. Surgical intervention should be considered for isolated metachronous PM when radical resection is feasible.

Current Practice and Barriers to the Implementation of Mobilization in ICUs in Japan: A Multicenter Prospective Cohort Study.

Background: Limited information is currently available on the barriers to implementing mobilization at the bedside for critically ill patients. Therefore, we investigated the current practice of and barriers to the implementation of mobilization in intensive care units (ICU). Methods: A multicenter prospective observational study was conducted at nine hospitals between June 2019 and December 2019. Consecutive patients admitted to the ICU for more than 48 h were enrolled. Quantitative data were analyzed descriptively, and qualitative data were analyzed thematically. Results: The 203 patients enrolled in the present study were divided into 69 elective surgical patients and 134 unplanned admission patients. The mean periods of time until the initiation of rehabilitation programs after ICU admission were 2.9 ± 7.7 and 1.7 ± 2.0 days, respectively. Median ICU mobility scales were five (Interquartile range: three and eight) and six (Interquartile range: three and nine), respectively. The most common barriers to mobilization in the ICU were circulatory instability (29.9%) and a physician's order for postoperative bed rest (23.4%) in the unplanned admission and elective surgery groups, respectively. Conclusions: Rehabilitation programs were initiated later for unplanned admission patients and were less intense than those for elective surgical patients, irrespective of the time after ICU admission.

Clinical Relevance of Lateral Pelvic Lymph Node Dissection for Enlarged Lateral Nodes in Locally Advanced Low Rectal Cancer without Preoperative Treatment.

Objectives: The present study aimed to investigate the clinical relevance of lateral pelvic lymph node dissection (LPLND) in low rectal cancer without preoperative treatment, with a focus on the presence of LPLN enlargement in preoperative imaging. Methods: Consecutive patients with cT3 to T4 low rectal cancer who underwent mesorectal excision and LPLND without preoperative treatment between 2007 and 2018 at a single dedicated cancer center were included. LPLN short-axis diameter (SAD) measured using preoperative multi-detector row computed tomography (MDCT) was evaluated retrospectively. Results: A total of 195 consecutive patients were analyzed. Overall, 101 (51.8%) and 94 (48.2%) patients had visible and no visible LPLNs in preoperative imaging, including 56 (28.7%), 28 (14.4%), and 17 (8.7%) patients had SADs of <5 mm, 5-7 mm, and ≥7 mm, respectively. Incidence of pathologically confirmed LPLN metastasis were 18.1%, 21.4%, 28.6%, and 52.9%, respectively. Overall, thirteen (6.7%) patients developed local recurrence (LR), including one patient who developed lateral recurrence, yielding a 5-year cumulative risk for LR of 7.4%. Five-year RFS and OS for all patients were 69.7% and 85.7%, respectively. No differences were observed in the cumulative risk for LR and OS between any pairs of groups. Conclusions: No significant difference was observed in the cumulative risk for LR and OS regardless of LPLN SAD, implying the good impact of LPLND on the prevention of lateral recurrence, as well as the difficulty of predicting LPLN metastasis using only LPLN SAD in preoperative imaging.