[A case of primary lung metastatic pancreatic tumor resected following chemoradiotherapy].

We observed a case of pancreatic metastasis of lung cancer being resected following chemoradiotherapy and reported with a review of the literature. The patient was a 60-year-old man and previously underwent an upper lobectomy of the right lung for the primary lesion and chemoradiotherapy for the metastatic lesion in the lower lobe of the right lung. During the follow-up period, positron emission tomography-computed tomography scan revealed a tumor in the pancreatic body, which was a hyperechoic mass on endoscopic ultrasonography (EUS) and hypervascularity on Sonazoid angiography. Fine needle aspiration cytology under EUS revealed dense growth of tumor cells with increased nuclear chromatin, markedly atypical nuclei, and eosinophilic sporangia. Immunostaining showed CK7 (+), CK20 (-), TTF-1 (+), and napsin A (+). He was diagnosed with pancreatic metastasis of lung cancer, underwent preoperative chemoradiotherapy followed by distal pancreatectomy and splenectomy, and discharged without perioperative complications. The right lower lobe metastasis of lung cancer was detected during an outpatient visit following chemoradiotherapy. However, he was found rectal cancer and considered a scheduled surgery. Forty-two months postoperatively, he was found dead at home;the cause of death was shock due to extreme dehydration.

Prophylactic effect of negative-pressure wound therapy and delayed sutures against incisional-surgical site infection after emergency laparotomy for colorectal perforation: A multicenter retrospective cohort study.

Aim: The prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after highly contaminated laparotomies has not been sufficiently explored. This study aimed to evaluate the prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after emergency surgery for colorectal perforation. Methods: This nationwide, multicenter, retrospective cohort study analyzed data from the 48 emergency hospitals certificated by the Japanese Society for Abdominal Emergency Medicine. Patients who underwent an emergency laparotomy for colorectal perforation between April 2015 and March 2020 were included in this study. Outcomes, including the incidence of incisional surgical site infection, were compared between patients who were treated with prophylactic negative-pressure wound therapy and delayed sutures (i.e., negative-pressure wound therapy group) and patients who were treated with regular wound management (i.e., control group) using 1:4 propensity score matching analysis. Results: The negative-pressure wound therapy group comprised 88 patients, whereas the control group consisted of 1535 patients. Of them, 82 propensity score-matched pairs (negative-pressure wound therapy group: 82; control group: 328) were evaluated. The negative-pressure wound therapy group showed a lower incidence of incisional surgical site infection [18 (22.0%) in the negative-pressure wound therapy group and 115 (35.0%) in the control group, odds ratio, 0.52; 95% confidence interval, 0.30 to 0.92; p = 0.026]. Conclusions: The prophylactic use of negative-pressure wound therapy with delayed sutures was associated with a lower incidence of incisional surgical site infection after emergency surgery for colorectal perforation.

Factors associated with the need for long-term total parenteral nutrition in survivors of acute superior mesenteric artery occlusion.

BACKGROUND: Acute superior mesenteric artery (SMA) occlusion is an uncommon condition associated with high mortality. If extensive bowel resection is performed for patients with acute SMA occlusion and the patient survives, long-term total parenteral nutrition (TPN) may be needed due to short bowel syndrome. This study examined factors associated with the need for long-term TPN after the treatment of acute SMA occlusion. METHODS: We retrospectively analyzed 78 patients with acute SMA occlusion. Patients were abstracted from a Japanese database from institutions with at least 10 patients with acute SMA occlusive disease from January 2015 through December 2020 RESULTS: Among the initial cohort there were 41/78 survivors. Of these, 14/41 (34%) required permanent TPN who were compared with those who did not require long-term TPN (27/41, 66%). Compared to patients in the non-TPN group, those in the TPN group had significantly shorter remaining small intestine (90.7 cm vs. 218 cm, P<0.01), more patients with time from onset to intervention >6 hours (P=0.02), pneumatosis intestinalis on enhanced computed tomography scan (P=0.04), ascites (Odds Ratio 11.6, P<0.01), and a positive smaller superior mesenteric vein sign (P= 0.03). These were considered significant risk factors for needing long-term TPN. Age, gender, underlying disease, presence of peritoneal sign, presence of shock requiring vasopressors, site of obstruction (proximal vs. distal), and initial treatment (surgery vs. interventional radiology vs. thrombolytic therapy) were not significantly different between the two groups. Long-term TPN was significantly associated with longer hospital stay (52 vs. 35 days, P=0.04). Multivariate analysis identified the presence of ascites as an independent risk factor for needing long-term TPN. CONCLUSION: The need for permanent TPN after treatment of acute SMA occlusion is significantly associated with longer hospital stay, longer time to intervention, and characteristic imaging findings (pneumatosis intestinalis, ascites, Smaller SMV sign). Ascites is an independent risk factor. LEVEL OF EVIDENCE: III.

Three millimeter needlescopic splenectomy using three-port technique: report of three cases.

We report our experience with needlescopic splenectomy (NS) for the surgical treatment of idiopathic thrombocytopenic purpura using a 3-mm needlescope with three ports. One patient was male and two were females, and their mean age was 58 years. The patient was placed in the right lateral decubitus position. The first 12-mm port was introduced through the lateral margin of the left rectus abdominis muscle, and the other two 3-mm ports were inserted in the left upper quadrant. NS was performed by a standard technique under the observation of 3.3-mm needlescope. The surgical procedure was successfully completed in all the patients. The mean duration of surgery, intra-operative bleeding volume and post-operative hospital stay were 176 min, 70 ml and 4.7 days, respectively. There were no particular peri-operative complications in spite of dense adhesions or simultaneous laparoscopic procedures. Our method is safe and feasible with low morbidity and without impairing cosmetic benefits.

Therapeutic effects of oxaliplatin-based neoadjuvant chemotherapy and chemoradiotherapy in patients with locally advanced rectal cancer: a single-center, retrospective cohort study.

BACKGROUND: Neoadjuvant chemoradiotherapy (NACRT) has now become the standard treatment for locally advanced rectal cancer (LARC). NACRT has decreased local relapse (LR) rate in patients with LARC; however, distant relapse has recently attracted much attention. This study aimed to assess the feasibility and efficiency of neoadjuvant chemotherapy (NAC) for LARC. METHODS: Data on patients with cT3/4 and N+ rectal cancer who were treated in our institution from April 2010 to February 2016 were reviewed retrospectively. Twenty-seven patients who received 2-9 cycles of oxaliplatin-based NAC and 28 patients who received NACRT (45 Gy delivered in 25 fractions and 5-fluorouracil-based oral chemotherapy) were analyzed. The primary and secondary endpoints of the present study were the 3-year relapse-free survival (RFS) and the local and distant relapse rates, respectively. RESULTS: Regardless of the kind of neoadjuvant therapy, no patient experienced any grade 3-4 therapy-related adverse events. The frequent toxic events were grade 1 diarrhea in patients with NACRT and neutropenia in patients with NAC. A significantly higher proportion of patients with NAC underwent laparoscopic surgery and anterior resection (p = 0.037 and p = 0.003, respectively). The percentages of patients with lymph node yield less than 12 in the NAC group, and those in the NACRT group were 26 and 68%, respectively (p = 0.002). Comparing the NAC with the NACRT groups, the local relapse and distant relapse rates were 7.4 and 7.1% and 7.4 and 18%, respectively. There were no significant differences in 3-year RFS and 4-year overall survival (OS) between NAC and NACRT (3-year RFS 85.2 vs. 70.4%, p = 0.279; 4-year OS 96.3 vs. 89.1%, p = 0.145, respectively). With an analysis excluding patients who received postoperative adjuvant chemotherapy, no patients who received NAC had a distant relapse, and there was a significant difference in 3-year RFS compared with the NACRT groups (94.4 vs. 63.2%, p = 0.043). CONCLUSION: These outcomes suggest that the therapeutic effect of oxaliplatin-based NAC is at least equal to that of NACRT and that NAC is a feasible and promising option for LARC.

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos).

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Laparoscopic surgery to remove a cage that migrated to the retroperitoneal space during posterior lumbar interbody fusion: A case report.

INTRODUCTION: Cage migration into the retroperitoneal space during posterior lumbar interbody fusion rarely occurs. Here, we report a patient who underwent laparoscopic surgery to remove a migrated cage from the retroperitoneal space. CASE PRESENTATION: A 76-year-old woman had a cage that had migrated into the retroperitoneal space during posterior lumbar interbody fusion. On abdominal CT, the migrated cage appeared at the front of the promontorium, just below the aortic and vena caval bifurcations. One day later, the patient underwent laparoscopic surgery using intraoperative fluoroscopy to extract the migrated cage. The patient's postoperative course was uneventful, and she was discharged on the fifth postoperative day. DISCUSSION: A cage that migrates during posterior lumbar interbody fusion can have serious consequences. In cases where the patient remains in stable condition, laparoscopic surgery is a useful and suitable method for removing the cage from the retroperitoneal space.

Obstruction in the third portion of the duodenum due to a diospyrobezoar: a case report.

BACKGROUND: Duodenal obstruction occurs mainly due to physical lesions such as duodenal ulcers or tumors. Obstruction due to bezoars is rare. We describe an extremely rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy for early gastric cancer. CASE PRESENTATION: A 73-year-old man who underwent laparoscopic distal gastrectomy for early gastric cancer 15 months before admission experienced abdominal distension and occasional vomiting. The symptoms worsened and ingestion became difficult; therefore, he was admitted to our department. Computed tomography (CT) performed on admission revealed a solid mass in the third portion of the duodenum and dilatation of the oral side of the duodenum and remnant stomach. Esophagogastroduodenoscopy (EGD) revealed a bezoar deep in the third portion of the duodenum. We could neither remove nor crush the bezoar. At midnight on the day of EGD, he experienced sudden abdominal pain. Repeat CT revealed that the bezoar had vanished from the duodenum and was observed in the ileum. Moreover, small bowel dilatation was observed on the oral side of the bezoar. Although CT showed neither free air nor ascites, laboratory data showed the increase of leukocyte (8400/µL) and C-reactive protein (18.1 mg/dL), and abdominal pain was severe. Emergency surgery was performed because conservative treatment was considered ineffective. We tried advancing the bezoar into the colon, but the ileum was too narrow; therefore, we incised the ileum and removed the bezoar. The bezoar was ocher, elastic, and hard, and its cross-section was uniform and orange. The postsurgical interview revealed that the patient loved eating Japanese persimmons (Diospyros kaki); therefore, he was diagnosed with a diospyrobezoar. His postoperative progress was good and without complications. He left the hospital 10 days after surgery. EGD performed 4 weeks after surgery revealed no abnormal duodenal findings. CONCLUSIONS: We describe a rare case of obstruction in the third portion of the duodenum caused by a diospyrobezoar 15 months after laparoscopic distal gastrectomy with Billroth I reconstruction for early gastric cancer.

Structural equation modeling of the relationship between posttraumatic growth and psychosocial factors in women with breast cancer.

OBJECTIVE: Posttraumatic growth (PTG) is a positive psychological change occurring after struggling with a highly challenging experience. The purposes of this study were to investigate how women's demographic and clinical characteristics as well as psychosocial factors are associated with PTG and to reveal the influence of PTG on depressive symptoms. METHODS: Participants were 157 women with breast cancer (BC) who attended a breast oncology clinic at a university hospital in Japan. The questionnaire included demographic and clinical characteristics, social support, coping strategies, depressive symptoms, and PTG. Structural equation modeling was conducted. RESULTS: Coping was directly related to PTG, and social support and having a religion were partially related to PTG. There was a moderate association between social support and coping. PTG mediated the effect of coping on depressive symptoms. PTG as well as a high level of perceived social support and using positive coping decreased depressive symptoms, whereas using self-restraining coping increased depressive symptoms. CONCLUSION: This study indicated the role of coping strategies and social support in enhancing PTG in Japanese women with BC. Furthermore, perceived social support, a positive approach coping style, and PTG may reduce depressive symptoms. Our results suggest that health care professionals should consider whether patients receive enough support from others, and whether the patients are using the appropriate coping style to adapt to stressors associated with the diagnosis and treatment of BC.

[NEEDLESCOPIC SURGERY].

We define needlescopic surgery (NS) as endoscopic surgery performed with 2- to 3-mm needlescopic instruments, and it has received attention as a form of reduced-port surgery. Reports on NS have been published since 1998, and their number has gradually increased. A Japanese study group called the "Needlescopic Surgery Meeting" was established in October 2000. The advantages of NS are improved cosmetic results and reduced postoperative pain. Although the cosmetic results of NS are inferior to those of single-incision endoscopic surgery, the creation of an operative field is similar to that using the conventional method, and NS involves less stress on surgeons. In the comparison of postoperative pain among conventional, single-incision, and needlescopic techniques, the amount of postoperative analgesics required after the needlescopic technique is significantly (p＜0.001) less than that after the other techniques. The disadvantages of NS are the poorer image quality of the needlescope, difficulty in grasping due to the fine shaft of the instruments, and difficulty in creating the operative field. If we understand the specific details of needlescopic instruments and endeavor to use them properly to avoid intra- and postoperative complications, NS will become more advanced in cooperation with single-incision endoscopic surgery.

Intragastric surgery using laparoscopy and oral endoscopy for gastric submucosal tumors.

We review the techniques and outcomes of the intragastric resection for gastric submucosal tumors (GSTs) using laparoscope and oral endoscope. In the literature, the mean operation time, intraoperative blood loss, pathological size of the tumor and postoperative hospital stay were 134 min, minimal, 31 mm and 6.4 d, respectively. There were no particular perioperative complications during the follow-up period (mean: 121.3 mo). Intragastric surgery using laparoscopy and oral endoscopy can be considerably beneficial for patients with GSTs locating in the upper third of the stomach between 2-5 cm in diameter and < 8 cm(2) in cross-sectional area and located in the upper third of the stomach.

Laparoscopic resection of a retroperitoneal pelvic schwannoma.

Schwannomas are rarely located in the pelvis. A 54-year-old woman was found incidentally to have a tumor in the abdomen. Abdominal computed tomography and magnetic resonance imaging revealed a well-defined, heterogeneous tumor, 5 cm in diameter, in the pelvic cavity. With a diagnosis of a mesenteric tumor, a laparoscopic procedure was performed. Intra-operatively, an elastic tumor was identified in the pelvis adjacent to the right internal iliac vein and ureter. The tumor was dissected free from adjacent structures using Liga-Sure and blunt maneuvers. A complete laparoscopic excision was performed. Histopathological examination revealed a benign schwannoma. The patient had an uneventful post-operative course, and was discharged on the fourth post-operative day. Laparoscopic treatment is useful and feasible for retroperitoneal pelvic schwannoma, with minimal invasiveness and an early post-operative recovery. Thus, this procedure may be the first-choice surgical procedure for retroperitoneal pelvic schwannomas.

Experience with laparoscopic treatment for paraesophageal hiatal hernia.

INTRODUCTION: Paraesophageal hiatal hernia is often associated with a number of complications such as intestinal obstruction, gastric volvulus and acute pancreatitis, each of which can result in critical conditions requiring surgery. Herein, we report our surgical procedure for paraesophageal hiatal hernia. METHODS: Since 2003, we have surgically treated hiatal hernia in 18 patients, including 2 men and 16 women, with a mean age of 73 years. Thirteen patients (72.2%) had a type-I hiatal hernia, two (11.1%) had type III and three (16.7%) had type IV. The operative procedure consisted of a crural repair and anti-reflux maneuver. RESULTS: Laparoscopic procedures were completed in all patients. The mean operation time was 160.2 min for type I and 230.8 min for types III and IV. The mean postoperative hospital stay was 7.8 days, and there was no mortality. Three patients relapsed during the mean follow-up period of 74.9 months. Two of them were asymptomatic and one required laparoscopic reoperation. CONCLUSION: Laparoscopic surgery for paraesophageal hiatal hernia is safe and effective with minimal morbidity and early recovery. However, it is important to determine the appropriate timing of surgery based on the severity of the hernia and the patient's general status and comorbidities.

Comparison of the indocyanine green fluorescence and blue dye methods in detection of sentinel lymph nodes in early-stage breast cancer.

PURPOSE: To assess the diagnostic performance of sentinel lymph node (SLN) biopsy using the indocyanine green (ICG) fluorescence method compared with that using the blue dye method, a prospective multicenter study was performed. METHODS: Patients with T1-3 primary breast cancer without clinical lymph node involvement were included in this study. ICG as a fluorescence-emitting source and indigo carmine as blue dye were injected into the subareolar area. Extracted lymph nodes were examined to identify the first, second, and other SLNs. The identified nodes were classified according to the ICG fluorescence signal and blue dye uptake. RESULTS: Ninety-nine eligible patients were included in this study. The ICG fluorescence method identified an average of 3.4 SLNs (range, 1-8) in 98 of 99 patients (detection rate, 99 %). The number of lymph nodes identified by the fluorescence method was significantly higher than that identified by the blue dye method (p < 0.001). SLN involvement was identified in 20 % (20 of 99) of patients, all of whom tested positive for the first SLN. In 16 patients, complete axillary lymph node dissection (ALND) was performed. In 25 % (4 of 16) of these patients, axillary metastases were identified; however, no axillary involvement was found in 8 patients with only one involved node, which was isolated as the first SLN. CONCLUSIONS: High rate of SLN detection was achieved using the ICG fluorescence method. The first SLN identified by fluorescence imaging provides an exact indication of the axillary status. Therefore, the ICG fluorescence method provides precise information required to avoid unnecessary ALND.

Single-port transumbilical laparoscopic excision of retroperitoneal schwannoma mimicking a nonfunctional endocrine tumor in the body of the pancreas: a case report.

Schwannomas are benign tumors that arise from neural sheath Schwann cells. Solitary benign schwannoma is generally located in the head and neck and is a rare neoplasm among the tumors of the retroperitoneal space. Reports of laparoscopic excision of retroperitoneal schwannomas have recently been on the increase. However, few cases of single-port laparoscopic excision of these tumors have been reported. Moreover, there are no reports of single-port excision of schwannomas attached to the body of pancreas and around the splenic vessels. This is the first report of a schwannoma lying adjacent to the body of the pancreas between the splenic artery and vein that was excised by single-port laparoscopic surgery. The most notable aspect of our procedure is the use of bipolar forceps. Single-port laparoscopic excision using bipolar forceps is a feasible and safe procedure for retroperitoneal solitary tumors, even when they are close to the splenic artery and vein.

Awareness and behavior of oncologists and support measures in medical institutions related to ongoing employment of cancer patients in Japan.

OBJECTIVE: Improved outcomes of cancer treatment allow patients to undergo treatment while working. However, support from oncologists and medical institutions is essential for patients to continue working. This study aimed to clarify oncologists' awareness and behavior regarding patients who work during treatment, support in medical institutions and their association. METHODS: A questionnaire was mailed to all 453 diplomates and faculty of the subspecialty board of medical oncology in the Japanese Society of Medical Oncology and all 1016 surgeons certified by the Japanese Board of Cancer Therapy living in the Kanto area. The questionnaire assessed demographics, oncologist awareness and behavior regarding patient employment and support measures at their medical institutions. Logistic regression analysis was used to examine the association of awareness and behavior of oncologists with support measures at their institutions. RESULTS: A total of 668 individuals participated. The overall response rate was 45.5%. Only 53.6% of respondents advised patients to tell their supervisors about prospects for treatment and ask for understanding. For medical institutions, 28.8% had a nurse-involved counseling program and adjustments in radiation therapy (28.0%) and chemotherapy (41.9%) schedules to accommodate patients' work. There was a significant correlation between awareness and behavior of oncologists and medical institutions' measures to support employed cancer patients. CONCLUSIONS: There is room for improvement in awareness and behavior of oncologists and support in medical institutions for cancer patients continuing to work. Oncologists could support working patients by exerting influence on their medical institutions. Conversely, proactive development of support measures by medical institutions could alter the awareness and behavior of oncologists.

Reevaluation of needlescopic surgery.

BACKGROUND: Although the use of single-incision laparoscopic surgery (SILS) has spread rapidly, most procedures employ additional needlescopic instruments to ensure safety and shorten the operation time. Therefore, on the basis of results obtained in our department, the present study was conducted to reevaluate the current state of needlescopic surgery (NS) to improve the cosmetic results and postoperative quality of life of patients and to reduce cost and degree of stress on surgeons. METHODS: Between May 1998 and February 2011, we performed NS in 202 patients. The diagnoses included gallbladder diseases in 151 patients, spontaneous pneumothorax in 11, thyroid tumor and axillary lymph node metastases in 10 patients each, splenic cyst and appendicitis in 4 patients each, idiopathic thrombocytopenic purpura and postoperative abdominal wall hernia in 3 patients each, primary aldosteronism and hepatic cyst in 2 patients each, and adhesional bowel obstruction and gastric stromal tumor in 1 patient each. Under general anesthesia, one 12-mm and tow or three 2- or 3-mm ports were introduced into the operative field. The specimen was retrieved via the 12-mm wound using a plastic bag. RESULTS: The operations were completed in all patients without the need to convert to an open procedure. In 8 (5.3%) of the 151 cholecystectomies, a change to 5-mm instruments was required. There were no perioperative complications. Pertinent technical points included avoidance of direct organ mobilization to minimize injury, rotation of the operating table and utilization of organ gravity to create a better operative field, minimum use of needlescope to ensure safe maneuvering, and improvement of the bi-hand technique. CONCLUSIONS: NS is a safe and feasible procedure that allows experienced surgeons to achieve minimally invasive surgery with low morbidity, without the need to convert to a conventional or open procedure.

Laparoscopic resection of epidermoid cyst arising from an intrapancreatic accessory spleen: a case report with a review of the literature.

We describe a rare case of epidermoid cyst arising in an intrapancreatic accessory spleen that presented as a cystic mass in the tail of the pancreas, and for which laparoscopic distal pancreatectomy was performed successfully. A 36-year-old woman with a cystic mass in the tail of the pancreas, which had been discovered incidentally at a medical checkup, was referred to our department for further examination. Endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography and positron emission tomography demonstrated a multilocular cyst in the tail of the pancreas without any evidence of malignancy, although differential diagnosis was extremely difficult because of the neoplasm-like appearance of the lesion. Therefore, we performed laparoscopic distal pancreatectomy under a preoperative diagnosis of mucinous cystic neoplasm. Postoperative pathologic examination demonstrated an epidermoid cyst arising from a heterotopic spleen within the pancreas. This is the first report of successful laparoscopic distal pancreatectomy for an epidermoid cyst arising in an intrapancreatic accessory spleen. One virtually has no chance to diagnose an epidermoid cyst in an accessory spleen on the basis of preoperative diagnostic workup, and consequently the type of surgical resection (open vs. laparoscopic) would be conditioned by factors other than the clinical entity suspected at the preoperative period.

[Colorectal cancer].

Recent advances in chemotherapy and chemoradiation therapy for colorectal cancer have made neoadjuvant treatment an eligible therapeutic option for selected cases of marginally resectable colorectal cancer. However, marginally resectable colorectal cancer is not well defined. The authors suggest that a primary lesion is marginally resectable if extended resection such as pelvic exenteration and pancreaticoduedenectomy are not completely curative. Even if the lesion itself is resectable, it is marginally resectable if it has unfavorable prognostic factors such as numerous metastases to the regional lymph nodes. Rectal cancer invading beyond mesorectal fascia, or having bilateral or multiple lateral lymph node metastasis, may also be marginally resectable. All locally recurrent lesions may be marginally resectable because the prognosis after surgical resection is poor. Multiple liver metastases, liver metastasis for which resection requires vascular reconstruction, and technically resectable liver metastasis with unfavorable prognostic factors, are also thought to be marginally resectable. Neoadjuvant chemotherapy regimens including oxaliplatin and irinotecan combined with bevacizumab, cetuximab and panitumumab may be effective for hastening the curability of such marginally resectable tumors. For primary advanced rectal cancer and locally recurrent rectal cancer, neoadjuvant radiation combined with chemotherapy using oxaliplatin and irinotecan are being explored. A number of clinical trials are currently ongoing, and are expected to clarify the effectiveness of neoajuvant treatment for marginally resectable colorectal cancer.

Needlescopic surgery for liver, gallbladder and spleen diseases.

BACKGROUND: We propose that needlescopic surgery (NS) should be considered as a way of improving the esthetic result and post-operative quality of life of patients and of reducing costs and stress on surgeons, and we have evaluated the results of NS. METHODS: We used NS in 157 patients between May 1998 and December 2010: cholecystectomy in 150 patients, marsupialization of splenic and hepatic cysts in 4 and splenectomy in 3, respectively. Under general anesthesia, one 12-mm and two or three 2- or 3-mm ports were introduced into the operative field. The specimen was retrieved from the 12-mm wound using a plastic bag. RESULTS: The procedures were successfully completed in all patients without conversion to an open procedure. In eight (5.3%) of 150 cholecystectomies a change to 5-mm instruments was required. The mean operation times and postoperative hospital stays for cholecystectomy, splenectomy, and marsupialization of splenic and hepatic cysts were 80.2 min and 3.2 days, 167 min and 5.6 days, 170 min and 7 days, and 120 min and 7 days, respectively. There were a few perioperative complications. The most important factor for reducing operation time and achieving a low conversion rate is the use of at least one 3- or 5-mm port for the grasping instruments in cholecystectomy. We recognized a residual cyst requiring splenectomy 62 months after marsupialization in one case. Technical points for performing safe procedures on solid organs were: no direct organ mobilization to avoid organ injuries, the rotation of the operating table and the utilization of organ gravity to create a better operative field, the minimum use of the needlescope to perform a safe maneuver and the improvement of bi-manual technique. CONCLUSIONS: NS is a safe and feasible procedure for achieving minimal invasive surgery. We should consider NS as a first choice to treat operable diseases in this laparoscopic era.