Successful management following combined thoracic endovascular aortic repair and minimally invasive esophagectomy for primary aortoesophageal fistula: A case report.

Aortoesophageal fistula (AEF) is a rare but life-threatening pathology. We report a case of a primary AEF that was successfully managed with temporary thoracic endovascular aortic repair (TEVAR) and esophagectomy with video-assisted thoracoscopic surgery. A 73-year-old man was transferred to the emergency department with a complaint of hematemesis. A computed tomography scan identified an AEF due to aortic aneurysm. We placed a stent using TEVAR for the purpose of hemodynamic stasis, and the operation was performed 23 h after admission. Right video-assisted thoracoscopic esophagectomy (VATS-E) was chosen, and a cervical esophagostomy and a feeding gastrostomy tube was constructed. Infection had been effectively controlled postoperatively. Four months after the first operation, we performed esophageal reconstruction. At the 70-month follow-up examination, the patient had no signs of mediastinitis. VATS-E immediately after hemostabilization by TEVAR is useful management for primary AEF.

Symptom palliation with QUAD Shot radiation therapy to penile metastasis derived from descending colon cancer: a case report.

A 54-year-old man was diagnosed with descending colon cancer with metastases in the liver, para-aortic lymph nodes, and penis, and chemotherapy was introduced after construction of a colostomy. The patient reported only mild penile pain at the time of diagnosis; however, the pain gradually worsened and interfered with his daily life. Opioids did not provide sufficient analgesia, and the patient developed dysuria and priapism. Through construction of a cystostomy, palliative radiotherapy with QUAD Shot regimen (14 Gy in 4 fractions twice-daily on 2 days repeated every 4 weeks) to the penile metastasis was started for pain relief and tumor shrinkage. The radiation rapidly improved the penile symptoms, enabling opioid reduction and cystostomy removal. The patient remained pain-free and able to urinate on his own until his death. Metastatic penile tumors are rare, especially those derived from colon cancer. Penile metastases occur mainly in the late stages of cancer and may impair the patient's quality of life. In such cases, palliative radiotherapy, especially with QUAD Shot regimen, is useful with short treatment time, durable symptom control, and little adverse effect, maintaining quality of life.

Prognostic potential of METTL3 expression in patients with gastric cancer.

Methyltransferase-like 3 (METTL3) is a crucial component of the m6A methyltransferase complex, which serves pivotal roles in tumor progression. The present study investigated the prognostic significance of METTL3 expression in gastric cancer (GC). The expression levels of METTL3 were assessed by immunohistochemistry in formalin-fixed paraffin-embedded (FFPE) tissue specimens from 158 patients with GC. Propensity score matching (PSM) analysis was performed to clarify its prognostic potential. METTL3 gene expression was also investigated in fresh frozen specimens from another independent cohort of 57 patients with GC to establish its clinical relevance. Knockdown of METTL3 by small interfering RNA transfection was performed to evaluate its function in vitro. METTL3 expression was significantly higher in cancerous tissues compared with in corresponding normal mucosa (P<0.0001), and high METTL3 expression was an independent prognostic factor for overall and disease-free survival in the FFPE cohort of patients with GC. PSM analysis revealed that elevated METTL3 expression was significantly associated with poor survival outcomes, which was subsequently validated in another cohort of fresh frozen specimens. Knockdown of METTL3 inhibited proliferation, invasion, migration and anoikis resistance in GC cells. In conclusion, METTL3 expression may be used as a clinically feasible prognostic marker and could serve as a potential therapeutic target in patients with GC.

Combined assessment of muscle quality and quantity predicts oncological outcome in patients with esophageal cancer.

BACKGROUND: Sarcopenia consists of two dysregulation patterns of body composition, myopenia and myosteatosis. The aim of this study is to compare the preoperative status of various body composition indexes including our newly developed modified intramuscular adipose tissue content (mIMAC) to investigate these clinical values in esophageal cancer patients. METHOD: We assessed preoperative psoas muscle mass index (PMI), IMAC, and mIMAC in 150 esophageal cancer patients. RESULTS: Preoperative high IMAC and low mIMAC status were significantly associated with older age. Preoperative decreased mIMAC was significantly associated with advanced T classification and the presence of distant metastasis and low preoperative mIMAC was an independent prognostic factor for poor overall survival and disease-free survival in esophageal cancer patients. Combined assessment of preoperative mIMAC with PMI could help stratify risk for oncological outcomes. Finally, preoperative PMI and mIMAC were positively correlated with various nutritional factors in esophageal cancer patients. CONCLUSION: Combined assessment between preoperative PMI and mIMAC could stratify risk for oncological outcomes, and preoperative mIMAC might be surrogate marker for aging and nutritional status in esophageal cancer patients.

Clinical utility of lymphocyte to C-reactive protein ratio in predicting survival and postoperative complication for esophago-gastric junction cancer.

BACKGROUND: There are still no useful predictive biomarkers for esophago-gastric junction (EGJ) cancer. We compared 15 candidate inflammation-based markers and investigated the clinical impact of the selected biomarker. METHODS: One hundred three patients with EGJ cancer between 2002 and 2020 were enrolled, and associations between clinicopathological data and inflammatory biomarkers were retrospectively analyzed. Area under the curve (AUC) values of 15 candidate biomarkers were compared in receiver operating characteristic (ROC) curves regarding overall survival (OS). Clinical impacts of the selected marker were further investigated regarding long-term prognosis, postoperative complications, and preoperative chemotherapy effects. RESULTS: Lymphocyte/CRP ratio (LCR) demonstrated the highest AUC (0.68552) and was chosen as a candidate biomarker. The high LCR group (LCR >4610) demonstrated significantly better OS (p < 0.0001) and relapse-free survival (RFS) (p < 0.0001) compared with the low LCR group (LCR ≤4610), and preoperative LCR was an independent prognostic factor for both OS (HR 4.97, 95% CI:2.24-11.58; p < 0.0001) and RFS (HR 2.84, 95% CI:1.33-6.14, p = 0.007) in EGJ cancer patients. Another cut-off value was established for postoperative complications, and the incidence rates were significantly higher in the low LCR group (LCR ≤12000) than in the high LCR group (LCR >12000) for all postoperative complications, infectious complications, and surgical site infection (p = 0.013, p = 0.016, and p = 0.030, respectively). Furthermore, patients with decreased LCR after preoperative chemotherapy demonstrated significantly worse RFS compared with patients with increased LCR (p = 0.043). CONCLUSIONS: LCR is a potential biomarker to predict long-term prognosis as well as occurrence of postoperative complications in patients with EGJ cancer.

A Case of IgG and IgA Anti-Laminin-332 Antibody-Positive Mucous Membrane Pemphigoid with IgG and IgA Anti-Envoplakin and Anti-Periplakin Antibodies.

A 76-year-old Japanese man presented with a 6-year history of a sore throat. He was treated at several clinics without any improvement before being referred to us. Physical examination revealed widespread erosions and ulcers from the palate to the larynx. Approximately 25 × 15 mm in size, erosive lesions were present on the retroauricular regions, forearms, and glans penis. Pseudomembranous conjunctivitis was also observed. The skin biopsy revealed a partial cleft formation below the epidermis, suggesting subepidermal bullous disease. Immuno-serological tests were negative for anti-desmoglein 1 (Dsg1), anti-Dsg3, anti-BP180, and anti-BP230 antibodies by ELISAs. A whole-body examination revealed gastric cancer. The possibility of mucous membrane pemphigoid (MMP) or paraneoplastic pemphigus (PNP) was considered. Indirect immunofluorescence using rat bladders showed positive IgG reactivity with cell surfaces on the transitional epithelia. Immunoblotting using recombinant proteins of laminin-332 showed both IgG and IgA reactivities with laminin-α3, and immunoblotting using normal human epidermal extract showed double-positive reactivities with envoplakin and periplakin for both IgG and IgA antibodies. Based on the clinical and histopathological features and results of various immuno-serological tests, our case was diagnosed as anti-laminin-332-type MMP with serological findings of PNP. Twenty days after laparoscopic gastrectomy, treatment with oral methylprednisolone 32 mg/day was initiated, and mucosal and skin lesions improved.

Clinical Relevance of Myopenia and Myosteatosis in Colorectal Cancer.

Sarcopenia was initially described as a decrease in muscle mass associated with aging and subsequently also as a consequence of underlying disease, including advanced malignancy. Accumulating evidence shows that sarcopenia has clinically significant effects in patients with malignancy, including an increased risk of adverse events associated with medical treatment, postoperative complications, and a poor survival outcome. Colorectal cancer (CRC) is one of the most common cancers worldwide, and several lines of evidence suggest that preoperative sarcopenia negatively impacts various outcomes in patients with CRC. In this review, we summarize the current evidence in this field and the clinical relevance of sarcopenia in patients with CRC from three standpoints, namely, the adverse effects of medical treatment, postoperative infectious complications, and oncological outcomes.

[The Watch and Wait Strategy for Lower Rectal Cancer Patients Who Achieved Clinical Complete Response after Chemotherapy to Treat Inguinal Lymph Node Metastasis following Total Neoadjuvant Therapy-A Case Report].

The watch and wait strategy(W&W)is optional non-operative management for lower advanced rectal cancer patients who have achieved clinical complete response(cCR)following neoadjuvant treatment. However, the clinical implication of surgical intervention for the primary lesion is not well elucidated when distant metastasis appears with complete remission of the primary lesion. We report a case of a 47-year-old-woman with lower rectal cancer presenting inguinal lymph node metastasis after total neoadjuvant therapy(TNT)and managed through W&W after achieving cCR following chemotherapy. TNT was performed as a preoperative treatment for lower advanced rectal cancer, cT3N2aM0, cStage Ⅲb. Although the primary lesion and mesenteric lymph node metastasis completely disappeared, bilateral inguinal lymph node metastasis appeared immediately after TNT. The patient was treated with FOLFOX plus panitumumab for rectal cancer with RAS and BRAF wild-type. Four months after chemotherapy, the inguinal lymph node metastasis disappeared, and W&W was used for the management. She stayed alive without recurrence 1 year and 9 months after chemotherapy.

Cumulative C-reactive Protein in the Perioperative Period as a Novel Marker for Oncological Outcome in Patients with Colorectal Cancer Undergoing Curative Resection.

OBJECTIVES: Systemic inflammatory response is strongly associated with poor oncological outcome in colorectal cancer (CRC). Perioperative inflammation caused by surgical stress can lead to the development of postoperative infectious complications (PIC) as well as cancer-related inflammation. We aimed to evaluate the prognostic potential of perioperative systemic inflammation by calculating the time-dependent cumulative C-reactive protein (CRP) levels during the perioperative period. METHODS: We analyzed clinicopathological data from 540 patients with CRC who underwent potentially curative surgery at our institution. The time-dependent aggregated CRP level was denoted "cumulative CRP," which represents the area under the line of time (days) and the CRP levels preoperatively and on postoperative days 1, 3, and 7. RESULTS: Cumulative CRP was significantly higher in patients with CRC undergoing open surgery than in patients undergoing laparoscopic surgery. In multivariate analysis, high cumulative CRP was an independent prognostic factor for disease-free survival (DFS) and overall survival (OS) in both the laparoscopic and open surgery groups. Patients with CRC and high cumulative CRP had significantly poorer DFS and OS than those with low cumulative CRP, including those patients without PIC. CONCLUSIONS: Cumulative CRP is an independent predictive marker of OS and DFS in patients with CRC who undergo curative surgery.

Modified intramuscular adipose tissue content as a feasible surrogate marker for malnutrition in gastrointestinal cancer.

BACKGROUND & AIMS: Myosteatosis is gathering attention as a feasible indicator for sarcopenia and increased risk of morbidity. However, the prognostic value of intramuscular adipose tissue content (IMAC) as an assessment method for myosteatosis remains controversial. The objectives of this study are to compare the prognostic value of intramuscular adipose tissue content (IMAC) with our newly-developed modified IMAC (mIMAC), and to assess the clinical significance of mIMAC in colorectal cancer (CRC) and gastric cancer (GC). METHODS: We evaluated 892 patients with CRC or GC, and assessed preoperative IMAC and mIMAC to compare their prognostic and predictive values for postoperative infectious complications in both cohorts. RESULTS: Both preoperative IMAC and mIMAC were sex- and disease-dependent, and positively or negatively correlated with age in CRC and GC patients (IMAC: CRC: r = 0.33, P < 0.0001; GC: r = 0.304, P < 0.0001; mIMAC: CRC: r = -0.364, P < 0.0001; GC: r = -0.263, P < 0.0001). In contrast to IMAC, lower preoperative mIMAC was significantly associated with disease-development factors, and was an independent prognostic factor for both overall survival (OS) and disease-free survival (DFS) in both CRC (OS: hazard ratio (HR): 1.95, 95% confidence interval (CI): 1.25-3.03, p = 0.003; DFS: HR: 1.93, 95% CI: 1.22-3.04, p = 0.005) and GC patients (OS: HR: 2.11, 95% CI: 1.22-3.68, P = 0.008; DFS: HR: 2.03, 95% CI: 1.18-3.5, P = 0.011). Patients with postoperative remote infections had a poorer prognosis compared with those without in both cohorts (CRC: HR: 2.67, 95% CI: 1.46-4.89, P = 0.002; GC: HR: 3.01, 95% CI: 1.47-6.19, P = 0.003), and low mIMAC was an independent risk factor for postoperative remote infection in both cancers (CRC: odds ratio (OR): 2.56, 95% CI: 1.06-6.23, P = 0.038; GC: OR: 2.8, 95% CI: 1.03-7.58, P = 0.043). Finally, we assessed the correlation between IMAC or mIMAC and the representative frailty markers body mass index (BMI), serum albumin, and prognostic nutritional index (PNI). We found a positive correlation between preoperative mIMAC and all of these markers in both cohorts (CRC: BMI: r = 0.193, P < 0.0001; serum albumin: r = 0.42, P < 0.0001; PNI: r = 0.39, P < 0.0001; GC: BMI: r = 0.22, P < 0.0001; serum albumin: r = 0.212, P < 0.0001; PNI: r = 0.287, P < 0.0001). CONCLUSIONS: Preoperative mIMAC could be useful for perioperative and postoperative management in CRC and GC.

Cumulative perioperative lymphocyte/C-reactive protein ratio as a predictor of the long-term outcomes of patients with colorectal cancer.

PURPOSE: Systemic inflammatory response influences cancer development and perioperative surgical stress can affect the survival of patients with colorectal cancer (CRC). We developed a system to cumulatively assess perioperative inflammatory response and compare the prognostic value of various cumulative inflammatory and nutritional markers in patients with CRC. METHODS: We assessed perioperative cumulative markers using the trapezoidal area method in 307 patients who underwent surgery for CRC and analyzed the results statistically. RESULTS: The cumulative lymphocyte to C-reactive protein (CRP) ratio (LCR) predicted survival more accurately than other well-established markers (sensitivity: 80.0%, specificity: 69.3%; area under the curve (AUC): 0.779; P < 0.001). A low cumulative LCR was correlated with factors associated with disease development, including undifferentiated histology, advanced T stage, lymph node metastasis, distant metastasis, and advanced TNM stage classification. A decreased cumulative LCR was an independent prognostic factor for both overall survival (OS) (Hazard Ratio (HR):5.21, 95% confidence interval [CI] 2.42-11.2; P < 0.0001) and disease-free survival (DFS) (HR: 1.88, 95% CI 1.07-3.31; P = 0.02), and its prognostic significance was verified in a different clinical setting. The cumulative LCR was correlated negatively with the intraoperative bleeding volume (P < 0.0001, R = -0.4). Combined analysis of cumulative and preoperative LCR could help stratify risk for the oncological outcomes of CRC patients. CONCLUSIONS: The findings of this study demonstrate the value of the cumulative LCR in the postoperative management of patients with CRC.

Laparoscopic removal of an aberrant acupuncture needle in the gluteus that reached the pelvic cavity: a case report.

BACKGROUND: Intrapelvic aberrant needles are rare in clinical practice. Long-term foreign bodies in the abdominal cavity may form granulation tissue or an abscess, and may cause organ injury. Therefore, such foreign bodies need prompt removal. CASE PRESENTATION: A 26-year-old male athlete was referred to our hospital for investigation of an aberrant acupuncture needle in the gluteus. The needle was unable to be removed during acupuncture treatment, and the end broke off and remained in the gluteus. Abdominal X-ray examination showed a thin, 40-mm-long, metallic foreign body resembling an acupuncture needle. Abdominal computed tomography showed an abnormal shadow in the gluteus. However, it was unclear whether the tip of the needle reached the pelvic cavity. Thus, it was decided to surgically extract the needle via laparoscopic surgery under X-ray guidance as a safe and minimally invasive method. Although X-ray fluoroscopy confirmed that the aberrant needle was located in the gluteus, the needle could not be felt with the forceps, as the peritoneum surrounding the needle had granulomatous changes due to inflammation. Therefore, the retroperitoneum was further dissected to search for the needle. Once the needle was identified, its flexibility enabled it to be easily removed by grasping it directly with a needle holder. The length of the aberrant needle was 40 mm. The postoperative course was uneventful, and the patient was discharged from hospital on postoperative day 2. CONCLUSIONS: When a foreign body remains in the gluteus and its tip touches intrapelvic organs, such as the rectum, it is critical to determine the best approach for its safe removal. Given the anatomical location of the foreign body and the patient background, laparoscopic removal was considered the best approach in the present case.

Geriatric nutritional risk index predicts cancer prognosis in patients with local advanced rectal cancer undergoing chemoradiotherapy followed by curative surgery.

AIM: The clinical significance of the geriatric nutritional risk index (GNRI) in locally advanced rectal cancer (LARC) patients undergoing preoperative chemoradiotherapy (CRT) followed by curative surgery has not been comprehensively evaluated. METHODS: This retrospective study enrolled 93 LARC patients diagnosed with clinical lymph node metastasis. The GNRI formula was as follows: 1.489 × albumin (g/l) + 41.7 × current weight/ideal weight. Patients were categorized as GNRI low (GNRI < 104.25) or high (GNRI > 104.25) according to the receiver operating characteristic (ROC) curve for survival analysis. The impact of GNRI status on the prognostic outcomes of curative surgery for LARC was examined. RESULTS: There were 55 (59.14%) and 38 (40.86%) patients in the GNRI high and low groups, respectively. Of the investigated demographic factors, age, pathological tumor invasion, and presence of recurrence were significantly associated with the GNRI value. In Kaplan-Meier analysis, overall survival (OS) and disease-free survival (DFS) were significantly shorter in the GNRI low group (OS: p = 0.00020, DFS: p = 0.0044, log-rank test). Multivariate analysis using a Cox proportional hazards model showed that a low GNRI was an independent risk factor for poor OS (hazard ratio (HR) = 3.22; 95% confidence interval (CI), 1.37-8.23; p = 0.0068) and DFS (HR = 2.32; 95%CI = 1.15-4.79; p = 0.018). Although use of adjuvant therapy has no impact on prognosis (OS: p = 0.26, DFS: p = 0.29), low GNRI showed shorter OS and DFS in patients with pathological lymph node metastasis [ypN(+)] (OS: p = 0.033, DFS: p = 0.032, log-rank test). CONCLUSIONS: GNRI is a useful marker for LARC patients diagnosed with clinical lymph node metastasis and treated by preoperative CRT followed by curative surgery. GNRI is a useful tool to identify high risk of recurrence for improving the survival in LARC patients.

Prognostic Potential of Lymphocyte-C-Reactive Protein Ratio in Patients with Rectal Cancer Receiving Preoperative Chemoradiotherapy.

PURPOSE: The systemic inflammatory response is attracting increasing attention as a predictive biomarker for oncological outcome in patients with colorectal cancer. This study is aimed at verifying if the lymphocyte-C-reactive protein (CRP) ratio (LCR) could be used as a predictor of oncological outcome in patients with rectal cancer (RC) receiving preoperative chemoradiotherapy (CRT). METHODS: We analyzed data for 86 patients with RC who received preoperative CRT followed by total mesorectal excision at our institution. A ratio of 6000 was used as the cut-off value for LCR for further analysis. RESULTS: The post-CRT LCR was significantly lower than the pre-CRT LCR in patients with RC. Although post-CRT LCR status was not significantly correlated with overall survival (OS), low pre-CRT LCR was significantly associated with shorter recurrence-free survival (RFS: p = 0.02) and OS (p = 0.017) in this population and was an independent prognostic factor for both RFS and OS (hazard ratio (HR) 3.19, 95% confidence interval (CI) 1.33-7.66, p = 0.009; HR 2.83, 95%CI 1.14-7.01, p = 0.025, respectively). Furthermore, low pre-CRT LCR was a stronger indicator of early recurrence (p = 0.001) and poor prognosis (p = 0.025) in RC patients without pathological lymph node metastasis compared with patients with pathological lymph node metastasis, and prognostic potential of pre-CRT LCR was clearly revealed especially RC patients receiving long-course CRT. CONCLUSIONS: Assessment of pretreatment LCR status might aid decision-making regarding postoperative treatment strategies in patients with RC receiving CRT followed by potentially curative resection.

Clinical implications of the preoperative lymphocyte C-reactive protein ratio in esophageal cancer patients.

PURPOSE: We recently revealed the preoperative lymphocyte C-reactive protein ratio (LCR) to be a new marker for predicting various outcomes in malignancies. The aim of our present study was to clarify the potential utility of the preoperative LCR for predicting the perioperative risk and oncological outcome in esophageal cancer patients. METHODS: We analyzed the preoperative LCR from 153 esophageal cancer patients to clarify its clinical relevance. RESULTS: The preoperative LCR was significantly decreased in a stage-dependent manner, and a decreased preoperative LCR was significantly associated with the occurrence of postoperative surgical site infection. Esophageal cancer patients with a low LCR showed a poor outcome in both the overall survival and disease-free survival compared with those who had a high LCR. Multivariate analyses showed that a decreased LCR was an independent prognostic factor for both a poor overall survival and disease-free survival. A decreased preoperative LCR was an independent predictive factor for postoperative surgical site infection and significantly correlated with nutritional and inflammatory indicators. In addition, the LCR was useful for identifying esophageal cancer patients likely to have a poor outcome among patients with and without neoadjuvant chemotherapy. CONCLUSIONS: Assessing the preoperative LCR might help physicians identify populations at high risk for perioperative complication and oncological outcomes, and determine individualized perioperative therapeutic strategies.

Preoperative computed tomography predicts the risk of recurrent laryngeal nerve paralysis in patients with esophageal cancer undergoing thoracoscopic esophagectomy in the prone position.

BACKGROUND: Recurrent laryngeal nerve paralysis (RLNP) after thoracoscopic esophagectomy for esophageal cancer (EC) is known to be a major complication leading to poor quality of life. RLNP is mainly associated with surgical procedures performed near the RLN. Therefore, with focus on the region of the RLN, we used preoperative computed tomography to investigate the risk factors of RLNP in patients with EC undergoing thoracoscopic esophagectomy. METHODS: We retrospectively examined 77 EC patients who underwent thoracoscopic esophagectomy in the prone position at our department between January 2010 and December 2018. Bilateral cross-sectional areas (mm2) of the fatty tissue around the RLN at the level of the lower pole of the thyroid gland were measured on preoperative axial computed tomography (CT) images. Univariate and multivariate logistic regression analysis was used to evaluate the association between the incidence of RLNP and patient clinical factors, including the cross-sectional areas. RESULTS: RLNP occurred in 24 of 77 patients (31.2%). The incidence of RLNP was significantly more frequent on the left side than on the right. (26% vs. 5.2%, respectively). Univariate analysis identified the following left RLNP risk factors: intrathoracic operative time (> 235 min), and area around the RLN (> 174.3 mm2). Multivariate analysis found that the area around the RLN was an independent risk factor of left RLNP. CONCLUSION: An increased area around the RLN measured on an axial CT view at the level of the lower pole of the thyroid gland was a risk factor of RLNP in EC patients undergoing thoracoscopic esophagectomy in the prone position.

Lymphocyte-C-reactive Protein Ratio as Promising New Marker for Predicting Surgical and Oncological Outcomes in Colorectal Cancer.

BACKGROUND: Systemic inflammation via host-tumor interactions is currently recognized as a hallmark of cancer. The aim of this study was to evaluate the prognostic value of various combinations of inflammatory factors using preoperative blood, and to assess the clinical significance of our newly developed inflammatory score in colorectal cancer (CRC) patients. METHOD: In total 477 CRC patients from the discovery and validation cohorts were enrolled in this study. We assessed the predictive impact for recurrence using a combination of nine inflammatory markers in the discovery set, and focused on lymphocyte-C-reactive protein ratio (LCR) to elucidate its prognostic and predictive value for peri-operative risk in both cohorts. RESULTS: A combination of lymphocytic count along with C-reactive protein levels demonstrated the highest correlation with recurrence compared with other parameters in CRC patients. Lower levels of preoperative LCR significantly correlated with undifferentiated histology, advanced T stage, presence of lymph node metastasis, distant metastasis, and advanced stage classification. Decreased preoperative LCR (using an optimal cut-off threshold of 6000) was an independent prognostic factor for both disease-free survival and overall survival, and emerged as an independent risk factor for postoperative complications and surgical-site infections in CRC patients. Finally, we assessed the clinical feasibility of LCR in an independent validation cohort, and confirmed that decreased preoperative LCR was an independent prognostic factor for both disease-free survival and overall survival, and was an independent predictor for postoperative complications and surgical-site infections in CRC patients. CONCLUSION: Preoperative LCR is a useful marker for perioperative and postoperative management of CRC patients.

Billroth-I Reconstruction with Overlap Anastomosis Using an EndoWrist Linear Stapler After Robotic Distal Gastrectomy.

Introduction: Robotic distal gastrectomy (RDG) is now thought to be less invasive than conventional laparoscopic distal gastrectomy (LDG) for gastric cancer. Although the delta-shaped anastomosis is an established, widely performed procedure for intracorporeal Billroth-I (B-I) gastroduodenostomy after LDG, it has some difficulties and is performed in the ischemic region of the duodenum. We therefore developed a novel overlap B-I gastroduodenostomy after RDG. Materials and Methods: We started using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) for RDG in May 2017. The robotic overlap B-I reconstruction was performed via side-to-side anastomosis, as follows: Two small incisions were made, one on the greater curvature of the remnant stomach, 5 cm from the edge of the remnant gastric stump, and one on the superior edge of the anterior wall of the duodenal stump. A 45-mm EndoWrist linear stapler device (EWLS) loaded with a blue cartridge was inserted through the incision. After the remnant stomach and duodenum were attached to the V-shaped form by the EWLS, the incisions were closed by the EWLS. Results: Seven patients underwent RDG followed by a robotic overlap B-I procedure up to March 2019. Short-term outcomes were determined from medical records and operative videos. No intraoperative complications or conversions to open or conventional laparoscopic surgery occurred. The mean time for the anastomosis was 37 (range 29-45 minutes) minutes. No postoperative complications occurred following the robotic overlap B-I procedure. Discussion: RDG followed by an overlap B-I gastroduodenostomy might be feasible and safe. However, long-term follow-up is required to identify additional benefits.

Neutrophil priming as a risk factor for surgical site infection in patients with colon cancer treated by laparoscopic surgery.

BACKGROUND: The purpose of this study is to identify perioperative marker predicting postoperative surgical site infection (SSI) including with anastomotic leakage (AL) in curative colon cancer patients, laparoscopically. METHODS: In total, 135 colon cancer patients (stage I-III) undergoing curative laparoscopic surgery between January 2004 and December 2013 were enrolled in this study. We collected data on clinicopathological factors, laboratory data on pre and postoperative day 3 (POD3) and tumor markers levels to assess the relation to surgical site infection (SSI) including with anastomotic leakage (AL). RESULTS: SSI and AL occurred in 16 cases (5.6%) and 4 cases (3%), respectively. SSI and AL were not association with clinicopathological factors. Within laboratory data and tumor markers preoperatively, high neutrophil counts were significantly associated with SSI (P < 0.05) and AL (P < 0.01), respectively. Area under curves (AUC) of SSI and AL were 0.656 and 0.854, respectively. In addition, high neutrophil counts on POD3 also were significantly associated with SSI (P < 0.01) and AL (P < 0.01), respectively. Area under curves (AUC) of SSI and AL were 0.747 and 0.832, respectively. CONCLUSION: Neutrophil count on pre and POD3 are potentially valuable indicators of SSI including with AL in colon cancer patients undergoing curative surgery laparoscopically.

Laparoscopic esophagogastrostomy using a knifeless linear stapler after proximal gastrectomy.

Proximal gastrectomy should improve the late postoperative function in patients with gastric cancer located in the upper third of the stomach or esophagogastric junction. However, a standard method of esophagogastrostomy has not been established for improving the postoperative function. To prevent reflux and stenosis following proximal gastrectomy, we introduced a novel esophagogastrostomy method using a knifeless linear stapler. The stapler was inserted into holes created in both the esophagus and remnant stomach and fired proximally. A 1.5-cm incision was made from the edge of the entry hole between the staples. The entry hole was then closed with continuous sutures, and fundoplication was performed by wrapping the remnant stomach. We performed this technique in 12 consecutive patients without observing any anastomosis-related complications. The proportion of weight lost 1 year after surgery was 8.8%. Our surgical procedure might be feasible for treating gastric cancer located in the upper third of the stomach or esophagogastric junction.