Long-term results of minimally invasive transanal surgery for rectal tumors in 249 consecutive patients.

PURPOSE: To delineate the long-term results of minimally invasive transanal surgery (MITAS) for selected rectal tumors. METHODS: We analyzed data, retrospectively, on consecutive patients who underwent MITAS between 1995 and 2015, to establish the feasibility, excision quality, and perioperative and oncological outcomes of this procedure. RESULTS: MITAS was performed on 243 patients. The final histology included 142 cancers, 47 adenomas, and 52 neuroendocrine tumors (NET G1). A positive margin of 1.6% and 100% en bloc resection were achieved. The mean operative time was 27.4 min. Postoperative morbidity occurred in 7% of patients, with 0% mortality. The median follow-up was 100 months (up to ≥ 5 years or until death in 91.8% of patients). Recurrence developed in 2.9% of the patients. The 10-year overall survival rate was 100% for patients with NET G1 and 80.3% for those with cancer. The 5-year DFS was 100% for patients with Tis cancer, 90.6% for those with T1 cancer, and 87.5% for those with T2 or deeper cancers. MITAS for rectal tumors ≥ 3 cm resulted in perioperative and oncologic outcomes equivalent to those for tumors < 3 cm. CONCLUSION: MITAS is feasible for the local excision (LE) of selected rectal tumors, including tumors ≥ 3 cm. It reduces operative time and secures excision quality and long-term oncological outcomes.

Differential analysis of microbiomes in mucus and tissues obtained from colorectal cancer patients.

The outer mucus layer of the colorectal epithelium is easily removable and colonized by commensal microbiota, while the inner mucus layer is firmly attached to the epithelium and devoid of bacteria. Although the specific bacteria penetrating the inner mucus layer can contact epithelial cells and trigger cancer development, most studies ignore the degree of mucus adhesion at sampling. Therefore, we evaluated whether bacteria adhering to tissues could be identified by removing the outer mucus layer. Our 16S rRNA gene sequencing analysis of 18 surgical specimens of human colorectal cancer revealed that Sutterella (P = 0.045) and Enterobacteriaceae (P = 0.045) were significantly enriched in the mucus covering the mucosa relative to the mucosa. Rikenellaceae (P = 0.026) was significantly enriched in the mucus covering cancer tissues compared with those same cancer tissues. Ruminococcaceae (P = 0.015), Enterobacteriaceae (P = 0.030), and Erysipelotrichaceae (P = 0.028) were significantly enriched in the mucus covering the mucosa compared with the mucus covering cancers. Fusobacterium (P = 0.038) was significantly enriched in the mucus covering cancers compared with the mucus covering the mucosa. Comparing the microbiomes of mucus and tissues with mucus removed may facilitate identifying bacteria that genuinely invade tissues and affect tumorigenesis.

Establishment of the menthol test as a clinical evaluation method for oxaliplatin-induced neuropathy.

Objectives: To determine whether the tongue menthol test, which measures the cold sensation detection threshold (CDT) of the tongue, used before and after oxaliplatin administration is an objective evaluation method for oxaliplatin-induced peripheral neuropathy (OPN). Methods: The tongue menthol test was administered to patients both before and after undergoing chemotherapy containing oxaliplatin for colorectal cancer. The tongue menthol test was conducted by applying a menthol solution (a selective agonist of transient receptor potential cation channel subfamily M member 8 [TRPM8]) to the tongue and measuring the CDT. Results: The mean CDT before the first dose of oxaliplatin was 0.34% (0.005%-1%; n=38), and the mean CDT after the first dose was 0.32% (0.005%-1%; n=38). The CDT appeared to decrease after the first dose, but this difference was not significant. In patients who received five courses of oxaliplatin, changes in CDT values were compared before and after the five courses. In patients with Neurotoxicity Criteria of Debiopharm (DEB-NTC) grade 2 neuropathy, the pre-oxaliplatin administration CDT was compared between before grade exacerbation and when exacerbation occurred, and was found to decline when grade exacerbation occurred. Moreover, when the CDTs before and after administration were compared before grade exacerbation, there was a significant decrease in CDT after administration (P=0.04). Conclusions: By performing a menthol test in oxaliplatin-treated patients, it may be possible to objectively predict the exacerbation of peripheral neuropathy at an early stage.

Usefulness of laparoscopic right colectomy with intracorporeal anastomosis and preoperative weight reduction for ascending colon cancer in a severely obese patient.

Obesity has been considered a risk factor for postoperative complications following colorectal cancer surgery. However, the usefulness of a combination of intracorporeal anastomosis and preoperative weight reduction for severely obese patients with colon cancer remains unclear. A 66-year-old man with a body mass index (BMI) of 43 kg/m2 presented with abdominal pain and iron deficiency anemia. Colonoscopy and computed tomography revealed advanced ascending colon cancer with regional lymph node metastasis and excessive abdominal fat. Preoperative diet-induced weight reduction was performed for severe obesity, which decreased his BMI to 39.7 kg/m2 after 1 month. Thereafter, curative resection was performed using intracorporeal anastomosis for reconstruction to achieve minimal colon and mesentery mobilization and a shorter incision. The patient was discharged from the hospital without complications. Laparoscopic right hemicolectomy combining intracorporeal anastomosis and preoperative weight reduction was extremely useful in the current patient with severe obesity and ascending colon cancer.

[Lymph Node Dissection and Postoperative Follow-Up for T2 Cancer of the Lower Rectum].

The outcomes of 88 patients with lower rectal T2 cancer who underwent radical A surgery(T2)were compared with those of 340 patients with T3 or T4a cancer(T3/T4a)and 51 patients with T1 cancer(T1). The rates of all lymph node(LN) metastasis, paraintestinal LN metastasis, intermediate and main LN metastasis, and lateral LN metastasis in T2 were all significantly lower than in T3/T4a and not different from those in T1. The recurrence rate of T2 was 15.9%, significantly lower than that of T3/T4a and not different from that of T1. Fifty percent of T2 recurrences were observed after 30 months postoperatively, significantly higher than that of T3/T4a and not different from that of T1. The 5-year survival rate of T2 was significantly higher than that of T3/T4a and did not differ from that of T1. In lower rectal T2, cancer LN dissection similar to that in T1 is appropriate, and high preoperative serum CA19-9 level is a risk factor for recurrence, suggesting the need for follow-up after 30 months postoperatively to take recurrence into consideration.

Prevalence and Risk Factors of Anal and Fecal Incontinence in Japanese Medical Personnel.

OBJECTIVES: This study aimed to elucidate the actual state of anal incontinence (AI), fecal incontinence (FI), and the associated factors in Japanese medical personnel. METHODS: A questionnaire was completed by Japanese medical personnel after listening to lectures on AI. AI was defined as involuntary loss of feces or flatus. RESULTS: A total of 463 persons (mean age, 35.6 years; range, 20-91; male/female/no answer, 132/324/7) participated in the questionnaire. AI occurred in 34.4% of 450 participants (flatus/liquid stool/solid stool: 30.4%/3.6%/0.4%). AI was significantly more prevalent in females (male/female: 15.5%/42.7%, p < 0.001). AI and FI occurred significantly more prevalent in participants aged ≧40 years (p < 0.024). AI was significantly associated with childbirth, frequency of childbirth (more than three times), vaginal delivery, urinary incontinence, the style of urination/defecation, and a history of gynecologic surgery and systemic diseases (p < 0.05). Female gender and age as well as urinary incontinence and inability to defecate separately in female and previous colorectal disease and/or surgery in male were risk factors of AI by multivariate analysis (p < 0.05). FI was correlated with urinary incontinence. CONCLUSIONS: AI and FI occurred in 34.4% and 4.0% of Japanese medical personnel, respectively. Gas incontinence was common in every age group. AI was associated with female gender, higher age group, urinary incontinence, the style of urination and defecation in female, and previous colorectal disease and/or surgery in male. FI was associated with urinary incontinence.

Outcomes of Transvaginal Anterior Levatorplasty with Posterior Colporrhaphy for Symptomatic Rectocele.

OBJECTIVES: To clarify the long-term outcomes of transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele with defecographic changes. METHODS: Consecutive patients undergoing transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele were prospectively registered and retrospectively reviewed using medical records. Symptoms, fecal incontinence, and defecographic findings were evaluated before and after surgery. RESULTS: Fifty-seven women (mean age, 68 years) were identified, and the median disease duration was 24 months. Symptoms of vaginal mass (n = 32) and difficult defecation (n = 21) disappeared (90.6% and 71.4%, respectively) or improved (6.3% and 28.6%, respectively) after surgery. However, the feeling of residual stool was unchanged in two of eight patients. Seventeen patients who performed digitation on defecation before surgery discontinued digitation after surgery. The proportion of patients who had fecal incontinence preoperatively (40.4%) decreased significantly after surgery (17.5%) during a median follow-up period of 47 months. Defecography revealed a disappearance or improvement of rectocele in all 18 patients examined. The average rectocele size decreased significantly in six improved patients (p = 0.0006, paired t-test). CONCLUSIONS: Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele was a useful option to improve symptoms and anatomical disorders in the long term, but it had limitations in improving defecatory symptoms.

Robotic low anterior resection for rectal cancer with side-to-end anastomosis in a patient with anal stenosis.

BACKGROUND: Colorectal anastomosis using the double stapling technique (DST) has become a standard procedure. However, DST is difficult to perform in patients with anal stenosis because a circular stapler cannot be inserted into the rectum through the anus. Thus, an alternative procedure is required for colorectal anastomosis. CASE PRESENTATION: A 78-year-old woman presented with bloody stool. Colonoscopy and computed tomography revealed advanced low rectal cancer without lymph node or distant metastasis. We initially planned to perform low anterior resection using a double stapling technique or transanal hand-sewn anastomosis, but this would have been too difficult due to anal stenosis and fibrosis caused by a Milligan-Morgan hemorrhoidectomy performed 20 years earlier. The patient had never experienced defecation problems and declined a stoma. Therefore, we inserted an anvil into the rectal stump and fixed it robotically with a purse-string suture followed by insertion of the shaft of the circular stapler from the sigmoidal side. In this way, side-to-end anastomosis was accomplished laparoscopically. The distance from the anus to the anastomosis was 5 cm. The patient was discharged with no anastomotic leakage. Robotic assistance proved extremely useful for low anterior resection with side-to-end anastomosis. CONCLUSION: Performing side-to-end anastomosis with robotic assistance was extremely useful in this patient with rectal cancer and anal stenosis.

[Clinical Study of Inguinal Lymph Node Metastasis in Anal Canal Adenocarcinoma].

We reviewed clinical records of 73 cases with anal canal adenocarcinoma who underwent bilateral inguinal lymph node (ILN)dissection. Eleven patients with positive ILN metastasis(ILNM)were compared with 62 patients with negative ILNM in clinicopathological items and treatment outcomes to evaluate the effectiveness of ILN dissection. Positive ILNM were older, higher preoperative serum levels of CEA and CA19-9, more frequencies of undifferentiated carcinoma, T4b and severe lymphatic invasion than negative ILNM. And the number of mesorectal and lateral node metastasis were significantly more in positive ILNM than negative ILNM. Although the frequency of curability A surgery was significantly less in positive ILNM (63.6%)than negative ILNM(93.5%), there were no significant differences in recurrence rate and prognosis between positive ILNM and negative ILNM in Stage Ⅲ cancer. Recurrence in ILN occurred significantly more in positive ILNM (2 cases) than in negative ILNM(0 case)as initial recurrent site. And recurrence in pelvic local site occurred significantly more in positive ILNM(4 cases)than in negative ILNM(6 cases). Although there was no significant difference in oncological outcome in Stage Ⅲ anal canal adenocarcinoma, ILN recurrence and pelvic local recurrence should be cared for positive ILNM in postoperative follow-up.

Outcomes of stapler repair with anastomosis for stoma prolapse.

PURPOSE: The published data on the outcomes of an operative repair for stoma prolapse are limited. This study aimed to clarify the long-term outcomes of stapler repair with anastomosis for stoma prolapse. METHODS: Twenty-four patients (15 men, median age 64 years, range 33-88 years) undergoing 25 stapler repairs with anastomosis were prospectively registered, and their medical records were retrospectively reviewed. RESULTS: The median length of prolapse was 10 cm (range 5-22). Stoma prolapse repair was performed by means of 16 loop colostomies, four end colostomies, three loop ileostomies, and one end ileostomy. A stapler was used 4.6 times on average (range 4-8). The average operative time and bleeding were 40.8 (range 15-75) min and 40 (range 0-214) mL, respectively. No mortality and morbidity were observed after surgery. A recurrence of stoma prolapse was reported in only one of 25 repairs (4%) at the proximal limb of loop ileostomy during a median follow-up period of 1 year (range 1-120 months). However, a new stoma prolapsed in one untreated limb of loop stoma. CONCLUSIONS: Stapler repair with anastomosis is a safe and minimally invasive treatment option for stoma prolapse with a low recurrence. However, the effectiveness of reparing stoma prolapse on the proximal limb of loop ileostomy might be limited.

Transvaginal peritoneocele repair with anterior levatorplasty for patients with a rectocele and an enterocele.

Enteroceles and rectoceles are often identified as the cause of a vaginal mass and pelvic discomfort. The combination of a rectocele and an enterocele as pelvic organ prolapses is not infrequent; however, there are few reports on possible simultaneous treatments of these two conditions. We report a new and simple procedure for repairing an enterocele during a transvaginal anterior levatorplasty with posterior colporrhaphy for a rectocele repair. This technique involves making an excision in the peritoneal sac, with high ligation, and attaching the uterine cervix and/or cardinal ligament to the upper most part of the approximation of the levator muscles, to reinforce and lift the deep peritoneal sac. This procedure allows for transvaginal repair of both an enterocele and a rectocele. The enterocele is visualized by applying barium to the posterior vaginal wall during defecography.

Exfoliated cancer cells during intersphincteric resection for very low rectal cancer.

PURPOSE: To investigate the frequency of exfoliated cancer cells and the efficacy of rectal washout during intersphincteric resection (ISR) in patients not receiving chemoradiotherapy (CRT) for very low rectal cancer. METHOD: The subjects of this prospective study were 16 consecutive patients who underwent ISR without CRT for very low rectal cancer. Brushing cytology of the posterior anorectal wall was performed twice in each step of the ISR procedure and the samples were sent for blind cytological examination to identify exfoliated cancer cells. RESULTS: Exfoliated cancer cells were identified in 9 of 13 patients (69%) preoperatively. The number of cancer cells identified after abdominal total mesorectal dissection decreased significantly from 94% (15/16) to 25% (4/16) after transanal irrigation with 2000 mL saline (p < 0.001). No cancer cells were identified after swabbing the anal wall following transanal dissection with purse-string closure of the distal stump. No suture-line recurrence was found during a median follow-up duration of 6 years. CONCLUSION: Exfoliated cancer cells, confirmed in 94% of patients after total mesorectal excision, could be eliminated by performing rectal irrigation after clamping the rectum proximal to the tumor and swabbing the anorectal wall during ISR.

Robotic Surgery for Rectal Cancer: Operative Technique and Review of the Literature.

The number of patients undergoing robotic surgery for rectal cancer has rapidly increased in Japan, since the government approved the procedure for national insurance coverage in April 2018. Robotic surgery has the potential to overcome some limitations of laparoscopic surgery, especially in the narrow pelvis, providing a three-dimensional view, articulated instruments, and a stable camera platform. Although meta-analyses and randomized controlled trials have failed to demonstrate the superiority of robotic surgery over laparoscopic surgery with respect to the short-term clinical outcomes, the published findings suggest that robotic surgery may be potentially beneficial for patients who are obese, male, or patients undergoing sphincter-preserving surgery for rectal cancer. The safety and feasibility of robotic surgery for lateral lymph node dissection, the standard procedure for locally advanced lower rectal cancer in Japan, have been demonstrated in some retrospective studies. However, additional prospective, randomized trials are required to determine the actual benefits of robotic surgery to ameliorate the urogenital and oncological outcomes. The cost of this approach is a long-standing principal concern. A literature search showed that the cost of robotic surgery for rectal cancer was 1.3-2.5 times higher per patient than that for the laparoscopic approach. We herein describe our surgical technique using a da Vinci Surgical System (S/Si/Xi) with 10 years of experience in performing robotic surgery. We also review current evidence regarding short-term clinical and long-term oncological outcomes, lateral lymph node dissection, and the cost of the procedure.

[Postoperative Follow-Up for Stage â ¡ Low Rectal Cancer with Curative Surgery].

We reviewed clinical records of 354 cases with low rectal carcinoma(RC)after curative surgery(stage Ⅱ 149 cases and stage Ⅲ 205 cases). Stage Ⅱ with recurrence(23 cases)were compared with stage Ⅱ without recurrence(126 cases)in clinicopathological items to evaluate the factors affecting recurrence of stage Ⅱ RC, and were compared with stage Ⅲ with recurrence(89 cases)in treatment outcomes to identify the proper follow-up. Multivariate analysis revealed that sex and serum CA19-9 level were affecting factors for recurrence in stage Ⅱ low RC. The local recurrence rate of recurrence cases in stage Ⅱ RC(47.8%)was higher than in stage Ⅲ RC(29.2%). Recurrence was more found by serum tumor marker level in stage Ⅲ RC than in stage Ⅱ RC. Surgery for recurrent diseases was significantly more performed in stage Ⅱ RC(60.9%) than stage Ⅲ RC. Overall survival in stage Ⅱ RC with recurrence was significantly better than in stage Ⅲ RC with recurrence. And the prognosis after recurrence was also better in stage Ⅱ RC than in stage Ⅲ RC. It was thought that proper follow-up mainly by image examination would be effective to improve the prognosis.

Short- and long-term outcomes of robotic surgery for rectal cancer: a single-center retrospective cohort study.

PURPOSE: This study aimed to clarify the short- and long-term outcomes of robotic surgery with or without lateral lymph node dissection (LLND) for rectal cancer at Fujita Health University Hospital, Aichi, Japan, during a self-pay period. METHODS: We retrospectively evaluated 115 consecutive patients who underwent robotic surgery for rectal cancer between September 2009 and March 2018, with a median follow-up period of 48 months. Total mesorectal excision was completed by two certified surgeons using a da Vinci S, Si, or Xi Surgical System with an entirely robotic single-docking technique. The surgical and pathological outcomes, morbidity, and oncological results were examined. RESULTS: Lateral lymph node dissection was performed in 26 patients (22.6%). Neither conversion to open surgery nor perioperative blood transfusion occurred. Ten patients (8.7%) experienced Clavien-Dindo grade III postoperative complications. Pathologically, both the distal and radial margins were negative in all cases. The 5-year relapse-free survival rates for stages I, II, III, and IV were 93.5%, 100%, 83.8%, and not reached, respectively. CONCLUSIONS: Even in the period before coverage by the health insurance system, robotic surgery for rectal cancer performed by experienced surgeons was safe and technically feasible, with favorable perioperative results and long-term oncological outcomes, including rates of the relapse-free survival.

Repeat hepatectomy with systemic chemotherapy might improve survival of recurrent liver metastasis from colorectal cancer-a retrospective observational study.

BACKGROUND: Although hepatectomy for metastatic colorectal cancer (mCRC) prolongs survival in up to 40% of people, recurrence rates approach 70%. We used a multidisciplinary approach to treat recurrent liver metastases, including chemotherapy, surgery, and palliative care. On the other hand, development of chemotherapeutic agents is remarkable and improves long-term survival. However, whether chemotherapy and repeat hepatectomy combination therapy improve survival or not is still unclear. The aim of this study was to analyze the outcomes of repeat hepatectomy with systemic chemotherapy for mCRC. METHODS: Following Institutional Review Board approval, we reviewed the records of all patients who underwent hepatectomy for mCRC between 1974 and 2015 at Fujita Health University Hospital. We used the Kaplan-Meier method to estimate overall survival from the first and last hepatectomy in multi hepatectomy cases after 2005 and compared outcomes between groups using the log-rank test. RESULTS: A total of 426 liver resections were performed for mCRC; of these, 236 cases were performed after 2005 (late group). In 118 (50%) cases, the site of recurrence was the liver, 59 (50%) underwent repeat hepatectomy, and 14 cases had ≥ 2 repeat hepatectomies. Overall survival (OS) before and after 2005 was 42.2 and 64.1 months, respectively, with the late group having better OS compared to the early (1974-2004) group. OS for single hepatectomy cases was 83.2 months, for two hepatectomies was 42.9 months, and for three hepatectomies was 35.3 months. In total, 59 patients did not undergo surgery after recurrence with an OS of 28.7 months. Mortality of the second and third repeat hepatectomy was 1.7% and 15.3%, respectively. CONCLUSION: Repeat hepatectomy with systemic chemotherapy for mCRC is feasible and might achieve improved survival in carefully selected patients.

A case of locally advanced adenosquamous carcinoma of the cecum with long-term survival.

A 63-year-old woman was admitted to our hospital with a right lower abdominal mass and general fatigue. Preoperative examination suggested a large ovarian tumor or cecal carcinoma. However, her intraoperative diagnosis was colon cancer; we therefore performed an ileocecal resection with oophorectomy. The tumor was pathologically diagnosed as adenosquamous carcinoma T4bN1M-stage IIIa. We administrated CapeOX adjuvant chemotherapy for 6 months. Adenosquamous carcinoma is extremely rare, at around 0.1% of all colorectal cancers, and usually has a poor prognosis. The patient is still alive without recurrence after 84 post-operative months, even with later developments of metachronous early colorectal cancer and breast cancer. We herein report a rare case of cecal ASC with good prognosis.

[Study of Skip Metastasis to Lateral Lymph Nodes in Low Rectal Cancer].

We reviewed the clinical records of 302 patients with low rectal carcinoma to evaluate the effectiveness of lateral lymph node(LLN)dissection in cases of skip metastases to the LLN. Patients were divided into 4 groups according to nodal status: group N(133 cases), no metastasis in both the mesorectum lymph node(MLN)and LLN; groupM(100 cases), metastasis in the MLN and no LLN metastasis; group L(15 cases), which was defined as skip metastasis, with no metastasis in the MLN and LLN metastasis; and group ML(54 cases), node metastases in both the MLN and LLN. LLN metastasis was found in 22.8% of all patients, and skip metastasis was found in 10.1%. The recurrence rate in group L(40.0%, 6 cases)was significantly lower than that in group ML(75.9%, 41 cases)and not different from that in group M(43.0%, 43 cases). The initial recurrence sites in group L were the lung(3 cases)and local recurrence(3 cases). In group L, 20.0% had hematogenous recurrence, which was lower than in group ML. There was no significant difference between group L(5-year survival rate: 57.1%)and group M(71.7%)in terms of prognosis. Multivariate analysis revealed that histology was a risk factor for LLN metastasis in lowrectal cancer without MLN metastasis. The positive predictive value of LLN metastasis based on computed tomography was 43.9%. It was believed that LLN dissection was important, especially for non-differentiated cancer, in consideration of skip metastases to the LLN.

[Outcomes of Anal Squamous Cell Carcinoma Treated with Chemoradiotherapy].

We evaluated the effectiveness of chemoradiotherapy(CRT)by reviewing 11 clinicalcases of analsquamous cellcarcinoma( SCC). Radiotherapy(RT)consisted of 40 Gy delivered to pelvic and bilateral inguinal lesions, and a perianal booster dose of 20 Gy in fractions of 2.0 Gy per day, 5 days per week. 5-fluorouracil(5-FU)and mitomycin C were administered twice every 4weeks as standard chemotherapy. On the first day of RT, patients received a single bolus dose of 10mg/m2 mitomycin C, and a continuous 24-hour infusion of 750mg/m2 5-FU for 5 days. One patient with a T3 tumor was orally administered S- 1 during RT because of his poor generalcondition, and 1 patient with a T2 tumor did not receive 1 course of 5-FU and MMC owing to an adverse event. Grade 3 adverse effects occurred in 3 patients, but all 11 patients completed CRT. The anal lesions of 10 patients had complete response after CRT. Recurrence of anal lesions occurred in 4 patients, including 2 patients who were not treated with standard CRT. Of 8 patients who received CR via standard CRT, 2 patients had recurrence of anal lesions more than 60 months after completion of CRT. CRT is believed to be safe and effective for improving the prognosis of anal squamous cell carcinoma; however, sufficient and appropriate follow-up is necessary after complete response.