Risk Factors for Early Postoperative Small Bowel Obstruction After Anterior Resection for Rectal Cancer.

PURPOSE: The aim of the study was to evaluate risk factors for small bowel obstruction (SBO) in early postoperative period after anterior resection for rectal cancer. METHODS: Patients who underwent anterior resection (AR) [high AR (HAR) or low AR (LAR)] for rectal cancer between January 2009 and April 2016 were enrolled into the study after fulfilling selection criteria. In included patients, risk factors for early postoperative SBO (EPSBO) were analyzed by means of univariate and multivariate analysis. Cases with perioperative major complications other than intestinal obstruction and with simultaneous resection of other organs were excluded. The same analyses were also performed for cases of redo surgery due to EPSBO. EPSBO was defined as clinically and radiologically confirmed SBO that developed after resuming oral intake within 30 days following surgery. The logistic regression method was used for statistical analyses. RESULTS: In enrolled 180 patients, EPSBO occurred in 23 (12.8%). In univariate analysis, male sex [odds ratio (OR) = 2.17, 95% CI = 0.82-6.84, p < 0.0001], previous abdominal surgery (OR = 0.20, 95% CI = 0.03-0.73, p = 0.0117), low tumor (OR = 3.26, 95% CI = 1.28-8.13, p = 0.0140), LAR (OR = 17.25, 95% CI = 3.49-312.55, p < 0.0001), D3 node dissection (OR = 13.61, 95% CI = 2.75-246.69, p = 0.0002), defunctioning ileostomy (DI) formation (OR = 9.88, 95% = 3.80-29.14, p < 0.0001), and prolonged operation time (OR = 1.01, 95% CI = 1.00-1.01, p = 0.0122) were significantly related to EPSBO. Multivariate analysis demonstrated that D3 node dissection (OR = 10.93, 95% CI = 1.94-208.23, p = 0.0038) and DI formation (OR = 5.82, 95% CI = 1.55-25.31, p = 0.0083) were independent risk factors for EPSBO. Four cases (17.4%) with EPSBO required re-operation because conservative therapies failed; all were laparoscopic DI formation cases. In three of those four cases, stenosis of stoma at the level of the posterior sheath of rectus abdominis muscle was the reason of SBO, and in one case it was kinking of the stomal limb. CONCLUSIONS: D3 lymph node dissection and DI formation are independent risk factors for EPSBO in AR.

Laparoscopic modified Sugarbaker parastomal hernia repair with 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh technique.

BACKGROUND: The ideal mesh and mesh fixation technique for laparoscopic Sugarbaker (SB) parastomal hernia repair have not yet been identified. METHODS: Sixteen patients with parastomal hernia who underwent laparoscopic modified SB repair (LSB) between June 2012 and October 2015 were retrospectively analyzed. LSB was performed using a developed standardized 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh (PCO-PM) technique. RESULTS: Out of 16 cases, 14 were primary and 2 recurrent hernias; 13 were para-end colostomy and 3 were para-ileal conduit (PIC) hernias. The median longitudinal and transverse diameters of the hernia orifice were 5 cm (2.5-7 cm) and 4.2 cm (2-6 cm), respectively. Five cases had a concomitant midline incisional hernia, which was simultaneously repaired. In all cases, the mesh was placed without deflection. The median operation time was 193 (75-386) min. Perioperative complications occurred in two cases (13 %) with PIC, one intra-operatively and the other postoperatively. The intra-operative complication was enterotomy close to the ureteroenteric anastomosis of the ileal conduit; it was repaired through a mini-laparotomy. LSB was accomplished without any subsequent postoperative complications. The postoperative complication was ureteral obstruction that required creation of nephrostomy. Mini-laparotomy was necessary in those two cases (13 %) because of intra-operative enterotomy and severe intra-abdominal adhesions. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed with a median follow-up of 14.5 (2-41) months. CONCLUSIONS: Our LSB using standardized mesh fixation technique is safe and feasible, and the PCO-PM seems to be the most optimal prosthesis.

Transperineal Repair of Secondary Perineal Hernia Using a Mesh with a Memory-recoil Ring.

Objectives: The aim of this study was to evaluate the effectiveness of transperineal repair of secondary perineal hernia (SPH) using a mesh with a memory-recoil ring. Methods: Seven patients with SPH who underwent transperineal repair (TPR) between July 2010 and May 2022 were retrospectively analyzed. TPR was performed using a mesh with a memory-recoil ring. Results: All SPHs developed after abdominoperineal resections in patients with anorectal malignancies. The median longitudinal and transverse diameters of the hernia orifice were 8 (7-10) cm and 6 (5-7) cm, respectively. In all cases, the mesh was fixed to the ischial tuberosity, residual levator muscle, coccygeus muscle, and coccyx after thorough dissection of the sac. The median operation time was 154 (142-280) min. Perioperative complications occurred in 2 cases (29%). One was enterotomy, which caused postoperative mesh infection requiring extraction of the mesh. The other was vaginal injury, which resulted in vaginal fistula but closed spontaneously. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed during a median follow-up of 35 (9-151) months. Conclusions: TPR using a mesh with a memory-recoil ring is safe, feasible and promising technique for SPH repairs.

Possibility of sandwiched liver surgery with molecular targeting drugs, cetuximab and bevacizumab on colon cancer liver metastases: a case report.

A 31-year-old man with sigmoid colon cancer with concomitant simultaneous multiple liver metastases had received FOLFIRI (leucovorin, fluorouracil and irinotecan) and FOLFOX6 (leucovorin, fluorouracil and oxaliplatin) after an ordinary sigmoidectomy. However, his serum carcinoembryonic antigen (CEA) level increased rapidly during the fifteen months after the operation while he was on FOLFOX6. Abdominal computed tomography revealed expanding multiple liver tumors. As the third line chemotherapy, a combination therapy of cetuximab with irinotecan was given, which markedly reduced his levels of serum CEA, and the size and number of liver tumors. He underwent lateral segmentectomy of the liver and microwave coagulation of the liver metastases in the remnant liver. Thereafter, a good quality of life with tumor dormancy was obtained for 6 months. However, his serum CEA started to rise again in the absence of liver tumors. Therefore, FOLFOX6 with bevacizumab was chosen as the fourth line chemotherapy, and the serum CEA was reduced with tumor dormancy. A good quality of life was obtained again at 3 years after the first surgery. This report indicates the effectiveness of sandwiched liver surgery with the molecular targeting drugs cetuximab and bevacizumab on multiple liver metastases of colon cancer, and suggests the possibility of a regimen consisting of bevacizumab following cetuximab.

Single-incision laparoscopic ileoproctostomy for chronic constipation.

A 56-year-old woman who had undergone cesarean section thirty-five years ago and appendectomy forty years ago was referred to our department for surgical treatment of chronic constipation of over thirty years duration. She underwent laparoscopic ileoproctostomy using a single incision laparoscopic surgery (SILS) in July 2009. After laparoscopic mobilization of the ileocecal portion, the terminal ileum was transected by a stapler. Ileoproctostomy was performed by a circular stapler inserted transanally after the placement of an anvil on the ileal stump. The duration of the operation was 90 minutes and perioperative blood loss was less than 10mL. Her postoperative course was uneventful and she was discharged ten days after the operation. After discharge her bowel habits have been regular without any laxatives. SILS has been performed since the late 1990s for a wide variety of surgical procedures. To our knowledge however, this is the first report of ileoproctostomy using SILS for chronic constipation.

Feasibility study of adjuvant chemotherapy with S-1 (TS-1; tegafur, gimeracil and oteracil potassium) for colorectal cancer.

BACKGROUND/AIMS: The aim of this study is to evaluate feasibility and safety of 3-week method (3-week administration and 1-week withdrawal) for colorectal cancer as adjuvant chemotherapy with an oral anticancer drug, S-1. METHODOLOGY: Forty-two patients with stage II or III colorectal cancer who underwent curative resection in our hospital during a one year period in 2005 were enrolled in the preliminary pilot study. Between 2006 and 2007, 104 patients with stage II or III colorectal cancer who underwent curative resection in our hospital were chosen and were randomly divided into two groups, 3-week method or 4-week method (4-week administration and 2-week withdrawal) for a prospective randomized trial. RESULTS: The one-year completion rate in the 3-week method group was 98% (50/51) which was significantly better than that in the 4-week method group, 68% (36/53) (p=0.035). There were no grade 3 or 4 adverse reactions in both laboratory and clinical findings in the pilot study and in the prospective randomized trial. CONCLUSIONS: Three-week method of S-1 administration had good feasibility, easily manageable toxicity, high accumulated dose in one year and good compliance. The 3-week method with S-1 may be a standard adjuvant chemotherapy schedule for colorectal cancer.

Lateral pelvic lymph node dissection using latero-vesical approach with aspiration procedure for advanced lower rectal cancer.

BACKGROUND/AIMS: The aim of this study was to evaluate the impact of complete dissection of areolar tissue surrounding lymph nodes in lateral pelvic lymphadenectomy on the outcome of advanced rectal cancer at or below the peritoneal reflection. METHODOLOGY: From 1995 to 2004, lateral pelvic lymph node dissection was performed in 141 consecutive patients with advanced rectal cancer at or below the peritoneal reflection by open surgery in our hospital. They were divided into two groups according to the techniques used for lymph node dissection, i.e. conventional method (CM) and our original method, latero-vesical approach with aspiration procedure (LVA), which eliminates not only lymph nodes but also the tissue surrounding the lymph nodes. RESULTS: The number of dissected lateral pelvic lymph nodes by LVA was significantly higher than that by CM. In patients without lateral pelvic lymph node metastasis, no significant difference in the outcome was observed between the two groups. On the contrary, among the patients with lateral pelvic lymph node metastasis, five-year survival rates of the group with CM or with LVA was 50% and 70% respectively. CONCLUSIONS: For patients with lateral pelvic lymph node metastasis, lateral pelvic lymphadenectomy, complete dissection of areolar tissue surrounding lymph nodes, may contribute to improve the prognosis of advanced rectal cancer at, or below, the peritoneal reflection.

[A case report of complete response to low-dose S-1 monotherapy for pancreatic cancer in elderly patient].

A 87-year-old woman was diagnosed with pancreatic body cancer(Stage II ). Because of her age and history of open distal partial gastrectomy, it seemed that having her undergo an invasive surgery would be difficult. Therefore, S-1 was administered orally at a dose of 50mg/day for 28 consecutive days followed by a 14-day rest course(low-dose S-1 monotherapy). After 2 courses, the tumor marker(CA19-9)dramatically decreased to within the normal range. After 5 courses, the tumor could not be identified on the abdominal CT image, and it was judged to be a complete response. Low-dose S-1 monotherapy may be useful for improving the prognosis of pancreatic cancer without causing intolerable toxicity, especially for elderly patients.

Emergency transanal total mesorectal excision for perforated rectal cancer: a two-case series.

BACKGROUND: Surgery for perforated rectal cancer is technically difficult because of paralytic dilatation due to generalized fecal peritonitis, the presence of a bulky tumor, and fecal retention due to obstruction. Transanal total mesorectal excision (TaTME) is the latest minimally invasive transanal technique pioneered to facilitate difficult pelvic dissections. It can provide a good surgical field linearly from the perineal side and reduce manipulations from the intraabdominal side. Here, we present two cases of emergency TaTME performed for perforated rectal cancer. CASE PRESENTATION: The patients were a 38-year-old female and a 75-year-old male. They were diagnosed with perforated rectal cancer and were in a state of septic shock. Emergency Hartmann's procedure was performed in both cases. Intraoperative findings showed fecal contamination of the entire abdomen and dilated intestines and bulky tumors with perforation. The female patient had multiple uterine fibroids, and the male patient had an enlarged prostate. For both patients, dissection of the mesorectum to the anal side of the tumor and transection of the rectum on the anal side of the tumor via a linear stapler were considered difficult because of the insufficient surgical field of view into the pelvis. Therefore, a two-team approach with TaTME was adopted. En bloc resection of the rectum was completed by collaboration of the abdominal team and the transanal team, and the autonomic nerves were successfully preserved. Finally, the specimens were resected, and the anal edge of the rectum was closed with a purse-string suture by the transanal team. Although these two cases were emergency surgeries in difficult situations, the cancer lesions were successfully and safely removed without involvement of the resection margin. CONCLUSIONS: This is the first report of emergency TaTME. Although these cases were emergency operations in a situation where it was difficult to pursue radical resection-and often times in these situations, the operation may end with only stoma creation-the specimens were safely resected. Emergency TaTME is a useful procedure for treatment of perforated rectal cancer.

Feasibility of using a tailored mesh in laparoscopic Sugarbaker parastomal hernia repair.

BACKGROUND: In parastomal hernia (PH) repair, laparoscopic Sugarbaker technique (LS) is considered the best practice; however, meshes specific for LS repairs ceased to be available. PURPOSE: The aim of the study was to evaluate feasibility of using a physician-modified mesh (tailored mesh: TM) in LS. METHODS: Thirty-three patients who underwent LS for PH between June 2012 and September 2021 were examined to compare surgical outcomes between LS with TM (n = 11) and with a ready-made specific mesh (SM, n = 22). All meshes were coated plastic meshes. Statistical analysis was performed with the Mann-Whitney U test and Fisher's exact test. P < .05 was considered to be statistically significant. RESULTS: We compared the outcomes of TM with SM in LS for similar hernia types during median follow-up periods of 23 (range, 2-29) and 74 (range, 36-110) months (P < .0001), respectively. The median operation times were 146 (range, 45-423) for TM and 193 (range, 65-386) minutes for SM (P = .2301). Perioperative complications were observed in one TM patient (9%) and two SM patients (9%) (P = 1.0000). The lengths of postoperative stay were similar. Recurrence was observed in two cases in the SM group (9%) within 1 year after the operation. CONCLUSION: In LS, TM seems to be a feasible mesh comparable to SM within short- and mid-term follow-up.

Usefulness of one suprapubic assist port in umbilical incision laparoscopic surgery for right-side colon cancer.

BACKGROUND/AIMS: Although single incision laparoscopic surgery (SILS) has been performed for right-side colon cancer, it cannot always be completed by only umbilical incisional ports. One suprapubic assist port in SILS for right-side colon cancer is useful for such cases. METHODOLOGY: Seventeen patients underwent SILS for right-side colon cancer between September 2009 and August 2010. Six patients (35%) who could not complete the procedure with only umbilical incisional ports for right-side colon cancer were evaluated. RESULTS: All six patients could not be operated on with only the umbilical incisional ports because the root of the ileocolic artery and vein could not be dissected because of obesity or difficulty with controlling the intestine. However, they could undergo laparoscopic surgery when only one suprapubic assist port was inserted. The mean operation time was 192.2 minutes (range 128-230), the mean intraoperative blood loss was 26.7mL (range 0-90) and the mean postoperative hospital stay was 9.2 days (range 9-10). Postoperatively, none of the six patients had any complications. CONCLUSIONS: One suprapubic assist port in SILS for right-side colon cancer seems to be useful for patients who cannot be operated on with only umbilical incisional ports.

Colorectal anastomosis using retroperitoneal window after wide colorectal resection.

After wide colorectal resection, some patients require colostomy due to the difficulty with performing primary colorectal anastomosis. For such patients, we have devised a novel technique of coloproctostomy or coloanal anastomoses through an extra-anatomical route, the retroperitoneal window (RPW), as a reconstruction route. The peritoneum over the inferior margin of the horizontal portion of the duodenum is incised, and the retroperitoneal route is dilated dorsal to the ileocolic artery and vein from the incision below the duodenum towards the right ventral aspect of the aortic bifurcation in the retroperitoneal space. This route is called RPW. After colorectal resection, the proximal stump of the colon is delivered through the RPW, and coloproctostomy or coloanal anastomoses is performed. Nine patients underwent this procedure during a three-year period from December 2007 to November 2010. This technique allowed coloproctostomy was performed in six and coloanal anastomoses in three patients. Without any complications, none of the nine patients required temporary colostomy. By using RPW, the necessity of colostomy would be reduced in patients who require wide colorectal resection.

Risk of Outlet Obstruction Associated With Defunctioning Loop Ileostomy in Rectal Cancer Surgery.

Background: The outlet obstruction (OO) rate is 5.4-18.4% after defunctioning ileostomy (DI) following rectal cancer resection to reduce the incidence and severity of anastomotic leakage; OO affects a patient's quality of life and prolongs hospitalization. Patients and Methods: A retrospective analysis was performed of patients who underwent anterior rectal resection and DI for rectal cancer. Results: Among 100 patients undergoing anterior rectal resection with DI for rectal cancer, 28 (28%) developed OO. Anastomotic leakage and a rectus abdominis muscle thickness ≥10 mm on preoperative computed tomography were significantly associated with the risk of OO in univariate analysis. Multivariate analysis also demonstrated that anastomotic leakage (odds ratio=4.320, 95% confidence interval=1.280-14.60, p=0.019) and rectus abdominis muscle thickness ≥10 mm (odds ratio=3.710, 95% confidence intervaI=1.280-10.70, p=0.016) were significantly risk factors for OO. Conclusion: When OO is observed, an anastomotic leakage should be suspected, especially if there is a high rectus abdominis muscle thickness.

Retrograde single stapling technique for laparoscopic ultralow anterior resection.

A highly effective surgical technique is required for laparoscopic low rectal transection without sufficient distal margins when ultralow anterior resection (ULAR) with a stapler is a technical challenge for laparoscopic surgery. We report a retrograde single stapling technique (RSST) for laparoscopic ULAR. Total mesorectal excision is performed laparoscopically. After the anal side of the tumor has been closed transanally, the distal line in the right lateral wall of the rectum is partially transected with laparoscopic coagulation shears (LCS). The distal line in the rectum is transected circularly with LCS after detecting the cutting part in the right lateral wall of the rectum laparoscopically. The end of the distal rectum is closed by a purse-string suture using 2-0 prolene transanally. Intestinal resection is performed extracorporeally through a suprapubic incision. After an anvil is placed in the proximal end of the colon over a purse-string suture, it is introduced to the anal canal transabdominally. The purse-string suture is tied to the anvil shaft before connecting it to the center shaft of the circular stapler; the instrument is then fired to create end-to-end anastomosis. For the prevention of anastomotic leakage, a 24-french balloon catheter which decompresses the anastomosis is inserted through the anus.

Umbilical incision laparoscopic surgery with one assist port for anterior resection.

BACKGROUND: A high surgical technique is required for laparoscopic anterior resection using single-incision laparoscopic surgery such as multiport surgery. We report a novel surgical technique of umbilical incision laparoscopic surgery with one assist port which could be performed like conventional multiport surgery. METHODS: With the patient in the lithotomy position, a 3-cm longitudinal skin incision is made at the umbilicus and carried down to the peritoneum. A 12-mm and two 5-mm trocars are placed through the incision. Another 12-mm trocar is placed for the insertion of laparoscopic coagulation shears and a stapler in the right lower quadrant. After surgery, the trocar in the right lower quadrant is removed and a drain is replaced through the insertion site. The operator mainly uses two trocars, a 5-mm trocar placed at the umbilicus and a 12-mm trocar in the right lower quadrant, making it like conventional laparoscopic surgery. RESULTS: The median operation time was 195 (range 180-205) min, intraoperative blood loss was 20 (range 0-60) ml, and none of the 3 patients had any complications postoperatively. CONCLUSION: As opposed to surgery with only three ports, so-called single-incision laparoscopic surgery, this operation can be performed much more comfortably if another port is inserted in the right lower quadrant.

Where should the specimen be excised for the chemosensitivity of colorectal cancer to 5-fluorouracil?

BACKGROUND/AIMS: The aim of this study was to reveal the relationship between the expression of dihydropyrimidine dehydrogenase (DPD) and thymidylate synthase (TS) in normal tissue, lymph nodes or tumors and as a prognostic indicator in T3 rectal carcinoma. METHODOLOGY: This study was prospectively conducted on 20 consecutive patients with T3 rectal cancer for whom surgically curative resection was performed between 2000 and 2002. Specimens were obtained from normal tissue more than 10cm away from the tumor, the lymph node in the mesorectum, and tumor tissue during surgery. The specimens were promptly frozen at -80 degrees C for DPD and TS value assaying. RESULTS: DPD expression in the tumor did not correlate with postoperative recurrence. However, there was a strong relationship between recurrence and expression of TS at the invasive front of the tumor or in the lateral border of the tumor. Particularly, TS expression at the invasive front of the tumor strongly correlated with recurrence (p = 0.002). CONCLUSIONS: For the chemosensitivity of colorectal cancer to 5-Fluorouracil, the specimen should be excised from the invasive front of the tumor, and TS expression should be evaluated in it.

Laparoscopy-assisted lateral pelvic lymph node dissection for advanced rectal cancer.

In Japan, there has been no indication of laparoscopic surgery for advanced lower rectal cancer because of the problem about the treatment of lateral pelvic lymph node metastasis. We report a new technique which allows lateral pelvic lymph node dissection like in open surgery for advanced rectal cancer. After laparoscopic total mesorectal excision for rectal cancer, a surgical incision of approximately 8 cm is placed in the supra-pubic area. Then, the latero-vesical area of the retroperitoneum, latero-vesical space is dissected bluntly with forceps. The external iliac artery and vein are taped and lymph node dissection is performed. As the external iliac vein is pulled internally, fatty tissue including lymph nodes in the obturator space is separated from the psoas major muscle. After completing of such a procedure, the obturator nerve is indentified in the fatty tissue with surrounding lymph nodes. As the external iliac vein is pulled laterally, fatty tissue including lymph nodes in the oburator space is dissected by fat aspiration procedure (FAP) using a suction tip. FAP is helpful to confirm the vascular system, by which the obturator space is skeletonized and anatomical structures are identified clearly.

Single-incision laparoscopic right colectomy for recurrent Crohn's disease.

A 36-year-old male with Crohn's disease who had undergone partial resection of the small intestine twelve years ago developed recurrent disease in the terminal ileum in March, 2009. He was referred to our department for the second operation because his abdominal pain and appetite loss were progressively worse. He underwent laparoscopic right colectomy using single incision laparoscopic surgery (SILS) for the recurrent lesion in May, 2009. The duration of the operation was 130 min, and perioperative blood loss was 100 ml. His postoperative course was uneventful and was transferred to the Department of Internal Medicine ten days after the operation for the chemotherapy with infliximab. SILS has been performed since the late 1990s for a wide variety of surgical procedures. We describe the reported first case of single incision laparoscopic right colectomy for recurrent Crohn's disease.

Where is the best skin incision for partial resection of the small intestine?

BACKGROUND/AIMS: For partial resection of the small intestine for benign disease such as Crohn's disease, a large incision has been placed in the mid-abdomen, for which ideal location and its length remain to be clarified. This study evaluated the validity of anthropometric placement of such an incision for partial resection of the small intestine. METHODOLOGY: Thirty consecutive patients with advanced rectal cancer (Age 30-82 {mean 60.1} years, 15 men and 15 women) who underwent anterior resection by open surgery between 2005 and 2006 were studied. The position of the viscera was projected on the anterior wall of the abdomen in relation to the umbilicus. RESULTS: The position of each viscera (Xcm, Ycm) was as follows; Duodenojejunal flexure (1.3 +/- 1.3, 9.4 +/- 2.1) and ileoceal valve (-7.3 +/- 1.0, -2.8 +/- 1.7). The small intestine which is not fixed to the retroperotoneum was located between the duodenojejunal flexure and the ileoceal valve. CONCLUSION: The ideal location of a small skin incision for small intestinal lesions is above the umbilicus for jejunal lesions, and below the umbilicus for ileal lesions.

Serum p53 antibody is a useful tumor marker of early colorectal cancer.

The aim of this study was to evaluate the significance of preoperative serum p53 antibodies (Abs) in patients with colorectal cancer. Between 2007 and 2008, serum p53 Abs were measured by enzyme-linked immunoabsorbent assay in 100 consecutive patients with colorectal cancer. Relationships between clinicopathologic features and the preoperative presence of serum p53 Abs were evaluated. Serum p53 Abs were positive in approximately 30%, regardless of the depth of tumor invasion--sm (submucosa), mp (muscularis propria), or ss (subserosa). Two patients among 23 T1 patients (9%) had lymph node metastasis. These 2 patients belonged to a group of 7 patients who were determined positive for serum p53 Abs (29%), although none of 16 patients negative for serum p53 Abs had lymph node metastasis, regardless of vascular invasion. Preoperative serum p53 Abs do not seem to be a marker of tumor progression but may be a useful marker for detecting high risk of lymph node metastasis in T1 colorectal cancer.