[Experience of Introduction of Robotic-Assist Surgery at Regional Hospital].

Our hospital introduced the da Vinci Xi Surgical System in April 2022. At the same time, laparoscopic surgery was also introduced to produce endoscopic surgical skill qualification system: qualified surgeon. Open surgery for trainees was also continued as before, and young surgeons were instructed to always keep their motivation high. After the introduction of robotic surgery, conferences that were accessible to trainees were held on a regular basis. In addition, the environment was designed to allow anyone to train da Vinci Surgical System. The introduction of robotic surgery has certainly reduced the number of procedures performed by trainees, especially in rectal cancer. However, surgical outcomes were better after the introduction of robotic surgery. The trend was similar for both open and laparoscopic surgery. We report on our efforts to introduce robot-assisted surgery and the actual situation in which surgeons at various stages of their education can work together to achieve a win-win situation.

Treatment and subsequent prognosis in locally recurrent rectal cancer: a multicenter retrospective study of 498 patients.

PURPOSE: Locally recurrent rectal cancer (LRRC) has a tremendous impact on prognosis as well as the quality of life. Because of the low incidence and various recurrence patterns, the treatment outcome of LRRC is not fully elucidated. The current study aimed to evaluate the prognosis and identify the prognosticators in patients with LRRC. METHODS: We conducted a multicenter study at 24 hospitals in Japan. Patients with primary rectal cancer who underwent curative resection between 1997 and 2012 and developed local recurrence only as a first recurrent event were recruited. The primary outcome of our study was overall survival (OS) after a diagnosis of LRRC. RESULTS: Four hundred and ninety-eight patients were included in the study. Of these, 213 (42.8%) underwent surgical resection; this was associated with the best 5-year OS rate of 52%, followed by carbon ion/proton therapy (44%). Among LRRC patients, undifferentiated type, T4, high CEA level, and high CA19-9 level were independent prognosticators of OS (hazard ratio (HR) = 1.83, P = 0.008, HR = 1.54, P = 0.004, HR = 1.35, P = 0.03, and HR = 1.58, P = 0.003, respectively). CONCLUSIONS: This large-scale cohort study showed that surgical resection led to a favorable prognosis compared to other treatments for LRRC. Therefore, surgical resection should be considered whenever feasible for LRRC patients. In addition, undifferentiated type, T4, and tumor marker (CEA and CA19-9) elevation were identified as independent prognostic factors for OS among patients with LRRC.

[Meningeal Carcinomatosis of Sigmoid Colon Cancer-A Case Report].

A 60-year-old man with sigmoid colon cancer invading the urinary bladder underwent sigmoid colectomy and partial cystectomy. He developed headache and vomiting 12 weeks after surgery, and urgently hospitalized. Contrast MRI of head and whole spinal cord inspected no abnormality. CSF examination showed elevated CA19-9 20,551 U/mL, and the cytology revealed atypical cells similar to the sigmoid colon cancer cells. He was diagnosed as meningeal carcinomatosis, and received 1 course of CAPOX plus bevacizumab chemotherapy. He died 18 weeks after the surgery.

[Surgical Treatment for Extremely Elderly Patients Over 90 Years of Age with Colorectal Cancer].

We report 18 cases of colorectalcancer in patients aged over 90 years who received surgicaltreatment . Except for 2 patients who had StageⅣ colorectal cancer, all patients underwent R0 colorectal resection. The mean operation time, blood loss, and length of hospitalization were 167 min, 115 mL, and 23.5 days, respectively. Postoperative complications occurred in 15 patients(83%), of which the most common was delirium. All the patients were discharged safely. We treated them successfully with a collaborative medical team that included experienced staffs for rehabilitation, oral care, skin care, and mentalcare; socialworkers; and others. Regarding the surgicaltreatment for elderly patients with colorectalcancer who are over 90 years of age, not only perioperative treatment but also post-discharge comprehensive and palliative care must be considered.

[A Case of Gastric Large-Cell Neuroendocrine Carcinoma Combined with Adenocarcinoma in the Cecum].

A 74-year-old man with anemia visited our department. Esophagogastroduodenoscopy showed a type 2 lesion from the angulus to the antrum. Histopathological findings indicated gastric neuroendocrine carcinoma. Colonoscopy showed a type 1 lesion at the cecum. Distal gastrectomy was performed with D1+lymph node dissection, Roux-en-Y reconstruction, and ileocecal resection with D3 lymph node dissection. The patient was pathologically diagnosed with large-cell neuroendocrine carcinoma in the stomach, pT4a(SE), med, INF a>>b-c, ly1-2, v1(SM, EVG), pN0, pM0, pStageⅡB, and adenocarcinoma (tub1>tub2)of the cecum, pT2(MP), ly1(HE), v1(EVG, SM), pN0, pM0, pStageⅠ. Postoperatively, he received oral S-1 as an adjuvant chemotherapy. His postoperative course was uneventful without any recurrence over 18 months.

[Review of the Efficacy of Endoscopic Stenting for Malignant Colorectal Obstruction at Tokyo Metropolitan Ohtsuka Hospital].

BACKGROUND: The use of self-expandable metallic stent(SEMS)was first authorized by insurance and became available nationwide in Japan in 2012. Insertion of SEMS for colorectal obstruction due to colorectal cancer is useful as a bridge to surgery(BTS)approach and releases stenosis as palliative care. AIM: To assess the outcomes of SEMS placement for colorectal obstruction. PATIENTS AND METHODS: A total of 14 patients were treated with SEMS between April 2014 and March 2017. We reviewed their medical records to assess the usefulness of SEMS placement and the clinical course. RESULTS: SEMS insertion was effective in 93% of the 14 patients. In 10 patients with BTS, the median interval between SEMS insertion and operation was 16 days, and no severe complications were noted in them. In 4 patients with palliative care, all patients were released from colorectal stenosis. CONCLUSION: SEMS placement played a satisfactory role in improvement of patient QOL by paying scrupulous attention to a colonic stent retained.

[A Case of Endocrine Cell Carcinoma of the Transverse Colon with Very Poor Prognosis, Onset with Bowel Obstruction].

We report a case of endocrine cell carcinoma of the colon with very poor prognosis, onset with bowel obstruction and multiple liver metastases. The patient was a 77-year-old man who underwent left hemicolectomy after a colon stent treatment for bowel obstruction due to cancer of the transverse colon with unresectable multiple liver metastases. Chemotherapy was not initiated because of his poor health. He died of primary cancer 52 days after the surgery. Endocrine cell carcinoma of the large intestine has a poor prognosis due to an early onset of liver and lymph node metastases, as well as peritoneal dissemination. A large-scale clinical study is needed to establish an effective adjuvant chemotherapy.

[Surgical Treatment for Extremely Elderly Patients over 90 Years of Age with Stage IV Colorectal Cancer - A Report of Four Cases].

We report 4 cases ofStage IV colorectal cancer patients over 90 years ofage who received surgical treatment. All of 4 cases were right-sided advanced colon cancer(1 case had also recto-sigmoid advanced cancer)and were received emergency operation. Two cases received resection ofprimary tumors and anastomosis, the other 2 cases received only ileostomy or colostomy. Three cases were able to be discharged from hospital successfully, but unfortunately, we lost one case because of cerebrovascular complication after surgery. We could provide palliative care facilities or home care services for survived three cases after spending certain time with their families peacefully. We treated them successfully with a collaborative medical team including experienced staffs for oral care, skin care, rehabilitation, mental care and social workers and others. Regarding to surgical treatment ofStage IV colorectal cancer patient, especially for extremely elderly patients over 90 years of age, we should consider not only perioperative treatment but also post- discharge comprehensive and palliative care.

[A Case of Solitary Metastatic Diaphragmatic Tumor from Resected Rectal Cancer].

A 54-year-old woman underwent high anterior resection with D3 lymphadenectomy for rectal cancer at another hospital. She was diagnosed with well-differentiated adenocarcinoma of rectal cancer, pT3, N1, H0, P0, M0, fStage III a. She did not receive adjuvant chemotherapy. Eighteen months after surgery, abdominal CT at our hospital showed a 19mm-sized mass in S7 of the liver. EOB-MRI also showed a mass in the same location. The mass was a ring contrast-enhanced lesion on dynamic phase, had a low signal pattern on liver cell phase, and had high signal pattern on diffusion-weighted imaging. As such, it was diagnosed as liver metastasis of rectal cancer, and surgery was performed. During surgery, the tumor was found to be located between the liver and diaphragm. Thus, we performed partial resection of the liver diaphragm. Histopathologically, the tumor was the same well-differentiated adenocarcinoma as the primary tumor. In addition, the tumor existed only in the diaphragm and was pumping out the liver. Therefore, we diagnosed the tumor as a diaphragm metastasis of rectal cancer. On literature review, only 8 reports of colorectal metastatic tumors involving the diaphragm were found.

[Two Cases of Obstructive Colorectal Cancer Effectively Treated with Colonic Stent Placement].

We report 2 cases of obstructive colorectal cancer that were successfully treated with a self-expanding metallic stent (SEMS). They were both diagnosed with obstructive colorectal cancer. Colonoscopy was performed to make a definitive and qualitative diagnosis and to relieve the stenosis using a SEMS. The SEMSs were inserted without complications. A few days later, the patients underwent laparoscope-assisted sigmoidectomy with lymph node resection. Despite the colon obstruction, a primary anastomosis was performed. They were both discharged without complications. Obstructive colorectal cancer is an oncological emergency commonly observed in our daily clinical practice. Conventional treatments such as stoma creation or insertion of a trans-analdrainage tube have been performed. However, these treatments significantly reduce the patient's QOL. On the other hand, colonic stent placement plays a satisfactory role in improvement of the patient's QOL by paying scrupulous attention to retaining the colonic stent.

[A Case of Ileocecal Intussusception Due to Small Intestinal Adenocarcinoma].

A 67-year-old female with abdominal pain and vomiting was admitted to our hospital. Abdominal X-ray showed dilated small bowel in the left upper abdomen. She was diagnosed with ileocecal intussusception based on abdominal contrastenhanced computed tomography. Computed tomography showed a "pseudo kidney sign" in the right flank region. We also observed an enhanced mass lesion in the presenting portion ofthe intussusception. Laparotomy was performed to treat the invagination. We tried to reduce the invagination, without success. Ileocecal resection was performed. Pathological findings revealed that poorly differentiated adenocarcinoma in the ileum end portion had induced the invagination. Intussusception in adults should be treated with the knowledge that about 80% ofsuch cases have an organic lesion in the presenting portion.

[A Case of Drug-Induced Thrombocytopenia Resulting from Sensitivity to Oxaliplatin].

A 67-year-old man was diagnosed with pulmonary metastasis from advanced transverse colon cancer. Thus, a local resection was performed. Adjuvant chemotherapy with mFOLFOX6 was started. Sixteen courses were carried out without problems. However, he complained of chills and chest discomfort 2 hours after beginning the 17th course of chemotherapy. Laboratory data showed remarkable thrombocytopenia, and platelet-associated IgG level was high. After administration of steroids and platelet transfusions, the platelet count improved. Therefore, we diagnosed drug-induced thrombocytopenia resulting from sensitivity to oxaliplatin (L-OHP). Since then, sLV5FU2 therapy was started, and the patient received the whole adjuvant chemotherapy without problems. Thrombocytopenia resulting from sensitivity to L-OHP is a relatively rare side effect. We herein report this case with a review of the relevant literature.

[A case of advanced rectal cancer treated with leucovorin, fluorouracil, and oxaliplatin plus panitumumab preoperative chemotherapy].

A 58-year-old woman had a very large advanced rectal cancer( with wild-type K-RAS expression). Abdominal computed tomography( CT) revealed a space-occupying lesion in the pelvis and an enlarged lymph node. We established a diagnosis of unresectable rectal cancer and subsequently performed transverse colostomy. The patient received 6 courses of Leucovorin, fluorouracil, and oxaliplatin( mFOLFOX6) plus panitumumab( Pmab), 2 courses of simplified Leucovorin plus 5-fluorouraci(l sLV5-FU) plus Pmab, and 1 course of Pmab. The size of the primary tumor decreased remarkably after chemotherapy. Low anterior resection was performed. The pathological stage was T4a, N0, M1, Stage IVa. The results from this case suggest that mFOLFOX6 plus Pmab preoperative chemotherapy is a useful regimen for the treatment of locally advanced K-RAS wild-type rectal cancer.

[A case of advanced rectal cancer with bone metastasis successfully treated with chemo-radiation therapy].

A 62-year-old man presented to a hospital with left buttock pain, and sacral neoplasia was suspected. He was referred to our hospital. Colonoscopy( CS) and bone biopsy showed rectal cancer with metastasis to the sacrum. There was no bleeding or ileus associated with the primary lesion, and the sacral metastasis was unresectable; therefore, we decided to provide palliative care for pain relief. Radiation therapy( 40 Gy) was performed on the sacral metastasis and included the primary lesion, and zoledronate was administered concomitantly. Both CS and computed tomography (CT) showed tumor regression of both the primary and metastatic lesions, and the patient's carcinomatous pain was alleviated. Irinotecan, 5- fluorouracil, and Leucovorin (FOLFIRI)+cetuximab was administered to reduce the progression of the primary lesion. After 3 months, CT showed significant tumor regression of both the primary and metastatic lesions. The sacral metastasis was no longer evident on the CT images, and positron emission tomography( PET)-CT did not show fluorodeoxyglucose (FDG) accumulation. The primary lesion had shrunk and become flat, but biopsy indicated residual lesion. Although clinically the frequency of bone metastasis of colon cancer has been reported to be 8.6 to 10.7%, single metastasis is not often seen. In this report, we present a case of advanced rectal cancer with bone metastasis, which was successfully treated with chemo-radiation therapy.

[A case of neuroendocrine carcinoma of the anal canal with multiple bone metastases successfully treated with combined modality therapy].

Neuroendocrine carcinoma (NEC) of the anal canal is a comparatively rare tumor with a poor prognosis. We report herein a case of NEC of the anal canal with multiple bone metastases that was successfully treated with combined therapy. A 63-year-old man was referred to our hospital with the chief complaint of anal and back pain. A tumor was found in the anal canal, and pathologic examination revealed it to be NEC( Ki-67 expression>50%); fluorodeoxyglucose( FDG) positron emission tomography (PET)-computed tomography (CT) showed multiple bone metastases. Initially, a l-leucovorin/5- fluorouraci(l 5-FU)/oxaliplatin( L-OHP)(: mFOLFOX6)/bevacizumab( Bmab) regimen and octreotide were administered to treat the unresectable and advanced NEC. Strontium-89 and zoledronate were used to treat pain related to the bone metastases. After 3 months, the tumor and bone metastases became difficult to identify. The patient experienced grade 2 neurotoxicity after 5 months, and thus, we stopped L-OHP administration. After 10 months, we reintroduced L-OHP because of additional progression of the bone metastases.

Advantages of preoperative counseling with video for robotic rectal cancer surgery compared with conventional counseling: A randomized controlled trial.

PURPOSE: Surgeons should provide patients with appropriate explanations before surgery and obtain informed consent. However, this process requires time and effort and can be a great burden. The purpose of this study was to compare preoperative counseling with video (VC) and conventional counseling (CC) for rectal cancer patients. METHODS: Rectal cancer patients indicated for surgery were included between April 2021 and March 2022, and eligible patients were randomly assigned to the CC and VC groups. The primary outcomes were the comprehension, satisfaction, and anxiety levels, and the secondary outcome was the preoperative counseling time. This exploratory study protocol was registered with the UMIN Clinical Trials Registry (UMIN000038133). RESULTS: We included 13 patients in the CC group and 17 in the VC group. All eligible patients were scheduled for robotic rectal cancer surgery. There were no significant differences between the two groups, including patients' general condition, preoperative diagnosis, and planned procedures. Although the comprehension, satisfaction, and anxiety test scores were not significantly different between the groups, the preoperative counseling time was significantly shorter in the VC group than in the CC group (20 vs. 35 minutes, P = .002). A 4-year college degree significantly increased the counseling time, whereas VC significantly decreased it. CONCLUSION: Using videos in preoperative counseling for rectal cancer patients is useful. This novel method could reduce the burden on surgeons during preoperative counseling in the era of robotic surgery and work style reforms.

[A case report of stage IV cecal cancer exhibiting a complete response to multidisciplinary therapy].

A 52-year-old man underwent ileocecal resection for cecal cancer, followed by left hepatectomy and S6 partial resection for liver metastasis. A month later, abdominal computed tomography revealed metastases in the mediastinal lymph nodes, para-aortic lymph nodes, and left adrenal gland. After 4 courses of the capecitabine plus oxaliplatin(CapeOX) regimen and 4 courses of CapeOX plus bevacizumab, a complete response was observed regarding the lymph nodes metastasis. Then, left adrenalectomy was performed for the residual left adrenal metastasis. CapeOX plus bevacizumab was administered as a postoperative chemotherapy for 8 courses, Capecitabine was started due to adverse reactions, such as peripheral neuropathy (grade 2) and a gastric ulcer. After the gastric ulcer healed, capecitabine plus bevacizumab was administered for 5 courses. The patient has had no recurrence for almost 2 years since the resection of the adrenal metastasis.

[A case of advanced rectal cancer with lung and bone metastasis that was successfully treated with mFOLFOX6+bevacizumab].

A 48-year-old man with respiratory discomfort was diagnosed with rectal cancer with carcinomatous lymphangiosis, together with lung and sternum metastasis. As the patient's performance status(PS) was 2, mFOLFOX6+bevacizumab (Bmab)therapy with a 20% reduction in the dose was started. Three courses of this treatment resulted in improved respiratory function, and his PS dropped to 1. A chest computed tomography(CT) scan taken after four courses of this treatment indicated that pleural effusion had almost disappeared, and that the shadow on the lung had also reduced. However, after 20 courses of this treatment the disease had progressed. The regimen was changed to irinotecan (CPT-11)+Bmab administration. All of these chemotherapeutic treatments were administered on an outpatient basis. Sixteen months after the diagnosis of rectal cancer, the patient died. In recent years, combination chemotherapy for unresectable colorectal cancer has become recognized as a standard regimen, though adverse effects frequently occur. Thus, intensive chemotherapy is not always recommended for patients with poor PS. In this report, we presented a case of pulmonary metastases from rectal cancer, carcinomatous lymphangiosis, and sternum metastasis that was successfully treated with mFOLFOX6+Bmab.

[A case of sigmoid colon cancer, successfully treated by a multidisciplinary strategy for local recurrence and distant metastases].

We report a case of sigmoid colon cancer, successfully treated by a multidisciplinary strategy for local recurrence and distant metastases. This 60-year-old male patient underwent sigmoidectomy for sigmoid colon cancer. Three years after the operation, local recurrence with invasion to the left ureter was found, and we performed colectomy and left nephroureterectomy. One year after the resection, a second relapse lesion was discovered, which was considered unresectable, and was treated instead with radiation therapy(total 50 Gy). One year after the radiation therapy, five pulmonary metastases each of 12 mm in diameter were found in both lungs. He had renal dysfunction due to nephrectomy. Several regimens of chemotherapy [irinotecan (CPT-11), capecitabine+oxaliplatin (CapeOx) and CPT-11+panitumumab] were performed. He is still alive 7.5 years after the initial surgery and 4.5 years after the first recurrence.

Robotic-assisted Surgery: Expanding Indication to Colon Cancer in Japan.

In recent years, robotic-assisted surgery has demonstrated remarkable progress as a minimally invasive procedure for colorectal cancer. While there have been fewer studies investigating robotic-assisted surgery for the treatment of colon cancer than rectal cancer, evidence regarding robotic-assisted colectomy has been accumulating due to increasing use of the procedure. Robotic-assisted colectomy generally requires a long operative time and involves high costs. However, as evidence is increasingly supportive of its higher accuracy and less invasive nature compared to laparoscopic colectomy, the procedure is anticipated to improve the ratio of conversion to laparotomy and accelerate postoperative recovery. Robotic-assisted surgery has also been suggested for a specific level of effectiveness in manipulative procedures, such as intracorporeal anastomosis, and is increasingly indicated as a less problematic procedure compared to conventional laparoscopy and open surgery in terms of long-term oncological outcomes. Although robotic-assisted colectomy has been widely adopted abroad, only a limited number of institutions have been using this procedure in Japan. Further accumulation of experience and studies investigating surgical outcomes using this approach are required in Japan.