Revealing the role of early peripancreatic bacterial contamination and Enterococcus faecalis in pancreatic fistula development after pancreaticoduodenectomy: Implications for useful antibiotic prophylaxis-An observational cohort study.

BACKGROUND: Peripancreatic bacterial contamination (PBC) is a critical factor contributing to the development of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). Controlling pathogenic bacteria is essential in preventing CR-POPF; however, the precise relationship between specific bacteria and CR-POPF remains unclear. This study aimed to investigate the relationship between PBC and CR-POPF after PD, with a focus on identifying potentially causative bacteria. METHODS: This prospective observational study enrolled 370 patients who underwent PD. Microbial cultures were routinely collected from peripancreatic drain fluid on postoperative days (PODs) 1, 3, and 6. Predictive factors for CR-POPF and the bacteria involved in PBC were investigated. RESULTS: CR-POPF occurred in 86 (23.2%) patients. In multivariate analysis, PBC on POD1 (Odds ratio [OR] = 3.59; P = 0.005) was one of the main independent predictive factors for CR-POPF, while prophylactic use of antibiotics other than piperacillin/tazobactam independently influenced PBC on POD1 (OR = 2.95; P = 0.010). Notably, Enterococcus spp., particularly Enterococcus faecalis, were significantly isolated from PBC in patients with CR-POPF compared to those without CR-POPF on PODs 1 and 3 (P < 0.001), and they displayed high resistance to all cephalosporins. CONCLUSIONS: Early PBC plays a pivotal role in the development of CR-POPF following PD. Prophylactic antibiotic administration, specifically targeting Enterococcus faecalis, may effectively mitigate early PBC and subsequently reduce the risk of CR-POPF. This research sheds light on the importance of bacterial control strategies in preventing CR-POPF after PD.

Effects of communication delay in the dual cockpit remote robotic surgery system.

PURPOSE: To evaluate the impact of dual cockpit telesurgery on proctors and operators, and acceptable levels of processing delay for video compression and restoration. METHODS: Eight medical advisors and eight trainee surgeons, one highly skilled per group, performed gastrectomy, rectal resection, cholecystectomy, and bleeding tasks on pigs. Using the Medicaroid surgical robot hinotori™, simulated delay times (0 ms, 50 ms, 100 ms, 150 ms, and 200 ms) were inserted mid-surgery to evaluate the tolerance level. Operative times and dual cockpit switching times were measured subjectively using 5-point scale questionnaires (mSUS [modified System Usability Scale], and Robot Usability Score). RESULTS: No significant difference was observed in operative times between proctors and operators (proctor: p = 0.247, operator: p = 0.608) nor in switching times to the dual cockpit mode (p = 0.248). For each survey setting, proctors tended to give lower ratings to delays of ≥ 150 ms. No marked difference was observed in the operator evaluations. On the postoperative questionnaires, there were no marked differences in the mSUS or Robot Usability Score between the proctors and operators (mSUS: p = 0.779, Robot Usability Score: p = 0.261). CONCLUSION: Telesurgery using a dual cockpit with hinotori™ is practical and has little impact on surgical procedures.

Clinical practice guidelines for telesurgery 2022 : Committee for the promotion of remote surgery implementation, Japan Surgical Society.

Telesurgery is expected to improve medical access in areas with limited resources, facilitate the rapid dissemination of new surgical procedures, and advance surgical education. While previously hindered by communication delays and costs, recent advancements in information technology and the emergence of new surgical robots have created an environment conducive to societal implementation. In Japan, the legal framework established in 2019 allows for remote surgical support under the supervision of an actual surgeon. The Japan Surgical Society led a collaborative effort, involving various stakeholders, to conduct social verification experiments using telesurgery, resulting in the development of a Japanese version of the "Telesurgery Guidelines" in June 2022. These guidelines outline requirements for medical teams, communication environments, robotic systems, and security measures for communication lines, as well as responsibility allocation, cost burden, and the handling of adverse events during telesurgery. In addition, they address telementoring and full telesurgery. The guidelines are expected to be revised as needed, based on the utilization of telesurgery, advancements in surgical robots, and improvements in information technology.

Field experiment of a telesurgery system using a surgical robot with haptic feedback.

PURPOSE: To verify the usefulness of haptic feedback in telesurgery and improve the safety of telerobotic surgery. METHODS: The surgeon's console was installed at two sites (Fukuoka and Beppu; 140 km apart), and the patient cart was installed in Fukuoka. During the experiment, the surgeon was blinded to the haptic feedback levels and asked to grasp the intestinal tract in an animal model. The surgeon then performed the tasks at each location. RESULTS: No marked differences in task accuracy or average grasping force were observed between the surgeon locations. However, the average task completion time was significantly longer, and the system usability scale (SUS) was significantly lower rating for remote operations than for local ones. No marked differences in task accuracy or task completion time were observed between the haptic feedback levels. However, with haptic feedback, the organ was grasped with a significantly weaker force than that without it. Furthermore, with haptic feedback, experienced surgeons in robotic surgery tended to perform an equivalent task with weaker grasping forces than inexperienced surgeons. CONCLUSION: The haptic feedback function is a tool that allows the surgeon to perform surgery with an appropriate grasping force, both on site and remotely. Improved safety is necessary in telesurgery; haptic feedback will thus be an essential technology in robotic telesurgery going forward.

[A Case of Breast Cancer That Developed Pulmonary Tumor Thrombotic Microangiopathy during Adjuvant Chemotherapy].

A 68-year-old woman underwent neoadjuvant chemotherapy for left breast cancer(triple negative type), cT2N3cM0, cStage ⅢC, and Bt+Ax(Ⅲ). The pathological diagnosis was ypT1aN2aM0, ypStage ⅢA, ER-, PgR-, HER2 score 1+, Ki- 67 25%. Adjuvant radiotherapy(50 Gy/25 Fr)was then administered, followed by capecitabine as adjuvant chemotherapy. Dyspnea occurred during administration of capecitabine, and computed tomography(CT)and blood test results suggested drug-induced interstitial pneumonia and disseminated intravascular coagulation(DIC). The patient was admitted, and steroid pulse therapy, anticoagulant therapy, and antibiotics were administered; however, the treatment was ineffective, and she died 3 days after admission. An autopsy provided a final diagnosis of pulmonary tumor thrombotic microangiopathy(PTTM). There is no established treatment for PTTM, and the prognosis is poor even with anticoagulant therapy and chemotherapy. The definitive diagnosis of PTTM is based on pathological findings; however, during respiratory failure, invasive tests such as lung biopsy are not recommended. Therefore, if a significantly worsening respiratory disorder develops, as in this case, chemotherapy should be considered for suspected PTTM.

Exploration of Malignant Characteristics in Neoadjuvant Chemotherapy-Resistant Rectal Cancer, Focusing on Extramural Lesions.

BACKGROUND: Extramural vascular invasion (EMVI) and tumor deposits (TD) are poor prognostic factors in rectal cancer (RC), especially when resistant to neoadjuvant chemotherapy (NAC). We aimed to define differential expression in NAC responders and non-responders with concomitant EMVI and TD. METHODS: From 52 RC surgical patients, post-NAC resected specimens were extracted, comprising two groups: cases with residual EMVI and TD (NAC-resistant) and cases without (NAC-effective). Proteomic analysis was conducted to define differential protein expression in the two groups. To validate the findings, immunohistochemistry was performed in another cohort that included 58 RC surgical patients. Based on the findings, chemosensitivity and prognosis were compared. RESULTS: The NAC-resistant group was associated with a lower 3-year disease-free survival rate than the NAC-effective group (p = 0.041). Discriminative proteins in the NAC-resistant group were highly associated with the sulfur metabolism pathway. Among these pathway constituents, selenium-binding protein 1 (SELENBP1) expression in the NAC-resistant group decreased to less than one-third of that of the NAC-effective group. Immunohistochemistry in another RC cohort consistently validated the relationship between decreased SELENBP1 and poorer NAC sensitivity, in both pre-NAC biopsy and post-NAC surgery specimens. Furthermore, decrease in SELENBP1 was associated with a lower 3-year disease-free survival rate (p = 0.047). CONCLUSIONS: We defined one of the differentially expressed proteins in NAC responders and non-responders, concomitant with EMVI and TD. SELENBP1 was suspected to contribute to NAC resistance and poor prognosis in RC.

Telesurgery and telesurgical support using a double-surgeon cockpit system allowing manipulation from two locations.

BACKGROUND: Although several studies on telesurgery have been reported globally, a clinically applicable technique has not yet been developed. As part of a telesurgical study series conducted by the Japan Surgical Society, this study describes the first application of a double-surgeon cockpit system to telesurgery. METHODS: Surgeon cockpits were installed at a local site and a remote site 140 km away. Three healthy pigs weighing between 26 and 29 kg were selected for surgery. Non-specialized surgeons performed emergency hemostasis, cholecystectomy, and renal vein ligation with remote assistance using the double-surgeon cockpits and specialized surgeons performed actual telesurgery. Additionally, the impact of adding internet protocol security (IPsec) encryption to the internet protocol-virtual private network (IP-VPN) line on communication was evaluated to address clinical security concerns. RESULTS: The average time required for remote emergency hemostasis with the double-surgeon cockpit system was 10.64 s. A non-specialized surgeon could safely perform cholecystectomy or renal vein ligation with remote assistance. Global Evaluative Assessment of Robotic Skills and System Usability Scale scores were higher for telesurgical support-assisted surgery by a non-specialized surgeon using the double-surgeon cockpits than for telesurgery performed by a specialized surgeon without the double-cockpit system. Adding IPsec encryption to the IP-VPN did not have a significant impact on communication. CONCLUSION: Telesurgical support through our double-surgeon cockpit system is feasible as first step toward clinical telesurgery.

Real-time telementoring with 3D drawing annotation in robotic surgery.

BACKGROUND: In telementoring, differences in teaching methods affect local surgeons' comprehension. Because the object to be operated on is a three-dimensional (3D) structure, voice or 2D annotation may not be sufficient to convey the instructor's intention. In this study, we examined the usefulness of telementoring using 3D drawing annotations in robotic surgery. METHODS: Kyushu University and Beppu Hospital are located 140 km apart, and the study was conducted using a Saroa™ surgical robot by RIVERFIELD Inc. using a commercial guarantee network on optical fiber. Twenty medical students performed vertical mattress suturing using a swine intestinal tract under surgical guidance at the Center for Advanced Medical Innovation Kyushu University. Surgical guidance was provided by Beppu Hospital using voice, 2D, and 3D drawing annotations. All robot operations were performed using 3D images, and only the annotations were independently switched between voice and 2D and 3D images. The operation time, needle movement, and performance were also evaluated. RESULTS: The 3D annotation group tended to have a shorter working time than the control group (25.6 ± 63.2 vs. - 36.7 ± 65.4 min, P = 0.06). The 3D annotation group had fewer retries than the control group (1.3 ± 1.7 vs. - 1.1 ± 0.7, P = 0.006), and there was a tendency for fewer needle drops (0.4 ± 0.7 vs. - 0.5 ± 0.9, P = 0.06). The 3D annotation group scored significantly higher than the control group on the Global Evaluate Assessment of Robot Skills (16.8 ± 2.0 vs. 22.8 ± 2.4, P = 0.04). The 3D annotation group also scored higher than the voice (13.4 ± 1.2) and 2D annotation (16.2 ± 1.8) groups (3D vs. voice: P = 0.03, 3D vs. 2D: P = 0.03). CONCLUSION: Telementoring using 3D drawing annotation was shown to provide good comprehension and a smooth operation for local surgeons.

Efficacy of chemotherapy for comorbid cancer in patients with simultaneous double cancers: a multicenter study.

PURPOSE: Anticancer drugs for double cancers are selected based on their therapeutic effects on the target cancer, but there are insufficient data on the effects of anticancer drugs on comorbid cancer. We investigated the effect of chemotherapy on comorbid cancer in patients with simultaneous double cancers. METHODS: The subjects of this retrospective study were 51 patients with simultaneous double cancers at the time of receiving systemic chemotherapy. We evaluated the types of anticancer drugs used for double cancers, the therapeutic effects on targeted and comorbid cancers, and prognoses. RESULTS: Disease control was achieved for 90.9% of the target cancers and 90.7% of the comorbid cancers. The prognosis was significantly better when the disease was controlled, not only in the target cancer but also in the comorbid cancer. CONCLUSION: Physicians treating double cancers should develop treatment strategies focusing not only on the treatment for advanced cancer, but also on the course of comorbidities and the therapeutic effects of anticancer drugs. This study is important because it presents new possibilities to expand the indications for anticancer drugs, while allowing unnecessary clinical research to be avoided.

[A Case of Long-Term Survival of Breast Cancer with Extra-Regional Lymph Node Metastases].

We present the case of a 65-year-old woman who presented with nipple retraction of her left breast. The patient has a family history of breast cancer. She was diagnosed with bilateral breast cancer with left axillary, cervical, and mediastinal lymph node metastasis(right breast cancer, cT1cN0M0, cStage Ⅰ, Luminal A-like, left breast cancer, cT2N3bM1[LYM], Stage Ⅳ, triple negative type). She was recommended chemotherapy due to her inoperable advanced-stage breast cancer. After 6 courses of administration of AC chemotherapy(doxorubicin and cyclophosphamide)and 5 courses of tri-weekly docetaxel chemotherapy, shrinkage of the primary lesion and disappearance of each swollen lymph node were observed via computed tomography. Surgery was performed 11 weeks post-chemotherapy. Residual lesions, less than 10 mm in size in both the left and right breast masses, were observed. No lymph node metastasis was observed. Four years later, no signs of recurrence have been noted.

[A Case of Triple Negative Breast Cancer with Left Buttock Metastasis].

A female patient in her 50s was diagnosed with triple negative breast cancer in the left breast with a buttock metastasis. After neoadjuvant chemotherapy, the patient underwent surgery on the left breast. As the histopathological findings indicated a residual tumor, she was further treated with capecitabine postoperatively. Twenty months postoperatively, a CT scan revealed a tumor on her left buttock. She was also diagnosed with a relapse of the breast cancer after a core needle biopsy. She was treated with atezolizumab and nab-paclitaxel as first-line therapy for the metastasis and with eriburlin as second- line therapy. As she became uncomfortable sitting owing to the regrowth of the buttock tumor, the left buttock tumor was resected. She has been treated with bevacizumab and paclitaxel for subsequent lung metastases.

[Short Term and Long Term Outcomes of Robotic Surgery in Sphincter Function Preserving Surgery for Lower Rectal Cancer].

BACKGROUND: Surgical and oncological outcomes of lower rectal cancer remain unsatisfactory. We investigated the short term and long term outcomes of robotic surgery for sphincter function-preserving surgery(SPS)for lower rectal cancer. METHOD: 433 lower rectal cancer patients who underwent SPS at our institution from January 2000 to July 2021 were included, excluding Stage Ⅳ cases and patients with multiple cancers. There were 288 cases of laparotomy, 81 cases of laparoscopic surgery, and 64 cases of robotic surgery; we abbreviated the group names as: OP, LAP, and R, respectively. We retrospectively reviewed the anastomotic leakage rate and prognosis of these groups. RESULTS: The anastomotic leakage rate was 23.6% in the OP group, 17.3% in the LAP group, and 6.3% in the R group, with a significant difference between the OP group and the R group. The 3-year recurrence free survival rate was 86.7% in the LAP group and 95.6% in the R group. Although there was no significant difference, the prognosis tended to be better in the R group. Local recurrence was observed in 3 patients in the LAP group and 1 patient in the R group. CONCLUSION: In SPS for advanced lower rectal cancer, robotic surgery may contribute to a reduction in anastomotic leakage.

[A Case of Robot-Assisted Laparoscopic Surgery for Stenotic Sigmoid Colon Cancer with Simultaneous Lateral Lymph Node Metastasis].

The patient is a 63-year-old man. He visited his previous physician for abdominal pain. After close examinations, he was diagnosed with stenotic sigmoid colon cancer with left lateral lymph node metastasis. On the same day, colonic stenting was performed to relieve the symptoms of stenosis. After 1 month of stenting, a robot-assisted laparoscopic sigmoid colectomy and left lateral lymph node dissection were performed. Postoperative pathological examination revealed regional lymph node metastasis and left lateral lymph node metastasis(#283); the patient was diagnosed with pT4aN1bM1a(LYM), fStage Ⅳa. The patient was discharged on postoperative day 10, and is stable 5 months after surgery without recurrence. This case suggests that robot-assisted laparoscopic lateral lymph node dissection can be effective even in atypical cases of sigmoid colon cancer with lateral lymph node metastasis.

The diversity and abundance of gut microbiota are associated with the pain sensation threshold in the Japanese population.

Small fibre neuropathy (SFN) is an initial pathology of diabetic polyneuropathy (DPN). Serum lipopolysaccharide binding protein levels are positively correlated with the pain threshold in the foot, suggesting that the abundance of gut Gram-negative bacilli, which are a source of lipopolysaccharides, may be involved in the development of DPN. Furthermore, the abundance of the gut and oral microbiota is assumed to be involved in the pathogenesis of diabetes. Nevertheless, the association between SFN and the microbiota has not been clarified. A total of 1056 individuals were recruited in the 2018 Iwaki Health Promotion Project. Pain sensation was evaluated based on the pain threshold from intraepidermal electrical stimulation (PINT). Patients with PINT scores <0.15 mA were categorized into the low-PINT group (n = 718); otherwise, they were categorized into the high-PINT group (n = 283). Furthermore, each group was divided into the subjects with or without glucose tolerance based on HbA1c levels, fasting blood glucose levels and diabetic history. Principal coordinate analysis and α- and ß-diversity of the microbiota were evaluated. The correlation between clinical and microbiota data was examined. Oral microbiota diversity showed no structural differences according to PINT scores, whereas principal coordinate analysis and α- and ß-diversity revealed significant structural differences in gut microbiota (p < 0.01, p < 0.05 and p < 0.05, respectively), even after the participants with glucose intolerance were excluded (p < 0.01, p < 0.05 and p < 0.05, respectively). The relative abundance of the genus Bacteroides was significantly lower in high-PINT participants compared with low-PINT participants (10 ± 6.7% vs. 11.3 ± 7.0%, p < 0.01), even after the exclusion of subjects with diabetes and impaired fasting glucose (10.0 ± 6.5% vs. 11.2 ± 6.9%, p < 0.05). In univariate linear regression analyses, PINT was significantly correlated with metabolic syndrome parameters, eGFR, uric acid level and the abundance of Bacteroides. The correlation between Bacteroides and PINT scores remained significant after adjustment for multiple factors (ß = -0.07181, p < 0.05). Changes of bacterial diversity and a low abundance of gut Bacteroides were correlated with elevated PINT scores in the Japanese population. This correlation may represent a new therapeutic option for SFN.

Development of a Biomarker-Based Scoring System Predicting Early Recurrence of Resectable Pancreatic Duct Adenocarcinoma.

BACKGROUND: Resectable pancreatic ductal adenocarcinoma (R-PDAC) often recurs early after radical resection, which is associated with poor prognosis. Predicting early recurrence preoperatively is useful for determining the optimal treatment. PATIENTS AND METHODS: One hundred and seventy-eight patients diagnosed with R-PDAC on computed tomography (CT) imaging and undergoing radical resection at Hirosaki University Hospital from 2005 to 2019 were retrospectively analyzed. Patients with recurrence within 6 months after resection formed the early recurrence (ER) group, while other patients constituted the non-early recurrence (non-ER) group. Early recurrence prediction score (ERP score) was developed using preoperative parameters. RESULTS: ER was observed in 45 patients (25.3%). The ER group had significantly higher preoperative CA19-9 (p = 0.03), serum SPan-1 (p = 0.006), and CT tumor diameter (p = 0.01) compared with the non-ER group. The receiver operating characteristic (ROC) curve analysis identified cutoff values for CA19-9 (133 U/mL), SPan-1 (78.2 U/mL), and preoperative tumor diameter (23 mm). When the parameter exceeded the cutoff level, 1 point was given, and the total score of the three factors was defined as the ERP score. The group with an ERP score of 3 had postoperative recurrence-free survival (RFS) of 5.5 months (95% CI 3.02-7.98). Multivariate analysis for ER-related perioperative and surgical factors identified ERP score of 3 [odds ratio (OR) 4.63 (95% CI 1.82-11.78), p = 0.0013] and R1 resection [OR 3.20 (95% CI 1.01-10.17), p = 0.049] as independent predictors of ER. CONCLUSIONS: For R-PDAC, ER could be predicted by the scoring system using preoperative serum CA19-9 and SPan-1 levels and CT tumor diameter, which may have great significance in identifying patients with poor prognoses and avoiding unnecessary surgery.

A Prospective Multicenter Phase II Study on the Feasibility and Efficacy of S-1 and Oxaliplatin Neoadjuvant Chemotherapy for Locally Advanced Rectal Cancer.

BACKGROUND: Neoadjuvant chemoradiotherapy and total mesorectal excision compose the standard of care for rectal cancer in multiple guidelines. However, neoadjuvant chemoradiotherapy has not exhibited clear survival benefits but rather has led to an increase in adverse events. Conversely, neoadjuvant chemotherapy is expected to prevent adverse events caused by radiation, yet this treatment is still controversial. OBJECTIVE: The purpose of this study was to evaluate the feasibility and efficacy of S-1 and oxaliplatin neoadjuvant chemotherapy together with total mesorectal excision for resectable locally advanced rectal cancer. DESIGN: The study was a prospective, single-arm phase II trial. SETTINGS: The study was conducted at multiple institutions. PATIENTS: Fifty-eight patients with resectable locally advanced rectal cancer were enrolled. INTERVENTION: Three cycles of S-1 and oxaliplatin were administered before surgery. S-1 was administered orally at 80 mg/m2 per day for 14 consecutive days, followed by a 7-day resting period. Oxaliplatin was given intravenously on the first day at a dose of 130 mg/m2 per day. The duration of 1 cycle was considered to be 21 days. Total mesorectal excision with bilateral lymph node dissection was carried out after neoadjuvant chemotherapy. MAIN OUTCOME MEASURES: The study was designed to detect the feasibility and efficacy of S-1 and oxaliplatin as neoadjuvant chemotherapy. RESULTS: The completion rate of 3 courses of S-1 and oxaliplatin as neoadjuvant chemotherapy was 94.8% (55/58). The reasons for discontinuation were thrombocytopenia (3.4%) and liver injury (1.7%). The most common severe (grade ≥3) adverse effect of neoadjuvant chemotherapy was thrombocytopenia (3.4%). There were no severe adverse clinical symptoms. Consequently, R0 resection was achieved in 51 (98.1%) of 52 patients. Pathologic complete response occurred in 10 patients (19.2%). LIMITATIONS: This was a single-arm, nonrandomized phase II study. CONCLUSIONS: The combination of S-1 and oxaliplatin neoadjuvant chemotherapy and total mesorectal excision is a feasible and promising treatment option for resectable locally advanced rectal cancer. See Video Abstract at http://links.lww.com/DCR/B555. UN ESTUDIO PROSPECTIVO MULTICNTRICO FASE II SOBRE LA FACTIBILIDAD Y EFICACIA DE LA QUIMIOTERAPIA NEOADYUVANTE SCON OXALIPLATINO PARA EL CNCER DE RECTO LOCALMENTE AVANZADO: ANTECEDENTES:La quimiorradioterapia neoadyuvante y la escisión mesorrectal total constituyen el estándar de atención para el cáncer de recto en varias guías. Sin embargo, la quimiorradioterapia neoadyuvante no ha mostrado beneficios claros en la sobrevida, pero si ha creado un aumento de eventos adversos. Por otro lado, se espera que la quimioterapia neoadyuvante prevenga los eventos adversos asociados a la radiación, aunque este tratamiento sigue siendo controvertido.OBJETIVO:Evaluar la factibilidad y eficacia de la quimioterapia neoadyuvante S-1 con oxaliplatino en conjunto con la escisión mesorrectal total para el cáncer de recto localmente avanzado resecable.DISEÑO:El estudio fue un ensayo prospectivo fase II de brazo único.AMBITO:Estudio realizado en múltiples instituciones.PACIENTES:Se incluyeron 58 pacientes con cáncer de recto localmente avanzado resecable.INTERVENCIÓN:Se administraron tres ciclos de S-1 con oxaliplatino antes de la cirugía. Se administró S-1 por vía oral a 80 mg / m2 / día durante 14 días consecutivos, seguido de un período de descanso de 7 días. El oxaliplatino se administró por vía intravenosa el primer día a una dosis de 130 mg / m2 / día. Se consideró la duración de un ciclo de 21 días. Posterior a la quimioterapia neoadyuvante se realizó la excisión total mesorrectal con disección ganglionar bilateral.PRINCIPALES VARIABLES EVALUDADAS:El estudio fue diseñado para conocer la factibilidad y eficacia de S-1 con oxaliplatino como quimioterapia neoadyuvante.RESULTADOS:La tasa de conclusión con tres ciclos de S-1 con oxaliplatino como quimioterapia neoadyuvante fue del 94,8% (55/58). Los motivos de interrupción fueron trombocitopenia (3,4%) y daño hepático (1,7%). El efecto adverso grave más común (grado ≥ 3) de la quimioterapia neoadyuvante fue la trombocitopenia (3,4%). No hubo síntomas clínicos adversos graves. Como resultado, la resección R0 se logró en 51 de 52 pacientes (98,1%). Una respuesta patológica completa se obtuvo en 10 pacientes (19,2%).LIMITACIONES:Fue un estudio de fase II no aleatorizado de un solo brazo.CONCLUSIONES:La combinación de S-1 con oxaliplatino como quimioterapia neoadyuvante y escisión mesorrectal total es factible y es una opción de tratamiento prometedora para el cáncer de recto localmente avanzado resecable. Consulte Video Resumen en http://links.lww.com/DCR/B555. (Traducción-Dr Juan Antonio Villanueva-Herrero).

Tele-assessment of bandwidth limitation for remote robotics surgery.

PURPOSE: We investigated the communication bandwidth (CB) limitation for remote robotics surgery (RRS) using hinotori™ (Medicaroid, Kobe, Japan). METHODS: The operating rooms of the Hokkaido University Hospital and Kyushu University Hospital were connected using the Science Information NETwork (SINET). The minimum required CB for the RRS was verified by decreasing the CB from 500 to 100 Mbps. Ten surgeons were tested on a task (intracorporeal suturing) at different levels of video compression (VC) (VC1: 120 Mbps, VC2: 40 Mbps, VC3: 20 Mbps) with the minimum required CB, and assessed based on the task completion time, Global Evaluative Assessment of Robotic Skills (GEARS), and System and Piper Fatigue Scale-12 (PFS-12). RESULTS: Packet loss was observed at 3-7% and image degradation was observed at 145 Mbps CB. The task performance with VC1 was significantly worse than that with VC2 and VC3 according to the task completion time (VC1 vs VC2, P = 0.032; VC1 vs. VC3, P = 0.032), GEARS (VC1 vs VC2; P = 0.029, VC1 vs VC3; P = 0.031), and PFS-12 (VC1 vs. VC2; P = 0.032, VC1 vs. VC3; P = 0.032) with 145 Mbps. CONCLUSION: Our findings provide evidence that RRS using hinotori™ requires a CB ≥ 150 Mbps. We also found that when there is insufficient CB, RRS can be continued by compressing the image.

Social implementation of a remote surgery system in Japan: a field experiment using a newly developed surgical robot via a commercial network.

PURPOSE: In recent years, the expectations for telesurgery have grown with the development of robot-assisted surgical technology and advances in communication technology. To verify the feasibility of the social implementation of telesurgery, we evaluated the communication integrity, availability, and communication delay of robotic surgery by remote control under different communication conditions of commercial lines. METHODS: A commercial line was used to connect hospitals 150 km apart. We had prepared guaranteed-type lines (1Gbps, 10Mbps, 5Mbps) and best effort-type lines. Two types of robotic teleoperations were performed, and we evaluated the round-trip time (RTT) of communication, packet loss, and glass-to-glass time. RESULTS: The communication delay was 4 ms for the guaranteed-type line and 10 ms for the best effort-type line. Packet loss occurred on the 5 Mbps guaranteed-type line. The mean glass-to-glass time was 92 ms for the guaranteed-type line and 95 ms for the best effort-type line. There was no significant difference in the number of errors in the task according to the type of line or the bandwidth speed. CONCLUSIONS: The social implementation of telesurgery using the currently available commercial communication network is feasible.

Robotic surgery contributes to the preservation of bowel and urinary function after total mesorectal excision: comparisons with transanal and conventional laparoscopic surgery.

BACKGROUND: Determine whether robotic surgery is more effective than transanal and conventional laparoscopic surgery in preserving bowel and urinary function after total mesorectal excision (TME). METHODS: Of 79 lower rectal cancer patients who underwent function-preserving TME between 2016 and 2020, 64 patients consented to a prospective questionnaire-based functional observation study (52 responded). At 6 months post-resection or ileostomy closure, Wexner, low anterior resection syndrome (LARS), modified fecal incontinence quality of life, and international prostate symptom scores were used to evaluate bowel and urinary function, comparing robotic surgery (RTME) with transanal (taTME) or conventional laparoscopic surgery (LTME). RESULTS: RTME was performed in 35 patients (54.7%), taTME in 15 (23.4%), and LTME in 14 (21.9%). While preoperative bowel/urinary functions were similar in all three procedures, and the distance from the anal verge to tumor was almost the same, more hand-sewn anastomoses were performed and the anastomotic height from the anal verge was shorter in taTME than RTME. At 2 years post-resection, 8 patients (12.5%) had a permanent stoma; RTME showed a significantly lower rate of permanent stoma than taTME (2.9% vs. 40%, p < 0.01). Despite no significant difference, all bowel function assessments were better in RTME than in taTME or LTME. Major LARS was observed in all taTME and LTME cases, but only 78.8% of RTME. No clear difference arose between RTME and taTME in urinary function; urinary dysfunction was more severe in LTME than RTME (36.4% vs. 6.1%, p = 0.02). CONCLUSIONS: In function-preserving TME for lower rectal cancer, robotic surgery was suggested to be more effective than transanal and conventional laparoscopic surgery in terms of bowel and urinary functions.

[Treatment Strategy for Stage â £ Rectal Cancer Considering Local Treatment Outcomes].

We investigated 36 patients with Stage Ⅳ rectal cancer who underwent primary resection in our department between November 2015 and June 2020. Tumor localization was upper in 20 cases and lower in 16 cases. Six patients had the cT4b stage at initial diagnosis, and lateral lymph node metastases were detected in 6 cases. Preoperative treatment consisted of doublet chemotherapy in 20 cases, in combination with bevacizumab in 17 cases. Surgery for distant metastases was performed in 21 patients, and the final results were curative(Cur B)in 20 patients and palliative(Cur C)in 16 patients. Perioperative mortality was observed only in Cur C patients(5.6%). The local R1 resection rates in Cur B and Cur C patients were 10.0% and 18.8%, respectively, and the corresponding local RM≤1 mm rates were 55.0% and 43.8%. Additionally, the local recurrence rates were 25.0% and 0%, and the 3-year OS rates were 80.9% and 25.5%, respectively, in Cur B and Cur C patients. In Cur B, the local RM≤1 mm rates in the preoperative and non-preoperative treatment groups were 38.5% and 85.7%, respectively, and the corresponding local R1 resection rates were 7.7% and 14.3%. Additionally, the 3-year local recurrence-free survival rates were 68.2% and 66.7% and the 3-year OS rates were 82.1% and 80.0%, respectively, in the preoperative and non-preoperative treatment groups. We determined that preoperative chemotherapy alone is not sufficient for the local treatment of Stage Ⅳ rectal cancer, and concomitant preoperative radiotherapy should be considered. The prognosis of patients with Cur C is poor, and surgery-related deaths have been observed, which can be a problem for the palliative resection strategy.