Transanally assisted lateral pelvic lymph node dissection for rectal cancer.

BACKGROUND: Although lateral pelvic lymph node dissection (LLND) might be an effective approach for patients with rectal cancer with lateral lymph node metastasis, it is technically challenging because of the anatomical complexity and location of the deep pelvis. An assistance by transanal approach might be useful for a successful LLND. METHODS: From September 2016 to May 2021, 39 patients with low rectal cancer underwent transanal total mesorectal excision with LLND. Among them, 18 patients underwent LLND using a conventional laparoscopic approach alone, while the remaining 21 underwent LLND using both conventional and transanal approaches. Their clinical outcomes were retrospectively compared. RESULTS: The operation time for LLND on each side was significantly shorter in the transanal group (105 min vs. 54 min, P < 0.001). The intraoperative blood loss was also significantly less in the transanal group (40 g vs. 0 g, P = 0.031). The rate of overall postoperative complications ≥ grade II according to the Clavien-Dindo classification was significantly less in the transanal group (66.7% vs. 28.6%, odds ratio: 5.000, 95% confidence intervals: 1.313-19.047, P = 0.040). The number of harvested lateral lymph nodes in both groups was similar (8.5 vs. 8, P = 0.544). CONCLUSION: The transanal approach for LLND reduced operative time, blood loss, and morbidity compared with the conventional approach alone in a cohort of patients with rectal cancer.

Standardized Procedure of Transperineal Minimally Invasive Abdominoperineal Resection for Low Rectal Cancer.

Although transperineal minimally invasive abdominoperineal resection (tp-APR) based on the concept of transanal total mesorectal excision has recently been used for rectal cancer, the operative procedure has not been standardized to date due to its technical difficulty. The tp-APR procedure used by the authors for a male patient with low rectal cancer is presented in this video.

Short-term and long-term outcomes after laparoscopic surgery for elderly patients with colorectal cancer aged over 80 years: a propensity score matching analysis.

PURPOSE: There has been an increase in the percentage of elderly patients with colorectal cancer (CRC). However, few studies have reported the short- and long-term outcomes of laparoscopic surgery for elderly patients with CRC aged over 80 years. METHODS: This study included 529 patients who underwent laparoscopic resection for clinical stage 0-III CRC at Kobe University Hospital between January 2010 and December 2018. Propensity score matching (PSM) was used to create balanced cohorts of the elderly (aged ≥ 80, n = 113) and the non-elderly (aged < 80, n = 113). Their clinical outcomes were compared after PSM. RESULTS: After matching, carcinoembryonic antigen (CEA) level was higher in the non-elderly group, and adjuvant chemotherapy was less frequently employed in the elderly group. D3 dissection was performed more frequently and the number of the harvested lymph nodes tended to be larger in the non-elderly group. There was no significant difference in the rates of postoperative complications, reoperation within 30 days, and 30-day mortality between the groups. The 5-year relapse-free survival rate was not statistically different between the two groups (77.3% for the non-elderly vs. 62.7% for the elderly, p = 0.13). The multivariate analyses for the whole cohort showed that the factors of sex, tumor location, operation time, and conversion to open surgery, but not the age, were significant predictors of postoperative complications. CONCLUSION: Laparoscopic surgery for colorectal cancer patients aged over 80 years is technically and oncologically safe.

Sarcopenia assessed by skeletal muscle mass volume is a prognostic factor for oncological outcomes of rectal cancer patients undergoing neoadjuvant chemoradiotherapy followed by surgery.

INTRODUCTION: Recently, sarcopenia has been reported to be associated with poor postoperative outcomes in various cancers. However, its clinical significance for rectal cancer patients undergoing neoadjuvant chemoradiotherapy (NACRT) followed by surgery remains unknown. MATERIALS AND METHODS: This study included 46 patients with locally advanced rectal cancer who underwent curative surgery after NACRT. Sarcopenia was assessed by measuring the cross-sectional psoas muscle area (PA) at L3 and total bilateral psoas muscle volume (PV). Patients with a lower PV or PA value than the median were assigned to the sarcopenia group while others were assigned to the non-sarcopenia group. Clinical outcomes were then compared between groups. RESULTS: The sarcopenia group included 22 patients. The rate of overall postoperative complications did not differ between groups. Five-year relapse-free survival (RFS) was significantly lower in the sarcopenia group when sarcopenia was assessed by PV after NACRT (44.0% vs. 82.6%, P = 0.00494). In contrast, RFS did not differ between groups when sarcopenia was assessed by PA. Multivariable analysis identified PV after NACRT as the most significant risk factor for RFS (hazard ratio 4.00; 95% CI 1.27-12.66, P = 0.018). CONCLUSION: Sarcopenia assessed by total PV after NACRT may be an accurate and reliable predictor of poor oncological outcomes in rectal cancer patients.

Current status and trend of laparoscopic right hemicolectomy for colon cancer.

Laparoscopic right hemicolectomy (LRH) is utilized worldwide as one of the standard surgical treatments for right-sided colon cancer. However, there have been issues concerning its applicability, techniques, and trend. The present study aimed to elucidate the current status and trend of LRH by reviewing literature focusing on important issues associated with this surgery. Based on previous studies, LRH most likely provides better short-term outcomes and similar oncological outcomes compared to open surgery. Despite the increasing use of robotic approach in this surgery, it seems to have always been associated with longer operative times and greater hospital cost with limited advantage. Intracorporeal anastomosis seems to improve short-term outcomes, such as quicker recovery of bowel function, compared to extracorporeal anastomosis. However, it does not contribute to shorter hospital stay. With regard to dissection technique, various approaches, and landmarks have been advocated to overcome the technical difficulty in LRH. This difficulty is likely to be caused by anatomical variation, especially in venous structures. The superiority of one approach or landmark over another is still argued about due to the lack of large-scale prospective studies. However, deep understanding both of anatomical variation and characteristics of each approach would be of extreme importance to minimize adverse effects and maximize patient benefit after LRH.

Usefulness of Omentoplasty to Reduce Perineal Wound Complications in Abdominoperineal Resection After Neoadjuvant Chemoradiotherapy.

BACKGROUND: Omentoplasty is sometimes used to prevent perineal wound complications after abdominoperineal resection (APR) following neoadjuvant chemoradiotherapy (NACRT). However, recent studies have raised some controversy about its clinical benefit. PATIENTS AND METHODS: Outcomes for rectal cancer patients who received APR after NACRT were retrospectively compared between the groups with omentoplasty (n=28) and without omentoplasty (n=14). RESULTS: The operative time was significantly longer in the omentoplasty group (575 vs. 404 min, p<0.001). Laparoscopic surgery was performed more frequently in the omentoplasty group. Perineal wound problems including dehiscence and infection were significantly reduced in the omentoplasty group (46.4% vs. 78.6%, p<0.001). Univariate and multivariate analyses revealed that omentoplasty was the most important factor in reducing perineal wound complications (odds ratio=0.020, 95% confidence intervaI=0.001-0.393; p=0.001). CONCLUSION: Omentoplasty was useful in reducing perineal wound complications after APR following NACRT.

Laparoscopic gastrectomy with lymph node dissection for the treatment of remnant stomach gastrointestinal stromal tumors in incomplete-type Carney's triad: a case report.

BACKGROUND: We report a rare case of gastrointestinal stromal tumors (GISTs) in Carney's triad, successfully treated using laparoscopic gastrectomy with lymph node dissection after chemotherapy. CASE PRESENTATION: A 21-year-old woman presented to our hospital for treatment of recurrent GISTs. The patient had been admitted for treatment 11 years prior, with black stools being the chief presenting complaint at that time. On examination at that time, multiple submucosal tumors in the pyloric antrum and multiple pulmonary tumors had been observed. She underwent open partial gastrectomy, and the diagnosis of GISTs was confirmed. She was administered tyrosine kinase inhibitors to treat lung metastases from 2 months after surgery. Due to the increasing size of the lung tumors, a right upper lobectomy was performed 9 years after the index gastric surgery. Histopathological examination of the lung specimen, in combination with re-examination of the gastric specimens, was indicative of incomplete-type Carney's triad. Eleven years after the index gastric surgery, multiple GISTs were observed in her entire stomach. Tumor biopsy revealed a succinate dehydrogenase deficiency, confirming the diagnosis of recurrent GISTs. For treatment, the patient underwent laparoscopic completion gastrectomy, with D1 plus lymph node dissection. CONCLUSION: This is a first case report of completion gastrectomy performed laparoscopically for the treatment of GISTs associated with incomplete-type Carney's triad. The recurrent GISTs developed over a protracted period of 11 years from the index gastric surgery to tumor recurrence.

Increases of calcium and magnesium and decrease of iron in human posterior longitudinal ligaments of the cervical spine with aging.

To elucidate compositional changes of ligaments with aging, the authors investigated age-related changes of elements in the posterior longitudinal ligaments (PLLs) by inductively coupled plasma-atomic emission spectrometry. After the ordinary dissection, PLLs were resected from the subjects ranging in age from 65 to 95 yr. The PLLs of the cervical spine were resected between the fourth and fifth cervical vertebrae, the PLLs of the thoracic spine between the fifth and seventh thoracic vertebrae, and the PLLs of the lumbar spine between the second and third lumbar vertebrae. Calcium and magnesium increased progressively with aging in the PLLs of the cervical spine, but they did not increase with aging in the PLLs of the thoracic and lumbar spine. In contrast, iron decreased gradually with aging in the PLLs of the cervical spine. Regarding the relationships among elements, significant correlations were found among the contents of calcium, phosphorus, magnesium, and sodium in the PLLs of the cervical spine.

Persistent left hepatic venous connection with the right atrium and the ductus venosus.

An anomalous left hepatic vein opening independently of the coronary sinus into the right atrium was found in the cadaver of an 88-year-old Japanese man. This vein originated from the left lobe of the liver, perforated the diaphragm at the left side of the vena caval foramen and opened into the right atrium. The left hepatic vein anastomosed mutually with the middle hepatic vein at the level of venule. The ligamentum venosum originated from the left branch of the portal vein and was connected directly to the left hepatic vein. The development of the central systemic venous system and a possible explanation for the morphogenesis of this anomaly were reviewed. As a result, the occurrence of this anomalous vein was explained as being due to the persistence of the left vitelline connection with the left sinus horn and the ductus venosus.

Increased microorganisms DNA levels in peripheral blood monocytes from psoriatic patients using PCR with universal ribosomal RNA primers.

It has long been suspected that systemic and focal infections cause or exacerbate psoriatic lesions. We previously showed that peripheral blood monocytes in psoriatic patients are activated and overproduce inflammatory cytokines. In addition, it has been reported that macrophages activated by ingesting microorganisms release tumor necrosis factor (TNF)-alpha and interleukin (IL)-1beta. Therefore we hypothesized that the monocytes in psoriatic patients may be activated by ingesting microorganisms and overproduce inflammatory cytokines. We examined the detection of microorganism DNA in monocytes from 15 patients with psoriasis vulgaris and from 12 healthy controls. DNA was extracted from monocytes, and a polymerase chain reaction (PCR) assay was performed for the detection using universal primers from conserved regions of the bacterial 16S ribosomal RNA gene or the fungal 18S rRNA gene. At the same time, we calculated the psoriasis area and severity index (PASI) scores and analyzed their correlations with the microorganisms DNA levels. The results showed that bacterial 16S DNA levels in monocytes were significantly higher in psoriatic patients than in controls. The fungal 18S DNA levels were also higher in psoriatic patients than in controls, but the differences were not significant. Although the microorganisms DNA levels in monocytes of psoriatic patients were high, there was no correlation between the bacterial DNA levels in monocytes of the psoriatics and PASI scores. Our study suggests that monocytes in psoriatic patients engulf more bacteria than there in controls, causing an activation of monocytes and triggering the formation of new lesions in the initial stages of psoriasis.

Compositional changes of the muscular layers of the stomach with aging.

To elucidate compositional changes of the stomach with aging, the authors investigated age-related changes of the elements and relationships among the elements in the muscular layers of the pylorus, cardia, lesser curvature, and greater curvature by inductively coupled plasma-atomic emission spectrometry. After ordinary dissection by medical students, the pylori, cardias, lesser curvatures, and greater curvatures were removed from the subjects, consisting of 19 men and 1 woman, ranging in age from 65 to 95 yr. The muscular layers were isolated and the element contents were determined. The calcium content increased progressively with aging in the muscular layers of the pylorus, cardia, and lesser curvature, whereas it tended to increase in the muscular layer of the greater curvature with aging. Regarding sulfur, the content increased significantly in the muscular layer of the pylorus with aging, but not significantly in the muscular layers of the cardia, lesser curvature, and greater curvature with aging. Regarding the relationships among the elements, significant direct correlations were found among calcium, phosphorus, sulfur, and magnesium in both the muscular layers of the pylori and cardias, with some exceptions.

Silicon compatible with the height of human vertebral column.

In the study on human vertebral composites, silicon was found to be related to the height of the vertebral column. The element ratio of silicon to calcium in the lumbar vertebra was twice that of the lowest one in the cervical vertebra. The element ratio gradually increased from approx 0.5 at the cervical vertebra to approx 1.0 at the lumbar one. Silicon is preserved catastropically much more in the lower height of the backbone in contrast with the calcium amount, and the ratio to sulfur appears to be unchanged. This suggests that silicon is compatible with the biokinetics of the vertebral bone structure of calcium.

Accumulation of calcium in human common iliac artery, aortic valve, xiphoid process, costal cartilage, posterior longitudinal ligament, trigeminal nerve, and rib accompanied by increase of magnesium.

To examine whether an accumulation of Ca in the tissues was accompanied by an increase of Mg, the authors investigated the relationships between Ca and Mg contents in the common iliac arteries, aortic valves, xiphoid processes, costal cartilages, posterior longitudinal ligaments, trigeminal nerves, and ribs by inductively coupled plasma-atomic emission spectrometry. After the ordinary dissections by medical students were finished, the common iliac arteries, aortic valves, xiphoid processes, bilateral the fourth costal cartilages, posterior longitudinal ligaments between the fourth and fifth cervical vertebrae, trigeminal nerves, and bilateral the sixth ribs were resected from the subjects and elements were determined. It was found that there were extremely significant direct correlations between Ca and Mg contents in all of the common iliac arteries, aortic valves, costal cartilages, posterior longitudinal ligaments, and trigeminal nerves, whereas there were significant direct correlations in both the xiphoid processes and ribs. As for the tissues containing Ca higher than 20 mg/g, the average mass ratios of Mg/Ca were similar among the seven tissues. As Ca increased in all of the common iliac arteries, aortic valves, xiphoid processes, costal cartilages, posterior longitudinal ligaments, trigeminal nerves, and ribs, Mg increased simultaneously in the seven tissues.

Different accumulation of elements in the rami of the coronary arteries of Thai.

To analyze the accumulation of elements in the rami of the coronary arteries, the authors determined element contents in both the coronary arteries and their rami of the Thai by inductively coupled plasma-atomic emission spectrometry. The subjects consisted of 13 men and 6 women, ranging in age from 34 to 83 yr. It was found that a higher accumulation of calcium and phosphorus occurred in the proximal sites of coronary arteries such as the anterior descending, right coronary, left coronary, and circumflex arteries than the distal sites such as the diagonal, lateral, conus, acute marginal, and posterior descending arteries. The accumulation of calcium and phosphorus in the anterior descending and right coronary arteries of the Thai increased remarkably in the fifties, thereafter decreased, and increased again in the eighties. It should be noted that a very high accumulation of calcium and phosphorus in the coronary arteries occurred in the fifties. In regard to relationships among the average contents of elements in the coronary arteries and their rami, it was found that there were very significant direct correlations between calcium and phosphorus contents, between calcium and magnesium contents, and between phosphorus and magnesium contents. These results suggested that as calcium and phosphorus increased in the coronary arteries and their rami, magnesium increased simultaneously in all of the coronary arteries and their rami.

Age-related changes of elements and relationships among elements in human tendons and ligaments.

To elucidate compositional changes of the tendons and ligaments with aging, the authors investigated age-related changes of element contents in the insertion tendons of the biceps brachii muscle, central tendons of the diaphragma, Achilles' tendons, posterior longitudinal ligaments (PLLs) of the cervical spine, ligamenta capitum femorum, and anterior cruciate ligaments. After ordinary dissections by medical students, the three tendons and three ligaments were resected and element contents were determined by inductively coupled plasma-atomic emission spectrometry. It was found that the elements, such as Ca, P, S, Mg, Na, Zn, and Fe, did not change significantly in the three tendons and two ligaments with aging, except for the PLLs where Ca and Mg increased significantly with aging and Fe decreased significantly with aging. With regard to the relationships among elements, the common finding that there were significant correlations between Ca and P contents and between Ca and Mg contents was obtained in the three ligaments. Likewise, the common finding that there was a significant correlation between Ca and Mg contents was obtained in the three tendons. Regarding the relationship between Ca and P contents, the three tendons were different from the three ligaments.

Age-related changes of elements with their relationships in human cranial and spinal nerves.

To elucidate compositional changes of peripheral nerves with aging, the authors investigated age-related changes of elements and their relationships in the optic, trigeminal, vagus, median, radial, ulnar, femoral, sciatic, tibial, and common peroneal nerves by inductively coupled plasma-atomic emission spectrometry. The subjects consisted of 10 men and 12 women, ranging in age from 65 to 91 yr. It was found that although accumulations of Ca and P occurred only in the trigeminal nerve at old age, it hardly occurred in the optic, vagus, median, radial, ulnar, femoral, sciatic, tibial, and common peroneal nerves at old age. The average contents of Ca and P were three and two times higher in the trigeminal nerve than in the other nine kinds of nerve, respectively. Likewise, the average content of Mg was a little higher in the trigeminal nerve compared with the other nerves. With regard to the relationships among elements, significant direct correlations were found among the contents of Ca, P, S, and Mg in most, but not all, 10 kinds of nerve. In the trigeminal nerve, a significant inverse correlation was found between the contents of S and the other elements, such as Ca, P, and Mg. Regarding the relationships between the contents of S and other elements, the nerves, except for the trigeminal nerve, differed from those found in the arteries previously reported.

Differences in calcium accumulation between human plantar and palmar aponeuroses.

To elucidate the characteristics of calcium accumulation of human plantar and palmar aponeuroses, the authors determined the calcium content of human plantar and palmar aponeuroses by atomic absorption flame emission spectrophotometry. The subjects consisted of 9 men and 14 women, ranging in age from 61 to 93 yr. In the plantar aponeurosis, the calcium content was significantly higher in the anterior and posterior parts than in the middle part. It is known that pressure distribution under the sole of a foot is higher in the anterior and posterior parts than in the middle part. The present study suggests that the accumulation of calcium in the plantar aponeurosis is related with the pressure distribution under the sole of a foot. The calcium content increased progressively with aging in the anterior part of the plantar aponeurosis, but not in the middle and posterior parts. Regarding the palmar aponeurosis, the calcium content was significantly higher in the anterior and posterior parts in comparison with the middle part. It was found that the calcium content increased progressively with aging in the posterior part of the palmar aponeurosis, whereas it did not increase significantly with aging in the anterior and middle parts. Regarding the relationship between the calcium content of the aponeuroses and the bone mineral density, a significant correlation was found between the calcium content in the anterior part of the palmar aponeurosis and the bone mineral density of the scaphoid bone.

Inverse relationship between serum erythropoietin and blood lead concentrations in Kathmandu tricycle taxi drivers.

OBJECTIVE: Kathmandu tricycle taxi drivers, whose environmental lead (Pb) exposure is ascribable mainly to vehicular exhaust, were studied to examine a dose-response relationship between blood Pb (Pb-B) and serum erythropoietin (sEPO) concentrations. METHODS: Subjects were 27 drivers and 9 non-drivers. They were non-anemic healthy men with normal renal function. Pb-B was measured by an atomic absorption spectrometer with a graphite furnace, and sEPO was determined with a sandwich-type enzyme-linked immunosorbent assay. RESULTS: sEPO levels in drivers were lower than those of non-drivers, while Pb-B levels in drivers were higher than those of non-drivers. There was an inverse relationship between Pb-B and sEPO. CONCLUSIONS: The data suggest that Pb inhibits renal EPO production in a dose-dependent manner in persons with subclinical Pb toxicity. sEPO may serve as an early biochemical marker of subclinical Pb toxicity.