Pancreatitis After Treatment With Encorafenib, Binimetinib, and Cetuximab for BRAF V600E Mutation-Positive Colorectal Cancer.

BRAF V600E mutation-positive advanced recurrent colorectal cancer has a poor prognosis. Encorafenib, binimetinib, and cetuximab were approved for use to treat this cancer in 2020 in Japan. Here, we present the case of a patient with BRAF V600E mutation-positive colorectal cancer, who was treated with encorafenib, binimetinib, and cetuximab, and developed grade 3 pancreatitis at our hospital. After pancreatitis treatment, the drug doses were reduced from 300 mg to 225 mg of encorafenib and from 90 mg to 60 mg of binimetinib, and the treatment was resumed. Since then, no grade 3 or higher adverse events were observed. Although pancreatitis has been reported to occur after the use of encorafenib and binimetinib, it is rare. With appropriate dose reduction and attention to side effects, this regimen is considered feasible for the long-term treatment of BRAF V600E mutation-positive advanced recurrent colorectal cancer in patients aged >70 years.

A Case of Direct-Acting Oral Anticoagulant-Induced Intramural Colon Hematoma Successfully Treated by Laparoscopic Surgery.

Intramural intestinal hematoma is a rare disease, one of the triggering factors of which is the use of anticoagulants. In previous reports, most patients were on treatment with warfarin. Herein, we report a case of direct-acting oral anticoagulant (DOAC)-induced intramural hematoma of the ascending colon in a patient refractory to conservative treatment and required laparoscopic right hemicolectomy. An 80-year-old male patient with a history of atrial fibrillation and cerebral infarction, on treatment with apixaban, was brought to our hospital with the chief complaints of abdominal pain, vomiting, and melena. Imaging revealed the cause of symptoms to be intestinal obstruction caused by a mass lesion on the wall of the ascending colon. We initially opted for conservative treatment with discontinuation of apixaban and insertion of an ileus tube. Intestinal dilatation findings showed improvement; however, subsequent imaging examinations did not reveal the shrinkage of a lesion in the ascending colon. If the mass was not removed, recurrence of bowel obstruction symptoms was expected, so we decided to perform surgical intervention. A laparoscopic right hemicolectomy was performed, and an intramural hematoma of the ascending colon was diagnosed based on the excised specimen. He needed a blood transfusion for anemia but was discharged on postoperative day 14 with no other complications. DOACs are now widely used in patients with atrial fibrillation, and the risk of bleeding as a side effect is extremely low compared to conventional anticoagulants, including warfarin. However, when abdominal pain occurs, as in the present case, an intramural hematoma should be considered in the differential diagnosis. There is no established treatment plan for intestinal intramural hematoma. Although conservative treatment is effective in some cases, it is difficult to evaluate the risk of bleeding associated with DOACs using coagulation tests. Even if conservative treatment is selected, it is essential to determine surgical resection, if necessary, based on the clinical course and imaging and blood test findings.

Laparoscopic Surgery for Sigmoid Colon Cancer in a Patient With a History of Two Renal Transplantations and Peritoneal Dialysis.

The development of transplantation technology has improved the prognosis of transplantation surgery; however, the negative impact of immunosuppressive drugs has increased the number of patients with cancer after transplantation. Recently, minimally invasive surgery has become more common for cancer treatment. We report our experience of performing laparoscopic sigmoid colon resection for a patient with a history of two renal transplantations and peritoneal dialysis. A 42-year-old male patient who developed purpura nephropathy underwent renal transplantation at ages eight and 34 years. He had been on peritoneal dialysis for five years before the second transplantation. The patient was referred to our department with the chief complaint of sudden abdominal pain. After an examination of imaging, we obtained a diagnosis of sigmoid colon cancer. Despite a history of peritoneal dialysis, laparoscopic sigmoid colon resection was successfully performed without complications after confirming that there were no adhesions in the abdominal cavity. The left lower port position had to be adjusted because the transplanted kidney protruded into the left iliac fossa. No postoperative complications and graft loss occurred. In this case, laparoscopic surgery was effective in lowering the risk of damage to the transplanted kidney and safely performing the procedure. The number of colorectal cancer cases in renal transplant patients is expected to increase, and some of these patients will have a history of peritoneal dialysis, which may make surgery more difficult. The successful outcome of this case highlights that laparoscopic surgery could be viable for patients with such a complex medical history.

BRAF Mutation Heterogeneity Detected Using Circulating Tumor DNA Sequencing in Synchronous Colon Cancer: A Case Report.

Background/Aim: Synchronous colorectal cancer, which occurs in approximately 4.8-8.4% of all colorectal cancers, has a genetic profile with a higher rate of v-raf murine sarcoma viral oncogene homolog B1 (BRAF) mutation and microsatellite instability-high than solitary colorectal cancer. However, little information is available on heterogeneity among tumor lesions because of difficulty in performing genetic tests in all lesions in clinical practice. Case Report: A 44-year-old man presented with multiple recurrent lung metastases 42 months after the endoscopic resection of early stage synchronous ascending and sigmoid colon cancers. The genetic testing of sigmoid colon cancer tissue samples, their state being more advanced than that of ascending colon cancer, revealed a v-Ki-ras 2 Kirsten rat sarcoma viral oncogene homolog mutation (G13C) and BRAF wild type. However, the tumor was refractory to initial chemotherapy and rapidly progressed to new liver metastases. Therefore, we suspected that there may be biological heterogeneity between the primary sigmoid colon lesion and liver metastases. Next, we performed next-generation sequencing on circulating tumor DNA from the patient's plasma (Foundation One Liquid CDx®), which revealed the V600E mutation of BRAF, suggesting that there was genetic heterogeneity among the synchronized primary lesions, one of which was responsible for the chemo-refractory rapid-growing liver metastases. Conclusion: Genetic profiling with liquid biopsy at the time of recurrence and metastasis may be useful in patients with multiple synchronous cancers because there is less heterogeneity between primary and metastatic sites.

Advanced Appendiceal Cancer with Systematic Metastasis without Gastrointestinal Symptoms Found by Subcutaneous Tumor.

An 86-year-old woman with a subcutaneous nodule in her left axilla visited our hospital. She had no gastrointestinal symptoms, but contrast-enhanced computed tomography revealed a cecal mass and systemic metastasis, including cutaneous, bone, peritoneal dissemination and ascites. Colonoscopy revealed a circumferential, elevated cecal lesion. She underwent right hemicolectomy to prevent colon obstruction. The pathological diagnosis was poorly differentiated adenocarcinoma (por1>tub2>muc) arising from the appendix with a BRAFV600E mutation and microsatellite instability-high. Chemotherapy was administered, and she is currently still alive and undergoing chemotherapy. We describe a rare case of advanced appendiceal cancer without gastrointestinal symptoms diagnosed due to cutaneous metastasis.

Universal meta-competencies of operative performances: a literature review and qualitative synthesis.

BACKGROUND: Prioritizing patient health is essential, and given the risk of mortality, surgical techniques should be objectively evaluated. However, there is no comprehensive cross-disciplinary system that evaluates skills across all aspects among surgeons of varying levels. Therefore, this study aimed to uncover universal surgical competencies by decomposing and reconstructing specific descriptions in operative performance assessment tools, as the basis of building automated evaluation system using computer vision and machine learning-based analysis. METHODS: The study participants were primarily expert surgeons in the gastrointestinal surgery field and the methodology comprised data collection, thematic analysis, and validation. For the data collection, participants identified global operative performance assessment tools according to detailed inclusion and exclusion criteria. Thereafter, thematic analysis was used to conduct detailed analyses of the descriptions in the tools where specific rules were coded, integrated, and discussed to obtain high-level concepts, namely, "Skill meta-competencies." "Skill meta-competencies" was recategorized for data validation and reliability assurance. Nine assessment tools were selected based on participant criteria. RESULTS: In total, 189 types of skill performances were extracted from the nine tool descriptions and organized into the following five competencies: (1) Tissue handling, (2) Psychomotor skill, (3) Efficiency, (4) Dissection quality, and (5) Exposure quality. The evolutionary importance of these competences' different evaluation targets and purpose over time were assessed; the results showed relatively high reliability, indicating that the categorization was reproducible. The inclusion of basic (tissue handling, psychomotor skill, and efficiency) and advanced (dissection quality and exposure quality) skills in these competencies enhanced the tools' comprehensiveness. CONCLUSIONS: The competencies identified to help surgeons formalize and implement tacit knowledge of operative performance are highly reproducible. These results can be used to form the basis of an automated skill evaluation system and help surgeons improve the provision of care and training, consequently, improving patient prognosis.

Fascia Lata Grafting Combined with Gluteal Flaps for Pelvic Floor Reconstruction after Oncologic Resection.

Although recent methods of pelvic reconstruction using myocutaneous flaps have reduced postoperative morbidities' including pelvic abscess, the complication rates are still high due to the presence of a large dead cavity and poorly vascularized tissues secondary to preoperative chemoradiation therapy. We aimed to evaluate the usefulness and benefit of fascia lata autografting for pelvic floor reconstruction as a supplemental procedure for gluteal flap closure of perineal wounds. Methods: Our retrospective study included 144 consecutive patients who underwent rectal cancer resection with or without pelvic reconstruction, from 2010 to 2020. For reconstruction, fascia lata autografts were harvested from the thigh and affixed to the pelvic floor. The perineal wound was closed using gluteal advancement flaps. Results: The study included 33 reconstructed and 111 nonreconstructed patients (average age: 69.5 years). The reconstructed group was more likely to have undergone preoperative chemotherapy (81.8% versus 40.5%, P < 0.001) and radiotherapy (78.8% versus 48.6%, P = 0.002), compared with the nonreconstructed group. Additionally, the reconstructed group underwent fewer abdominoperineal resections (63.6% versus 94.6%, P < 0.001) and more pelvic exenterations (36.4% versus 5.4%). The mean size of fascia lata autografts was 8.3 × 5.9 cm. There were significant differences between the reconstructed and nonreconstructed groups, in the incidences of complications (15.2% versus 33.3%, P = 0.044) and pelvic abscess (3.0% versus 16.2%, P = 0.049). Conclusion: Combination of fascia lata autografts and gluteal flaps is considered an effective method of pelvic reconstruction for its low incidence of complications and stable outcomes.

Correction to: Clinical Impact of Inferior Mesenteric Lymph Node Metastasis in Patients with Cancer of the Sigmoid Colon or Rectum.

[This corrects the article DOI: 10.1007/s13193-021-01389-3.].

Non-operative management after chemoradiotherapy plus consolidation or sandwich (induction with bevacizumab and consolidation) chemotherapy in patients with locally advanced rectal cancer: a multicentre, randomised phase II trial (NOMINATE trial).

INTRODUCTION: Total mesorectal excision (TME) and postoperative adjuvant chemotherapy following neoadjuvant chemoradiotherapy (CRT) is the standard treatment for locally advanced rectal cancer (LARC). However, neoadjuvant CRT has no recognised impact on reducing distant recurrence, and patients suffer from a long-lasting impairment in quality of life (QOL) associated with TME. Total neoadjuvant therapy (TNT) is an alternative approach that could reduce distant metastases and increase the proportion of patients who could safely undergo non-operative management (NOM). This study is designed to compare two TNT regimens in the context of NOM for selecting a more optimal regimen for patients with LARC. METHODS AND ANALYSIS: NOMINATE trial is a prospective, multicentre, randomised phase II selection design study. Patients must have clinical stage II or III (T3-T4Nany) LARC with distal location (≤5 cm from the anal verge or for those who are candidates for abdominoperineal resection or intersphincteric resection). Patients will be randomised to either arm A consisting of CRT (50.4 Gy with capecitabine) followed by consolidation chemotherapy (six cycles of CapeOx), or arm B consisting of induction chemotherapy (three cycles of CapeOx plus bevacizumab) followed by CRT and consolidation chemotherapy (three cycles of CapeOx). In the case of clinical complete response (cCR) or near cCR, patients will progress to NOM. Response assessment involves a combination of digital rectal examination, endoscopy and MRI. The primary endpoint is the proportion of patients achieving pathological CR or cCR≥2 years, defined as the absence of local regrowth within 2 years after the start of NOM among eligible patients. Secondary endpoints include the cCR rate, near cCR rate, rate of NOM, overall survival, distant metastasis-free survival, locoregional failure-free survival, time to disease-related treatment failure, TME-free survival, permanent stoma-free survival, safety of the treatment, completion rate of the treatment and QOL. Allowing for a drop-out rate of 10%, 66 patients (33 per arm) from five institutions will be accrued. ETHICS AND DISSEMINATION: The study protocol was approved by Wakayama Medical University Certified Review Board in December 2020. Trial results will be published in peer-reviewed international journals and on the jRCT website. TRIAL REGISTRATION NUMBER: jRCTs051200121.

Oncologic benefit of adjuvant chemotherapy for locally advanced rectal cancer after neoadjuvant chemoradiotherapy and curative surgery with selective lateral pelvic lymph node dissection: An international retrospective cohort study.

INTRODUCTION: Intensive local treatment comprising total mesorectal excision (TME) with selective lateral pelvic lymph node dissection (LPND) after neoadjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC) has received attention among clinicians treating rectal cancer. It remains unclear whether adjuvant chemotherapy (ACT) after intensive local treatment is beneficial for these patients. We evaluated the oncologic benefit of ACT for patients with LARC who received intensive local treatment. MATERIALS AND METHODS: This international multicentre retrospective cohort study included 737 patients treated in Japan and Korea between 2010 and 2017. The effectiveness of ACT on recurrence-free survival (RFS) was evaluated using univariable and multivariable Cox proportional hazards models, with subgroup analyses to identify subpopulations potentially benefiting from ACT. RESULTS: The median follow-up was 49 months; the 5-year RFS and local recurrence rates for the entire cohort were 72.1% and 4.9%, respectively; 514 patients (69.7%) received adjuvant chemotherapy, without an oncologic benefit (hazard ratio, 1.14; 95% confidence interval [CI]: 0.79-1.68) demonstrated in the multivariable Cox regression analysis. In subgroup analyses, the distributions of the 95% CI in patients aged ≥70 years and those with ypStage 0 tended to place a disproportionate emphasis that favoured the non-ACT treatment strategy. CONCLUSION: Despite achieving good local control with intensive local treatment strategy, the effectiveness of ACT for the LARC patients with CRT followed by TME with selective LPND was not proved. Elderly patients and those with ypStage0 may not receive benefit from ACT after CRT and TME ± LPND.

Significance of preoperative nutritional status as a predictor for short-term and long-term outcomes of patients undergoing surgery for stage IV colorectal cancer.

PURPOSE: The clinical impact of the preoperative nutritional status has not fully been understood in an aggressive surgical approach for stage IV colorectal cancer (CRC). METHODS: The clinical records of 399 patients with stage IV CRC who underwent surgery for the primary tumor were reviewed. The predictive powers of reported nutritional/inflammatory indices of postoperative morbidity were compared, and their correlations with both the short- and long-term outcomes were investigated. RESULTS: Among the 10 tested nutritional/inflammatory indices, the Controlling Nutritional Status (CONUT) score showed the highest performance for predicting major morbidity (area under the curve [AUC], 0.605; P = 0.067) and any morbidity (AUC, 0.605; P = 0.001). When stratifying the population into 4 undernutrition grades based on the CONUT score, the CONUT undernutrition grades were found to show good correlations with the Clavien-Dindo grades of postoperative morbidity (P < 0.001) and the length of hospital stay (P < 0.001). Multivariate analysis confirmed the CONUT undernutrition grade was significantly associated with the survival outcomes in patients with stage IV CRC (light: hazard ratio [HR], 1.12; 95% CI, 0.80-1.58; moderate: HR, 1.54; 95% CI, 1.02-2.33; severe: HR, 3.61; 95% CI, 1.52-8.62). CONCLUSIONS: Preoperative nutritional status is a useful predictive marker for both the short- and long-term outcomes of surgical interventions for stage IV CRC.

Postoperative Nutritional Status is Predictive of the Survival Outcomes in Patients Undergoing Resection of Stage III Colorectal Cancer.

BACKGROUND: Preoperative nutritional status is reportedly associated with the clinical outcomes in patients with colorectal cancer (CRC), although it remains inconclusive whether the preoperative nutritional status that may improve after surgery is truly predictive of the survival outcomes of patients with CRC. METHODS: Clinical records of patients with stage III CRC (n = 821) in whom curative resection had been achieved were retrospectively reviewed and the prognostic impact of nutritional status, determined by the controlling nutritional status (CONUT) score, was analyzed. RESULTS: The CONUT undernutrition grade was significantly associated with the overall survival rate (OS) in the original population (P < 0.0001). By adopting a cut-off value of CONUT score of ≥ 2 and adjustment for clinical variables using the inverse probability treatment weighting methods, the group with a preoperative CONUT score of ≥ 2 showed a worse OS as compared to the groups with a preoperative CONUT score of < 2 (P = 0.037). However, sub-analysis based on the dynamic changes in the CONUT score revealed that sustained malnutrition in the postoperative period was more frequent among patients with preoperative CONUT score of ≥ 2, and that the OS and recurrence-free survival rate (RFS) were significantly correlated with the "postoperative" nutritional status, irrespective of the preoperative nutritional status. Patients who showed improvements of the nutritional status after surgery showed a significantly longer OS and RFS. CONCLUSIONS: Sustained undernutrition or worsening of the nutritional status after colectomy may be associated with a worse OS and RFS after curative resection in patients with stage III CRC.

Potential importance of vital capacity for the safety of laparoscopic surgery for colorectal cancer in patients with pulmonary dysfunction.

BACKGROUND: We examined the safety of laparoscopic surgery for colorectal cancer (CRC) in patients with pulmonary dysfunction, and evaluated risk factors (RF) for post-operative complications. METHODS: We defined pulmonary dysfunction as having any diagnosed pulmonary disease with spirometry findings of obstructive or restrictive defects. Clinicopathological factors of 213 patients with pulmonary dysfunction who underwent laparoscopic surgery for CRC at Toranomon Hospital from 1999 to 2016 were evaluated to retrospectively identify RFs for any post-operative complications and major complications, namely post-operative pulmonary complications (PPCs). Examined preoperative factors included age, gender, body mass index, tumour location, smoking history, percentage vital capacity (%VC), forced expiratory volume in 1 s (FEV1.0), a ratio of FEV1.0 to forced vital capacity and American Society of Anesthesiologists physical status grade. Intraoperative factors, such as operative time, blood loss and blood transfusion, were also assessed. RESULTS: Forty patients (18.8%) developed any complications including PPCs. Multivariate analysis revealed that male, rectal cancer and spirometry findings (both low FEV1.0 (0.8 L) and low %VC (<95)) were RFs (P = 0.026, 0.003 and 0.007, respectively). Six cases (2.8%) developed PPCs. The prevalence of PPCs was higher in patients with both low %VC (<95%) and low FEV1.0 (<0.8 L), with statistical significance (P = 0.006). CONCLUSION: Our study suggested that not only low FEV1.0 but also low %VC was an important RF for post-operative complications after laparoscopic surgery for CRC.

Hybrid resection of massive rectal gastrointestinal stromal tumor using laparoscopic and transanal approaches.

Rectal gastrointestinal stromal tumors (GISTs) are rare, and radical surgery such as abdominoperineal resection is necessary for large rectal GISTs to obtain tumor-free resection margins. Here, we describe a 77-year-old man with a locally advanced non-metastatic GIST in the left anterolateral wall of the lower rectum. Tumor size was estimated to be 73 mm, and invasion of the left seminal vesicle and prostate was suspected. Chemotherapy with imatinib mesylate reduced the tumor size, creating a slight gap between the tumor and anterior organs. Therefore, we performed sphincter-sparing partial rectal resection using a hybrid method of laparoscopic and transanal approaches. The postoperative course was uneventful, and the patient remains disease-free on adjuvant chemotherapy 12 months after surgery. This case suggests that a hybrid method of laparoscopic and transanal surgery allows oncological and function-preserving excision of large rectal GISTs.

Clinical Impact of Inferior Mesenteric Lymph Node Metastasis in Patients with Cancer of the Sigmoid Colon or Rectum.

The aim of this study was to clarify the clinical impact of inferior mesenteric lymph node (IMLN) metastasis from cancer of the sigmoid colon or rectum. A total of 952 patients underwent curative surgery with IMLN dissection for either sigmoid colon cancer or rectal cancer from January 2000 to August 2018. Of these, 26 (2.7%) were pathologically diagnosed with IMLN metastasis. Excluding 1 patient, 25 patients were retrospectively investigated for clinicopathological characteristics and long-term outcomes. Specifically, the clinical course of patients with recurrence was meticulously scrutinised. Of the 25 patients, 14 (56%) had recurrence during the follow-up period. The 5-year recurrence-free survival was 31.2%, and 5-year overall survival was 59.7%. No serious morbidity, such as anastomotic leakage, was observed. Of the 14 patients with recurrence, 6 underwent secondary surgery with curative intent and 5 of the 6 patients remained cancer-free. In contrast, 8 patients were treated with chemotherapy, radiotherapy or best supportive care. Although IMLN metastasis was strongly associated with recurrence, long-term survival could be expected in most cases. Furthermore, there could be a chance for complete cure in patients with recurrence if secondary surgery is successfully carried out.

Clinical impact of Endoscopic Surgical Skill Qualification System (ESSQS) by Japan Society for Endoscopic Surgery (JSES) for laparoscopic distal gastrectomy and low anterior resection based on the National Clinical Database (NCD) registry.

AIM: This study aimed to evaluate the association between surgeons certified via the Endoscopic Surgical Skill Qualification System (ESSQS) of the Japan Society for Endoscopic Surgery (JSES) and surgical outcomes of laparoscopic distal gastrectomy (LDG) and laparoscopic low anterior resection (LLAR). METHODS: Japanese National Clinical Database data on the patients undergoing LDG and LLAR between 2014-2016 were analyzed retrospectively. The proportion of cases performed by ESSQS-certified surgeons was calculated for each procedure, and clinicopathological factors with or without participation of ESSQS-certified surgeons as an operator were assessed. Then, effects of operations performed by ESSQS-certified surgeons on short-term patient outcomes were analyzed using generalized estimating equations logistic regression analysis. RESULTS: There were 110 610 and 65 717 patients who underwent LDG and LLAR, respectively. The operations performed by ESSQS-certified surgeons in each procedure totaled 28 467 (35.3%) and 12 866 (31.2%), respectively. A multivariable logistic regression model showed that odds ratios of mortality for LDG and LLAR performed by ESSQS-certified surgeons were 0.774 (95% CI, 0.566-1.060, P = 0.108) and 0.977 (0.591-1.301, P = 0.514), respectively. Odds ratios for secondary endpoints of anastomotic leakage in LDG and LLAR performed by ESSQS-certified surgeons were 0.835 (95% CI, 0.723-0.964, P = 0.014) and 0.929 (0.860-1.003, P = 0.059), respectively, whereas that of ileus/bowel obstruction for LLAR performed by ESSQS-certified surgeons was 1.265 (1.132-1.415, P < 0.001). There were no significant associations between the two operations performed by ESSQS-certified surgeons and other factors such as mortality and overall complications. CONCLUSIONS: ESSQS certification did not affect postoperative mortality following LDG and LLAR, but annual experience of laparoscopic surgery was associated with it. ESSQS certification may contribute to favorable outcomes regarding anastomotic leakage following LDG and LLAR.

Radiomics Approach Outperforms Diameter Criteria for Predicting Pathological Lateral Lymph Node Metastasis After Neoadjuvant (Chemo)Radiotherapy in Advanced Low Rectal Cancer.

BACKGROUND: Advanced low rectal cancer has a non-negligible risk of lateral pelvic lymph node (LPLN) metastasis (LPLNM) and lateral local recurrence (LR) after neoadjuvant (chemo)radiotherapy and total mesorectal excision. LPLN dissection (LPLND) reduces LR but increases postoperative complications and sexual/urinary dysfunction. OBJECTIVE: The aim of this study was to develop a new radiomics-based prediction model for LPLNM in patients with rectal cancer. METHODS: A total of 247 patients with rectal cancer and enlarged LPLNs treated by (chemo)radiotherapy and LPLND were enrolled in this retrospective, multicenter study. LPLN radiomic features were extracted from pretreatment portal venous-phase computed tomography images. A radiomics score of LPLN was constructed based on the least absolute shrinkage and selection operator regression in a primary cohort of 175 patients. Model performance was assessed in terms of discrimination, calibration, and decision curve analysis, and was externally validated in 72 patients. RESULTS: The radiomics score showed significantly better discrimination compared with pretreatment short-axis diameter measurements in both the primary (area under the curve [AUC] 0.91 vs. 0.83, p = 0.0015) and validation (AUC 0.90 vs. 0.80, p = 0.0298) cohorts. Decision curve analysis also indicated the superiority of the radiomics score. In a subanalysis of patients with a short-axis diameter ≥ 7 mm, the radiomics nomogram, incorporating the radiomics score and LPLN shrinkage to ≤ 4 mm, had better discrimination compared with a model incorporating only LPLN shrinkage in both cohorts. CONCLUSIONS: Radiomics-based prediction modeling provides individualized risk estimation of LPLNM in rectal cancer patients treated with (chemo)radiotherapy, and outperforms measurements of pretreatment LPLN diameter.

Congestive ischemic colitis occurring after resection of left colon cancer: 4 case series.

BACKGROUND: Ischemic colitis can occur after colectomy and is sometimes difficult to treat. We report 4 cases of refractory, delayed onset, regional congestive colitis occurring on the anal side of the anastomosis after laparoscopic left hemicolectomy. CASE PRESENTATION: A total of 191 patients underwent surgery for left colon cancer (transverse, descending, and sigmoid colon cancer) at our hospital from January 2012 to December 2017. During the procedures, the left colic artery (LCA) or sigmoid colic artery (SA) was dissected, the superior rectal artery (SRA) was preserved, and the inferior mesenteric vein (IMV) was dissected at the inferior margin of the pancreas. Congestive ischemic colitis due to venous return dysfunction occurred in 4 cases (2.1%), 5 to 34 months postoperatively. The patients had diarrhea and blood in the stool. On computed tomography (CT), the patients exhibited continuous intestinal edema and high-density adipose tissue from the anastomosis site to the rectum. Contrast enhancement showed dilation of the vasa recti and arteries from the inferior mesenteric artery (IMA) to the SRA. Three patients improved with long-term intestinal rest; in 1 case, the stenosis did not improve and required colorectal resection. CONCLUSION: Diagnoses were easy in these cases, but treatment was prolonged and surgery was necessary in 1 case. While this condition is rare, caution is warranted as it is difficult to treat.

Laparoscopic surgery for colovesical fistula associated with sigmoid colon diverticulitis: a review of 39 cases.

OBJECTIVES: Colonic diverticular disease is widespread in Western countries and its associated with aging. In Japan, diverticulitis and colovesical fistula are also occurring more frequently. Colonic resection for diverticula-related fistulas is frequently technically demanding because of associated acute or chronic inflammation. We evaluated the safety and efficacy of a standardized laparoscopic procedure. METHODS: Data from 39 consecutive patients who had undergone laparoscopic surgery for colovesical fistula between October 2006 and August 2017 were retrospectively reviewed. RESULTS: The patients' median age was 60 years and comprised 35 men and four women. Sigmoidectomy was performed in 33 patients, Hartmann's procedure in four, and anterior resection in two. The median operative time was 203 minutes and estimated blood loss 15 mL. There were no intraoperative complications or conversion to open surgery. No patients required bladder repair; three had minor postoperative complications, and none had recurrent diverticulitis or fistula at a mean follow-up of 5.1 years. CONCLUSIONS: The magnified vision and minimal invasiveness make a laparoscopic approach the ideal means of managing colovesical fistula. To our knowledge, this is the largest study of colovesical fistula managed by a standardized laparoscopic procedure.

Dynamic Changes in Normal Liver Parenchymal Volume During Chemotherapy for Colorectal Cancer: Liver Atrophy as an Alternate Marker of Chemotherapy-Associated Liver Injury.

BACKGROUND: The purpose of this study was to investigate the incidence, origin, and clinical significance of liver atrophy during chemotherapy for colorectal cancer. METHODS: This study included 103 patients who underwent chemotherapy before resection for colorectal liver metastases (training set) and 171 patients who underwent adjuvant or first-line chemotherapy without liver resection (validation set). A greater than 10% decrease (atrophy) or increase (hypertrophy) of the liver volume from the baseline was defined as a significant change. RESULTS: In the training set, the numbers of patients who developed atrophy, no change of volume, and hypertrophy of the liver after chemotherapy were 15 (14.6%), 73 (70.9%), and 15 (14.6%), respectively. Liver atrophy was associated with impaired hepatic function, and the postoperative morbidity rate and refractory ascites/pleural effusion were higher in the patients with liver atrophy than those without (60.0% vs. 31.8%, P = 0.045 and 46.7% vs. 8.0%, P < 0.001, respectively). Histopathological examination revealed a strong association between sinusoidal injury and liver atrophy (P < 0.001). The cumulative incidence of liver atrophy increased with increasing duration of chemotherapy, whereas the incidence of liver atrophy was less frequent in patients who had received bevacizumab than those who had not in both the training set (odds ratio [OR], 0.13; P = 0.001) and the validation set (OR, 0.31; P = 0.007). CONCLUSIONS: Liver atrophy is associated with impaired hepatic functional reserve and observed at an increasing frequency as the duration of chemotherapy increases with frequent histopathological evidence of sinusoidal injury in the liver. Bevacizumab may protect against the development of liver atrophy.