Topic highlight on texture and color enhancement imaging in gastrointestinal diseases.

Olympus Corporation developed texture and color enhancement imaging (TXI) as a novel image-enhancing endoscopic technique. This topic highlights a series of hot-topic articles that investigated the efficacy of TXI for gastrointestinal disease identification in the clinical setting. A randomized controlled trial demonstrated improvements in the colorectal adenoma detection rate (ADR) and the mean number of adenomas per procedure (MAP) of TXI compared with those of white-light imaging (WLI) observation (58.7% vs 42.7%, adjusted relative risk 1.35, 95%CI: 1.17-1.56; 1.36 vs 0.89, adjusted incident risk ratio 1.48, 95%CI: 1.22-1.80, respectively). A cross-over study also showed that the colorectal MAP and ADR in TXI were higher than those in WLI (1.5 vs 1.0, adjusted odds ratio 1.4, 95%CI: 1.2-1.6; 58.2% vs 46.8%, 1.5, 1.0-2.3, respectively). A randomized controlled trial demonstrated non-inferiority of TXI to narrow-band imaging in the colorectal mean number of adenomas and sessile serrated lesions per procedure (0.29 vs 0.30, difference for non-inferiority -0.01, 95%CI: -0.10 to 0.08). A cohort study found that scoring for ulcerative colitis severity using TXI could predict relapse of ulcerative colitis. A cross-sectional study found that TXI improved the gastric cancer detection rate compared to WLI (0.71% vs 0.29%). A cross-sectional study revealed that the sensitivity and accuracy for active Helicobacter pylori gastritis in TXI were higher than those of WLI (69.2% vs 52.5% and 85.3% vs 78.7%, respectively). In conclusion, TXI can improve gastrointestinal lesion detection and qualitative diagnosis. Therefore, further studies on the efficacy of TXI in clinical practice are required.

Endoscopic Lesions of Postoperative Anastomotic Area in Patients With Crohn's Disease in the Biologic Era: A Japanese Multi-Centre Nationwide Cohort Study.

BACKGROUND AND AIMS: Many patients have endoscopic evidence of recurrent Crohn's disease [CD] at 1 year after intestinal resection. These lesions predict future clinical recurrence. We endoscopically evaluated postoperative anastomotic lesions in CD patients from a large cohort of postoperative CD patients. METHODS: We retrospectively enrolled CD patients who underwent surgical resection between 2008 and 2013 at 19 inflammatory bowel disease [IBD]-specialist institutions. The initial analyses included patients who underwent ileocolonoscopy ~1 year after intestinal resection. Follow-up analyses assessed any changes in the endoscopic findings over time. We evaluated the postoperative endoscopic findings, which were classified into four categories [no lesion, mild, intermediate, severe] at the sites of the anastomotic line and peri-anastomosis. RESULTS: In total, 267 CD patients underwent postoperative ileocolonoscopy. Postoperative anastomotic lesions were widely detected in index ileocolonoscopy [61.0%] and were more frequently detected in follow-up ileocolonoscopy [74.9%]. Endoscopic severity also increased. Patients with intermediate or severe peri-anastomotic or anastomotic line lesions at the index ileocolonoscopy required significantly more interventions, including endoscopic dilatation or surgery, than patients with mild lesions or no lesions. CONCLUSIONS: Frequent anastomotic lesions were observed at the postoperative index ileocolonoscopy. These gradually increased for subsequent ileocolonoscopy, even in the biologic era. Regarding lesions on the anastomotic line, intermediate lesions on the anastomotic line [e.g. irregular or deep ulcers] might be considered recurrent disease, and mild lesions [e.g. linear superficial ulcers] might be considered non-recurrent disease. Prospective studies are needed to resolve this issue, including treatment enhancement.

Development of fluorogenic substrates for colorectal tumor-related neuropeptidases for activity-based diagnosis.

The M3 metalloproteases, neurolysin and THOP1, are neuropeptidases that are expressed in various tissues and metabolize neuropeptides, such as neurotensin. The biological roles of these enzymes are not well characterized, partially because the chemical tools to analyse their activities are not well developed. Here, we developed a fluorogenic substrate probe for neurolysin and thimet oligopeptidase 1 (THOP1), which enabled the analysis of enzymatic activity changes in tissue and plasma samples. In particular, the probe was useful for studying enzyme activities in a single-molecule enzyme assay platform, which can detect enzyme activity with high sensitivity. We detected the activity of neurolysin in plasma samples and revealed higher enzyme activity in the blood samples of patients with colorectal tumor. The result indicated that single-molecule neurolysin activity is a promising candidate for a blood biomarker for colorectal cancer diagnosis.

Clinical significance of the KRAS G13D mutation in anastomotic recurrence of colorectal cancer.

The genetic risk factors for anastomotic recurrence (AR) after curative surgery for colorectal cancer (CRC) are unclear. The present study is a single-center retrospective observational study that aimed to elucidate the association between the KRAS G13D mutation and AR in CRC. The present study included 21 patients with AR and 67 patients with non-anastomotic local recurrence (NALR) following curative surgery for CRC between January 2005 and December 2019. KRAS G13D mutation status was examined by droplet digital polymerase chain reaction. Data of clinicopathological findings and oncological outcomes were analyzed and compared between the AR group and the matched NALR group. The prevalence of the KRAS G13D mutation was significantly higher in the AR group (AR vs. NALR, 33.3 vs. 4.8%; P=0.047). Comparing the KRAS G13D mutation-positive and KRAS G13D mutation-negative patients in the AR group, there was no significant difference in the time from initial surgery to AR or resection rate of AR; however, all patients with KRAS G13D mutation who underwent resection of AR had subsequent recurrence within 2 years after resection, and overall survival was poor (3-year survival rate: Positive vs. negative, 68.6 vs. 90.9%; P=0.02). The prevalence of the KRAS G13D mutation was significantly higher in patients with AR, and KRAS G13D-mutant patients with AR had a poorer prognosis than those that were negative for the KRAS G13D mutation. In conclusion, postoperative surveillance and treatment strategies should be considered with attention to the possibility of AR and subsequent recurrence in KRAS G13D-mutant patients.

Long-time Survival of a Renal Transplant Recipient With Metastatic Mucinous Tubular and Spindle Cell Carcinoma: A Case Report.

BACKGROUND/AIM: Mucinous tubular and spindle cell carcinoma (MTSCC) of the kidney is a rare histological type of renal cell carcinoma (RCC). There are few reports of MTSCC occurring in renal transplant recipients (RTRs). The aim of this study was to report a case of long-term survival of a RTR with metastatic MTSCC of the kidney with sarcomatoid changes. CASE REPORT: A 53-year-old male with a left retroperitoneal tumor was referred to our department. He had been receiving hemodialysis since 1991 and underwent kidney transplantation in 2015. Computed tomography (CT) revealed suspected RCC, and a radical nephrectomy was performed in June 2020. Pathological findings revealed MTSCC with sarcomatoid changes. After the surgery, multiple metastases appeared in the bilateral adrenals, skin, para-aortic lymph nodes, muscles, mesocolon, and liver. We treated the patient with metastasectomy, radiation therapy, and sequential systemic therapy with tyrosine kinase inhibitors (TKI). Two years after the initial surgery, the patient died of cancer while controlling its progression. CONCLUSION: We report a RTR with aggressive and metastatic MTSCC with sarcomatoid changes, resulting in a longer survival time relative to multimodal therapy.

Clinicopathological Characteristics of Anastomotic Recurrence After Curative Resection for Colorectal Cancer: Comparison With Nonanastomotic Local Recurrences.

BACKGROUND: Anastomotic recurrence is thought to be caused by implantation of tumor cells to the anastomotic line; however, its risk factors and prognostic significance remain unclear. OBJECTIVE: This study aimed to clarify the risk factors for anastomotic recurrence in colorectal cancer and assess the prognosis in comparison to nonanastomotic local recurrence. DESIGN: A single-center retrospective observational study. SETTINGS: The medical records of the study participants were retrospectively collected from the Department of Surgical Oncology at the University of Tokyo Hospital database. PATIENTS: This study included 1584 patients with colorectal cancer who underwent surgical resection between January 2005 and December 2017. We focused on 15 patients who had an anastomotic recurrence. MAIN OUTCOME MEASURES: The main outcome measures were the risk factors of anastomotic recurrence at the primary resection and prognosis data in comparison to that of nonanastomotic local recurrence. RESULTS: There were 15 patients (0.95%) with anastomotic recurrence and 35 (2.21%) with nonanastomotic local recurrence. Univariate analysis revealed that lymph node metastasis and advanced T stage are the risk factors for anastomotic recurrence. The prognosis of patients with anastomotic recurrence was similar to that of those with nonanastomotic local recurrence who underwent resection. LIMITATIONS: The small number of patients with anastomotic recurrence is a major limitation of this study. Additionally, the retrospective study design may have increased the risk of selection bias. CONCLUSIONS: Lymph node metastasis and advanced T stage were associated with anastomotic recurrence. The prognosis of patients with anastomotic recurrence was similar to that with resected nonanastomotic local recurrence. Thus, surveillance should be carefully continued while considering the poor prognosis of patients with anastomotic recurrence. See Video Abstract at http://links.lww.com/DCR/C92 . CARACTERSTICAS CLINICOPATOLGICAS DE LA RECURRENCIA ANASTOMTICA DESPUS DE LA RESECCIN CURATIVA DEL CNCER COLORRECTAL COMPARACIN CON LAS RECURRENCIAS LOCALES NO ANASTOMTICAS: ANTECEDENTES:Se cree que la recurrencia anastomótica es causada por la implantación de células tumorales en la línea anastomótica; sin embargo, los factores de riesgo asociados y el significado en cuanto a pronóstico siguen sin estar claros.OBJETIVO:Este estudio tuvo como objetivo aclarar los factores de riesgo para la recurrencia anastomótica en el cáncer colorrectal y evaluar el pronóstico en comparación con la recurrencia local no anastomótica.DISEÑO:Un estudio observacional retrospectivo de un solo centro.ESCENARIO:Los registros médicos de los participantes del estudio se recopilaron retrospectivamente de la base de datos del Departamento de Cirugía Oncológica del Hospital de la Universidad de Tokio.PACIENTES:Este estudio incluyó a 1584 pacientes con cáncer colorrectal que se sometieron a resección quirúrgica entre enero de 2005 y diciembre de 2017. Nos enfocamos en 15 pacientes que tuvieron recurrencia anastomótica.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron los factores de riesgo de recurrencia anastomótica en la resección primaria y los datos de pronóstico en comparación con la recurrencia local no anastomótica.RESULTADOS:Hubo 15 pacientes (0.95%) con recurrencia anastomótica y 35 (2.21%) con recurrencia local no anastomótica. El análisis univariable reveló que la metástasis en los ganglios linfáticos y el estadio T avanzado son los factores de riesgo para la recurrencia anastomótica. El pronóstico de los pacientes con recidiva anastomótica fue similar al de aquellos con recidiva local no anastomótica sometidos a resección.LIMITACIONES:El pequeño número de pacientes con recurrencia anastomótica es una limitación importante de este estudio. Además, el diseño retrospectivo del estudio puede haber aumentado el riesgo de sesgo de selección.CONCLUSIONES:La metástasis en los ganglios linfáticos y el estadio T avanzado se asociaron con recurrencia anastomótica. El pronóstico de los pacientes con recidiva anastomótica fue similar al de la recidiva local no anastomótica resecada. Por lo tanto, la vigilancia debe continuarse cuidadosamente considerando el mal pronóstico de los pacientes con recurrencia anastomótica. Consulte Video Resumen en http://links.lww.com/DCR/C92 . (Traducción-Dr. Jorge Silva Velazco ).

Prediction model of Graves' disease in general clinical practice based on complete blood count and biochemistry profile.

Although untreated Graves' disease (GD) is associated with a higher risk of cardiac complications and mortality, there is no well-established way to predict the onset of thyrotoxicosis in clinical practice. The aim of this study was to identify important variables that will make it possible to predict GD and thyrotoxicosis (GD + painless thyroiditis (PT)) by using a machine-learning-based model based on complete blood count and standard biochemistry profile data. We identified 19,335 newly diagnosed GD patients, 3,267 PT patients, and 4,159 subjects without any thyroid disease. We built a GD prediction model based on information obtained from subjects regarding sex, age, a complete blood count, and a standard biochemistry profile. We built the model in the training set and evaluated the performance of the model in the test set by using the artificial intelligence software Prediction One. Our machine learning-based model showed high discriminative ability to predict GD in the test set (area under the curve [AUC] 0.99). The main contributing factors to predict GD included age and serum creatinine, total cholesterol, alkaline phosphatase, and total protein levels. We still found high discriminative ability even when we restricted the variables to these five most contributory factors in our prediction model (AUC 0.97) built by using artificial intelligence software showed high GD prediction ability based on information regarding only five factors.

Artificial Intelligence Program to Predict p53 Mutations in Ulcerative Colitis-Associated Cancer or Dysplasia.

BACKGROUND: The diagnosis of colitis-associated cancer or dysplasia is important in the treatment of ulcerative colitis. Immunohistochemistry of p53 along with hematoxylin and eosin (H&E) staining is conventionally used to accurately diagnose the pathological conditions. However, evaluation of p53 immunohistochemistry in all biopsied specimens is expensive and time-consuming for pathologists. In this study, we aimed to develop an artificial intelligence program using a deep learning algorithm to investigate and predict p53 immunohistochemical staining from H&E-stained slides. METHODS: We cropped 25 849 patches from whole-slide images of H&E-stained slides with the corresponding p53-stained slides. These slides were prepared from samples of 12 patients with colitis-associated neoplasia who underwent total colectomy. We annotated all glands in the whole-slide images of the H&E-stained slides and grouped them into 3 classes: p53 positive, p53 negative, and p53 null. We used 80% of the patches for training a convolutional neural network (CNN), 10% for validation, and 10% for final testing. RESULTS: The trained CNN glands were classified into 2 or 3 classes according to p53 positivity, with a mean average precision of 0.731 to 0.754. The accuracy, sensitivity (recall), specificity, positive predictive value (precision), and F-measure of the prediction of p53 immunohistochemical staining of the glands detected by the trained CNN were 0.86 to 0.91, 0.73 to 0.83, 0.91 to 0.92, 0.82 to 0.89, and 0.77 to 0.86, respectively. CONCLUSIONS: Our trained CNN can be used as a reasonable alternative to conventional p53 immunohistochemical staining in the pathological diagnosis of colitis-associated neoplasia, which is accurate, saves time, and is cost-effective.

We developed a diagnostic tool for determining the pathology of ulcerative colitis­associated neoplasia using artificial intelligence, which precisely predicted p53 immunohistochemical positivity of intestinal glands in the colon from the hematoxylin and eosin­stained slides.

Immune Checkpoint Inhibitor Combination Therapy for Renal Cell Carcinomas With Concomitant Inferior Vena Cava Thrombi.

BACKGROUND/AIM: The efficacy of immune checkpoint inhibitor (ICI) combinations in treating inferior vena cava (IVC) tumour thrombi has not yet been reported. We aimed to evaluate the clinical efficacy of ICIs for patients with renal cell carcinoma (RCC) and a concomitant IVC tumour thrombus. PATIENTS AND METHODS: Three men and two women with RCC and an IVC tumour thrombus were administered ICIs in 2020-2021. Three and two patients received nivolumab plus ipilimumab and pembrolizumab plus axitinib therapy, respectively. RESULTS: All ICI-treated patients showed tumour shrinkage. The IVC thrombus level was downstaged in two patients. The mean reduction in maximum primary tumour diameter and IVC thrombus height was 34 and 33 mm, respectively. CONCLUSION: Presurgical ICI therapy in three patients who underwent radical nephrectomy with thrombectomy resulted in a modified surgical strategy and approach and reduced surgical risk. Thus, ICIs may treat select cases of RCC with an IVC tumour thrombus effectively.

A review on the current status and definitions of activity indices in inflammatory bowel disease: how to use indices for precise evaluation.

Many clinical trials have been conducted for inflammatory bowel disease (IBD), so various clinical indices (CIs) and endoscopic indices (EIs) have also been evaluated. However, recently, with the progress of IBD management, review of established indices from previous studies, and establishment of new indices, the landscape of the use of indices in clinical trials have changed. We investigated the number and frequency of the indices adapted in recent clinical trials for ulcerative colitis (CI and EI) and Crohn's disease (CI, EI, index related to magnetic resonance imaging, index for evaluating patient-reported outcomes, and health-related quality of life). Based on the results, we selected representative indices and further reviewed their content and characteristics. Moreover, various definitions, including clinical and endoscopic response or remission, have been described by means of representative indices in clinical trials.

Laparoscopic vs open restorative proctectomy after total abdominal colectomy for ulcerative colitis or familial adenomatous polyposis.

PURPOSE: Randomized controlled trials (RCTs) demonstrated that a laparoscopic approach provides short-term benefits, such as reduced blood loss and a shorter hospital stay, in patients who undergo rectal surgery. On the other hand, a few RCTs investigating proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or familial adenomatous polyposis (FAP) suggested limited advantages of laparoscopic surgery over open surgery. A substantial proportion of patients with UC or FAP may undergo staged operations with IPAA, but no study has compared the two approaches for proctectomy with IPAA after total abdominal colectomy. METHODS: We examined 61 consecutive patients with UC or FAP who underwent proctectomy with IPAA after colectomy in our hospital. Patients were divided into the Lap group (n = 37) or the Op group (n = 24) according to surgical approach. Patient background and outcomes, such as operative time, blood loss, first bowel movement, postoperative complications, and pouchitis, were compared between these groups. RESULTS: One patient required conversion to open surgery in the Lap group. The median volume of blood loss was 90 mL in the Lap group and 580 mL in the Op group (p < 0.0001). The Lap group showed a shorter time to first bowel movement than the Op group (median: 1 vs 2 days, p = 0.0003). The operative time, frequencies of postoperative complications, and accumulation rate of pouchitis were similar between the two groups. CONCLUSIONS: Laparoscopic surgery was beneficial for patients undergoing restorative proctectomy in terms of blood loss and bowel recovery without increasing the operative time or rate of complications.

Safe Renal Transplantation to the Extraperitoneal Cavity in Children Weighing Less Than 15 kg.

Pediatric renal transplantation is associated with various surgical complications due to the complexity of the technique and the often-fragile condition of patients with end-stage renal disease. We evaluated the surgical complications associated with renal transplantation via the extraperitoneal approach in pediatric recipients. This retrospective study enrolled 280 patients younger than 16 years old who underwent renal transplantation via the extraperitoneal approach: 216 patients underwent transplant placement in the iliac fossa like in adults, and 64 underwent transplant placement in the distal part of the original renal lower pole (the extraperitoneal cavity). On the basis of the Clavien-Dindo classification, 30 patients (10.7%) showed grade 2 complications and 12 patients (4.3%) showed grade 3 or higher complications. None of the patients showed gastrointestinal complications. In a Cox regression analysis, grade 2 or higher complications were significantly associated with weight less than 15 kg (P = .027) and operative times longer than 245 minutes (P = .029). Among the 49 patients weighing less than 15 kg with an allograft placed in a distal portion of the original renal lower pole, only 3 patients (6.1%) developed surgical complications. Thus, allograft placement in the extraperitoneal cavity can be performed safely in children weighing less than 15 kg.

Effectiveness of Retzius-Sparing Robot-Assisted Radical Prostatectomy in a Renal Transplant Recipient: a Case Report.

BACKGROUND: Prostate cancer (PCa) has increased as a long-term outcome of advanced immunosuppression in renal transplant recipients (RTRs). Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) is reportedly less time-consuming and has a higher continence recovery rate than the standard RARP without increasing the risk of complications. However, only a few cases of Rs-RARP in RTRs have been reported. CASE PRESENTATION: A 65-year-old man, who received a renal transplant 2 years prior, was diagnosed with low-risk PCa, per the D'Amico risk classification system, and underwent Rs-RARP with the da Vinci Xi robotic system. All port sites were placed contralateral to the allograft and compared with the standard RARP. The operative time was 187 min, and the estimated blood loss was 100 mL. The urethral catheter was removed on postoperative day 7 after confirming the absence of leakage using voiding cystourethrography. The patient was discharged on postoperative day 8. Pathologic findings showed localized PCa with a Gleason score of 3 + 3 and negative surgical margins. One year after the surgery, the patient had adequate urinary continence. His prostate-specific antigen level was <0.01 ng/mL, and his renal function was similar to that before surgery. CONCLUSIONS: We reported a case of PCa in an RTR, successfully treated via Rs-RARP, resulting in adequate continence without complications.

Risk factors for non-reaching of ileal pouch to the anus in laparoscopic restorative proctocolectomy with handsewn anastomosis for ulcerative colitis.

BACKGROUND/AIMS: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis and handsewn anastomosis for ulcerative colitis requires pulling down of the ileal pouch into the pelvis, which can be technically challenging. We examined risk factors for the pouch not reaching the anus. METHODS: Clinical records of 62 consecutive patients who were scheduled to undergo RPC with handsewn anastomosis at the University of Tokyo Hospital during 1989-2019 were reviewed. Risk factors for non-reaching were analyzed in patients in whom hand sewing was abandoned for stapled anastomosis because of nonreaching. Risk factors for non-reaching in laparoscopic RPC were separately analyzed. Anatomical indicators obtained from presurgical computed tomography (CT) were also evaluated. RESULTS: Thirty-seven of 62 cases underwent laparoscopic procedures. In 6 cases (9.7%), handsewn anastomosis was changed to stapled anastomosis because of non-reaching. Male sex and a laparoscopic approach were independent risk factors of non-reaching. Distance between the terminal of the superior mesenteric artery (SMA) ileal branch and the anus > 11 cm was a risk factor for non-reaching. CONCLUSIONS: Laparoscopic RPC with handsewn anastomosis may limit extension and induction of the ileal pouch into the anus. Preoperative CT measurement from the terminal SMA to the anus may be useful for predicting non-reaching.

Surgical outcomes of robot-assisted laparoscopic partial nephrectomy for cystic renal cell carcinoma.

To compare the surgical outcomes of robot-assisted partial nephrectomy (RAPN) between patients with cystic renal cell carcinoma (cRCC) and those with solid RCC (sRCC). We retrospectively analyzed 1065 patients who underwent RAPN between 2013 and 2020 for a pathological diagnosis of RCC. Patients were divided into two groups: cRCC and sRCC. cRCC was diagnosed according to the Bosniak classification system. To minimize selection bias between the two groups, patient variables (patient characteristics) and tumor factors (such as size and complexity) were adjusted using 1:1 propensity score matching. Of the 1065 patients, 94 (9%) were diagnosed with cRCC. Bosniak categories of IIF, III, and IV were noted in 4 (4.2%), 31 (33%), and 59 (63%) patients, respectively. After matching, 83 patients each were assigned to the cRCC and sRCC groups. The operation time in cRCC tended to be longer than in sRCC but not significantly different (164 vs. 150 min, P = 0.0767). Other surgical outcomes, such as change in estimated glomerular filtration rate ( - 5.2 vs. - 7.2%, P = 0.1577), perioperative complications (14.5 vs. 15.7%, P = 0.9225), estimated blood loss (62 vs. 58 mL, P = 0.5613), or negative surgical margin status (100 vs 99%, P = 0.236), were not significantly different between the two groups. During the follow-up period of about 2 years, one and two patients showed recurrence in the cRCC and sRCC groups, respectively. The surgical outcomes of RAPN were similar between cRCC and sRCC, demonstrating the feasibility of RAPN for cRCC.

Improvement in Surgical Outcomes Using 3-Dimensional Printed Models for Lateral Pelvic Lymph Node Dissection in Rectal Cancer.

BACKGROUND: Lateral pelvic lymph node dissection for rectal cancer is challenging due to the complexity of the pelvic wall anatomy, and incomplete lateral pelvic lymph node dissection may result in local recurrence in the lateral pelvis. Although 3-dimensional printed organ models are useful for understanding spatial anatomy, it is currently unclear whether they improve surgical outcomes. OBJECTIVE: We aimed to assess whether the surgical effectiveness of lateral pelvic lymph node dissection is increased by the use of individualized 3-dimensional printed pelvic models. DESIGN: This was a retrospective study using a propensity matching analysis. SETTINGS: This study was conducted at a university hospital in Japan. PATIENTS: In total, 115 patients comprising 184 pelvic sides (right, 85 sides; left, 99 sides) who underwent lateral pelvic lymph node dissection for colorectal adenocarcinoma between January 2012 and December 2019 were enrolled. INTERVENTIONS: We compared surgical outcomes using 3-dimensional printed pelvic models with control outcomes. MAIN OUTCOME MEASURES: The primary outcome was the number of harvested lateral pelvic lymph nodes on 1 pelvic side after the propensity matching analysis. RESULTS: After matching, 35 pelvic sides each were allocated to the 3-dimensional model and control groups, and no significant differences were observed in patient characteristics between the 2 groups. The number of harvested lateral pelvic lymph nodes was significantly higher in the 3-dimensional model group (median, 9; range, 3-16) than in the control group (median, 6; range, 0-22; p = 0.047). LIMITATIONS: This was a retrospective study using propensity score matching. However, historical backgrounds were not matched, and the majority of lateral pelvic lymph node dissection procedures in the 3-dimensional model group were recently performed. This limitation may have influenced surgical outcomes. CONCLUSION: The present study demonstrated that, by referring to individualized 3-dimensional printed pelvic models, colorectal surgeons harvested a larger number of lateral pelvic lymph nodes during lateral pelvic lymph node dissection. This result suggests that 3-dimensional printed models help surgeons to complete more detailed procedures. See Video Abstract at http://links.lww.com/DCR/B776. MEJORA DE LOS RESULTADOS QUIRRGICOS MEDIANTE EL USO DE MODELOS IMPRESOS EN D PARA LA DISECCIN LATERAL DE LOS GANGLIOS LINFTICOS PLVICOS EN EL CNCER DE RECTO: ANTECEDENTES:La disección lateral de los ganglios linfáticos de la pelvis en el cáncer de recto es un desafío debido a la complejidad de la anatomía de la pared pélvica; la disección incompleta de las mismas puede resultar en una recidiva local en dicha zona. Aunque la impresión tridimensional de modelos de órganos es útil para comprender la estructura anatómica espacial, actualmente no está claro si mejoran los resultados quirúrgicos.OBJETIVO:Nuestro objetivo fue evaluar si la efectividad quirúrgica de la disección de los ganglios linfáticos laterales de la pelvis aumenta mediante el uso individualizado de modelos pélvicos impresos en 3D.DISEÑO:Este fue un estudio retrospectivo que utilizó un análisis de coincidencia de propensión.AJUSTE:Este estudio se realizó en un hospital universitario de Japón.PACIENTES:En total, se enrolaron 115 pacientes que comprendían 184 lados pélvicos (85 de lado derecho; 99 de lado izquierdo) que fueron sometidas a disección lateral de ganglios linfáticos de la pelvis por adenocarcinoma colorrectal entre enero de 2012 y diciembre de 2019.INTERVENCIONES:Comparamos los resultados quirúrgicos mediante modelos pélvicos tridimensionales impresos con los resultados de control.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el número de ganglios linfáticos laterales pélvicos extraídos en un lado pélvico después del análisis de coincidencia de propensión.RESULTADOS:Después del emparejamiento, se asignaron 35 lados pélvicos cada uno, tanto al modelo tridimensional como al grupo de control; no se observaron diferencias significativas con respecto a las características de los pacientes entre los dos grupos. El número de ganglios linfáticos pélvicos laterales extraídos fue significativamente mayor en el grupo del modelo tridimensional (mediana, 9; rango 3-16) que en el grupo de control (mediana, 6; rango, 0-22) (p = 0.047).LIMITACIONES:Este fue un estudio retrospectivo que utilizó el emparejamiento por puntuación de propensión. Sin embargo, antecedentes históricos no fueron encontrados y la mayoría de los procedimientos de disección de los ganglios linfáticos laterales pélvicos en el grupo del modelo tridimensional se realizaron recientemente. Esta limitación pudo haber influido en los resultados quirúrgicos.CONCLUSIONES:El presente estudio demostró que al referirse a modelos pélvicos individualizados impresos en 3D, los cirujanos colorrectales recolectaron un mayor número de ganglios linfáticos laterales de la pelvis durante la disección lateral. Este resultado sugiere que los modelos tridimensionales impresos ayudan a los cirujanos a completar procedimientos más detallados. Consulte Video Resumen en http://links.lww.com/DCR/B776.

Evidence-based clinical practice guidelines for inflammatory bowel disease 2020.

Inflammatory bowel disease (IBD) is a general term for chronic or remitting/relapsing inflammatory diseases of the intestinal tract and generally refers to ulcerative colitis (UC) and Crohn's disease (CD). Since 1950, the number of patients with IBD in Japan has been increasing. The etiology of IBD remains unclear; however, recent research data indicate that the pathophysiology of IBD involves abnormalities in disease susceptibility genes, environmental factors and intestinal bacteria. The elucidation of the mechanism of IBD has facilitated therapeutic development. UC and CD display heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management depends on the understanding and tailoring of evidence-based interventions by physicians. In 2020, seventeen IBD experts of the Japanese Society of Gastroenterology revised the previous guidelines for IBD management published in 2016. This English version was produced and modified based on the existing updated guidelines in Japanese. The Clinical Questions (CQs) of the previous guidelines were completely revised and categorized as follows: Background Questions (BQs), CQs, and Future Research Questions (FRQs). The guideline was composed of a total of 69 questions: 39 BQs, 15 CQs, and 15 FRQs. The overall quality of the evidence for each CQ was determined by assessing it with reference to the Grading of Recommendations Assessment, Development and Evaluation approach, and the strength of the recommendation was determined by the Delphi consensus process. Comprehensive up-to-date guidance for on-site physicians is provided regarding indications for proceeding with the diagnosis and treatment.

Clinical significance of CD8+ and FoxP3+ tumor-infiltrating lymphocytes and MFG-E8 expression in lower rectal cancer with preoperative chemoradiotherapy.

Preoperative chemoradiotherapy (CRT) for rectal cancer contributes to tumor down-staging and decreases locoregional recurrence. However, each patient shows a significantly different response to CRT. Therefore, the identification of predictive factors to CRT response would be beneficial to avoid unnecessary treatment. Cancer immunity in patients has been suggested to play an important role in the eradication of the tumor by CRT. In the present study, the utility of CD8+ and forkhead box P3 (FoxP3)+ tumor-infiltrating lymphocytes (TILs) and the expression of a novel immuno-regulatory factor, lactadherin (MFG-E8), in predicting CRT effectiveness in patients with rectal cancer was examined. A total of 61 patients with rectal cancer, who underwent curative resection following CRT were included in the study. The numbers of CD8+ and FoxP3+ TILs in a biopsy taken before CRT and MFG-E8 expression level in the specimens obtained at the time of the surgery after CRT were examined using immunohistochemical staining, and their association with clinicopathological characteristics, including patient survival, was determined. The tumors with more CD8+ TILs in the biopsy samples before CRT showed a significantly more favorable CRT response. The patients with tumors and a higher number of CD8+ TILs before CRT also exhibited significantly longer disease-free and overall survival times. Higher MFG-E8 expression level in post-CRT specimens was significantly associated with favorable CRT response; however, no significant association was found with any other clinicopathological characteristics, including survival time. The number of CD8+ TILs before CRT was a valuable predictor for CRT response and was associated with favorable prognosis in patients with lower rectal cancer and who were treated with CRT. High MFG-E8 expression level after CRT was also associated with a favorable CRT response.

Metachronous ileal cancer after surgery for ascending colon cancer in a patient with Lynch syndrome: A case report.

INTRODUCTION AND IMPORTANCE: Colorectal surveillance via colonoscopy in patients with Lynch syndrome reduces the mortality of colorectal cancer. On the other hand, it is unclear whether surveillance for other malignancies, including small bowel cancer, is beneficial. We report a patient with Lynch syndrome who developed ileal cancer after surgery for ascending colon cancer. CASE PRESENTATION: A 47-year-old man visited our hospital for a check-up for positive fecal occult blood. He was diagnosed with ascending colon cancer and met the clinical criteria for the diagnosis of Lynch syndrome based on his past and family history. The Bethesda markers demonstrated high-frequent microsatellite instability. Laparoscopy-assisted right hemicolectomy was performed. He received follow-up colonoscopy the next year, which revealed ileal cancer near the anastomosis. He underwent resection of the second cancer via a laparoscopic approach, and has been free from recurrence for five years. CLINICAL DISCUSSION: Small bowel cancer has a dismal prognosis because a high percentage of patients were diagnosed at advanced stages. The diagnosis of metachronous ileal cancer by the first follow-up colonoscopy after surgery for ascending colon cancer offered a long disease-free survival in our patient. CONCLUSION: The clinical course suggested the importance of inspecting the small bowel in Lynch syndrome patients, especially when colorectal cancer is diagnosed.

Establishment of deformable three-dimensional printed models for laparoscopic right hemicolectomy in transverse colon cancer.

BACKGROUND: Applications of three-dimensional (3-D) printed solid organ models for navigation and simulation were previously reported for abdominal surgeries, and their usefulness was shown by subjective evaluation. However, thus far, no study has examined the effect of intraoperative movements for tissue handling. Novel, deformable 3-D printed models of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) were created to optimize laparoscopic right hemicolectomy. The aim of this study was to establish a method using these individualized models for use in surgical practice. METHODS: Deformable 3-D models for laparoscopic right hemicolectomy were created using a 3-D printing flexible filamentous material (thermoplastic polyurethane). Five patients with transverse colon cancer who underwent laparoscopic right hemicolectomy with D3 lymphadenectomy between April 2017 and September 2019 were enrolled in this study. Then, the created patient-specific models were compared with the previously recorded intraoperative video views. RESULTS: Transverse colon mobilization changed the spatial arrangement of the branches of the SMA and SMV. The 3-D models reproduced the intraoperative view, although approaches to the dominant vessels to complete D3 lymphadenectomy may vary. CONCLUSIONS: Deformable 3-D models of the SMA and SMV with added branches may aid in optimizing laparoscopic right hemicolectomy operations.