Differential analysis of microbiomes in mucus and tissues obtained from colorectal cancer patients.

The outer mucus layer of the colorectal epithelium is easily removable and colonized by commensal microbiota, while the inner mucus layer is firmly attached to the epithelium and devoid of bacteria. Although the specific bacteria penetrating the inner mucus layer can contact epithelial cells and trigger cancer development, most studies ignore the degree of mucus adhesion at sampling. Therefore, we evaluated whether bacteria adhering to tissues could be identified by removing the outer mucus layer. Our 16S rRNA gene sequencing analysis of 18 surgical specimens of human colorectal cancer revealed that Sutterella (P = 0.045) and Enterobacteriaceae (P = 0.045) were significantly enriched in the mucus covering the mucosa relative to the mucosa. Rikenellaceae (P = 0.026) was significantly enriched in the mucus covering cancer tissues compared with those same cancer tissues. Ruminococcaceae (P = 0.015), Enterobacteriaceae (P = 0.030), and Erysipelotrichaceae (P = 0.028) were significantly enriched in the mucus covering the mucosa compared with the mucus covering cancers. Fusobacterium (P = 0.038) was significantly enriched in the mucus covering cancers compared with the mucus covering the mucosa. Comparing the microbiomes of mucus and tissues with mucus removed may facilitate identifying bacteria that genuinely invade tissues and affect tumorigenesis.

Establishment of the menthol test as a clinical evaluation method for oxaliplatin-induced neuropathy.

Objectives: To determine whether the tongue menthol test, which measures the cold sensation detection threshold (CDT) of the tongue, used before and after oxaliplatin administration is an objective evaluation method for oxaliplatin-induced peripheral neuropathy (OPN). Methods: The tongue menthol test was administered to patients both before and after undergoing chemotherapy containing oxaliplatin for colorectal cancer. The tongue menthol test was conducted by applying a menthol solution (a selective agonist of transient receptor potential cation channel subfamily M member 8 [TRPM8]) to the tongue and measuring the CDT. Results: The mean CDT before the first dose of oxaliplatin was 0.34% (0.005%-1%; n=38), and the mean CDT after the first dose was 0.32% (0.005%-1%; n=38). The CDT appeared to decrease after the first dose, but this difference was not significant. In patients who received five courses of oxaliplatin, changes in CDT values were compared before and after the five courses. In patients with Neurotoxicity Criteria of Debiopharm (DEB-NTC) grade 2 neuropathy, the pre-oxaliplatin administration CDT was compared between before grade exacerbation and when exacerbation occurred, and was found to decline when grade exacerbation occurred. Moreover, when the CDTs before and after administration were compared before grade exacerbation, there was a significant decrease in CDT after administration (P=0.04). Conclusions: By performing a menthol test in oxaliplatin-treated patients, it may be possible to objectively predict the exacerbation of peripheral neuropathy at an early stage.

Usefulness of laparoscopic right colectomy with intracorporeal anastomosis and preoperative weight reduction for ascending colon cancer in a severely obese patient.

Obesity has been considered a risk factor for postoperative complications following colorectal cancer surgery. However, the usefulness of a combination of intracorporeal anastomosis and preoperative weight reduction for severely obese patients with colon cancer remains unclear. A 66-year-old man with a body mass index (BMI) of 43 kg/m2 presented with abdominal pain and iron deficiency anemia. Colonoscopy and computed tomography revealed advanced ascending colon cancer with regional lymph node metastasis and excessive abdominal fat. Preoperative diet-induced weight reduction was performed for severe obesity, which decreased his BMI to 39.7 kg/m2 after 1 month. Thereafter, curative resection was performed using intracorporeal anastomosis for reconstruction to achieve minimal colon and mesentery mobilization and a shorter incision. The patient was discharged from the hospital without complications. Laparoscopic right hemicolectomy combining intracorporeal anastomosis and preoperative weight reduction was extremely useful in the current patient with severe obesity and ascending colon cancer.

Robotic low anterior resection for rectal cancer with side-to-end anastomosis in a patient with anal stenosis.

BACKGROUND: Colorectal anastomosis using the double stapling technique (DST) has become a standard procedure. However, DST is difficult to perform in patients with anal stenosis because a circular stapler cannot be inserted into the rectum through the anus. Thus, an alternative procedure is required for colorectal anastomosis. CASE PRESENTATION: A 78-year-old woman presented with bloody stool. Colonoscopy and computed tomography revealed advanced low rectal cancer without lymph node or distant metastasis. We initially planned to perform low anterior resection using a double stapling technique or transanal hand-sewn anastomosis, but this would have been too difficult due to anal stenosis and fibrosis caused by a Milligan-Morgan hemorrhoidectomy performed 20 years earlier. The patient had never experienced defecation problems and declined a stoma. Therefore, we inserted an anvil into the rectal stump and fixed it robotically with a purse-string suture followed by insertion of the shaft of the circular stapler from the sigmoidal side. In this way, side-to-end anastomosis was accomplished laparoscopically. The distance from the anus to the anastomosis was 5 cm. The patient was discharged with no anastomotic leakage. Robotic assistance proved extremely useful for low anterior resection with side-to-end anastomosis. CONCLUSION: Performing side-to-end anastomosis with robotic assistance was extremely useful in this patient with rectal cancer and anal stenosis.

[Clinical Study of Inguinal Lymph Node Metastasis in Anal Canal Adenocarcinoma].

We reviewed clinical records of 73 cases with anal canal adenocarcinoma who underwent bilateral inguinal lymph node (ILN)dissection. Eleven patients with positive ILN metastasis(ILNM)were compared with 62 patients with negative ILNM in clinicopathological items and treatment outcomes to evaluate the effectiveness of ILN dissection. Positive ILNM were older, higher preoperative serum levels of CEA and CA19-9, more frequencies of undifferentiated carcinoma, T4b and severe lymphatic invasion than negative ILNM. And the number of mesorectal and lateral node metastasis were significantly more in positive ILNM than negative ILNM. Although the frequency of curability A surgery was significantly less in positive ILNM (63.6%)than negative ILNM(93.5%), there were no significant differences in recurrence rate and prognosis between positive ILNM and negative ILNM in Stage Ⅲ cancer. Recurrence in ILN occurred significantly more in positive ILNM (2 cases) than in negative ILNM(0 case)as initial recurrent site. And recurrence in pelvic local site occurred significantly more in positive ILNM(4 cases)than in negative ILNM(6 cases). Although there was no significant difference in oncological outcome in Stage Ⅲ anal canal adenocarcinoma, ILN recurrence and pelvic local recurrence should be cared for positive ILNM in postoperative follow-up.

Novel use of the Nathanson liver retractor to prevent postoperative transient liver dysfunction during laparoscopic gastrectomy.

INTRODUCTION: The Nathanson liver retractor (N) has been known to cause postoperative transient liver dysfunction (POTLD) in laparoscopic gastrectomy (LG). To reduce the incidence of POTLD, specifically we added to the retractor the use of a disk (N + D) to reduce the localized pressure, and furthermore repositioned the retractor every 30 minutes (N + D TM) to reduce the liver retraction time. Before and after introducing this retractor, we assessed four consecutive retraction procedures. These included the following disk suspension methods (D), N, N + D, and N + D TM. METHODS: We retrospectively enrolled 85 patients who underwent an LG. In the D, N, N + D, and N + D TM groups, we evaluated the postoperative serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values. RESULTS: For the D and N groups, the AST value significantly increased from the immediate post-operation time point (IPOT) to the third postoperative day (POD3). Additionally, the ALT value increased from IPOT to POD7. In the N + D group, the only decrease was in the ALT value at IPOT compared to the N group. The N + D TM group decreased in both the AST value from IPOT to POD3 and in the ALT value from IPOT to POD7, compared to the N group. CONCLUSIONS: Our findings demonstrate the importance of reducing both the localized pressure and liver retraction time when using the Nathanson retractor to prevent POTLD during an LG. To make this possible, we successfully introduced the use of both a disk and the repositioning of the retractor at 30 minute intervals.

Laparoscopic surgery of a presacral epidermoid cyst: A case report.

INTRODUCTION: The best approach for resecting epidermoid cysts is still controversial. We describe a case of an epidermoid cyst in which laparoscopic resection was performed successfully. PRESENTATION OF CASE: 63 × 55-mm well-defined cystic mass was incidentally detected by computed tomography in the presacral cavity of a 50-year-old woman during evaluation for upper abdominal pain. Magnetic resonance imaging showed a cystic tumor with a low signal intensity on T1-weighted images and, high signal on T2-weighted images in the left dorsal side of the rectum. This tumor was diagnosed as a developmental cyst, and laparoscopic resection was performed. Resection of the tumor was performed with negative margins. This tumor was histopathologically diagnosed as an epidermoid cyst. There was no evidence of malignancy, and no postoperative event or signs of recurrence occurred 6 months postoperatively. DISCUSSION: In our patient, there was no difficulty in the field of view and forceps operability during laparoscopic surgery. Furthermore, it is possible to perform laparoscopic surgery with minimal damage to the muscles, nerves, and rectum, leading to the preservation of anal function. CONCLUSION: Laparoscopic resection of an epidermoid cyst may be a better option in carefully selected cases with consideration of the tumor size and location.

Evaluation of Hepatic Resection in Liver Metastasis of Gastric Cancer.

Gastric cancer is the second most common malignancy globally and the third most common cause of cancer-related deaths in Japan. In gastric cancer, benefit of surgical resection of liver metastasis, which was shown in colorectal cancer, is not well established. The present study aimed to examine the feasibility of hepatic resection for liver metastasis of gastric cancer. In this retrospective study, we reviewed the medical records of 10 patients with liver-only metastases of gastric cancer who underwent hepatectomy among 2043 patients with gastric cancer who underwent gastric resection between January and December 2016 at a single institution in Japan. Median 1-, 3-, and 5-year overall survival (OS) rates were 78.0%, 33.3%, and 22.2%, respectively, among 10 patients who underwent hepatic resection. There was a significant difference in OS rates between tumors measuring ≥ 5 cm and < 5 cm (hazard ratio [HR] 6.524, 95% confidence interval [CI] 1.145-37.171, p = 0.035). The longest survival was 205 months for one patient who was alive at the time of the analysis. Hepatic resection of liver metastasis in gastric cancer was associated with long-term survival in some patients. Additionally, primary tumor size was associated with long-term survival.

A case of gastric glomus tumor resection using laparoscopy endoscopy cooperative surgery (LECS).

INTRODUCTION: Gastric glomus tumors are rare submucosal mesenchymal tumors. Because gastric glomus tumors are submucosal tumors and resemble gastrointestinal stromal tumors (GISTs), preoperative diagnosis is difficult. We present a case of gastric glomus tumor that was removed by laparoscopy endoscopy cooperative surgery (LECS). CASE PRESENTATION: A 67-year-old female was taken to the emergency room at our hospital due to epigastric pain. An upper gastrointestinal endoscopy revealed a submucosal tumor (SMT) located in the lesser curvature of the upper body of the stomach. Endoscopic ultrasonography revealed an intraluminal hypoechoic tumor located in the third or fourth layer of the stomach wall. Contrast-enhanced computed tomography (CECT) of the abdomen showed a 20-mm, well-enhanced, intraluminal-type tumor located in the lesser curvature of the upper body of the stomach. Laparoscopy endoscopy cooperative surgery (LECS) was performed. Immunohistochemistry revealed the expression of smooth muscle actin and vimentin, but not of keratin, S-100 protein, C-kit, or CD34. The tumor was finally diagnosed as a gastric glomus tumor. CONCLUSION: Glomus tumors are rare submucosal tumors of the stomach, and they should be considered in the differential diagnosis of gastric submucosal tumors. LECS could be a less invasive and effective method for treatment of gastric glomus tumor.

Sewing needles in the abdominal cavity assumed to have been ingested and to have penetrated the GI tract 40 years ago: A case report.

A 60-year old woman had been hospitalized in a psychiatric hospital for 40 years for schizophrenia. An X-ray was performed when she fell, which showed needles in the abdominal field. After additional examinations and questioning, the patient was diagnosed with needles in the abdominal cavity, which were assumed to have been ingested and to have perforated the GI tract 40 years ago. They were removed by laparoscopic surgery. The needles were found in the omentum and near the left ovary. There were no inflammatory reactions around them. There have been previous reports about the removal of intra-abdominal foreign bodies, but foreign body reaction occurred in most of the reports. Our case had the longest period from ingestion of the foreign bodies to their removal. Laparoscopy and intraoperative fluoroscopy are useful for removing intra-abdominal foreign bodies because of their ability to help discriminate between structures and to navigate in real time.

Clinical Significance of Para-Aortic Lymph Node Dissection for Advanced or Metastatic Colorectal Cancer in the Current Era of Modern Chemotherapy.

BACKGROUND/AIMS: Surgical resection is not generally indicated for para-aortic lymph node (PALN) metastasis from colorectal cancer. However, the clinical significance of PALN dissection (PALND) in the current era of modern chemotherapy has not been fully discussed. METHODS: Between November 2006 and February 2013, 14 patients underwent PALND for colorectal cancer and were proven as having pathological PALN metastasis. The median follow-up was 33.2 months. RESULTS: Primary location was the right-colon in 2 patients, and the left-colon or rectum in 12 patients. The timing of metastasis was metachronous in 5 patients and synchronous in 9 patients. Eleven patients (79%) received perioperative aggressive modern chemotherapy. Neoadjuvant chemotherapy with targeted drugs was introduced in 9 patients (64%) and 6 patients received adjuvant chemotherapy. Recurrence after PALND occurred in 12 patients (86%). The most common site was the lung in 6 patients (43%). The 1- and 3-year disease-free survivals were 39.3 and 7.9%, respectively. The 3-year overall survival were 41.2%. CONCLUSION: The recurrence rate after PALND for strictly selected patients was quite high even in the current era of modern chemotherapy. However, some patients achieved long-term survival or could be cured. Therefore, we should re-evaluate the efficacy of PALND in a larger prospective study.

Gastric carcinoma with an invasive micropapillary carcinoma component showing HER2 gene amplification and CD10 expression: a case report and review of the literature.

An 81-year-old man was referred to our hospital because gastric cancer was detected on screening esophagogastroduodenoscopy. Surgical resection of the tumor was performed. It was 25 × 20 mm in size and swollen lymph nodes were present nearby. Lymphadenectomy was also performed. Histopathologically, the tumor reached the proper muscle layer via venous invasion. There were three components that constituted the tumor, that is, 40% of mass was invasive micropapillary carcinoma (IMPC), 40% was papillary adenocarcinoma and 20% tubular adenocarcinoma. Vascular invasion was prominent. Immunohistochemistry revealed that the tumor showed an entirely intestinal mucin phenotype, being positive only for CD10 and negative for MUC2, MUC5AC, and MUC6. HER2 staining score ranged from 2+ to 3+, depending on the components described above. HER2 gene amplification was present in all the components according to dual-color in situ hybridization. The metastatic lymph nodes were similar to the primary site in morphology and immunohistochemistry, but HER2 amplification was higher in the lymph nodes. The IMPC component with HER2 amplification is rarely seen and its positivity for CD10 is an unexpected finding for gastric IMPC. Hence, this is a highly unusual case judging by the literature; further studies are needed to clarify the nature of gastric IMPC.

[A case of breast reconstruction surgery using flap of latissimus dorsi after neoadjuvant chemotherapy].

We performed breast reconstruction surgery with mastectomy after neoadjuvant chemotherapy(NAC)for a patient with NAC indication desiring breast conservation. The case was a 34-year-old single woman. In March, 2007, she was aware of a lump in her left breast and visited our hospital. The diagnosis was solid-tubular carcinoma 3 cm in diameter from close examination. We performed preoperative chemotherapy with EC(epirubicin 90 mg/m(2), cyclophosphamide 600 mg/m(2))x4, followed by 3w-paclitaxel 175 mg/m(2)x4, and then performed mastectomy with axillary dissection and breast reconstruction surgery using the flap of latissimus dorsi at the same time. Pathologically, pCR was provided. We thought that there are many advantages to both treatment of breast cancer and the cosmetic characteristics. The patient was very satisfied. But further cumulative examinations are awaited because there is not much evidence at present.