Long-term prognosis after stapled and hand-sewn ileal pouch-anal anastomoses for familial adenomatous polyposis: a multicenter retrospective study.

PURPOSE: The long-term prognosis of stapled and hand-sewn ileal pouch-anal anastomoses in familial adenomatous polyposis patients in Japan remains unknown. This study aimed to compare the overall survival in familial adenomatous polyposis patients who underwent stapled or hand-sewn ileal pouch-anal anastomosis. METHODS: This multicenter retrospective study was conducted at 12 institutions in Shizuoka Prefecture, Japan. The clinical outcomes of 53 eligible familial adenomatous polyposis patients who underwent stapled (n = 24) and hand-sewn (n = 29) ileal pouch-anal anastomosis were compared. RESULTS: The median follow-up duration was 171.5 months. The incidence of adenoma in the remnant rectum or anal transitional zone and metachronous rectal cancer was significantly more common in stapled ileal pouch-anal anastomosis (adenoma: stapled, 45.8%, vs. hand-sewn, 10.3%, p = 0.005; metachronous rectal cancer: 29.2%, vs. none, p = 0.002). The number of deaths was remarkably higher in stapled ileal pouch-anal anastomosis (p = 0.002). Metachronous rectal cancer was the most common cause of death. Overall survival was worse in stapled ileal pouch-anal anastomosis than in hand-sewn ileal pouch-anal anastomosis (120 months, 90.7% vs. 96.6%; 240 months, 63.7% vs. 96.6%; p = 0.044). Cox regression analysis revealed the independent effects of preoperative advanced colorectal cancer and stapled ileal pouch-anal anastomosis on overall survival. CONCLUSION: Stapled ileal pouch-anal anastomosis negatively affected the overall survival of familial adenomatous polyposis patients. Therefore, hand-sewn ileal pouch-anal anastomosis is recommended for better prognosis in these patients.

Both MLH1 deficiency and BRAFV600E mutation are a unique characteristic of colorectal medullary carcinoma: An observational study.

Although immunohistochemistry (IHC) for mismatch repair (MMR) proteins (MMR IHC) is used to identify DNA MMR status, universal screening of all patients with colorectal cancer (CRC) using a combination of both MMR IHC and genetic testing for the BRAFV600E mutation is limited in Japan. This study aimed to better understand the histopathological characteristics of CRCs, which exhibit both deficient mismatch repair (dMMR) and BRAFV600E mutation. MMR IHC of formalin-fixed paraffin-embedded tissues from tumor areas obtained from 651 patients with CRC who underwent surgical resection at Hamamatsu University Hospital (Hamamatsu, Japan) between August 2016 and March 2022 were used to evaluate MMR status, which was determined by staining for the expression of 4 MMR proteins (MLH1, MSH2, PMS2, and MSH6). All dMMR tumors were additionally evaluated for BRAFV600 mutation status via Sanger sequencing. Patient clinical characteristics (age, sex, tumor location, size, and tumor pathology) were then classified using their dMMR and BRAFV600 mutation statuses. Among the 651 patients with CRC, 58 carried tumors with dMMR, of which 52 were deficiency in MLH1 (dMLH1). Interestingly, all 16 medullary carcinomas that were analyzed showed characteristics corresponding to the presence of both dMLH1 and BRAFV600E mutation (P = .01). These results suggest that colorectal medullary carcinomas can be diagnosed based on their unique characteristics of harboring the BRAFV600E mutation and exhibiting dMLH1 expression.

Using a multistep approach with multidisciplinary team to increase the diagnosis rate of Lynch syndrome-associated colorectal cancer after universal screening: a single-center study in Japan.

BACKGROUNDS: This study aimed to evaluate the changes in the rates of genetic counseling and genetic testing as well as the diagnosis rate of Lynch syndrome (LS)-associated colorectal cancer before and after multistep approach with multidisciplinary team in Japanese. METHODS: In September 2016, we started universal screening for LS by mismatch repair protein immunohistochemistry and prospectively collected the records. Following patient interviews, we started multistep approach with multidisciplinary team (MA) in January 2020. MA consists of six surgeons, one genetic counselor, one medical geneticist, and six pathologists. MA is set up to compensate for patients' lack of knowledge about genetic diseases and make case selection for elderly colorectal cancer patients with deficient mismatch repair (dMMR). MA is designed as a system that could be performed by a small number of medical genetic specialists. A total of 522 patients were included during the study duration, 323 and 199 patients in the pre-MA (P-MA) and MA groups, respectively. RESULTS: The frequency of dMMR in all patients was 10.0%. The patient interview results indicated a significant lack of patient education regarding genetic diseases. The rates of genetic counseling and genetic testing was significantly higher in MA group than in P-MA group (genetic counseling: MA 34.6% vs. P-MA 7.7%, p = 0.04; genetic testing: MA 30.8% vs. P-MA 3.8%, p = 0.02). Moreover, the diagnosis rate of LS-associated colorectal cancer was significantly higher in MA group (2.5%) than in P-MA group (0.3%) (P = 0.03). In addition, MA could be performed without problems despite the small number of medical and human genetics specialists. CONCLUSIONS: MA has achieved appropriate pickup of suspected hereditary colorectal cancer patients and complemented the lack of knowledge about genetic diseases. The introduction of MA increased LS-associated colorectal cancer after universal screening. MA is an appropriate LS screening protocol for Japanese patients who lag behind in medical and human genetics education.

Long-term Prognostic Impact of Metachronous Rectal Cancer in Patients With Familial Adenomatous Polyposis: A Single-center Retrospective Study.

AIM: To evaluate the risk factors and long-term prognosis of metachronous rectal cancer in the remnant rectum of patients with familial adenomatous polyposis (FAP). PATIENTS AND METHODS: Sixty-five patients (49 families) who underwent prophylactic surgery, including bowel resection, for FAP between January 1976 and August 2022 at Hamamatsu University Hospital were included and divided into two groups based on the presence of metachronous rectal cancer. Risk factors for metachronous rectal cancer development were analysed in cases treated with total colectomy with ileorectal anastomosis (IRA) and stapled total proctocolectomy with ileal pouch anal anastomosis (IPAA) (IRA, n=22; stapled IPAA n=20; total, n=42). RESULTS: The median surveillance period was 169 months. Twelve patients developed metachronous rectal cancer (IRA, n=5; stapled IPAA, n=7), of which six with advanced cancer died. Patients who temporarily dropped out of surveillance were significantly more likely to have metachronous rectal cancer (metachronous vs. non-metachronous rectal cancer: 33.3% vs. 1.9%, p<0.01). The mean duration of surveillance suspension was 87.8 months. Cox regression analysis revealed that temporary surveillance drop-out independently affected the risk (p=0.04). The overall survival associated with metachronous rectal cancer was 83.3% at 1 year and 41.7% at 5 years. Overall survival was significantly worse in advanced cancer than in early cancer cases (p<0.01). CONCLUSION: Temporary drop-out from surveillance was a risk factor for metachronous rectal cancer development, and advanced cancer had a poor prognosis. Continuous surveillance of patients with FAP, without temporary drop-out, is strongly recommended.

Prevention of ureteral injury during laparoscopic colorectal cancer surgery with horseshoe kidney using fluorescent ureteral catheters: a case report.

BACKGROUND: Horseshoe kidney is one of the most common congenital renal fusion anomalies and is characterized by abnormalities in the position, rotation, vascular supply, and ureteral anatomy of the kidney. When performing surgery for colorectal cancer in patients with horseshoe kidneys, anatomical identification is important to avoid organ injuries. Several reports on surgery for colorectal cancer with horseshoe kidneys have described the usefulness of three-dimensional (3D) computed tomography (CT) angiography for detecting abnormalities in vascular supply. However, few reports have focused on the prevention of ureteral injury in surgery for colorectal cancer with horseshoe kidney, despite abnormalities in the ureteral anatomy. Here, we report a case in which laparoscopic sigmoid colon resection for sigmoid colon cancer with a horseshoe kidney was safely performed using fluorescent ureteral catheters. CASE PRESENTATION: A 60-year-old Japanese man presented to our hospital testing positive for fecal occult blood. Colonoscopy revealed sigmoid colon cancer, and CT confirmed a horseshoe kidney. The 3D-CT angiography showed aberrant renal arteries from the aorta and right common iliac artery, and the left ureter passed across the front of the renal isthmus. A fluorescent ureteral catheter was placed in the left ureter before the surgery to prevent ureteral injury. Laparoscopic sigmoid colon resection with D3 lymph node dissection was performed. The fluorescent ureteral catheter enabled the identification of the left ureter that passed across the front of the renal isthmus and the safe mobilization of the descending and sigmoid colon from the retroperitoneum. The operative time was 214 min, with intraoperative bleeding of 25 mL. The patient's postoperative course was good: no complications arose and she was discharged on the seventh postoperative day. CONCLUSION: In patients with horseshoe kidney, the use of fluorescent ureteral catheters and 3D-CT angiography enables safer laparoscopic surgery for colorectal cancer. We recommend the placement of fluorescent ureteral catheters in such surgeries to prevent ureteral injury.

Analysis of external pressure on the left calf in the Lloyd-Davies position during colorectal surgery.

PURPOSE: Well-leg compartment syndrome (WLCS) is a potentially life-threatening postoperative complication related to the Lloyd-Davies surgical position, which can place increased external pressure on the calf region. We conducted this study to analyze external pressure changes, by applying a leg holder system to the left calf region of patients placed in the Lloyd-Davies position during laparoscopic surgery. METHODS: The study participants were 50 patients who underwent laparoscopic surgery for colorectal cancer in the Lloyd-Davies position. We assessed the maximum external pressure (MEP) on the left calf region using a pressure-distribution measurement system. Intraoperative measurements were taken continuously, and the MEP was evaluated with the patient horizontal and every 30 min during surgery in the head and right-down tilt position. RESULTS: The intraoperative MEP increased gradually when the patient was in the head and right-down tilt position and decreased when the patient was returned to the horizontal position. The MEP was higher in patients aged < 60 years, those who were obese, and those with a thick calf circumference. Both body mass index (BMI) and the maximum left calf circumference (MLCC) were found to correlate with the MEP. CONCLUSIONS: In addition to a high BMI, which is a well-known risk factor for WLCS, a high MLCC should be considered another risk factor, especially for patients under 60 years.

Refractory postoperative Staphylococcus hominis bacteremia in a patient with an ACTH-producing pancreatic neuroendocrine neoplasm: a case report.

BACKGROUND: Staphylococcus hominis (S. hominis) is an opportunistic pathogen that is often highly resistant to antibiotics and is difficult to treat. In patients diagnosed with an adrenocorticotropic hormone (ACTH)-producing tumor that compromises the immune system due to hypercortisolemia, cancer treatment and infection control should be considered simultaneously. This report presents a case of refractory postoperative S. hominis bacteremia requiring the prolonged administration of several antibiotics in a patient with an ACTH-producing pancreatic neuroendocrine neoplasm (pNEN). CASE PRESENTATION: A 35-year-old man visited a neighboring hospital for a thorough examination after experiencing weight gain and lower limb weakness for several months. Enhanced computed tomography revealed a pancreatic tail tumor and bilateral adrenal enlargement. Elevated plasma ACTH and serum cortisol were noted. Biopsy under endoscopic ultrasonography revealed the tumor as an ACTH-producing pNEN. The patient was transferred to our hospital for further treatment. Pneumocystis pneumonia was noted and treated with sulfamethoxazole and adjunctive glucocorticoids. Hypercortisolism was controlled with metyrapone and trilostane. Somatostatin receptor scintigraphy and ethoxybenzyl magnetic resonance imaging detected other lesions in the pancreatic head. A total pancreatectomy was performed given that the lesions were found in both the pancreatic head and tail. Plasma ACTH and serum cortisol levels decreased immediately after the resection. Pathological examination revealed that the pancreatic tail tumor was NEN G2 and T3N1aM0 Stage IIB and the pancreatic head lesions were SSTR-positive hyperplasia of the islet of Langerhans cells. On postoperative day 11, catheter-associated bacteremia occurred. Initially, meropenem hydrate and vancomycin hydrochloride were administered empirically. S. hominis was identified and appeared sensitive to these antibiotics according to susceptibility testing. However, S. hominis was repeatedly positive in blood cultures for more than one month, despite treatment with several antibiotics. Eventually, with the combined use of three antibiotics (meropenem hydrate, vancomycin hydrochloride, and clindamycin phosphate) for more than 3 weeks, the S. hominis-associated bacteremia improved. He was discharged 79 days after surgery. CONCLUSIONS: Our patient with an ACTH-producing pNEN was immunocompromised and needed meticulous attention for infectious complications even after successful tumor removal. Specifically, S. hominis bacteremia in such patients demands intensive treatments, such as with combinational antibiotics.

Risk Factors for Candidiasis as an Intra-Abdominal Infection after Gastrectomy in Patients with Gastric Cancer.

Intra-abdominal infections (IAIs) develop in 2.4%-26.6% of patients who underwent gastrectomy for gastric cancer and are occasionally serious. However, there are few reports on the causative organisms of IAI following upper gastrointestinal tract surgery and subsequent risk factors for Candida infections. This study aimed to identify the microorganisms that cause IAIs after gastrectomy and risk factors for Candida-related IAI. The records of patients who underwent gastrectomy for gastric cancer between January 2009 and December 2019 at Shizuoka General Hospital were retrospectively collected. Patients with IAIs of grade II or higher, as measured by the Clavien-Dindo classification, were included in the analysis. The selected patients were divided into the Candida and non-Candida groups according to the presence or absence of Candida as the causative organism. Of 1,379 patients, 56 (4.1%) were diagnosed with IAIs after gastrectomy. Fifty-two patients were included in the study based on culture analyses. A total of 111 strains and 28 bacterial species were isolated during the initial culture test. Candida constituted 7.2% of all identified pathogens. Regarding the risk factors for Candida-related IAI, a history of antimicrobial use and ≥ 4 postoperative days of IAI development were independent risk factors for Candida-related IAI.

Long-term prognosis of familial adenomatous polyposis with or without mucosectomy.

PURPOSE: This study primarily aimed to compare the long-term prognosis of patients who underwent total colectomy/proctocolectomy with or without mucosectomy to the dentate line for the diagnosis of familial adenomatous polyposis (FAP). METHODS: Patients who underwent total colectomy/proctocolectomy for FAP between January 1979 and December 2020 and were followed up at Hamamatsu University Hospital were included in this study. Those who underwent total proctocolectomy with hand-sewn ileal pouch-anal anastomosis were defined as the mucosectomy group. Those who underwent total colectomy or total proctocolectomy using the stapled ileal pouch-anal anastomosis approach were defined as the no mucosectomy group. RESULTS: A total of 61 individuals (37 families) were diagnosed during the surveillance period (median, 191 months). Between the mucosectomy (n = 24) and no mucosectomy groups (n = 34), metachronous rectal cancer was significantly more common in the no mucosectomy group (21% in no mucosectomy vs. 0% in mucosectomy, P = 0.02). Overall survival in the no mucosectomy group was worse than that in the mucosectomy group (84.5% in no mucosectomy vs. 100% in mucosectomy at 120 months, 81.1% vs. 90.0% at 240 months, 50.6% vs. 75.0% at 360 months, P = 0.09). Cox regression analysis revealed an independent effect of not performing mucosectomy on overall survival (P = 0.03). CONCLUSION: Long-term surveillance revealed that colectomy or total proctocolectomy without mucosectomy had a negative impact on the overall survival of patients with FAP. Therefore, we recommend total proctocolectomy with mucosectomy, i.e., hand-sewn ileal pouch-anal anastomosis, for FAP.

Defining the treatment strategy for uncomplicated appendicitis based on patient satisfaction feedback: A cross-sectional study.

BACKGROUND: Two surgical strategies are available for appendicitis: emergency laparoscopic appendectomy and interval laparoscopic appendectomy. However, timing of surgical intervention remains debatable. This study aimed to compare the surgical outcomes of emergency laparoscopic appendectomy and interval laparoscopic appendectomy and conduct a questionnaire survey to investigate the use of emergency laparoscopic appendectomy and patient satisfaction with regard to treatment. METHODS: We included 162 patients who underwent laparoscopic appendectomy at our hospital. Outcomes were assessed by operation time, blood loss, postoperative fasting time, length of hospital stay, and complication rate. Patient satisfaction was measured by questionnaire addressing degree of satisfaction, presurgery anxiety, and length of hospital stay. RESULTS: Of 162 patients, 74 (46%) and 88 (54%) received emergency and interval laparoscopic appendectomy, respectively. No significant difference was observed in the operation time, blood loss, length of hospital stay, or complication rate. Among 66 patients who responded to the questionnaire (28 emergency, 38 interval), a significant difference was observed only in the degree of satisfaction regarding the timing of the surgical intervention (p = 0.04). CONCLUSION: Surgical outcomes of emergency and interval appendectomy were equivalent; however, patient satisfaction favored emergency appendectomy, suggesting it is a preferable approach for the treatment of uncomplicated appendicitis.

Mismatch repair proteins immunohistochemical null phenotype in colon medullary carcinoma.

INTRODUCTION: In mismatch repair (MMR) immunohistochemistry, four MMR proteins' staining pattern reveals which particular gene may be defective. However, in the null phenotype, four MMR proteins are lost; consequently, it will be challenging to assume the target gene by immunohistochemistry and to determine whether deficient MMR was sporadic or germline. CASE REPORT: A 70-year-old man underwent right hemicolectomy with the diagnosis of ascending colon cancer. The postoperative histopathology revealed the diagnosis of medullary carcinoma and the loss of all four MMR expressions in immunohistochemistry. The mutation analysis using a peripheral blood sample showed no germline mutations in the four genes. DISCUSSION: This clinical case presents an unusual colon carcinoma that showed a MMR protein immunohistochemistry null phenotype. The cause of expression loss of MMR proteins can be explained by the loss of MLH1 and MSH2 functions associated with somatic loss of function mutations, functional loss in all four MMR proteins associated with somatic loss of function mutations, or Lynch-like syndrome. Correct interpretation and accumulation of relevant cases are necessary to unveil unusual cases in the era of universal screening.

Successful laparoscopic approach for idiopathic adult colo-colonic intussusception: a case report.

BACKGROUND: Adult intussusception is recognized as an abdominal emergency. More than 90% of adult patients with intussusception have distinct causes that are related to benign or malignant tumors. In contrast, idiopathic intussusceptions, which are observed in children, are rare conditions in adult. Especially, colo-colonic idiopathic intussusceptions are rare among them. Surgery is traditionally considered the primary treatment option. Recently, laparoscopic surgery has been reported to be safe and feasible. However, laparoscopic surgical reduction, which is a common procedure in pediatric surgery, is not common in adult intussusception. CASE PRESENTATION: We report a 34-year-old man who presented with sudden abdominal pain. Computed tomography revealed the target sign in the transverse colon. There was no evidence of bowel obstruction, bowel wall edema, or tumor. We diagnosed idiopathic intussusception and selected laparoscopic procedure because of the strong abdominal pain experienced by the patient. There were no signs of perforation, bowel wall ischemia, or tumor in abdominal cavity. We confirmed idiopathic colo-colonic anterograde intussusception. Laparoscopic surgical reduction was achieved by a combination of delicate direct pressure on the anal side of the transverse colon and gentle pulling on the oral side. The patient's postoperative course was uneventful. CONCLUSIONS: We achieved successful surgical reduction laparoscopically because of an accurate preoperative diagnosis based on characteristic computed tomography features and appropriate surgical technique. Laparoscopic procedure and surgical reduction is considered to be an effective treatment strategy for adult idiopathic intussusceptions with severe symptoms.

The successful management for long-term intractable enteroatmospheric fistula: A case report.

INTRODUCTION: Efficacy of open abdomen management with negative pressure wound therapy for enteroatmospheric fistula has been performed. But, few reports have shown its utility for enteroatmospheric fistula several years after onset. PRESENTATION OF CASE: A 46 year-old woman underwent total colectomy due to total ulcerative colitis in her twenties. Three years before the onset of enteroatmospheric fistula, she underwent simple total hysterectomy for uterine smooth muscle tumor. Small bowel obstruction occurred early and a small bowel bypass was performed. However, she had sudden abdominal pain and was diagnosed with anastomotic leakage of small bowel bypass. Although antibiotic treatment was initiated, infection was difficult to control, and a midline abdominal incision was performed, followed by the formation of enteroatmospheric fistula. She declined early surgical intervention and started receiving home parenteral nutrition with antibiotic treatment. Although central vein management was continued, catheter infection became frequent. Hence, surgical intervention was planned 30 months after the formation of enteroatmospheric fistula. Two-stage abdominal wall reconstruction using open abdomen management with negative pressure wound therapy was planned. The definitive abdominal wall reconstruction was performed 14 days after the initial operation. Finally, she was discharged without reoperation. DISCUSSION: Enteroatmospheric fistula has no overlying soft tissue and no real fistula tract. Besides these complications, there were complications of the scarred abdominal wall from intestinal fluid exposure for 30 months. CONCLUSION: The strategy using open abdomen management with negative pressure wound therapy for long-term enteroatmospheric fistula will have a good postoperative outcome with the same as early intervention.

Emergency laparoscopic approach without sufficient preoperative decompression for intersigmoid hernia: A case report.

INTRODUCTION: In acute care surgery, an increasing number of patients operatively treated for small bowel obstruction undergo laparoscopic procedures. However, intersigmoid hernia is a rare condition. In some reports, surgeons have successfully operated on patients with an intersigmoid hernia via a laparoscopic approach. The laparoscopic approach has the advantage of facilitating simultaneous diagnosis and surgical intervention for intersigmoid hernias. In the laparoscopic approach, sufficient decompression of the small bowel is preoperatively performed in most cases. PRESENTATION OF CASE: We encountered a patient with an intersigmoid hernia who underwent an emergency laparoscopic approach without sufficient decompression. Because sufficient decompression of the small bowel was not preoperatively performed, it was difficult to establish a working space and visualize the site of obstruction; however, we performed the laparoscopic approach safely, and diagnosis and surgical intervention were possible. Moreover, the postoperative course was uneventful. DISCUSSION: We successfully performed an emergency surgery using a laparoscopic approach for an intersigmoid hernia without sufficient decompression. The success of the procedure is attributable to the disease-specific surgical strategy, surgical technique, and the recent technological advances in multidetector-row computed tomography. CONCLUSION: We believe that careful preoperative diagnosis and strategy can lead to a good outcome and that the significance of emergency laparoscopic approach without sufficient decompression will keep increasing.

[Postoperative Adjuvant Chemotherapy for Descending Colon Cancer Treated with Imatinib for Chronic Myeloid Leukemia].

A66 -year-old man was diagnosed with chronic myeloid leukemia(CML). Imatinib treatment had been initiated, and a major molecular response(MMR)was achieved. The patient had anemia and was diagnosed with descending colon cancer. The patient was surgically treated, and then received postoperative adjuvant chemotherapy with UFT/LV. However, imatinib was not administered during that period. The patient could undergo postoperative adjuvant chemotherapy for 6 months without acute exacerbation of the CML.