Long-term survival and functional outcomes of laparoscopic surgery for clinical stage I ultra-low rectal cancers located within 5 cm of the anal verge: A prospective phase II trial (Ultimate trial).

OBJECTIVE: To clarify the long-term oncological outcomes and postoperative anal, urinary, and sexual functions after laparoscopic surgery for clinical stage I very low rectal carcinoma located near the anal canal. SUMMARY BACKGROUND DATA: Laparoscopic surgery is widely applied for rectal cancer; however, concerns remain, with some studies showing poorer outcomes compared to open surgery. METHODS: This single-arm, phase II trial included patients registered preoperatively from 47 institutions in Japan. The planned sample size was 300. The primary endpoint was the 3-year local recurrence rate. Anal, urinary, and sexual functions were evaluated using a prospective questionnaire. RESULTS: Three-hundred patients were registered between January 2014 and March 2017. Anus-preserving surgery was performed in 278 (93%), including 172 who underwent intersphincteric resection (58%) and 106 (36%) who underwent low anterior resection. The 3-year cumulative local recurrence rate was 6.3%. At 3 years postoperatively, 87% of patients used their own anus, and the median incontinence score improved from 12 at 3 months to 8 at 3 years. Only 5% of patients had severe incontinence (incontinence score of 16 points). Postoperative urinary function evaluation showed that International Prostate Symptom Score and Overactive Bladder Symptom Score decreased 1 week after surgery, but recovered to preoperative level 1 month after surgery. International Consultation on Incontinence Questionnaire-Sort Form remained almost stable after surgery. Sexual function evaluation using the International Index of Erectile Function-5 and International Index of Erectile Function-15 revealed that the patients had deteriorated 3 months after surgery but had recovered only slightly by 6 months. CONCLUSIONS: Laparoscopic surgery achieves feasible long-term oncological outcomes and a high rate of anus preservation with moderate anal function, and an acceptable incontinence score. While urinary function recovered rapidly, sexual function showed poor recovery.

Impact of the Diverting Stoma on Renal Function.

BACKGROUND: Although loop ileostomy as a diverting stoma has been considered to affect renal dysfunction, few reports have compared loop colostomy with loop ileostomy regarding renal function. This is an important issue in the current setting of increased opportunities to perform surgery on patients with poor renal function. OBJECTIVE: This study aims to reveal the effect of ileostomy on renal dysfunction compared to colostomy following sphincter-preserving rectal surgery. DESIGN: This study was a retrospective analysis. We compared preoperative and postoperative blood urea nitrogen, serum creatinine and estimated glomerular filtration rate values. SETTINGS: The study was conducted at a single academic institution in Osaka, Japan. PATIENTS: From October 2013 to November 2021, 135 consecutive patients underwent rectal surgery with diverting stoma are included. MAIN OUTCOME MEASURES: Differences in pre- and postoperative renal function values by stoma creation site in patients with preoperative chronic kidney disease. Risk factors for patients with newly kidney disease after stoma creation. RESULTS: In the preoperative chronic kidney disease (+) patients, the differences between the pre- and post-values in the blood urea nitrogen (p = 0.047) and the serum creatinine (P = 0.028) values were higher than in the preoperative chronic kidney disease (-) patients. In the preoperative chronic kidney disease (+) patients, ileostomy was significantly associated with an elevation of the serum creatinine value (p = 0.025) and a decrease in estimated glomerular filtration rate value (p = 0.041) from the pre-operative one compared with that of colostomy. In multivariate analysis, ileostomy (odds ratio; 7.443, p = 0.011) and hypertension (4.226, p = 0.008) were independent risk factors of newly kidney disease postoperatively. LIMITATIONS: Limitations to our study includes its retrospective nature and bias due to the stoma site being determined by each surgeon. CONCLUSION: We should take care to choose diverting stoma especially in patients with a risk of kidney disfunction. See Video Abstract.

Final analyses of the prospective controlled trial on the efficacy of uracil and tegafur/leucovorin as an adjuvant treatment for stage II colon cancer with risk factors for recurrence using propensity score-based methods (JFMC46-1201).

BACKGROUND: The efficacy of adjuvant chemotherapy for high-risk stage II colon cancer (CC) has not been well established. Using propensity score matching, we previously reported that the 3-year disease-free survival (DFS) rate was significantly higher in patients treated with uracil and tegafur plus leucovorin (UFT/LV) against surgery alone. We report the final results, including updated 5-year overall survival (OS) rates and risk factor analysis outcomes. METHODS: In total, 1902 high-risk stage II CC patients with T4, perforation/penetration, poorly differentiated adenocarcinoma/mucinous carcinoma, and/or < 12 dissected lymph nodes were enrolled in this prospective, non-randomized controlled study based on their self-selected treatment. Oral UFT/LV therapy was administered for six months after surgery. RESULTS: Of the 1880 eligible patients, 402 in Group A (surgery alone) and 804 in Group B (UFT/LV) were propensity score-matched. The 5-year DFS rate was significantly higher in Group B than in Group A (P = 0.0008). The 5-year OS rates were not significantly different between groups. The inverse probability of treatment weighting revealed significantly higher 5-year DFS (P = 0.0006) and 5-year OS (P = 0.0122) rates in group B than in group A. Multivariate analyses revealed that male sex, age ≥ 70 years, T4, < 12 dissected lymph nodes, and no adjuvant chemotherapy were significant risk factors for DFS and/or OS. CONCLUSION: The follow-up data from our prospective non-randomized controlled study revealed a considerable survival advantage in DFS offered by adjuvant chemotherapy with UFT/LV administered for six months over surgery alone in individuals with high-risk stage II CC. TRIAL REGISTRATION: Japan Registry of Clinical Trials: jRCTs031180155 (date of registration: 25/02/2019), UMIN Clinical Trials Registry: UMIN000007783 (date of registration: 18/04/2012).

The academic impact and value of an international online surgery lecture series.

Due to the worldwide travel restrictions caused by the 2019 coronavirus disease pandemic, many universities and students lost opportunities to engage in international exchange over the past 2 years. Teleconferencing systems have thus been developed to compensate for severe travel restrictions. Kansai Medical University in Japan and Vilnius University in Lithuania have a collaborative research and academic relationship. The two universities have been conducting an online joint international surgery lecture series for the medical students of both universities. Fifteen lectures were given from October 2021 to May 2022. The lectures focused on gastrointestinal surgery, gastroenterology, radiology, pathology, genetics, laboratory medicine, and organ transplantation. A survey of the attendees indicated that they were generally interested in the content and satisfied with attending this lecture series. Our efforts were successful in providing Japanese and Lithuanian medical students with the opportunity to engage in international exchange through lectures held in each other's countries.

Prospective observational study of the efficacy of oral uracil and tegafur plus leucovorin for stage II colon cancer with risk factors for recurrence using propensity score matching (JFMC46-1201).

BACKGROUND: The efficacy of adjuvant chemotherapy for high-risk stage II colon cancer (CC) has not been well established. We compared the effects of surgery with and without oral uracil and tegafur plus leucovorin (UFT/LV) in patients with high-risk stage II CC, adjusting for potential risk factors. METHODS: We enrolled patients with histologically confirmed stage II colon adenocarcinoma with at least one of the following conditions: T4 disease, perforation/penetration, poorly differentiated adenocarcinoma/mucinous carcinoma, or < 12 dissected lymph nodes. Patients chose to be non-randomized or randomized to undergo surgery alone (NR-Group S or R-Group S) or surgery followed by 6 months of UFT/LV (NR-Group U or R-Group U). The primary endpoint was disease-free survival (DFS) after adjusting for previously reported risk factors using propensity score matching (1:2) and inverse probability of treatment weighting (IPTW) in the non-randomized arm. RESULTS: Overall, 1,902 (98%) and 36 (2%) patients were enrolled in the non-randomized and randomized arms, respectively. There were too few patients in the randomized arm and these were therefore excluded from the analysis. Of the 1,902 patients, 402 in NR-Group S and 804 in NR-Group U were propensity score-matched. The 3-year DFS rate (95% confidence interval) was significantly higher in NR-Group U (80.9% [77.9%-83.4%]) than in NR-Group S (74.0% [69.3%-78.0%]) (hazard ratio, 0.64 [0.50-0.83]; P = 0.0006). The 3-year overall survival rate was not significantly different between NR-Group S and NR-Group U. Significantly higher 3-year DFS (P = 0.0013) and overall survival (P = 0.0315) rates were observed in NR-Group U compared with NR-Group S using IPTW. CONCLUSIONS: Adjuvant chemotherapy with UFT/LV showed a significant survival benefit over surgery alone in patients with high-risk stage II CC characterized by at least one of the following conditions: T4 disease, perforation/penetration, poorly differentiated adenocarcinoma/mucinous carcinoma, or < 12 dissected lymph nodes. TRIAL REGISTRATION: Japan Registry of Clinical Trials: jRCTs031180155 (date of registration: 25/02/2019) (UMIN Clinical Trials Registry: UMIN000007783 , date of registration: 18/04/2012).

Image Navigation Surgery With the Fluorescent Ureteral Catheter of Recurrent Tumors in the Pelvic Cavity.

INTRODUCTION: Ureteral injury during pelvic surgery is a serious complication that requires special attention. The fluorescent ureteral catheter near-infrared ray catheter sets are 6.0F catheters containing fluorescent substances along their length that can be recognized by a laparoscopic indocyanine green camera. We present our experience using a near-infrared ray catheter in 6 consecutive patients who underwent surgery for recurrent pelvic tumors. TECHNIQUE: The near-infrared ray catheters were inserted into the bilateral ureters in all patients, with the exception of patient 5 (left unilateral), by urologists using a cystoscope with the same technique as that commonly used in placing ureteral stents under general anesthesia. A laparoscopic indocyanine green camera was adapted to identify the ureters. From February 2020 to July 2020, 6 consecutive patients with recurrent pelvic tumors underwent surgery using a near-infrared ray catheter. In 3 patients, recurrent tumors were detected in the pelvic cavity after surgery for colon cancer (1 patient each of peritoneal recurrence behind the seminal vesicles, lymph node metastasis on the residual superior rectal artery, and peritoneal recurrence at the peritoneal reflection). Two patients had postoperative local recurrences of rectal cancer. The last patient had a recurrence of cervical carcinoma invading the rectum. RESULTS: All patients underwent surgery under ureteral image navigation using near-infrared ray catheter not only for ureter preservation during the operation (4 patients) but also for the combined resection of the ureter with recurrent tumors (2 patients). One patient experienced postoperative ureteral stenosis on postoperative day 21 that required a ureteral double J-stent placement in the left ureter. CONCLUSION: Near-infrared ray catheter has the potential to reduce inadvertent periureteral dissection because the ureter can be identified before approaching it.

Para-sacral approach followed by laparoscopic low anterior resection of a gastrointestinal stromal tumour at the anterior wall of the lower rectum.

AIM: We present a para-sacral approach followed by a laparoscopic low anterior resection of gastrointestinal stromal tumours located between the urethra and the low rectum. METHOD: Case 1 is a 56-year-old male patient whose tumour (37 × 28 mm) was located 3.0 cm above the anal verge between the anterior wall of the rectum and the urethra; he underwent surgery after 14 months' administration of imatinib mesylate (400 mg/day). Case 2 is a 68-year-old male patient who presented with dysuria; a tumour (89 × 84 mm) was detected between the urethra and the anterior wall of the low rectum by MRI. He underwent surgery after 5 months' administration of imatinib mesylate (400 mg/day). In order to perform sphincter-preserving surgery and avoid injury not only to the tumour capsule but also to the urethra, a para-sacral approach followed by laparoscopic low anterior resection was adopted in these patients. Restoration of bowel continuity was done by coloanal anastomosis in case 1 and the double stapling technique in case 2. The postoperative course of the patients was uneventful. In case 2, tumour dissection from the urethra caused injury to the posterior wall of the urethra, which could be repaired easily under direct vision. The urethral catheter was removed after 117 postoperative days, and the diverting stoma was closed after 143 postoperative days. CONCLUSION: The para-sacral approach followed by a laparoscopic low anterior resection of an extraluminal gastrointestinal stromal tumour located between the urethra and anterior wall of the low rectum enables R0 resection of the tumour and an appropriate reconstruction of the rectum.

p62 is a useful predictive marker for tumour regression after chemoradiation therapy in patients with advanced rectal cancer: an immunohistochemical study.

AIM: This study aimed to evaluate the relationship between p62 expression status and tumour regression grade in advanced rectal cancer. METHODS: We enrolled 47 consecutive patients with advanced rectal cancer who underwent chemoradiation therapy (CRT) before surgery. p62 expression in the biopsy specimens was immunohistochemically evaluated, and p62 expression score (staining intensity × positive tumour cells, %) was calculated (range 0-300). The relationship between p62 expression score and CRT effect was analysed. RESULTS: The staining intensity was +2 and +3 in 29 and 18 patients, respectively. The median proportion of positive neoplastic cells was 87.8%, and that of the p62 expression score was 200. Stronger staining intensity and a higher proportion of p62-positive neoplastic cells were significantly associated with CRT non-effectiveness (P = 0.0002 and P = 0.0116, respectively), and a higher p62 expression score was significantly associated with CRT non-effectiveness (P < 0.0001). The optimal cut-off value for predicting the CRT effect was 240. CONCLUSIONS: A higher p62 expression score was significantly associated with less CRT effectiveness in patients with advanced rectal cancer. Analysis of p62 expression score using biopsy specimens is a useful and easily assessable prediction marker for CRT effect and might help select patients who can undergo a 'watch-and-wait' strategy after CRT.

[Diagnosis of Serous Adenocarcinoma following Pneumatosis Intestinalis Development during Bevacizumab Therapy for Cancer of Unknown Primary-A Case Report].

A 75-year-old woman was treated with TC plus Bev for cancer of unknown primary. During treatment, she presented to the clinic with chief complaints of general malaise and anorexia. On presentation, abdominal distention and upper abdominal tenderness were noted, and sepsis was suspected. A thoracoabdominal CT scan revealed prominent intramural emphysema and mesenteric gas in the ascending colon. An emergency laparotomy was performed for suspected pneumatosis intestinalis non-obstructive intestinal ischemia. However, no intra-abdominal contamination or ischemic changes were observed intraoperatively. Histological examination revealed a small adenocarcinoma on the serous surface of the ascending colon, and immunochemical staining confirmed the diagnosis of serous adenocarcinoma as the patient's primary cancer. This report describes a case in which the patient achieved long-term survival after diagnosis. It also emphasizes the importance of identifying the subset of patients with cancer of unknown primary who have a good prognosis in order to provide appropriate treatment.

The possibility of a transanal tube as an alternative to diverting stoma in terms of preventing severe postoperative anastomotic leakage after laparoscopic low anterior resection.

PURPOSE: The purpose of this study was to reveal whether a transanal tube (TAT) could act as an alternative to a diverting stoma (DS) after laparoscopic low anterior resection. PATIENTS AND METHODS: A total of 89 consecutive rectal cancer patients whose tumors were located within 15 cm from the anal verge who underwent laparoscopic low anterior resection without a DS at our institution between May 12, 2015 and August 31, 2019 were included. All patients received a postoperative Gastrografin enema study (GES) through a TAT between the 3rd and 10th postoperative day. We planned two study protocols. From May 12, 2015 to March 31, 2017, we conducted a second operation including a DS construction immediately when radiological anastomotic leakage (rAL) was detected (Group A, n=46). From April 1, 2017 to August 31, 2019, we continued TAT drainage even if rAL was detected and repeated the GES weekly until the rAL was healed (Group B, n=43). RESULTS: In Group A (n=46), 14 cases of rAL were included, 11 of which underwent stoma construction. The remaining 3 patients who refused stoma construction were treated conservatively. In Group B (n=43) rAL was encountered in 10, and 7 of these patients were treated successfully by TAT continuous drainage. The rate of DS in Group B (7.0%) was significantly lower than that in Group A (23.9%) (p=0.028). CONCLUSIONS: A TAT could act as a DS to mitigate the symptoms of anastomotic leakage after laparoscopic low anterior resection.

[A Case of Aggressive Angiomyxoma in a 75-Year-Old Man].

Aggressive angiomyxoma is an uncommon mesenchymal tumor that mostly involves the pelvic and perineal regions in young women.We herein report an extremely rare case of aggressive angiomyxoma in a 75-year-old man. The patient had undergone follow-up for an intraductal papillary mucinous neoplasm.In September 2015, CT detected a tumor measuring 33 mm in diameter around the pelvis, and the tumor showed gradual increase in size.MRI revealed a relatively sharply marginated tumor with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images.For treatment and diagnosis, we laparoscopically resected the tumor. Histopathologically, the specimen showed spindle tumor cells within a myxoid background and vascular structures.The tumor was diagnosed as aggressive angiomyxoma, and surgical margins were negative for tumor cells. The patient is currently doing well without any signs of recurrence as of 18 months postoperatively.

[Two Successful Cases of Surgical Treatment of Reconstructed Gastric Tube-Bronchial Fistula after Esophagectomy for Esophageal Cancer by Pedunculated Latissimus Dorsi Flap].

We herein report 2 cases of successful surgical treatment of reconstructed gastric tube-bronchial fistulas caused by leakage after esophagectomy for esophageal cancer. One patient was a 56-year-old man who developed a reconstructed gastric tube-bronchial fistula, and the fistula was closed by conservative treatment. However, he developed pneumonia on postoperative day 117, and the reconstructed gastric tube-bronchial fistula was found to have recurred. Fibrin glue was endoscopically injected into the fistula, but this treatment was unsuccessful. The other patient was a 60-year-old man who developed a reconstructed gastric tube-bronchial fistula and severe pneumonia, and his condition did not improve by conservative treatment. We performed a reoperation for both patients using a pedunculated latissimus dorsi flap, and both patients recovered well.

Influence of hospital type on survival in stage IV colorectal cancer.

PURPOSE: Hospital factors along with various patient and surgeon factors are considered to affect the prognosis of colorectal cancer. Hospital volume is well known, but little is known regarding other hospital factors. METHODS: We reviewed data on 853 patients with stage IV colorectal cancer who underwent elective palliative primary tumor resection between January 2006 and December 2007. To detect the hospital factors that could influence the prognosis of incurable colorectal cancer, the relationships between patient/hospital factors and overall survival were analyzed. Among hospital factors, hospital type (Group A: university hospital or cancer center; Group B: community hospital), hospital volume, and number of colorectal surgeons were examined. RESULTS: In univariate analysis, Group A hospitals showed significantly better prognosis than Group B hospitals (p = 0.034), while hospital volume and number of colorectal surgeons were not associated with overall survival. After adjustment for patient factors in multivariate analysis, hospital type was significantly associated with overall survival (hazard ratio: 1.31; 95 % confidence interval: 1.05-1.63; p = 0.016). However, there was no significant difference in short-term outcomes between hospital types. CONCLUSIONS: Hospital type was identified as a hospital factor that possibly affects the prognosis of stage IV colorectal cancer patients.

Impact of intraoperative blood loss on morbidity and survival after radical surgery for colorectal cancer patients aged 80 years or older.

PURPOSE: This study aimed to assess the effect of intraoperative blood loss (IBL) on short- and long-term outcomes of colorectal cancer surgery for very elderly patients. METHODS: We acquired the data of consecutive patients aged 80 years or older who underwent elective radical surgery for stage I to III colorectal cancer between January 2003 and December 2007 in 41 institutions. The patients were divided into high and low IBL groups, and the differences in postoperative morbidity and survival between the two groups were primarily assessed. Eleven factors were treated as potential confounders in multivariate analyses. RESULTS: A total of 1554 patients were eligible for this study, with an age range of 80-103 years. Median IBL was 71 ml (interquartile range, 25 to 200 ml), and 412 patients had IBL ≥200 ml. Morbidity was 46% among patients with IBL ≥200 ml, compared with 30 % among those with IBL <200 ml (p < 0.001). Patients with IBL ≥200 ml had worse overall survival rates and recurrence-free survival rates at 1, 3, and 5 years than those with IBL <200 ml. In multivariate analyses, IBL ≥200 ml was identified as an independent risk factor for postoperative adverse events (odds ratio (OR) 1.41, 95% confidence interval (CI) 1.08 to 1.86), overall survival (hazard ratio (HR) 1.34, 95% CI 1.04 to 1.72), and recurrence-free survival (HR 1.29, 95% CI 1.03 to 1.62). CONCLUSION: The degree of IBL is significantly associated with postoperative morbidity and survival in very elderly colorectal cancer patients.

[A Case of Intra-Abdominal Desmoid Tumor with Abacterial Peritonitis].

A woman in her 50s visited our hospital in February 2015 with a complaint of dull abdominal pain in the right lower quadrant. She had a medical history of appendectomy for appendicitis in her 20s. Computed tomography(CT)revealed a tumor 90 mm in diameter near the ileocecum. Elective surgery was planned under the suspicion of gastrointestinal tumor, malignant lymphoma, or ileal cancer. She was emergently hospitalized 1 day earlier than scheduled because of high fever and severe abdominal pain. CT revealed that the tumor had increased to 120 mm in diameter without free air. Her white blood cell count was not elevated, and her symptoms improved readily with medical treatment. Thus, we performed the operation as scheduled. A tumor with a dark red recess on the surface had invaded the transverse colon intraoperatively, and a small amount of purulent ascites was present at the pouch of Douglas. We performed ileocecal resection with partial transverse colectomy. Histopathological examination led to the diagnosis of desmoid tumor in the mesentery of the terminal ileum. The surgical margins were negative for tumor cells. The tumor surface around the recess showed peritonitis, and the ascites showed no bacteria or tumor cells. The patient had been doing well without recurrence after discharge. Some cases of desmoid tumor with peritonitis have been reported, but most were caused by tumor penetration into the intestinal tract. We report herein a rare case of intra-abdominal desmoid tumor with abacterial peritonitis.