Laparoscopic total pelvic peritonectomy for colorectal cancer pelvic carcinomatosis: a retrospective case series and photographic/videographic step-by-step guide.

BACKGROUND: Cytoreductive surgery (CRS) for colorectal cancer peritoneal carcinomatosis has been shown to prolong survival with acceptable morbidity rates. Total pelvic peritonectomy (TPP), or complete removal of all pelvic peritoneum, constitutes an important and technically challenging component of CRS. Here we report our experience and describe our technique of laparoscopic total pelvic peritonectomy (LTPP), using a photographic/videographic step-by-step guide. METHODS: All patients who underwent LTPP for pelvic carcinomatosis from a colorectal origin were included in the study. Only patients with peritoneal cancer index (PCI) score of ≤ 10 were selected for CRS with LTPP. Patients who had extra-abdominopelvic cavity metastases were excluded. The final decision to proceed with CRS was made following laparoscopic assessment. RESULTS: From January 2017 to December 2020, 15 consecutive patients underwent LTPP for colorectal cancer pelvic carcinomatosis. Median patient age and PCI score was 53 years (range 33-78) and 8 (range 3-10), respectively. Complete cytoreduction was achieved in all patients. Thirteen patients (87%) underwent concomitant hyperthermic intraperitoneal chemotherapy (HIPEC). The median operative duration was 748 min (interquartile range [IQR] 681-850). Median intra-operative blood loss and length of hospital stay was 100 ml (IQR 50-300) and 10 days (IQR 8-12), respectively. Five patients (33%) experienced 30-day post-operative morbidity, with one (6.7%) experiencing a higher grade (Clavien-Dindo IIIa) complication. Median follow-up duration was 13 months (IQR 3-19), during which four (27%) had systemic recurrence and one (6.7%) died after 15 months following peritoneal and systemic recurrences. CONCLUSION: LTPP is a feasible option for low-volume pelvic carcinomatosis from colorectal cancer, offering the benefits of a minimally invasive approach. Strict patient selection is essential, and the procedure should be converted if the PCI score cannot be assessed or complete cytoreduction cannot be achieved. Proficiency at laparoscopic pelvic surgery is mandatory for performing LTPP.

Uncomplicated Sigmoid Volvulus Is Ideal for Laparoscopic Sigmoidectomy With Transrectal Natural Orifice Specimen Extraction.

INTRODUCTION: Natural orifice specimen extraction is the next step in minimally invasive colorectal surgery but can be technically challenging, with additional risks, especially for oncologic surgery. For several key reasons, sigmoid volvulus is well suited for natural orifice specimen extraction surgery. We describe our method and experience with double-stapled anastomosis transrectal natural orifice specimen extraction for sigmoid volvulus. TECHNIQUE: Using 3- or 4-port laparoscopy, the mesentery is separated from the long sigmoid loop. After the distal bowel is tied off and washed out, the rectum is completely transected and the proximal bowel delivered transrectally through a wound protector. Proximal transection is performed externally, and the circular stapler anvil is set before the bowel is returned into the abdominal cavity. The rectum stump is closed with an endoscopic linear stapler, and a circular-stapled anastomosis is performed. RESULTS: After successful endoscopic decompression, 6 patients underwent elective laparoscopic sigmoidectomy with natural orifice specimen extraction for volvulus at China Medical University Hospital from 2015 to 2020. The median operative time was 179 minutes (range, 151-236 min). No intraoperative complications were encountered. The median postoperative length of stay was 4 days (range, 2-9 d). One patient experienced postoperative small-bowel ileus resulting in readmission. The median follow-up duration was 12 months (range, 2-49 mo). One recurrence of volvulus was recorded 27 months postsurgery. CONCLUSION: Uncomplicated sigmoid volvulus can be treated effectively with sigmoidectomy and natural orifice specimen extraction. Surgeons who attempt this procedure should be well versed with conventional laparoscopy but do not necessarily need to be experienced with natural orifice specimen extraction for successful surgery.

Methylation of the Tumor Suppressor Genes HIC1 and RassF1A Clusters Independently From the Methylation of Polycomb Target Genes in Colon Cancer.

BACKGROUND: Methylation changes within tumor suppressor (TS) genes or polycomb group target (PcG) genes alter cell fates. Chromatin associated with PcG targets is bivalent in stem cells, while TS genes are not normally bivalent. PcG target methylation changes have been identified in tumor stem cells, and abnormal methylation is found in TS genes in cancers. If the epigenetic states of genes influence DNA methylation, then methylation of PcG targets and TS genes may evolve differently during cancer development. More importantly, methylation changes may be part of a sequence in tumorigenesis. METHODS: Chromatin and methylation states of 4 PcG targets and 2 TS genes were determined in colon cancer cells. The methylation states were also detected in 100 pairs of colon cancer samples. Principle component analysis (PCA) was used to reveal whether TS methylation or PcG methylation was the main methylation change associated with colon cancers. RESULTS: Chromatin and methylation states differ in colon cancer cell lines. The methylation states within PcG targets clustered independently from the methylation states in TS genes, a finding we previously reported in liver cancers. PCA in colon cancers revealed the strongest association with methylation changes in 2 TS genes, HIC1 and RassF1A. Loss of HIC1 methylation correlated with decreased tumor migration. CONCLUSIONS: PcG and TS methylation states cluster independently from each other. The deduced principle component correlated better with TS methylation than PcG methylation in colon cancer. Abnormal methylation changes may represent a sequential biomarker profile to identify developing colon cancer.

Colon cancer mesenchymal stem cells modulate the tumorigenicity of colon cancer through interleukin 6.

Multipotent mesenchymal stem cells (MSCs) have been isolated from several tumors and are implicated to play critical roles to increase malignant cell growth, invasion and metastasis. Here, we show that the MSC-like cells were isolated from human colon cancer tissues. These isolated hCC-MSCs (human colon cancer-derived mesenchymal stem cells) shared similar characteristic features with bone marrow-derived MSCs, which include cell morphology, surface antigens and specific gene expression. Additionally, the hCC-MSCs could differentiate into osteocytes or adipocytes under appropriate culture conditions. The conditioned medium collected from the cultured hCC-MSCs was shown to enhance the migration and invasive activity of HCT-116 colon cancer cells in vitro. Besides, transplantation of HCT-116 cells along with hCC-MSCs in nude mice increased the tumor growth and metastasis. Further study revealed that IL-6 present in the hCC-MSC-conditioned medium sufficiently induced the levels of Notch-1 and CD44 in HCT-116 and HT-29 cells, which contribute to enhance tumorigenic activity of HCT-116 and HT-29 cells. By using immunohistochemical staining, the intense co-expression of IL-6, Notch-1 and CD44 was predominantly detected in human colon cancer tissues. Taken together, our findings suggest the importance of the IL-6/Notch-1/CD44 signaling axis in the interaction between hCC-MSCs and colon cancer cells.

Missed cancerous lesions in emergency laparoscopic surgery: retrospective study of 2074 cases.

Abdominal laparoscopy is a widely accepted surgical procedure effective even for acute abdominal ailments. However, one major concern in using abdominal laparoscopy is missed lesions, in the past this has not been adequately explored. The aim of this retrospective study, therefore, is to evaluate cancerous lesions that are missed during emergency laparoscopic surgeries. The medical records of 2074 patients who had a laparoscopy from March 1996 to April 2006 for acute abdomen symptoms, including diagnostic laparoscopy (n = 119), laparoscopic appendectomy (n = 1336), laparoscopic duodenorrhaphy (n = 30), and laparoscopic cholecystectomy (n = 589) were reviewed. Missed cancerous lesions included cecal cancer (n = 2), sigmoid cancer (n = 1), and jejunum lymphoma (n = 1). The incidence of missed cancerous lesions in an emergency laparoscopic surgery is 0.19%, mainly due to its lower tactile sensitivity compared to the direct hand palpation and masqueraded by inflammatory process. Therefore, careful observation is recommended for post-emergency laparoscopic patients and follow-up should be performed within three months, especially for patients with intra-abdominal and/or severe inflammation status.

A Randomized Trial Comparing the Bowel Cleansing Efficacy of Sodium Picosulfate/Magnesium Citrate and Polyethylene Glycol/Bisacodyl (The Bowklean Study).

Bowel cleansing is essential for a successful colonoscopy, but the ideal clearing agent and the volume have yet to be determined. A small-volume cleanser is important for patient compliance. This study aimed to compare the bowel cleansing efficacy, safety, tolerability, and acceptability of a 300-mL small-volume sodium picosulfate/magnesium citrate (PSMC) preparation-Bowklean with one 2-L polyethylene glycol (PEG)/bisacodyl-Klean-Prep/Dulcolax preparation under identical dietary recommendations. This multicenter, randomized, parallel-group, pre-specified noninferiority study enrolled 631 outpatients scheduled to undergo colonoscopy (Bowklean = 316 and Klean-Prep/Dulcolax = 315). After bowel preparation, an independent evaluator blinded to the subject's treatment allocation rated the quality of the colon cleansing. Efficacy was evaluated using the Aronchick Scale and Ottawa Bowel Preparation Scale (OPBS). Safety was assessed by monitoring adverse events. Tolerability and acceptability were measured via a patient questionnaire. Bowklean was non-interior to Klean-Prep/Dulcolax in overall colon cleansing but was associated with significantly better preparation quality. Notably, Bowklean was associated with significantly greater tolerability and acceptability of bowel preparations than Klean-Prep/Dulcolax. Safety profiles did not differ significantly between the groups. Our data indicate that Bowklean is a more effective and better-tolerated bowel cleansing preparation before colonoscopy than Klean-Prep/Dulcolax. Bowklean may therefore increase positive attitudes toward colonoscopies and participation rates.

Prospective randomized comparison of oral sodium phosphate and polyethylene glycol lavage for colonoscopy preparation.

AIM: To compare the effectiveness, patient acceptability, and physical tolerability of two oral lavage solutions prior to colonoscopy in a Taiwanese population. METHODS: Eighty consecutive patients were randomized to receive either standard 4 L of polyethylene glycol (PEG) or 90 mL of sodium phosphate (NaP) in a split regimen of two 45 mL doses separated by 12 h, prior to colonoscopic evaluation. The primary endpoint was the percent of subjects who had completed the preparation. Secondary endpoints included colonic cleansing evaluated with an overall assessment and segmental evaluation, the tolerance and acceptability assessed by a self-administered structured questionnaire, and a safety profile such as any unexpected adverse events, electrolyte tests, physical exams, vital signs, and body weights. RESULTS: A significantly higher completion rate was found in the NaP group compared to the PEG group (84.2% vs 27.5%, P<0.001). The amount of fluid suctioned was significantly less in patients taking NaP vs PEG (50.13+/-54.8 cc vs 121.13+/-115.4 cc, P<0.001), even after controlling for completion of the oral solution (P = 0.031). The two groups showed a comparable overall assessment of bowel preparation with a rate of "good" or "excellent" in 78.9% of patients in the NaP group and 82.5% in PEG group (P = 0.778). Patients taking NaP tended to have significantly better colonic segmental cleansing relative to stool amount observed in the descending (94.7% vs 70%, P = 0.007) and transverse (94.6% vs 74.4%, P = 0.025) colon. Slightly more patients graded the taste of NaP as "good" or "very good" compared to the PEG patients (32.5% vs 12.5%; P = 0.059). Patients' willingness to take the same preparation in the future was 68.4% in the NaP compared to 75% in the PEG group (P = 0.617). There was a significant increase in serum sodium and a significant decrease in phosphate and chloride levels in NaP group on the day following the colonoscopy without any clinical sequelae. Prolonged (>24 h) hemodynamic changes were also observed in 20-35% subjects of either group. CONCLUSION: Both bowel cleansing agents proved to be similar in safety and effectiveness, while NaP appeared to be more cost-effective. After identifying and excluding patients with potential risk factors, sodium phosphate should become an alternative preparation for patients undergoing elective colonoscopy in the Taiwanese population.

Effect of preoperative concurrent chemoradiotherapy in locally advanced low rectal cancer after radical resection surgery.

To evaluate the outcome of patients with locally advanced low rectal adenocarcinoma who required preoperative concurrent chemoradiotherapy (CCRT), a total of 22 patients underwent preoperative CCRT and radical resection for locally advanced low rectal adenocarcinoma. Patients received concurrent chemotherapy with high-dose 5-fluorouracil (5-FU) in continuous infusion and leucovorin and preoperative radiation with a mean dose of 50.4 Gy (range, 45-50.4 Gy). Radical resection surgery was performed 6 weeks after treatment. Fifty-five percent of patients achieved tumor downstaging, and 14% patients. showed pathological complete remission. No severe hematological and gastrointestinal toxicity of preoperative CCRT was noted. Sphincter-saving rate was 82%, and there were no deaths related to preoperative CCRT and surgery. Overall, 3-year survival rate was 69%, and a rate of locoregional recurrence was 13.6%. This study shows that many patients with locally advanced rectal cancer can be operated on with sphincter-saving radical resection surgery under good local control after preoperative concurrent chemoradiotherapy, which induces tumor downstaging.

Pattern of relapse after curative surgery for metastatic colorectal cancer.

OBJECTIVE: To investigate patterns in the relapse frequency after curative surgical intervention, with the intention of determining the feasibility of a complete holiday from chemotherapy for metastatic colorectal cancer (mCRC) patients. METHODS: Patients with stage IV mCRC who received curative surgical intervention between January 1999 and December 2009 at Changhua Christian Hospital, Changhua, Taiwan were investigated retrospectively. Factors influencing the frequency and pattern of relapse were analyzed by logistic regression. Factors influencing overall survival (OS) were analyzed with Cox proportional hazard ratios. Significant factors were extracted and relationships to OS were evaluated by Kaplan-Meier with Log-Rank test. RESULTS: One hundred and thirty-two patients were included in the study in which 94 (71.2%) suffered from relapse. The number of relapses peaked between 3 and 6 months. The incidence of relapse and Disease-free survival had a negative influence on OS, with a hazard ratio (HR) of 0.36 (95% CI: 0.01-0.26) and 0.93 (95% CI: 0.90-0.95). The prognosis was significantly worse when the relapse (n=25) occurred within 6 months after metastectomy (p<0.001). Patients exhibited significantly better long-term OS if the relapse does not occur within 28 months after surgery (p<0.001). CONCLUSION: Early relapse indicated a worse prognosis. We determined that if mCRC patients remain cancer-free for 28 months after curative surgery, their chance of long-term survival is significantly better.