Anatomy of the right colic vein and pancreaticoduodenal branches: a surgical landmark for laparoscopic complete mesocolic excision of the right colon.

PURPOSE: Knowledge of mesenteric venous anatomy is important to safely perform laparoscopic complete mesocolic excision (CME) of the right colon. Despite their previously reported diversity, consistent features of the right colonic and pancreatic veins can be discerned. The objective of this study was to evaluate anatomical consistency of the right colic vein (RCV) and the pancreaticoduodenal vein associated with the colic vein (PDV-C). METHODS: This study included 125 consecutive patients undergoing contrast-enhanced multidetector-row CT of the abdomen. Images of 100 of these cases were retrospectively reviewed for the positioning of the colonic, gastric and pancreatic veins associated with the superior mesenteric vein (SMV). RCV were classified as three types: Type-I, running on the ventral aspect of the pancreatic head and draining into the right lateral wall of the SMV; Type-II, running apart from the pancreatic head and directly draining into the SMV; and Type-III, draining into the tributaries of the SMV. RESULTS: The RCV was identified in 88% of cases, in which the frequencies of Type-I, -II and -III anatomies were 84.1, 9.1, and 6.8%, respectively. All of the Type-I RCVs formed a common trunk with other veins, including the gastroepiploic vein (93.2%) and the superior RCV (59.5%). The PDV-C joined the RCV in 63.5% of the Type-I cases. CONCLUSIONS: Anatomical consistency of the RCV together with the PDV-C is present in the majority of cases. Our findings support the view that the appearance of the veins is a useful landmark for laparoscopic CME of the right colon.

[A Case of Gastric Cancer Associated with Sjögren's Syndrome and Interstitial Pneumonia].

A 77-year-old man presented with poor appetite and dyspnea. A gastroendoscopy showed an advanced gastric cancer and a CT scan demonstrated diffuse interstitial infiltrative shadows in both lungs. Laboratory data showed high level of anti-SSA and anti-SSB antibodies, suggestive of interstitial pneumonia associated with Sjögren's syndrome. Although the levels of KL-6 and SP-D, markers of interstitial pneumonia, decreased after steroid and immunosuppressive therapy, the CT findings of interstitial pneumonia showed no remarkable change. Surgery was performed 2 months after the administration of prednisolone since the respiratory function had improved, allowing the administration of general anesthesia. A CT scan revealed remarkable improvement of the lung lesions after the surgery. Therefore, it is likely that Sjögren's syndrome and interstitial pneumonia manifested as paraneoplastic syndromes in the presented case.

[A Case of Bullous Pemphigoid Relieved after Sigmoid Colon Cancer Resection].

A 76-year-old man presented with many bullous lesions and erythema over his whole body in August 2014. Blood examination showed an elevation of the anti-BP180 antibody (658 U/mL) and a biopsied specimen of the skin lesions showed subepidermal bulla. A diagnosis of bullous pemphigoid was made based on the clinical and histological findings. Although 20 mg/day of prednisolone was administered, there was a poor response and consequently the dose of steroid was increased to 70 mg/day after 2 weeks. Bullous pemphigoid related to a malignant tumor was suspected. Colonic endoscopic examination revealed a sigmoid colon cancer and he underwent a sigmoidectomy with lymphodenectomy. The histopathological findings revealed a moderately-differentiated adenocarcinoma, pT1b, pN1, pStage Ⅲa, and he received adjuvant chemotherapy(UFT/ LV). The dermatological findings were rapidly relieved after tumor resection and anti-BP180 antibody was normalized. He has had no signs or symptoms of recurrence, both of the cancer and the bullous pemphigoid, for 9 months after the operation.

[A Case of Local Recurrence and Lung Metastasis from a Rectal Cancer Treated with Systemic Chemotherapy and Cyberknife].

A 73-year-old man underwent abdominoperineal resection for a rectal cancer. He developed a hip pain 3 years and 6 months after the surgery. A CT scan revealed a local recurrence in the perineum and multiple lung metastases in the bilateral lung. He received systemic chemotherapy consisting of XELOX with bevacizumab. Thereafter, the hip pain was slightly relieved. The hip pain worsened 1 year and 6 months after the recurrence. The border between the perineal tumor and skin was very narrow, and conventional radiation therapy could cause a perineal skin necrosis and subsequent poor wound healing. Therefore, we selected a Cyberknife treatment. The hip pain was relieved and a CT scan showed a reduction of the perineal tumor's size after the Cyberknife treatment. A Cyberknife treatment may be effective and promising as palliation for patients with local recurrence of rectal cancer.

The relationship of lymph node evaluation and colorectal cancer survival after curative resection: a multi-institutional study.

BACKGROUND: Esophagectomy remains the mainstay treatment for clinical T1bN0M0 esophageal cancer because pathologic lymph node metastases in these patients are not negligible. Recently, chemoradiotherapy (CRT), which can preserve the esophagus, has been reported to be a promising therapeutic alternative to esophagectomy. However, to our knowledge, no comparative studies of esophagectomy and CRT have been reported in clinical T1bN0M0 esophageal cancer. METHODS: A total of 173 patients with clinical T1bN0M0 squamous cell carcinoma of the thoracic esophagus were enrolled in this study, 102 of whom were treated with radical esophagectomy (S group) and 71 with definitive CRT (CRT group). Treatment results of both groups were retrospectively compared. RESULTS: No statistically significant difference was found in overall survival, but the S group displayed significantly better progression-free survival than the CRT group. Disease recurrence was observed in 12 S group patients and 20 CRT group patients. The incidence of distant recurrence was similar, while local recurrence and lymph node recurrence were significantly more frequent in the CRT group. In the S group, 20 patients had pathologic lymph node metastasis. The progression-free survival of patients with pathologic lymph node metastasis did not differ from those without nodal metastasis. In the CRT group, local recurrence could be controlled by salvage esophagectomy, but treatment results of lymph node recurrence were poor; only 4 of 12 patients with lymph node recurrences were cured. CONCLUSIONS: Selection of patients at high risk of pathologic lymph node metastasis is essential when formulating treatment decisions for clinical T1bN0M0 esophageal cancers.

Prolonged survival of patients with metastatic colorectal cancer following first-line oxaliplatin-based chemotherapy with molecular targeting agents and curative surgery.

BACKGROUND: The ability of molecular targeting agents to improve overall survival (OS) in metastatic colorectal cancer (MCRC) patients who underwent oxaliplatin-based chemotherapy remains controversial. METHODS: We retrospectively analyzed 331 patients with MCRC who underwent first-line oxaliplatin-based chemotherapy. Treatment outcomes were compared between patients who started chemotherapy from April 2005 to March 2007 (cohort A; n = 157) and those who started it from April 2007 to March 2009 (cohort B; n = 174). To evaluate the impact of exposure to agents, we applied time-varying covariate analysis to avoid possible lead-time bias. RESULTS: Median OS of cohorts A and B was 21.3 and 28.6 months, respectively (HR 0.66, 95% CI 0.50-0.87, p = 0.003). Exposure to bevacizumab (25 vs. 76%), anti-epidermal growth factor receptor (EGFR) (18 vs. 33%) or curative surgery after chemotherapy (4 vs. 10%) was significantly higher in cohort B. According to a multivariate Cox model with exposure to each agent or treatment as a time-varying covariate, hazard ratios of death were 0.71 (95% CI, 0.51-0.96; p = 0.03) for bevacizumab, 0.62 (95% CI, 0.40-0.89; p = 0.01) for anti-EGFR and 0.22 (95% CI, 0.06-0.57; p = 0.004) for surgery. CONCLUSIONS: Increased exposure to molecular targeting agents or surgery after chemotherapy appears to contribute to an improvement in OS in recent patients with MCRC who have undergone oxaliplatin-based chemotherapy.

Conversion chemotherapy using cetuximab plus FOLFIRI followed by bevacizumab plus mFOLFOX6 in patients with unresectable liver metastases from colorectal cancer.

Recently, in patients with unresectable colorectal liver metastasis, liver resection sometimes becomes possible by intensive systemic chemotherapy, i.e. conversion therapy. However, among cases that do not respond well to first-line chemotherapy, it is rare that second-line chemotherapy results in a marked response allowing liver resection. We consider that the liver resection rate may be increased by initiating second-line treatment at an earlier stage before progression subsequent to first-line chemotherapy. We are conducting a multicentre Phase II study to evaluate the efficacy and safety of sequential chemotherapy using six cycles of cetuximab plus FOLFIRI (5-fluorouracil, folinic acid and irinotecan) followed by six cycles of bevacizumab plus FOLFOX (5-fluorouracil, folinic acid and oxaliplatin) as conversion chemotherapy. The primary endpoint is the liver resection rate during the bevacizumab + FOLFOX phase. Fifty patients are required for this study.

Phase II trial of neoadjuvant chemotherapy with XELOX plus bevacizumab for locally advanced rectal cancer.

In Western countries, the standard treatment for locally advanced rectal cancer is preoperative chemoradiotherapy followed by total mesorectal excision. On the other hand, in Japan, treatment results without radiotherapy are by no means inferior; therefore, extrapolation of results of preoperative treatment in Western countries to Japan is controversial. We consider that survival may be improved by preoperative treatment with new anticancer agents as they are expected not only to decrease the local recurrence rate but also to prevent distant metastases. We are conducting a multicentre Phase II study to evaluate the safety and efficacy of neoadjuvant chemotherapy using XELOX plus bevacizumab without radiotherapy in patients with locally advanced rectal cancer. The primary endpoint of the study is treatment compliance. Secondary endpoints are overall survival, disease-free survival, local recurrence-free survival, objective response rate, R0 resection rate and adverse events. Thirty patients are required for this study.

Analysis of lymph node metastatic pattern according to the depth of in-growth in the muscularis propria in T2 rectal cancer for lateral lymph node dissection.

BACKGROUND/AIMS: The biological behavior of rectal cancers that invade the muscularis propria (pT2) has not been well studied. We retrospectively studied the pattern of lymph node metastases in patients with T2 rectal cancer. METHODS: We enrolled 88 patients who had undergone curative resection of T2 colorectal cancer through mesorectal excision and lateral pelvic lymph node dissection; we microscopically estimated the maximum depth of muscularis propria invasion and classified the results into 3 groups representing distinct growth patterns. RESULTS: In cases of pT2 colorectal carcinomas, lateral pelvic lymph node metastases depended on the degree of muscularis propria invasion, and the frequency of metastasis increased with the depth of muscularis propria invasion. Lateral pelvic lymph node metastases were not observed when the depth of muscularis propria invasion was less than half of the thickness of the inner circular layer. CONCLUSIONS: These findings suggest that lateral pelvic lymph node metastasis of pT2 colorectal cancer depends on the depth of vertical invasion, which is analogous to the findings in pT1 and pT3 cancers. This information will be useful in select cases in which resection of the lateral pelvic lymph node is required for the treatment of rectal cancer invading the muscularis propria (pT2).

[Pathologically complete response of multiple liver metastases from rectal cancer treated with mFOLFOX6 plus bevacizumab].

We report a case of pathologically complete response of multiple liver metastases from rectal cancer after neoadjuvant chemotherapy. The patient was a 74-year-old woman who had advanced rectal cancer with synchronous liver metastases (T4N1M1). Following resection of the primary tumor, she received biweekly mFOLFOX6 plus bevacizumab neoadjuvant chemotherapy. After 5 courses, the liver tumors were markedly reduced in size. Three weeks after the final treatment, she underwent partial hepatectomies. Histologically, no cancer cells were detected in any resected specimens. The postoperative course was uneventful, and she has been well without recurrence for one year at the time of writing. Regimens containing bevacizumab may result in good tumor response. Surgical resection is crucial for proof of pathologically complete response.

Novel approach to intraoperative peritoneal lavage with an extracorporeal stirring method in laparoscopic surgery for generalized peritonitis: Preliminary results.

INTRODUCTION: The primary concern with laparoscopic intraoperative peritoneal lavage (IOPL) for generalized peritonitis relates to the difficulty and uncertainty in ensuring adequate washout of contaminated fluid. Here, we describe a new method of laparoscopy-assisted IOPL. METHODS: We performed emergency surgery in 10 patients with generalized peritonitis necessitating IOPL. A small wound retractor was inserted into the abdominal cavity through an incision and elevated to raise the abdominal wall. More than 3-L saline was injected via the retractor at one time. The abdomen was manually shaken by pressure from outside the body. Contaminated fluid was removed with a long suction device through the retractor. This procedure was repeated until the fluid was confirmed to be transparent by laparoscopy, and then drains were placed. RESULTS: Median lavage time was 23.5 minutes (range, 15-34 minutes), and volume of lavage fluid was 19 L (range, 10-20 L). Median time to resumption of fluid intake was 3 days (range, 1-12 days), time to food intake was 6 days (range, 3-14 days), and time to first bowel movement was 5 days (range, 3-10 days). Median duration of antibiotic use was 8.5 days (range, 5-15 days). Complications were one case of antibiotic-induced rash, two cases of paralytic ileus, and one case of pelvic abscess. All patients recovered well without additional surgical intervention. CONCLUSIONS: This new approach to laparoscopy-assisted IOPL was feasible for these patients with generalized peritonitis. This procedure enabled corpus lavage to be performed in a similarly short time to open surgery but with less invasiveness. Further research is needed to confirm indications and long-term outcomes.

Laparoscopic repair of secondary perineal hernia with coverage by the mobilized cecum.

The incidence of secondary perineal hernia (SPH) has increased since the introduction of extralevator abdominoperineal resection and laparoscopic abdominoperineal resection. Currently, laparoscopic mesh repair is the usual procedure. Here, we demonstrate a repair of SPH without mesh that uses the mobilized cecum to cover the pelvic hernial orifice. An 83-year-old man complained of discomfort when sitting for long periods. He was status post laparoscopic abdominoperineal resection and was diagnosed with SPH. Hernia repair was performed. After transperitoneal adhesiolysis in the inferior pelvis, the right colon was laparoscopically mobilized, and the pelvic orifice was covered by suturing the cecum to the pelvic brim. The perineal skin was managed with negative pressure wound therapy. The postoperative course was uneventful. There has been no sign of recurrent herniation for 12 months. This method of SPH repair is simple to perform and avoids mesh-related complications.

Intersphincteric resection for very low rectal adenocarcinoma: univariate and multivariate analyses of risk factors for recurrence.

BACKGROUND: The aim of this study was to analyze the risk factors for local and distant recurrence after intersphincteric resection (ISR) for very low rectal adenocarcinoma. METHODS: One hundred twenty consecutive patients with T1-T3 rectal cancers located 1-5 (median 3) cm from the anal verge underwent ISR. Univariate and multivariate analyses of prospectively recorded clinicopathologic parameters were performed. RESULTS: Fifty patients had disease categorized as stage I, 21 as stage II, 46 as stage III, and 3 as stage IV on the basis of International Union Against Cancer tumor, node, metastasis staging system. Median follow-up time was 3.5 years. The 3-year rates of local and distant recurrence were 6% and 13%, respectively. Univariate analysis of the risk factors for local recurrence revealed pathologic T, pathologic stage, focal dedifferentiation, microscopic resection margins, and preoperative serum CA 19-9 level to be statistically significant. Multivariate analysis showed resection margin, focal dedifferentiation, and serum CA 19-9 level to be independently significant. Univariate analysis of the risk factors for distant recurrence indicated tumor location, combined resection, tumor annularity, pathologic N, lateral pelvic lymph node metastasis, pathologic stage, histologic grade, lymphovascular invasion, perineural invasion, and adjuvant chemotherapy to be significant. Multivariate analysis identified pathologic N, histologic grade, and tumor location to be independently significant. CONCLUSION: Profiles of risk factors for local and distant recurrences after ISR are different. With local recurrence, the resection margin, focal dedifferentiation, and serum CA 19-9 level are important. For distant recurrence, the lymph node status, histologic grade, and tumor location need to be taken into account.

Effect of a clinical pathway after laparoscopic surgery for colorectal cancer.

BACKGROUND/AIMS: The purpose of this study was to evaluate whether implementation of a clinical pathway (CP) reduces length of stay after laparoscopic surgery for colorectal carcinoma. METHODOLOGY: We retrospectively reviewed 330 patients with colorectal carcinoma who underwent laparoscopic surgery between 2002 and 2006. The patients were divided into 2 groups: no clinical pathway patients in 2002-03 (Group A) and those managed with clinical pathway in 2004-06 (Group B). Patients in Group B were planned to be discharged and return home within postoperative day 8, with use of CP. RESULTS: There was no mortality in either group. In Group B, the rate of patients who started solid food within postoperative day 3 was significantly higher than in Group A for both colon carcinoma (96.7 vs. 82.8%, p = 0.001) and rectal carcinoma (94.2 vs. 65.5%, p = 0.001). The rate of patients discharged within postoperative day 8 was significantly higher in Group B than in Group A (98.5 vs. 64.8%, p = 0.001), although there were more advanced cases in Group B. CONCLUSIONS: The implementation of clinical pathway has led to the standardization of patient care and considerable decrease in length of stay after laparoscopic surgery for colorectal carcinoma.

Sphincter-preserving surgery for recurrent pelvic malignancy using a hybrid procedure of open laparotomy and transanal endoscopic approach.

BACKGROUND: Surgery for the treatment of recurrent pelvic malignancy is challenging. Sphincter-preserving surgery (SPS) has been applied in limited cases. Transanal endoscopic approach (TEA) has been used for primary rectal cancer, predominantly for hybrid transabdominal-transanal total mesorectal excision. Here, we describe the use of TEA as a hybrid approach in a case of recurrent ovarian cancer. CASE PRESENTATION: A 59-year-old woman had recurrence of serous ovarian adenocarcinoma in the vaginal stump, near the site of anastomosis from a rectal resection 18 months previously. We used a hybrid approach comprising conventional open laparotomy and TEA to accomplish sphincter preservation. In addition to sphincter preservation, TEA allowed for the creation of a "terminal" space, which was made by anterior dissection between the rectum and the vagina. We employed TEA to create an opening in the scar tissue along the sacrum, which was used as a "guide" for pelvic dissection to prevent nerve injury. After exteriorization of the tumor, bowel continuity was achieved by hand-sewn coloanal anastomosis with a protective diverting ileostomy. Pathological examination revealed no involvement of the surgical margins. The diverting ileostomy was taken down 8 months postoperatively. CONCLUSION: A hybrid approach comprising conventional open laparotomy and TEA allowed for safe and secure SPS and complete excision of a recurrent pelvic malignancy. This hybrid surgical approach expands the use of SPS in highly selected cases.

Closure of the cystic duct orifice in laparoscopic subtotal cholecystectomy for severe cholecystitis.

INTRODUCTION: Laparoscopic subtotal cholecystectomy (LSC) has been recognized as an alternative to conversion to laparotomy for severe cholecystitis. However, it may be associated with an increased risk of recurrent stones in the gallbladder remnant. The objective of this study was to evaluate the safety and feasibility of the complete removal of the gallbladder cavity in LSC for severe cholecystitis using the cystic duct orifice suturing (CDOS) technique. METHODS: In a consecutive series of 412 laparoscopic cholecystectomies that were performed from January 2015 to June 2017, 12 patients who underwent LSC with CDOS were enrolled in this retrospective study. In this procedure, Hartmann's pouch was carefully identified, and the infundibulum-cystic duct junction was transected while the posterior wall adherent to Calot's triangle was left behind. The clinical records, including the operative records and outcomes, were analyzed. RESULTS: The median operating time and blood loss were 158 min and 20 mL, respectively. In all cases, LSC with CDOS was completed without conversion to open surgery. No injuries to the bile duct or vessels were experienced. The median postoperative hospital stay was 6 days. Postoperative complications occurred in two patients (bile leakage, n = 1: common bile duct stones, n = 1) and were successfully treated by endoscopic management. A gallbladder remnant was not delineated by postoperative imaging in any of the cases. CONCLUSION: These results suggest that LSC with CDOS is a promising approach that can avoid dissection of Calot's triangle and achieve the complete removal of the gallbladder cavity in patients with severe cholecystitis.

Intrapericardial diaphragmatic hernia into the pericardium after esophagectomy: a case report.

BACKGROUND: Intrapericardial diaphragmatic hernia (IPDH), defined as prolapse of the abdominal viscera into the pericardium, is a rare clinical condition. This case illustrates the possibility of IPDH after esophagectomy with antethoracic alimentary reconstruction, although such hernias are extremely rare. IPDH often presents with symptoms of bowel obstruction such as abdominal discomfort or vomiting. If not properly treated, life-threatening necrosis and/or perforation of the herniated contents may occur. CASE PRESENTATION: A 68-year-old Japanese man underwent subtotal esophagectomy with three-field lymph node dissection for treatment of esophageal cancer. Completion gastrectomy with perigastric lymph node dissection was also performed because the patient had previously undergone distal partial gastrectomy for treatment of gastric cancer. The alimentary continuity was reconstructed using the pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. The patient was readmitted to our hospital because of abdominal discomfort and vomiting 6 months after the esophagectomy. A diagnosis of IPDH after esophagectomy was made. The patient was treated by primary closure of the diaphragmatic defect using vertical mattress sutures and additional reinforcement of the closing defect using a graft harvested from the rectus abdominis posterior sheath. The postoperative course was uneventful, and he was discharged on the seventh day after hernia repair. CONCLUSIONS: This patient's clinical course provides two important clinical suggestions. First, we must be aware of the possibility of iatrogenic IPHD after esophagectomy with antethoracic alimentary reconstruction. Second, a graft from the rectus abdominis posterior sheath is beneficial in the treatment of IPDH.

Wound infection after elective laparoscopic surgery for colorectal carcinoma.

BACKGROUND: The aim of this study was to evaluate various clinical parameters that would influence the occurrence of wound infection (WI) in elective laparoscopic surgery (LS) for colorectal carcinoma. METHODS: The study included 290 patients who underwent LS between June 2001 and December 2005. WI was diagnosed within 30 days of the operation, and both superficial and deep incision surgical site infection were evaluated together. RESULTS: Eighteen (6.2%) were diagnosed with WI. Of the infected patients, nine (50%) had WI at the extraction site, six (33%) at the port site of the drainage tube, and three (17%) at the supraumbilical incision. Following bivariate analysis, the variables of stoma creation, intraoperative hypotension, and length of operation were selected for multivariate analysis as their P values were <0.2, the predominant cutoff, and stoma creation and intraoperative hypotension were independently predictive of developing WI. Regarding the duration of postoperative hospital stay, there was no significant difference between patients with or without WI. CONCLUSIONS: Stoma creation and intraoperative hypotension were independent risk factors for WI. The results obtained in this study should be considered in an effort to prevent WI in LS for colorectal carcinoma, although these risk factors need further evaluation.

Feasibility of umbilical loop ileostomy in overweight and obese patients with rectal cancer during laparoscopic surgery: Preliminary results.

We examined the feasibility of umbilical diverting ileostomy for overweight and obese patients with rectal cancer undergoing laparoscopic surgery. Four patients who were overweight or obese (BMI > 27 kg/m2 ) were initially scheduled for the creation of a conventional loop ileostomy. Intraoperatively, however, this was considered too complicated because of thick subcutaneous fat, bulky mesentery, or both. Instead, patients received a diverting ileostomy with the placement of an umbilical stoma. All patients had protruding umbilical ileostomies. No severe stoma-related complications were encountered. One patient had minor skin dehiscence, and another had paralytic ileus but resumed oral intake after a short time. Performing a temporary loop ileostomy at the umbilicus was safe and feasible in this small group of overweight and obese patients. This stoma placement may avoid the problems inherent to conventional loop ileostomy in obese subjects.

The G2 checkpoint inhibitor CBP-93872 increases the sensitivity of colorectal and pancreatic cancer cells to chemotherapy.

CBP-93872 suppresses maintenance of DNA double-stranded break-induced G2 checkpoint, by inhibiting the pathway between ataxia-telangiectasia mutated (ATM) and ATM- and Rad3-related (ATR) activation. To examine the potential use of CBP-93872 for clinical applications, we analyzed the synergistic effects of platinum-containing drugs, oxaliplatin and cisplatin, pyrimidine antimetabolites, gemcitabine and 5-fluorouracil (5-FU), in combination with CBP-93872, on cell lethality in colorectal and pancreatic cancer cell lines. Treatment with CBP-93872 significantly increased cancer cell sensitivities to various chemotherapeutic agents tested through suppression of checkpoint activation. Our results thus reveal that combination treatment of CBP-93872 with known chemotherapeutic agents inhibits phosphorylation of ATR and Chk1, and induces cell death.