The impact of preclinical clerkship in general surgery on medical students' attitude to a surgical career.

PURPOSE: With the advent of a new program for postgraduate medical students in 2004, the number of applicants choosing surgical careers in Japan has been declining. We conducted this study to evaluate the impact of preclinical clerkship and how it affects students' attitudes toward a surgical career. METHODS: The subjects of our study were fifth-year medical students who participated in a clinical clerkship in general surgery in our department between April 2021 and March 2022. We conducted pre- and post-preclinical clerkship surveys to assess the perceived image of surgeons and the impact of clerkship on surgical career interest. RESULTS: Among 132 medical students (77 men and 55 women) who rotated through preclinical clerkship in our department, 125 participated in the survey and 66% expressed interest in a surgical career. In the post-clerkship survey, an increased interest in a surgical career was expressed by 79% of the students; notably, including those who initially expressed interest. Approximately 77% of students were satisfied with the practical skill training they received. CONCLUSION: Engaging medical students early in surgical experience through a preclinical clerkship for general surgery appears to promote their interest in a surgical career.

Evaluation of abdominal aortic calcification by plain CT predicts anastomotic leakage in laparoscopic surgery for colorectal cancer.

BACKGROUND: Anastomotic leakage is one of the most severe and critical complications of laparoscopic surgery for colorectal cancer. However, definitive preoperative predictors of anastomotic leakage remain elusive. With the ageing of society, the number of colorectal cancer patients with arteriosclerotic disease in Japan is increasing. This study was performed to evaluate the correlation between preoperative arteriosclerosis and anastomotic leakage. METHODS: In total, 98 patients undergoing laparoscopic surgery for colorectal cancer with reconstruction using the double-stapling technique without diversion of the stoma were enrolled in the study. Preoperative assessment of arteriosclerotic disease was performed by abdominal computed tomography. The calcification volume percentage of the aorta between the level of the celiac artery root and aortic bifurcation was calculated using ZIOstation2 software, and the relationship between arteriosclerosis and anastomotic leakage was analysed. RESULTS: Among 98 cases, anastomotic leakage was observed in 16 (16.3%). The median calcification volume percentage (range) was 2.35% (0-40.3%). Age, male sex, hypertension, dissection number, estimated glomerular filtration rate and tumour location were correlated with anastomotic leakage on statistical analysis. Statistical analysis showed that calcification volume percentage was one of the robust risk factors for anastomotic leakage (odds ratio: 1.09, 95% confidence interval: 1.03-1.17, P < 0.01). CONCLUSIONS: Calcification of the abdominal aorta may be a promising predictor of AL after laparoscopic surgery for colorectal cancer reconstruction using the double-stapling technique.

Surgical glove perforation during laparoscopic colorectal procedures.

BACKGROUND: It has been reported that in conventional open surgery, approximately 10% of surgical gloves are perforated during surgery without being noticed. To protect both the patient and medical staff from harm, double gloving or changing gloves routinely at certain intervals during surgery is recommended. However, whether these protective measures are also necessary for laparoscopic colorectal surgery is unknown because the actual perforation rate during laparoscopic procedures is unclear. METHODS: Seventy-seven laparoscopic colorectal surgeries were evaluated, and a total of 616 surgical gloves used in the surgeries were collected for analysis. The presence of glove perforation was tested by the standard water-leak test method (EN455-1). RESULTS: Seven perforations were detected (1.1%). The duration of the laparoscopic procedure was not a statistically significant risk factor for glove perforation (p = 0.41). Postoperative surgical site infections (SSIs) were observed in 12 cases (15.6%), but there was no significant correlation between the presence of glove perforation and SSI (p = 0.92). According to the bacterial cultivation results, the majority of causative agents of SSI were enterobacteria, which belong to the major gut flora. CONCLUSION: Although the perforation rate was considerably lower than that in open surgery, surgical glove perforation occurred during laparoscopic procedures. Double gloving in laparoscopic colorectal surgery is recommended not to prevent SSI but to protect medical workers from harmful infections after direct contact with the patient.

Impact of intraoperative hypocapnia on postoperative complications in laparoscopic surgery for colorectal cancer.

PURPOSE: In laparoscopic surgery (LS) for colorectal cancer (CRC), the relationship between intraoperative end-tidal carbon dioxide concentration (EtCO2) and surgery-related complications remains unexplored. This study assessed the impact of intraoperative EtCO2 on postoperative complications in LS for CRC. METHODS: In total, 909 patients who underwent LS for CRC were enrolled. Hypocapnia and hypercapnia were defined as EtCO2 < 35 mmHg and > 40 mmHg, respectively, and the relationships between hypocapnia or hypercapnia duration and postoperative complications were analyzed. RESULTS: The median (range) durations of hypocapnia and hypercapnia were 2.0 (0-8.3) h and 0.3 (0-5.8) h, respectively. Complications were observed in 208 cases (23.0%), which included 37 (4.1%) instances of anastomotic leakage and 86 (9.5%) of superficial surgical site infection (SSI). While the hypercapnia duration was not associated with the short-term outcomes, prolonged hypocapnia was significantly correlated with complications (p = 0.02), specifically superficial SSI (p = 0.005). Multivariate analyses adjusted for confounding factors confirmed that hypocapnia prolongation was an independent risk factor for postoperative superficial SSI [OR 1.19; 95% confidence interval (Cl) 1.03-1.36, p = 0.01]. CONCLUSION: Intraoperative hypocapnia may be a risk factor for postoperative complications, in particular superficial SSI, in LS for CRC.

Horizontal spread of pericolic lymph node metastasis as a prognostic factor for recurrence in Stage III colorectal cancer.

AIM: Main lymph node (LN) metastasis dissected with a high vascular tie at the root of the feeding artery is a poor prognostic factor in colorectal cancer (CRC). However, the effects of horizontal spread on recurrence after curative resection remain unclear. The purpose of this study is to evaluate the relationship between the horizontal spread of LN metastasis and recurrence in CRC. METHOD: In this retrospective study, 189 CRC patients (98 men, 91 women) who underwent curative resection at our hospital from 2003 to 2018 and had only pericolic LN metastasis were divided into two groups: patients with LN metastasis beside the tumour only (T group, n = 121) and those with LN metastasis with horizontal spread (S group, n = 68) (mean follow-up period 50.9 ± 34.1 months). The primary outcome was recurrence-free survival (RFS). We investigated the correlation between clinicopathological background factors and recurrence using Cox regression analysis. RESULTS: Fewer than three LN metastases (N1) were found in 157 patients (107 T group, 50 S group), and four or more metastases (N2a) were found in 32 patients (14 T group, 18 S group). Univariate analyses revealed significantly shorter RFS in the S group [hazard ratio (HR) 1.95, 95% CI 1.07-3.55; p = 0.03). Multivariate analyses revealed that horizontal spread is an independent risk factor for recurrence (HR 1.95, 95% CI 1.05-3.68; p = 0.03). CONCLUSION: Although further investigation is needed, horizontal spread of LN metastasis is a prognostic factor for recurrence in Stage III CRC.

Relationship between anastomotic leakage and CT value of the mesorectum in laparoscopic anterior resection for rectal cancer.

OBJECTIVE: This study aims to indicate whether the CT value of the mesorectum could be correlated with the incidence of anastomotic leakage (AL) in laparoscopic surgery for rectal cancer. METHODS: The study subjects included 173 patients who underwent laparoscopic anterior resection (LAR) for rectal cancer from September 2005 to 2016 in our institution as well as reliable contrast-enhanced CT preoperatively. Univariate and multivariate analyses were performed to determine the correlation between surgical outcomes, including AL and CT value of the mesorectum. RESULTS: AL was observed in 30 (17.3%) patients. Amongst short-term surgical outcomes, overall complication showed significant correlation with the CT value of the mesorectum (P = 0.003). In addition, AL was the only factor, which significantly correlated with the CT value of the mesorectum (P = 0.017). By plotting receiver operating characteristic curve, -75 HU was the threshold of the CT value of the mesorectum for predicting AL with an area under the curve of 0.772. Categorized into two groups as per the threshold, low group showed significantly higher incidence of AL (OR, 2.738; 95% CI, 1.105-6.788; P = 0.030) as well as whole complications (OR, 4.431; 95%CI, 1.912-10.266; P = 0.001). CONCLUSION: The CT value of the mesorectum may be a helpful preoperative radiological biomarker to predict AL after LAR for rectal cancer.

Interleukin-13 and its signaling pathway is associated with obesity-related colorectal tumorigenesis.

The incidence of colorectal cancer (CRC) has been on the rise, which is linked to the increasing prevalence of obesity, based on global epidemiological evidence. Although chronic inflammation is implicated in tumor development, the mechanisms underlying obesity-associated CRC remain unknown. Here, we sought to identify the inflammatory cytokines and their roles in obesity-related colorectal tumorigenesis using cytokine array analyses in a mouse model. Colorectal tumorigenesis was induced through i.p. injection of azoxymethane once a week for 6 weeks in 6-week-old female WT C57Black/6J mice and the obesity diabetes model mouse KK/TaJcl, KK-Ay/TaJcl. The formation of aberrant crypt foci and colorectal tumors were more frequent in obese mice compared with WT mice, and both serum interleukin (IL)-13 and IL-13 receptor (R) expression in the normal intestinal mucosal epithelium were significantly increased in the obese mice. Furthermore, addition of IL-13 to a human CRC cell line and a human colon organoid culture altered the phenotype of intestinal epithelial cells. Knockdown experiments further revealed that IL-13Rα1 dominantly induced mucosal proliferation. Collectively, These results suggest an association between anti-inflammatory cytokines and colorectal carcinogenesis, and provide new research directions for cancer prevention strategies. In particular, inflammation provoked by obesity, notably by increased expression of the cytokine IL-13, could play an important role in the carcinogenesis of obesity-related CRC.

The impact of the mesorectal apparent diffusion coefficient value on surgical difficulty in laparoscopic anterior resection for rectal cancer.

PURPOSE: We aimed to clarify the impact of the apparent diffusion coefficient (ADC) value of the mesorectum from preoperative magnetic resonance imaging (MRI) on surgical difficulty in laparoscopic anterior resection (Lap-AR) for rectal cancer. METHODS: In total, 67 patients who had undergone curative Lap-AR for rectal cancer in our hospital from January 2008 to March 2015 and had preoperative MRI findings available were included. We randomly calculated the average ADC in three regions of the mesorectum at the level of the upper edge of the superior border of the femur. Univariate and multivariate analyses were performed to evaluate the correlation between the patients' clinicopathological characteristics, including the ADC value and short-term surgical outcomes. RESULTS: The univariate analysis revealed that a lower ADC value was associated with a significantly increased operative blood loss (p = 0.008) and prolonged operative time (p < 0.001). The multivariate analysis adjusted for the body mass index, anal verge, tumor location, covering stoma, clinical T factor and conversion revealed that the ADC value was an independent risk factor for a prolonged operative time (R2 = 0.6003, p < 0.001). Furthermore, the multivariate analysis adjusted for the body mass index, anal verge, covering stoma, clinical T factor and conversion revealed that the ADC value was an independent risk factor for an increased blood loss (R2 = 0.4345, p = 0.008). CONCLUSION: A lower ADC value of the mesorectum might be a predictor of surgical difficulty in Lap-AR for rectal cancer.

Comparison of Preoperative Inflammation-based Prognostic Scores in Patients With Colorectal Cancer.

OBJECTIVE: To evaluate the prognostic impact of the systemic inflammation score (SIS) in colorectal cancer (CRC) patients in comparison with a conventional inflammation-based score, the modified Glasgow Prognostic Score (mGPS). SUMMARY BACKGROUND DATA: The SIS, which is calculated based on the preoperative serum albumin level and lymphocyte-to-monocyte ratio, is a reported prognostic marker in clear-cell renal cell carcinoma. However, the utility of the SIS in CRC remains unclear. METHODS: The study involved 727 CRC patients who underwent curative resection between September 2005 and December 2011. The prognostic impact of SIS and mGPS was evaluated using survival analyses. The prognostic impact of each score was compared visually by means of time-dependent receiver operating characteristics analysis. RESULTS: The median age of the patients was 67 (interquartile range: 58-75) years. The TNM stage distribution was stage I, 29.8%; stage II, 33.6%; stage III, 30.3%; and stage IV, 6.3%. The median follow-up period was 5.61 years (interquartile range: 4.24-7.06). Multivariate analysis revealed that an increased SIS and mGPS were independent prognostic factors (SIS: P = 0.018; mGPS: P = 0.005, respectively). The time-dependent receiver operating characteristics curve of the SIS was superior to that of the mGPS throughout the observation period. The estimated area under the curve (AUC) of the SIS was significantly higher than that of the mGPS (7-yr survival: SIS 0.673, mGPS 0.605, P = 0.030). CONCLUSIONS: The SIS is a novel prognostic factor in CRC patients. Additionally, the SIS is an alternative inflammation-based biomarker, which may improve the prediction of clinical outcomes.

Adhesive intestinal obstruction increases the risk of intestinal perforation in peritoneal dialysis patients: a case report.

BACKGROUND: Peritonitis secondary to bowel perforation is a rare and potentially fatal complication in peritoneal dialysis (PD) patients. However, the early diagnosis of bowel perforation is difficult in PD patients because the initial symptoms and signs of bowel perforation are similar to those of PD-associated peritonitis. Furthermore, the risk of bowel perforation in PD patients is unclear. Here, we present a case of intestinal perforation located at the site of adhesive intestinal obstruction in a PD patient. CASE PRESENTATION: A 73-year-old man on PD presented with progressive worsening of abdominal pain and cloudy peritoneal fluid. The peritoneal fluid cell count was increased to 980/ml and peritoneal dialysis-associated peritonitis was diagnosed. Computed tomography showed local adhesions causing agglomeration of the dilated intestine. He initially responded to antibiotic treatment; however, his abdominal pain was rapidly worsened after resumption of oral intake. On hospital day 23, computed tomography showed loss of contents from the dilated intestine and discharge of fecal material from the PD tube was noted. Thus, small bowel perforation was diagnosed, and he underwent ileocecal resection with colostomy creation. As indicators of EPS was not evident, PD catheter was removed. Since then, he has been on maintenance of hemodialysis since then. CONCLUSION: The findings of the present case suggest that adhesive intestinal obstruction in PD patients can increase the risk of intestinal perforation. Careful monitoring for the early detection of intestinal perforation is required in such cases.

Pelvic inlet shape measured by three-dimensional pelvimetry is a predictor of the operative time in the anterior resection of rectal cancer.

PURPOSE: We evaluated pelvic shape as a predictor of the surgical outcome of anterior resection in patients with rectal cancer. METHODS: In total, 228 patients who had undergone anterior resection (R0 resection and double-stapling anastomosis) for rectal cancer from 2005 to 2014 were included in this study. The anteroposterior (AP) and transverse (T) diameters of the pelvic inlet and outlet and pelvic depth were analyzed on three-dimensional volume-rendered images, and the AP/T ratio was calculated. Univariate and multivariate analyses were performed to determine the predictive significance of the operative time and intraoperative blood loss as surgical outcomes. RESULTS: No difference was observed between the inlet AP/T and patient sex ratios, but the other pelvic dimensions were significantly shorter in males than in females. The univariate analysis revealed that the operative time was significantly correlated with the inlet T diameter and that it tended to be correlated with the outlet T diameter and the inlet AP/T ratio. A multivariate analysis adjusted for operation-related factors revealed that the inlet AP/T ratio was the only independent risk factor for an extended operative time (p = 0.036). None of the pelvic dimensions were independent risk factors for increased blood loss. CONCLUSION: The shape of the pelvic inlet may be useful for predicting the operative time.

Is preoperative spirometry a predictive marker for postoperative complications after colorectal cancer surgery?

BACKGROUND: Spirometry is a basic test that provides much information about pulmonary function; it is performed preoperatively in almost all patients undergoing colorectal cancer (CRC) surgery in our hospital. However, the value of spirometry as a preoperative test for CRC surgery remains unknown. The aim of this study was to determine whether spirometry is useful to predict postoperative complications (PCs) after CRC surgery. METHODS: The medical records of 1236 patients who had preoperative spirometry tests and underwent CRC surgery between 2005 and 2014 were reviewed. Preoperative spirometry results, such as forced vital capacity (FVC), one-second forced expiratory volume (FEV1), %VC (FVC/predicted VC) and FEV1/FVC (%FEV1), were analyzed with regard to PCs, including pneumonia. RESULTS: PCs were found in 383 (30.9%) patients, including 218 (56%) with surgical site infections, 67 (17%) with bowel obstruction, 62 (16%) with leakage and 20 (5.2%) with pneumonia. Of the spirometry results, %VC was correlated with PC according to logistic regression analysis (odds ratio, OR = 0.99, 95% confidence interval, CI = 0.98-0.99; P = 0.034). Multivariate analysis after adjusting for male sex, age, laparoscopic surgery, tumor location, operation time and blood loss showed that a lower %VC tends to be a risk factor for PC (OR = 0.99, 95% CI = 0.98-1.002; P = 0.159) and %VC was an independent risk factor for postoperative pneumonia in PCs (OR = 0.97, 95% CI = 0.94-0.99; P = 0.049). CONCLUSIONS: In CRC surgery, %VC may be a predictor of postoperative complications, especially pneumonia.

Randomized phase II trial of TEGAFIRI (tegafur/uracil, oral leucovorin, irinotecan) compared with FOLFIRI (folinic acid, 5-fluorouracil, irinotecan) in patients with unresectable/recurrent colorectal cancer.

Irinotecan-based chemotherapy with bevacizumab is one of the first-line standard therapies for metastatic colorectal cancer (mCRC). TEGAFIRI (UFT/LV + irinotecan) is an irinotecan-based chemotherapy regimen. Currently, few clinical data regarding TEGAFIRI are available. This study evaluated the efficacy and safety of TEGAFIRI in Japanese patients with mCRC. This is a multicenter, randomized, phase II study. The major inclusion criteria were previously untreated patients with mCRC (age: 20-75 years, Eastern Cooperative Oncology Group performance status: 0-1). Eligible patients were randomly assigned (1:1) to receive either FOLFIRI ± bevacizumab or TEGAFIRI ± bevacizumab. The primary endpoint was progression-free survival (PFS). The secondary endpoints were response rate, overall survival, dose intensity and toxicity. From November 2007 to October 2011, 36 and 35 patients assigned to the FOLFIRI and TEGAFIRI groups were included in the primary analysis. No significant difference in PFS was observed between the groups {median PFS: TEGAFIRI 9.9 months [95% confidence interval (CI), 6.5-14.7], FOLFIRI 10.6 months [95% CI, 7.7-16.5]; Hazard ratio, 0.98, 95% CI, 0.57-1.66, p = 0.930}. The response rates in the FOLFIRI and TEGAFIRI groups were 56% and 66%, respectively. Relative dose intensity was similar between the groups. The most common Grade 3/4 adverse event was diarrhea (26%) in TEGAFIRI group and neutropenia (39%) in the FOLFIRI group. The results of the present study indicate that TEGAFIRI ± bevacizumab is an effective and tolerable first-line treatment regimen for mCRC.

The impact of hepatic fibrosis on the incidence of liver metastasis from colorectal cancer.

BACKGROUND: The aim of this study was to clarify the influence of hepatic fibrosis on metachronous liver-specific recurrence in colorectal cancer (CRC) patients who underwent colorectal surgery with curative intent. Non-alcoholic steatohepatitis (NASH) is closely associated with hepatic fibrosis (HF). The number of patients who suffer from NASH is increasing because of the consumption of high-calorie diets. It remains unclear how much of an impact NASH and HF have on the development of liver metastasis in CRC. METHODS: Patients who underwent curative surgical resection for CRC between 2000 and 2011 were included in this study. We evaluated the progression of HF by the non-alcoholic fatty liver disease fibrosis score (NFS) based on preoperative blood test results, age, body mass index, and diabetes mellitus. Patients were grouped according to high (fibrotic liver; FL) or low (normal liver; NL) NFS. The influence of HF on hepatic recurrence was assessed by survival analyses. RESULTS: A total of 953 CRC patients were enrolled, comprising 293 in stage I, 327 in stage II, and 333 in stage III. The patients included were categorised as FL (77) or NL (876). The hepatic recurrence rates were 5.3% in the NL group and 10.4% in the FL group (P=0.02), whereas the overall recurrence rates were 16.0% in the NL group and 20.7% in the FL group (P=0.03). The 5-year liver-specific recurrence-free survival rate in the FL group was significantly poorer than that in the NL group (FL 89.1%, 95% confidence interval (CI) 78.4-94.7 vs NL 96.0%, 95% CI 94.3-97.2, log-rank test P<0.01). Multivariate analysis demonstrated that HF significantly promoted liver-specific recurrence compared with NL (HR=2.98, 95% CI 1.23-7.21; P=0.02). CONCLUSION: HF is a valuable prognostic factor for hepatic recurrence after curative surgical resection of CRC.

Lung exposure to lipopolysaccharide causes atherosclerotic plaque destabilisation.

Epidemiological studies have implicated lung inflammation as a risk factor for acute cardiovascular events, but the underlying mechanisms linking lung injury with cardiovascular events are largely unknown.Our objective was to develop a novel murine model of acute atheromatous plaque rupture related to lung inflammation and to investigate the role of neutrophils in this process.Lipopolysaccharide (LPS; 3 mg·kg(-1)) or saline (control) was instilled directly into the lungs of male apolipoprotein E-null C57BL/6J mice following 8 weeks of a Western-type diet. 24 h later, atheromas in the right brachiocephalic trunk were assessed for stability ex vivo using high-resolution optical projection tomography and histology. 68% of LPS-exposed mice developed vulnerable plaques, characterised by intraplaque haemorrhage and thrombus, versus 12% of saline-exposed mice (p=0.0004). Plaque instability was detectable as early as 8 h post-intratracheal LPS instillation, but not with intraperitoneal instillation. Depletion of circulating neutrophils attenuated plaque rupture.We have established a novel plaque rupture model related to lung injury induced by intratracheal exposure to LPS. In this model, neutrophils play an important role in both lung inflammation and plaque rupture. This model could be useful for screening therapeutic targets to prevent acute vascular events related to lung inflammation.

Age, Preoperative Subcutaneous Fat Area, and Open Laparotomy are Risk Factors for Incisional Hernia following Colorectal Cancer Surgery.

BACKGROUND: Although incisional hernia (IH) is a common complication of abdominal surgery, the incidence rate and risk factors are not well known. The objectives of this study are to determine the incidence rate of IH following colorectal cancer surgery and to describe the associated risk factors. METHODS: Between 2005 and 2010, patients who underwent surgery to treat colorectal cancer were examined. The diagnosis of IH was performed by CT scan, and the visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus were calculated using a 3D-image analysis system. Survival analysis was used to assess the incidence and risk factors of IH. RESULTS: A total of 626 patients (326 open, 300 laparoscopic) were included in this study, with median follow-up of 54 (range 2-97) months. Forty patients were diagnosed with postoperative IH, and the cumulative, 5-year incidence of IH was 7.3 %. Univariate analysis revealed that age, body mass index, waist circumference, hip circumference, open laparotomy, wound infection, VFA, and SFA were significantly associated with incidence of IH. Multivariate analysis revealed that age [hazard ratio (HR) 1.043 (1.005-1.083), p = 0.027], open laparotomy [HR 4.410 (1.018-19.095), p = 0.047], and SFA [HR 1.013 (1.004-1.022), p = 0.005] were significant risk factors for developing IH. CONCLUSIONS: Higher age and SFA, along with open surgery, are risk factors for developing IH.

A meta-analysis of the use of a transanal drainage tube to prevent anastomotic leakage after anterior resection by double-stapling technique for rectal cancer.

BACKGROUND: The safety and efficacy of transanal drainage tube (TDT) placement to decrease the risk of postoperative anastomotic leakage after rectal cancer surgery has not been validated. The objective of this meta-analysis was to evaluate the usefulness of a TDT for the prevention of anastomotic leakage after an anterior resection for rectal cancer. METHODS: The PubMed and Cochrane Library databases were searched for studies comparing TDT and non-TDT. The endpoint utilized in this study was defined as the rates of anastomotic leakage and re-operation. The relative effects of these variables were synthesized using Review Manager 5.1 software. RESULTS: Four trials including 909 participants (401 TDT cases and 508 non-TDT cases) met our inclusion criteria. The weighted mean anastomotic leakage rate was 4% [95% confidence interval (CI) 1-6%], and a significantly lower risk of anastomotic leakage was identified in the TDT group compared with the non-TDT group [odds ratio (OR) 0.30; 95% CI 0.16-0.55; p = 0.0001]. Furthermore, there were significant differences between the TDT and non-TDT groups in terms of the re-operation rate (OR 0.18; 95% CI 0.07-0.44; p = 0.0002). No significant covariates related to anastomotic leakage or re-operation were identified in meta-regression analysis. Both the anastomotic leakage and re-operation rates for all studies lay inside the 95% confidence interval boundaries. No visible publication bias was found by visual assessment of the funnel plot (Egger's test; anastomotic leakage: p = 0.056, re-operation: p = 0.681). CONCLUSIONS: Placement of a TDT is an effective and safe procedure that can decrease the rate of anastomotic leakage and re-operation after an anterior resection.

Meta-analysis of laparoscopic surgery for recurrent Crohn's disease.

PURPOSES: It remains unclear whether laparoscopic surgery is suitable for recurrent Crohn's disease (CD). The objective of this meta-analysis was to evaluate the safety and feasibility of laparoscopic resection for recurrent vs. primary CD by comparing intraoperative and postoperative outcomes. METHODS: We searched the PubMed and Cochrane Library databases for studies that compared complications associated with laparoscopic resection for primary and recurrent CD. The primary study endpoints were conversion rates and postoperative complication rates. RESULTS: Seven trials with a collective total of 627 participants (413 with primary CD and 214 with recurrent CD) met our inclusion criteria. Laparoscopic resection was associated with a significantly higher conversion rate when performed for recurrent CD than for primary CD (OR = 2.53; 95 % CI 1.22-5.25; p = 0.01). However, there was no significant difference in the total complication rate between laparoscopic resection for primary vs. that for recurrent CD (OR = 1.41; 95 % CI 0.86-2.34; p = 0.18). CONCLUSIONS: Although a higher conversion rate suggests technical complexity, laparoscopic resection for recurrent CD is considered a safe and feasible procedure, without an increased risk of postoperative complications.

Transanal drainage tube placement to prevent anastomotic leakage following colorectal cancer surgery with double stapling reconstruction.

PURPOSE: Anastomotic leakage (AL) is a critical complication of colorectal cancer surgery. The transanal drainage tube (TDT) is designed to prevent AL caused by decompression and stasis at the anastomosis. We conducted this study to investigate the feasibility of using the TDT to prevent AL following double-stapling technique reconstruction (DST). METHODS: The subjects of this study were 179 patients who underwent curative resection and DST reconstruction for sigmoid colon and rectal cancer in our institution between 2008 and 2013. We analyzed the effectiveness of the TDT for preventing AL. RESULTS: A TDT was placed in 78 patients (43.6 %, TDT group) and not placed in the remaining 101 patients (56.4 %, NTDT group). AL developed in 2 (2.6 %) patients from the TDT group and in 14 (13.9 %) patients from the NTDT group (p = 0.009). Univariate analysis revealed that AL was significantly correlated with tumor distance from the anal verge (AV), the number of staples, and TDT placement. Multivariate analysis revealed a significantly positive correlation between AL and AV [OR 0.877 (0.783-0.982) p = 0.023] and a significantly negative correlation between AL and TDT placement [OR 0.07 (0.013-0.374) p = 0.002]. CONCLUSIONS: Anastomotic decompression with TDT placement may prevent AL after colorectal cancer surgery with DST reconstruction.