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Wang Y, Wang Y, Zou L, Deng L, Wu T, Liu L, Jiang J, An T. Does the level of inferior mesenteric artery ligation affect short-term and long-term outcomes of patients with sigmoid colon cancer or rectal cancer? A single-center retrospective study. World J Surg Oncol 2022; 20:274. [PMID: 36045369 PMCID: PMC9434919 DOI: 10.1186/s12957-022-02741-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background For sigmoid colon or rectal cancer, a definite consensus regarding the optimal level ligating the inferior mesenteric artery (IMA) has not been reached. We performed this study to determine whether the ligation level significantly affected short-term and long-term outcomes of patients with sigmoid colon or rectal cancer after curative laparoscopic surgery. Methods Medical records of patients with sigmoid colon or rectal cancer who had undergone curative laparoscopic surgery between January 2008 and December 2014 at the Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine were reviewed. Then, the high tie group (HTG) was compared with the low tie group (LTG) in terms of short-term and long-term outcomes. Results Five-hundred ninety patients were included. No significant differences between two groups regarding baseline characteristics existed. HTG had a significantly higher risk of anastomotic fistula than LTG (21/283 vs 11/307, P = 0.040). Additionally, high ligation was proven by multivariate logistic regression analysis to be an independent factor for anastomotic fistula (P = 0.038, OR = 2.232, 95% CI: 1.047–4.758). Furthermore, LT resulted in better preserved urinary function. However, LTG was not significantly different from HTG regarding operative time (P = 0.075), blood transfusion (P = 1.000), estimated blood loss (P = 0.239), 30-day mortality (P = 1.000), ICU stay (P = 0.674), postoperative hospital stay (days) (P = 0.636), bowel obstruction (P = 0.659), ileus (P = 0.637), surgical site infection (SSI) (P = 0.121), number of retrieved lymph nodes (P = 0.501), and number of metastatic lymph nodes (P = 0.131). Subsequently, it was revealed that level of IMA ligation did not significantly influence overall survival (OS) (P = 0.474) and relapse-free survival (RFS) (P = 0.722). Additionally, it was revealed that ligation level did not significantly affect OS (P = 0.460) and RFS (P = 0.979) of patients with stage 1 cancer, which was also observed among patients with stage 2 or stage 3 cancer. Ultimately, ligation level was not an independent predictive factor for either OS or RFS. Conclusions HT resulted in a significantly higher incidence of anastomotic fistula and worse preservation of urinary function. Level of IMA ligation did not significantly affect long-term outcomes of patients with sigmoid colon or rectal cancer after curative laparoscopic surgery.
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Affiliation(s)
- Yawei Wang
- The First Department of Surgery, Shenzhen Traditional Chinese Medicine Hospital, Fuhua Road 1, Futian District, Shenzhen, 518033, Guangdong, People's Republic of China
| | - Yan Wang
- Department of Radiology, Shenzhen People's Hospital, Dongmen Road 1017, Luohu District, Shenzhen, 518020, Guangdong, People's Republic of China
| | - Liaonan Zou
- Department of General Surgery, The Affiliated Zhuhai Hospital, Guangdong Provincial Hospital of Traditional Chinese Medicine, Jingle Road 52, Xiangzhou District, Zhuhai, 519015, Guangdong, China.,Department of Gastrointestinal Surgery, Guangdong Provincial Hospital of Traditional Chinese Medicine, Dade Road 111, Yuexiu District, Guangzhou, 510006, Guangdong, China
| | - Lingna Deng
- Department of Pathology, Qingyuan People's Hospital, Yinquan Road B24, Qingcheng District, 511518, Qingyuan, Guangdong, People's Republic of China
| | - Tianchong Wu
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital, Dongmen Road 1017, Luohu District, Shenzhen, 518020, Guangdong, People's Republic of China
| | - Linsen Liu
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital, Dongmen Road 1017, Luohu District, Shenzhen, 518020, Guangdong, People's Republic of China
| | - Jiling Jiang
- The First Department of Surgery, Shenzhen Traditional Chinese Medicine Hospital, Fuhua Road 1, Futian District, Shenzhen, 518033, Guangdong, People's Republic of China.
| | - Tailai An
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital, Dongmen Road 1017, Luohu District, Shenzhen, 518020, Guangdong, People's Republic of China.
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Sokolov M, Petrov B, Maslyankov S, Angelov K, Atanasova MP, Tzoneva D, Gribnev P. Technical considerations depending on the level of vascular ligation in laparoscopic rectal resection. Surg Endosc 2021. [PMID: 33876306 DOI: 10.1007/s00464-021-08479-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
Abstract
AIM In addition to ischemia there is also anastomotic ends tension proven to be a risk factor for anastomotic leak. HT vascular ligation is accepted as a rule, in attempt to achieve tension-free anastomosis. LT is a preferred option, based on the more accurate preservation of proximal intestinal segment microperfusion and lower risk of damage to the hypogastric plexus. The aim of this study is evaluation of comparative indicators in high tie (HT) and low tie (LT) laparoscopic rectal resections. METHODS A prospective nonrandomized comparative cohort study of patients in our department with cancer of the rectum in clinical stage I-III, operated on in laparoscopic approach over a 6-years period. RESULTS For the period 2015-2020, a number of 208 laparoscopic surgeries have been done for rectal cancer. Patients were divided into three groups-group A with HT vascular ligation 116 pts. (69%), group B-53 pts. (25%), underwent low ligation-LT and group C-39pts. (19%) low tie plus lymph node dissection of the apical LN group (LT-appic LND). The distribution was made without randomization, based on the operators' expertise. Anastomotic leaks were 3.8% in group A, 3.0% in group B and 2.9% in group C (p > 0.05) with no significance difference. There is no significant difference in the number of lymph nodes obtained in group A and group B, while in group C the number of the harvested lymph nodes was higher (p < 0.05). The indicators for intestinal / defecation dysfunction, as well as for urinary/sexual dysfunction, according to our data, are significantly more favorable in patients with LT, in contrast to the other two groups. CONCLUSION HT vascular ligation attempts to achieve tension-free anastomosis and more harvested lymph nodes. However, LT could be a preferred option, based on the lack of significant evidence for a difference in specific oncological survival and due to more accurate preservation of proximal intestinal segment microperfusion to prevent anastomosis dehiscence, also for its lower risk of damage to the hypogastric plexus. Splenic flexure mobilization provides elongation of the proximal intestinal segment, but has no proven effect on anastomotic leakage incidence. It increases surgical duration and is in fact necessary in up to 30% of the cases. At the present moment there is no precise data whether LT has an advantage in terms of prevention of autonomic nervous and urogenital dysfunction. New prospective randomized and highly probative studies are needed to standardize the procedures in specific clinical situations.
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Wikner F, Matthiessen P, Sörelius K, Legrell P, Rutegård M. Discrepancy between surgeon and radiological assessment of ligation level of the inferior mesenteric artery in patients operated for rectal cancer-impacting registry-based research and surgical practice. World J Surg Oncol 2021; 19:115. [PMID: 33849560 PMCID: PMC8045315 DOI: 10.1186/s12957-021-02222-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/31/2021] [Indexed: 12/12/2022] Open
Abstract
Background The reliability of the registered ligation level of the inferior mesenteric artery (IMA) in the Swedish Colorectal Cancer Registry has been questioned. The primary aim of this study was to evaluate this parameter in the registry by comparing the registered ligation levels with a postoperative computed tomography angiography (CT-angiography) in patients operated for rectal cancer. Methods Patients operated for rectal cancer at two Swedish university hospitals were prospectively included between December 2016 and December 2019. At the 1-year postoperative follow-up, an additional CT-angiography was performed and independently examined by two radiologists. The radiological assessment of the ligation level was compared to registry data, using different measures of agreement. Results A total of 94 patients were included, 55 (59%) were men and 39 (41%) women. All patients underwent abdominal resection: conventional or robot-assisted laparoscopic surgery, n=56 (60%), or open resection, n=38 (40%). The ligation level as assessed on CT-angiography was high in 29 (31%) patients and low in 65 (69%). The registered level of ligation of the IMA and the radiological assessment of the CT-angiographies were consistent in 77/94 cases, demonstrating an 82% agreement and a sensitivity and specificity of 86% and 72%, respectively. The estimated Kappa value was 0.58, reaching 0.64 after prevalence bias adjustment. Conclusion This study showed that CT-angiography can be used to evaluate the reliability of the registered ligation level in the Swedish Colorectal Cancer Registry. The demonstrated agreement between the registry and postoperative CT-angiography was moderate to good. This discrepancy impacts registry-based research using IMA ligation data and may ultimately influence surgical practice. Trial registration Clinical Trials identifier NCT03875612 Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02222-5.
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Affiliation(s)
| | - Peter Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Karl Sörelius
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Petter Legrell
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden. .,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden.
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Girard E, Trilling B, Rabattu P, Sage P, Taton N, Robert Y, Chaffanjon P, Faucheron J. Level of inferior mesenteric artery ligation in low rectal cancer surgery: high tie preferred over low tie. Tech Coloproctol 2019; 23:267-71. [DOI: 10.1007/s10151-019-01931-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 01/21/2019] [Indexed: 12/17/2022]
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Campbell A, Macdonald A, Oliphant R, Russell D, Fogg QA. Neurovasculature of high and low tie ligation of the inferior mesenteric artery. Surg Radiol Anat 2018; 40:1343-1348. [PMID: 30173375 PMCID: PMC6244984 DOI: 10.1007/s00276-018-2092-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 08/10/2018] [Indexed: 11/06/2022]
Abstract
Purpose Controversy exists as to whether a high or low tie ligation of the inferior mesenteric artery (IMA) is the preferred technique in surgeries of the left colon and rectum. This study aims to contribute to the discussion as to which is the more beneficial technique by investigating the neurovasculature at each site. Methods Ten embalmed cadaveric donors underwent division of the inferior mesenteric artery at the level of the low tie. The artery was subsequently ligated at the root to render a section of tissue for histological analysis of the proximal (high tie), mid and distal (low tie) segments. Results Ganglia observed in the proximal end of seven specimens in the sample imply that there would be disruption to the innervation in a high tie procedure. Conclusion This study suggests that a high tie should be avoided if the low tie is oncologically viable.
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Affiliation(s)
- Amy Campbell
- Laboratory of Human Anatomy, School of Life Sciences, University of Glasgow, Glasgow, UK. .,University of Dundee, School of Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.
| | - Angus Macdonald
- Department of Surgery, Monklands District General Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, UK
| | - Raymond Oliphant
- Department of Surgery, Monklands District General Hospital, Monkscourt Avenue, Airdrie, North Lanarkshire, ML6 0JS, UK
| | - David Russell
- Laboratory of Human Anatomy, School of Life Sciences, University of Glasgow, Glasgow, UK
| | - Quentin A Fogg
- Laboratory of Human Anatomy, School of Life Sciences, University of Glasgow, Glasgow, UK
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Fujii S, Ishibe A, Ota M, Suwa H, Watanabe J, Kunisaki C, Endo I. Short-term and long-term results of a randomized study comparing high tie and low tie inferior mesenteric artery ligation in laparoscopic rectal anterior resection: subanalysis of the HTLT (High tie vs. low tie) study. Surg Endosc 2018; 33:1100-1110. [DOI: 10.1007/s00464-018-6363-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/10/2018] [Indexed: 12/11/2022]
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Sohn M, Schlitt HJ, Hornung M, Zülke C, Hochrein A, Moser C, Agha A. Preservation of the superior rectal artery: influence of surgical technique on anastomotic healing and postoperative morbidity in laparoscopic sigmoidectomy for diverticular disease. Int J Colorectal Dis 2017; 32:955-60. [PMID: 28378155 DOI: 10.1007/s00384-017-2792-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate the impact of superior rectal artery (SRA) sparing technique on anastomotic leakage in laparoscopic sigmoidectomy for diverticular disease. MATERIAL AND METHODS A retrospective multicenter analysis of all patients undergoing laparoscopic sigmoid resection for diverticular disease between 2002 and 2015 was conducted. Data were recorded in three hospitals: University Hospital Regensburg, Marienhospital Gelsenkirchen, and Städtisches Klinikum München Bogenhausen. The SRA was resected between 2002 and 2005. Since 2005, the artery was preserved in most cases. RESULTS Two hundred sixty-seven patients were included. One hundred sixty patients presented with complicated diverticulitis (60%). The SRA was resected in 102 patients (group 1) and preserved in 157 patients (group 2, no data in eight cases). Anastomotic leakage occurred in 7% of patients in group 1 and 1.9% of patients in group 2 (p = 0.053). Duration of surgery was significantly shorter (157 vs. 183 min, p < 0.001) in group 2 patients. Length of hospital stay was without significant difference (group 1 8.2 days; group 2 8.3 days; p = 0.83). The conversion rate was higher in group 2 patients; however, the difference was not statistically significant (9 vs. 3%, p = 0.07). There was no significant difference between both groups regarding intraoperative complications and overall complication rate. The length of the resected specimen (19 vs. 21 cm, p = 0.001) was significantly shorter in group 2 patients. CONCLUSION Preservation of the SRA seems to be associated with favorable outcome in patients undergoing laparoscopic sigmoid resection for diverticular disease.
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Yasuda K, Kawai K, Ishihara S, Murono K, Otani K, Nishikawa T, Tanaka T, Kiyomatsu T, Hata K, Nozawa H, Yamaguchi H, Aoki S, Mishima H, Maruyama T, Sako A, Watanabe T. Level of arterial ligation in sigmoid colon and rectal cancer surgery. World J Surg Oncol 2016; 14:99. [PMID: 27036117 PMCID: PMC4818479 DOI: 10.1186/s12957-016-0819-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 02/29/2016] [Indexed: 01/04/2023] Open
Abstract
Background Curative resection of sigmoid colon and rectal cancer includes “high tie” of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the leakage rate, and it is unclear whether this confers a survival advantage. Accordingly, the IMA may be ligated at a point just below the origin of the left colic artery (LCA) “low tie” combined with lymph node dissection (LND) around the origin of the IMA (low tie with LND). However, no study has investigated the detailed prognostic results between “high tie” and “low tie with LND.” The aim of this study was to assess the utility of “low tie with LND” on survival in patients with sigmoid colon or rectal cancer. Methods A total of 189 sigmoid colon or rectal cancer patients who underwent curative operation from 1997 to 2007 were enrolled in this study. The patient’s medical records were reviewed to obtain clinicopathological information. Overall survival (OS) and relapse-free survival (RFS) rates were calculated using the Kaplan-Meier method, with differences assessed using log-rank test. Results Forty-two and 147 patients were ligated at the origin of the IMA (high tie) and just below the origin of the LCA combined with LND around the origin of the IMA (low tie with LND), respectively. No significant differences were observed in the complication rate and OS and RFS rates in the two groups. Further, no significant difference was observed in the OS and RFS rates in the lymph node-positive cases in the two groups. Conclusions “Low tie with LND” is anatomically less invasive and is not inferior to “high tie” with prognostic point of view.
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Affiliation(s)
- Koji Yasuda
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kensuke Otani
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Tomomichi Kiyomatsu
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hironori Yamaguchi
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Shigeo Aoki
- Department of Surgery, Hitachi General Hospital, 2-1-1 Jonan,, Hitachi, Ibaraki Pref, Japan
| | - Hideyuki Mishima
- Department of Surgery, Hitachi General Hospital, 2-1-1 Jonan,, Hitachi, Ibaraki Pref, Japan
| | - Tsunehiko Maruyama
- Department of Surgery, Hitachi General Hospital, 2-1-1 Jonan,, Hitachi, Ibaraki Pref, Japan
| | - Akihiro Sako
- Department of Surgery, Hitachi General Hospital, 2-1-1 Jonan,, Hitachi, Ibaraki Pref, Japan
| | - Toshiaki Watanabe
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Yasuda K, Kawai K, Ishihara S, Murono K, Otani K, Nishikawa T, Tanaka T, Kiyomatsu T, Hata K, Nozawa H, Yamaguchi H, Aoki S, Mishima H, Maruyama T, Sako A, Watanabe T. Level of arterial ligation in sigmoid colon and rectal cancer surgery. World J Surg Oncol 2016. [PMID: 27036117 DOI: 10.1186/s12957-016-0819-3.pmid:27036117;pmcid:pmc4818479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Curative resection of sigmoid colon and rectal cancer includes "high tie" of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the leakage rate, and it is unclear whether this confers a survival advantage. Accordingly, the IMA may be ligated at a point just below the origin of the left colic artery (LCA) "low tie" combined with lymph node dissection (LND) around the origin of the IMA (low tie with LND). However, no study has investigated the detailed prognostic results between "high tie" and "low tie with LND." The aim of this study was to assess the utility of "low tie with LND" on survival in patients with sigmoid colon or rectal cancer. METHODS A total of 189 sigmoid colon or rectal cancer patients who underwent curative operation from 1997 to 2007 were enrolled in this study. The patient's medical records were reviewed to obtain clinicopathological information. Overall survival (OS) and relapse-free survival (RFS) rates were calculated using the Kaplan-Meier method, with differences assessed using log-rank test. RESULTS Forty-two and 147 patients were ligated at the origin of the IMA (high tie) and just below the origin of the LCA combined with LND around the origin of the IMA (low tie with LND), respectively. No significant differences were observed in the complication rate and OS and RFS rates in the two groups. Further, no significant difference was observed in the OS and RFS rates in the lymph node-positive cases in the two groups. CONCLUSIONS "Low tie with LND" is anatomically less invasive and is not inferior to "high tie" with prognostic point of view.
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Affiliation(s)
- Koji Yasuda
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kensuke Otani
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Takeshi Nishikawa
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Toshiaki Tanaka
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Tomomichi Kiyomatsu
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hironori Yamaguchi
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Shigeo Aoki
- Department of Surgery, Hitachi General Hospital, 2-1-1 Jonan,, Hitachi, Ibaraki Pref, Japan
| | - Hideyuki Mishima
- Department of Surgery, Hitachi General Hospital, 2-1-1 Jonan,, Hitachi, Ibaraki Pref, Japan
| | - Tsunehiko Maruyama
- Department of Surgery, Hitachi General Hospital, 2-1-1 Jonan,, Hitachi, Ibaraki Pref, Japan
| | - Akihiro Sako
- Department of Surgery, Hitachi General Hospital, 2-1-1 Jonan,, Hitachi, Ibaraki Pref, Japan
| | - Toshiaki Watanabe
- Department of Surgical Oncology, Faculty of Medicine, the University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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