Histological differentiation between sporadic and colitis-associated intestinal cancer in a nationwide study: A propensity-score-matched analysis

BACKGROUND AND AIM

Colitis-associated intestinal cancer (CAC) can develop in patients with inflammatory bowel disease; however, the malignant grade of CAC may differ from that of sporadic colorectal cancer (CRC). Therefore, we compared histological findings distinct from cancer stage between CAC and sporadic CRC to evaluate the features of CAC.

METHODS

We reviewed the clinical and histological data collected from a nationwide database in Japan between 1983 and 2020. Patient characteristics were compared to distinguish ulcerative colitis (UC), Crohn's disease (CD), and sporadic CRC. Comparisons were performed by using all collected data and propensity score-matched data.

RESULTS

A total of 1077 patients with UC-CAC, 297 with CD-CAC, and 136 927 with sporadic CRC were included. Although the prevalence of well or moderately differentiated adenocarcinoma (Tub1 and Tub2) decreased according to tumor progression for all diseases (P < 0.01), the prevalence of other histological findings, including signet ring cell carcinoma, mucinous carcinoma, poorly differentiated adenocarcinoma, or squamous cell carcinoma, was significantly higher in CAC than in sporadic CRC. Based on propensity score-matched data for 982 patients with UC and 268 with CD, the prevalence of histological findings other than Tub1 and Tub2 was also significantly higher in those with CAC. At pT4, mucinous carcinoma occurred at a significantly higher rate in patients with CD (45/86 [52.3%]) than in those with sporadic CRC (13/88 [14.8%]) (P < 0.01).

CONCLUSION

CAC, including early-stage CAC, has a higher malignant grade than sporadic CRC, and this difference increases in significance with tumor progression.

Prediction model of the risk for lateral local recurrence in locally advanced rectal cancer without enlarged lateral lymph nodes: Lessons from a Japanese multicenter pooled analysis of 812 patients

Aim

Although the oncological impact of lateral lymph node dissection on enlarged lateral lymph nodes has been gradually accepted over the last decade, that on lateral lymph nodes without swelling remains doubtful. This study aimed to develop a prediction model for the future risk of lateral local recurrence and to clarify the value of adding lateral lymph node dissection in locally advanced rectal cancer without enlarged lateral lymph nodes.

Methods

This retrospective, multi-institutional study recruited 812 patients with cStage II/III low rectal cancer without enlarged lateral lymph nodes <7 mm. Total lateral local recurrence was a hypothetical value of future risk of lateral local recurrence when lateral lymph node dissection was never performed.

Results

Overall, total lateral local recurrences were observed in 67 patients (8.3%). In the multivariate analyses, the strongest risk factor for total local recurrences was no preoperative chemoradiotherapy (odds ratio [OR][95%Cl]: 33.2 [4.56-241.7], P < 0.001), followed by tumor distance ≤40 mm (OR [95%Cl]: 2.71 [1.51-4.86], P < 0.001) and lateral lymph node 5-7 mm (OR[95%Cl]: 2.38 [1.26-4.48], P = 0.007). In patients with lateral lymph nodes of 5-7 mm, the total lateral recurrence rate was 4.8% after preoperative chemoradiotherapy. Lateral lymph node dissection could reduce from a total lateral local recurrence of 21.6% to an actual lateral local recurrence of 8.0% in patients without preoperative treatment.

Conclusion

We introduce a novel prediction model of future risk of lateral local recurrences, which has the potential to enable us to indicate lateral lymph node dissection selectively according to the patients' risks.

[A Case of Descending Colon Cancer with Distant Metastasis That Was Controlled Severe Side Effects of Chemotherapy and Achieved Long-Term CR]

A 69-year-old male patient with descending colon cancer with para-aortic lymph node metastasis underwent surgery to resect the primary tumor. After the surgery mFOLFOX6 plus panitumumab was introduced. Because 2 times drug-induced lung disease and Stevens Johnson syndrome were occurred, changes in chemotherapy regimen were required. 18 months after administration, complete response was achieved. The chemotherapy was discontinued 48 months after administration. He is alive without recurrence for 32 months after completion of treatment.

Crohn's Disease-Associated Anorectal Cancer Has a Poor Prognosis With High Local Recurrence: A Subanalysis of the Nationwide Japanese Study

INTRODUCTION

Colorectal cancer (CRC) is one of the major life-threatening complications in patients with Crohn's disease (CD). Previous studies of CD-associated CRC (CD-CRC) have involved only small numbers of patients, and no large series have been reported from Asia. The aim of this study was to clarify the prognosis and clinicopathological features of CD-CRC compared with sporadic CRC.

METHODS

A large nationwide database was used to identify patients with CD-CRC (n = 233) and sporadic CRC (n = 129,783) over a 40-year period, from 1980 to 2020. Five-year overall survival (OS), recurrence-free survival (RFS), and clinicopathological characteristics were investigated. The prognosis of CD-CRC was further evaluated in groups divided by colon cancer and anorectal cancer (RC). Multivariable Cox regression analysis was used to adjust for confounding by unbalanced covariables.

RESULTS

Compared with sporadic cases, patients with CD-CRC were younger; more often had RC, multiple lesions, and mucinous adenocarcinoma; and had lower R0 resection rates. Five-year OS was worse for CD-CRC than for sporadic CRC (53.99% vs 71.17%, P < 0.001). Multivariable Cox regression analysis revealed that CD was associated with significantly poorer survival (hazard ratio 2.36, 95% confidence interval: 1.54-3.62, P < 0.0001). Evaluation by tumor location showed significantly worse 5-year OS and RFS of CD-RC compared with sporadic RC. Recurrence was identified in 39.57% of CD-RC cases and was mostly local.

DISCUSSION

Poor prognosis of CD-CRC is attributable primarily to RC and high local recurrence. Local control is indispensable to improving prognosis.

Feasibility and learning curve for robotic surgery in a small hospital: A retrospective cohort study

Robotic surgery rates, typified by the use of the da Vinci Surgical System, have increased in recent years. However, robotic surgery is mostly performed in large hospitals and has not been fully implemented in small hospitals. Therefore, we aimed to verify the feasibility of robotic surgery in small hospitals and verify the number of cases in which perioperative preparation for robotic surgery is stable by creating a learning curve in small hospitals. Forty robot-assisted rectal cancer surgeries performed in large and small hospitals by a surgeon with extensive experience in robotic surgery were validated. Draping and docking times were recorded as perioperative preparation times. Unexpected surgical interruptions, intraoperative adverse events, conversion to laparoscopic or open surgery, and postoperative complications were recorded. Cumulative sum analysis was used to derive the learning curve for perioperative preparation time. Draping times were significantly longer in the small hospital group (7 vs 10 minutes, P = .0002), while docking times were not significantly different (12 vs 13 minutes, P = .098). Surgical interruptions, intraoperative adverse events, and conversions were not observed in either group. There were no significant differences in the incidence of severe complications (25% [5/20] vs 5% [1/20], P = .184). In the small hospital group, phase I of the draping learning curve was completed in 4 cases, while phase I of the docking learning curve was completed in 7 cases. Robotic surgery is feasible for small hospitals, and the preoperative preparation time required for robotic surgery stabilizes relatively early.

Simultaneous colonic metastasis of advanced gastric cancer: a case report

BACKGROUND

Although distant metastasis in gastric cancer can be present at the time of the initial diagnosis, colonic metastasis is extremely rare. This report describes a case of simultaneous colonic metastasis of advanced gastric cancer.

CASE PRESENTATION

The patient was a 78-year-old woman with nausea and epigastric pain. Upper gastrointestinal endoscopy revealed an advanced invasive ulcerative tumor in the lesser curvature of the stomach extending from the anterior to the middle portion. Colonoscopy revealed a 4-mm polyp-like lesion in the mid-transverse colon; therefore, a polypectomy was performed. Both gastric and colonic tumors showed poorly differentiated adenocarcinoma with signet ring cell carcinoma. After providing informed consent, the patient underwent a total gastrectomy. Histologic examination showed similar morphologic features of both gastric and colonic tumors. Immunohistochemistry staining showed that these tumor cells were positive for cytokeratin (CK) 7 and negative for CK20.

CONCLUSIONS

This was an extremely rare case of simultaneous colonic metastasis of advanced gastric cancer. Because missed metastasis can result in a poorer prognosis, we propose a systemic search including colonoscopy for patients with advanced gastric cancer, especially cases involving poorly differentiated adenocarcinoma or signet ring cell carcinoma.

Successful Laparoscopic Treatment of Pancreatic Metastasis From Sigmoid Colon Cancer: A Case Report

Progressive colorectal cancer frequently presents with various manifestations, including hepatic, pulmonary, and peritoneal metastases, as well as local and anastomotic site recurrences. However, pancreatic metastasis is extremely rare. Complete surgical resection is currently considered the most effective and only potentially curative treatment for colorectal cancer with distant metastases. We report the successful laparoscopic treatment of a patient with pancreatic metastasis after initial surgery for Stage IV sigmoid colon cancer with pulmonary metastasis. An 84-year-old man was initially diagnosed with sigmoid colon cancer and pulmonary metastasis. Laparoscopic sigmoidectomy and thoracoscopic partial resection of the right lung were performed in 2017. After 8 months, an approximately 20-mm tumor was detected in the pancreatic tail during imaging investigations. We performed laparoscopic distal pancreatectomy without lymph node dissection at 1 year after the initial operation. The histopathological findings suggested metachronous pancreatic metastasis from the sigmoid colon cancer. The patient has had an uneventful postoperative course with no signs of recurrent disease during 29 months of follow-up after the pancreatic surgery. After prior surgery for Stage IV sigmoid colon cancer with pulmonary metastasis, curative resection was performed for pancreatic metastasis. We believe that curative resection may be useful for pancreatic tumors that involve hematogenous metastasis.

A new spray-type adhesion barrier (AdSpray) improves condition for surgical treatment in the reversal of Hartmann procedure: A case report

RATIONALE

Hartmann procedure (HP) often causes severe postoperative adhesions in the pelvic space; therefore, the reversal of Hartmann procedure (RHP) is a challenging surgery. A new spray-type antiadhesion agent, AdSpray, has been reported to be useful in three-dimensional fields such as the liver. However, there are no reports of its use in HP. We present a case of a male patient with rectal cancer who underwent laparoscopic HP with AdSpray to prevent postoperative adhesions.

PATIENT CONCERNS

A 52-year-old man presented with melena and constipation.

DIAGNOSIS

Colonoscopy revealed an almost obstructive type II tumor at the rectosigmoid colon, and histopathological examination revealed moderately differentiated adenocarcinoma. Enhanced abdominal computed tomography revealed slightly enlarged regional lymph nodes but no ascites around the tumor, and there was no metastasis to the liver or lungs. Therefore, we diagnosed clinical stage T4aN1bM0 rectosigmoid colon cancer. Intraoperatively, a metastatic tumor of the liver surface and a high degree of valve retention in the oral colon were identified.

INTERVENTIONS

After performing laparoscopic HP with AdSpray, we scheduled a laparoscopic RHP with staged hepatic surgery for synchronous liver metastasis from colorectal cancer 1 month later.

OUTCOMES

No postoperative inflammatory adhesions were observed in the pelvis or around the rectal stump, allowing us to perform RHP by a single-incision laparoscopic surgery from the stoma site without any problem. The operation time for RHP was 80 minutes; the patient was in good general condition after the operation, and he was discharged on postoperative day 7.

LESSONS

In laparoscopic HP, Adspray was easy to use for three-dimensional fields such as the pelvis and effectively prevented postoperative inflammatory adhesions. Thus, RHP may become less risky and be performed more as a minimally invasive surgery.

Institutional variation in survival and morbidity in laparoscopic surgery for colon cancer: From the data of a randomized controlled trial comparing open and laparoscopic surgery (JCOG0404)

BACKGROUND

Institutional variation in outcomes is a key factor to ascertain the generalizability of results and reliability of the clinical trial. This study evaluated institutional variation in survival and postoperative complications using data from JCOG0404 comparing laparoscopic colectomy (LAP) with open colectomy (OP).

METHODS

Institutions with fewer than 10 registered patients were excluded from this analysis. Institutional variation was evaluated in terms of early postoperative complications, overall survival, and relapse-free survival and estimated using a mixed-effect model with institution as a random effect after adjusting for background factors.

RESULTS

This analysis included 1028 patients in the safety analysis and 1040 patients in the efficacy analysis from 26 institutions. In the safety analysis, there was no variation in grades 3-4 early postoperative complications (in OP, median 6.3% [range 6.3%-6.3%]; in LAP, median 2.6% [range 2.6%-2.6%]), but some variation in grades 1-4 early postoperative complications was observed (in OP, median 20.8% [range 13.2%-31.8%]; in LAP, median 11.9% [range 7.2%-28.7%]), and that in grades 2-4 was observed only in LAP (median 8.8% [range 4.7%-24.0%]; in OP, median 12.7% [range 12.7%-12.7%]). Two specific institutions showed especially high incidences of postoperative complications in LAP. In the efficacy analysis, there was no institutional variation in OP, although a certain variation was observed in LAP.

CONCLUSIONS

Some institutional variations in safety and efficacy were observed, although only in LAP. We conclude that a qualification system, including training and education, is needed when new surgical techniques such as laparoscopic surgery are introduced in clinical practice.

Clinical experience with near-infrared ray catheter, a fluorescent ureteral catheter, on laparoscopic surgery for colon diverticulitis: A case report

RATIONALE

As the world's population ages, the number of surgical cases of colovesical fistulas secondary to colon diverticulitis is also expected to increase. The key issue while performing laparoscopic surgery for these fistulas is the avoidance of iatrogenic ureteral injury. There are no reports of Near-infrared Ray Catheter being used in surgery for diverticulitis, which is one of the diseases with the highest risk of ureteral injury. We present a case of a male patient with colovesical fistulas secondary to sigmoid colon diverticulitis who underwent laparoscopic surgery with visualization of the ureter using a new surgical technique in laparoscopic surgery.

PATIENTS CONCERN

An 82-year-old man presented to our urological department with general fatigue and air and fecal matter in the urine.

DIAGNOSES

Cystography showed delineation of the sigmoid colon. Abdominal computed tomography findings revealed multiple sigmoid colon diverticula with thickened walls as well as large stones and a small amount of air in the bladder. He was diagnosed with a urinary tract infection with colovesical fistulas and bladder stones due to sigmoid diverticulitis.

INTERVENTIONS

After the creation of a transverse colostomy, we scheduled a laparoscopic anterior resection and cystolith removal.

OUTCOMES

Severe inflammatory adhesions around the sigmoid colon and a high risk of ureteral injury were expected preoperatively. After induction of anesthesia, we inserted a Near-infrared Ray Catheter, a fluorescent ureteral catheter, which allowed us to easily identify and visualize the ureter in real-time. This allowed bowel dissection without concerns of ureteral injury. The operative time for the gastrointestinal part of the procedure was 150 minutes, and the patient was in a good general condition after the operation and was discharged on postoperative day 7.

LESSONS

The course of the ureter was easily and quickly identified by the green fluorescence from the ureteral catheter during laparoscopic surgery for fistulas associated with diverticulitis, where severe inflammation and dense fibrosis were present. Our technique is an easy and feasible approach that provides real-time urethral navigation during surgery for colovesical fistulas secondary to colon diverticulitis.

Preventing anastomotic leakage after laparoscopic intersphincteric resection without a diverting stoma: "pull-through/reborn"

INTRODUCTION

Patients with very low rectal cancer who undergo intersphincteric resection (ISR) often experience anastomotic leakage (AL), even with a diverting stoma. The aim of this study was to introduce a technique for anastomosis after laparoscopic ISR to avoid AL.

MATERIALS AND SURGICAL TECHNIQUE

In the first ISR procedure, the rectum was mobilized, the mesorectum was excised, and total, subtotal, or partial internal sphincter incision was performed transanally. In the second surgery, the adhesions between the prolapsed colon and the anal canal were bluntly dissected only as needed for suturing. After sufficient blood flow was confirmed using indocyanine green fluorescence imaging, coloanal transanal anastomosis was performed without a diverting stoma. We call this method "pull-through/reborn".

DISCUSSION

"Pull-through/reborn" method can prevent AL after laparoscopic ISR. However, more cases and more experience are necessary to analyze anal functions after this method is applied.

Primary Tumor Resection Plus Chemotherapy Versus Chemotherapy Alone for Colorectal Cancer Patients With Asymptomatic, Synchronous Unresectable Metastases (JCOG1007; iPACS): A Randomized Clinical Trial

It remains controversial whether primary tumor resection (PTR) before chemotherapy improves survival in patients with colorectal cancer (CRC) with asymptomatic primary tumor and synchronous unresectable metastases.

Evaluation of lymphatic flow pattern using indocyanine green fluorescence imaging in a highly metastatic mouse model

Recently, the feasibility of real‐time indocyanine green (ICG) fluorescence imaging–guided complete mesocolic excision in colon cancer surgery has been demonstrated; however, its application to the evaluation of lymphatic flow in widespread lymph node metastasis is uncertain. This study aimed to evaluate lymphatic flow using the real‐time ICG fluorescence imaging. A mouse model of subcutaneous inoculation of BJMC3879Luc2 cells, which have been demonstrated to highly metastasize to the lymph nodes, was used as an evaluation model. Tumor growth and lymphatic flow were monitored weekly by bioluminescent imaging and near‐infrared (NIR) fluorescence imaging, respectively. After sacrificing the mice, lymph node metastases were evaluated by bioluminescent imaging and histopathology. Lymphatic flows in a model of high lymph node metastasis were evaluated using NIR fluorescence imaging. Pathological metastases of bilateral axillary, femoral, and para‐aortic lymph nodes were detected in all inoculated mice (100%: 5/5). Real‐time NIR fluorescence imaging showed the primary lymphatic vessels staining through the metastatic lymph nodes as before the inoculation of the cancer cells. Hitherto, it has been considered that lymphatic flow was changed using the bypass pathway due to occlusion of the primary lymphatic vessels. In this presented study, real‐time ICG fluorescence imaging showed no changes in lymphatic flow after lymph node metastasis. Our results suggest that real‐time ICG fluorescence imaging may have potential for the guidance of colon cancer surgery in cases of widespread lymph node metastasis.

Natural orifice specimen extraction in laparoscopic colorectal cancer surgery: A case series study

•

Now that laparoscopic surgery is widespread, minimally invasive surgery is desired.

•

Natural orifice specimen extraction is minimally invasive surgery.

•

Transanal specimen extraction and transvaginal specimen extraction.

•

Natural orifice specimen extraction appears to be feasible and safe.

Introduction

In recent years, natural orifice specimen extraction (NOSE) has been attracting attention as a further minimally invasive operation for colorectal cancer, and not only improvement of appearance, but also reduction of pain and wound-related complications due to abdominal wall destruction has been reported. However, NOSE is technically complicated and difficult, and it has not yet been widely used. The aim of this study was to confirm the feasibility, safety, and short-term outcomes of total laparoscopic colon cancer surgery with NOSE.

Case presentation

From May 2018 to October 2019, eight patients with stage 0 or I colon cancer underwent NOSE surgery in our hospital. Transanal specimen extraction was performed in six cases, and transvaginal specimen extraction was performed in two cases. All operations were successfully accomplished without conversion to open surgery. The anastomosis method was double stapling technique in three cases and overlap method in five cases. The median operative time was 224 min. The median blood loss was 10 mL. The median time to first flatus was 1 day, and the median time to first stool was 2 days. The median postoperative observation period was 18 months, but there was no recurrence. There were no postoperative complications in these cases.

Conclusion

Total laparoscopic colon cancer surgery with NOSE appears to be feasible, safe, and show promising efficacy for selected patients.

γ-H2AX as a potential indicator of radiosensitivity in colorectal cancer cells

Preoperative radiotherapy improves local disease control and disease-free survival in patients with advanced rectal cancer; however, a reliable predictive biomarker for the effectiveness of irradiation has yet to be elucidated. Phosphorylation of H2A histone family member X (H2AX) to γ-H2AX is induced by DNA double-strand breaks and is associated with the development of colorectal cancer (CRC). The current study aimed to clarify the relationship between γ-H2AX expression and CRC radiosensitivity in vitro and in vivo. H2AX levels were analyzed in datasets obtained from cohort studies and γ-H2AX expression was investigated by performing immunohistochemistry and western blotting using clinical CRC samples from patients without any preoperative therapy. In addition, the CRC cell lines WiDr and DLD-1 were subjected to irradiation and/or small interfering RNA-H2AX, after which the protein levels of γ-H2AX were examined in samples obtained from patients undergoing preoperative chemoradiotherapy. To quantify the observable effect of treatment on cancer cells, outcomes were graded as follows: 1, mild; 2, moderate; and 3, marked, with defined signatures of cellular response. Datasets obtained from cohort studies demonstrated that H2AX mRNA levels were significantly upregulated and associated with distal metastasis and microsatellite instability in CRC tissues, in contrast to that of normal tissues. In addition, γ-H2AX was overexpressed in clinical samples. In vitro, following irradiation, γ-H2AX expression levels increased and cell viability decreased in a time-dependent manner. Combined irradiation and γ-H2AX knockdown reduced the viability of each cell line when compared with irradiation or γ-H2AX knockdown alone. Furthermore, among clinical CRC samples from patients undergoing preoperative chemoradiotherapy, levels of γ-H2AX in the grade 1 group were significantly higher than those in grade 2 or grade 3. In conclusion, γ-H2AX may serve as a novel predictive marker and target for preoperative radiotherapy effectiveness in patients with CRC.

Evaluating the Learning Curve Associated with Laparoscopic Left Hemicolectomy for Colon Cancer

The role of laparoscopic surgery for transverse and descending colon cancer remains controversial. The aim of the present study was to characterize the learning curve for laparoscopic left hemicolectomy including the splenic flexure and to identify factors that influence this learning curve. Data from 120 consecutive patients undergoing laparoscopic left hemicolectomy for transverse and descending colon cancer including the splenic flexure between December 1996 and December 2009 were analyzed. Patients undergoing resection combined with cholecystectomy, hepatectomy, hysterectomy, or gastrectomy were excluded. Operative time was analyzed using the moving average method. The operative time, conversion rate, and postoperative complication rate were evaluated among four groups based on the number of cases required for analysis of operative time. In addition, risk factors that influenced conversion to open surgery were analyzed. Operative time for left hemicolectomy decreased with increasing case number with stabilization at 30 cases. There was no significant difference in the conversion rate or postoperative complications over time. Significant factors for conversion to open surgery were T stage (odds ratio [OR], 5.56; 95% confidence interval [CI], 1.5 to 27.4) and previous abdominal surgery (OR, 5.38; 95% CI, 1.6 to 20.2). The learning curve for laparoscopic left hemicolectomy is steep. Thus, surgeons in the early part of this curve should carefully select patients to allow them to build experience in a stepwise manner. Laparoscopic surgery may become the gold standard for management of colon cancer regardless of stage or tumor location.

Ultimate Stomaless Technique of Two-Stage Operation for Lower Rectal Cancer Performed on a Patient with a High Body Mass Index: The Reborn Operation (Novel Pull-Through Method)

A 58-year-old Japanese man, with a body mass index of 41.7 kg/m² (height: 179.8 cm; weight: 133.8 kg), underwent a laparoscopic pull-through procedure with delayed coloanal anastomosis performed in two surgical stages for lower rectal cancer. This method was selected because the volume of the abdominal wall was fairly thick and it would have been impossible to perform diverting ileostomy and colostomy, which are routinely conducted. First, a colonic pull-through segment of about 10 cm was left outside the anal canal without any tension and was fixed by sutures under indocyanine green fluorescence imaging (ICG FI). The second surgical stage was performed 10 days after the first operation under general anesthesia. Final coloanal anastomosis was performed with near-infrared light without diverting the stoma under ICG FI. The patient demonstrated a good postoperative course and was discharged from our hospital in remission 15 days after the latest operation. We could inspect the coloanal flow of the anastomosis under ICG FI before the reconstruction. This procedure was considered to be a standard method, but it was overtaken by new technology, ICG FI. This procedure is an ultimate stomaless surgery for ultralow rectal cancer that can be performed in selected cases, such as in patients with a high body mass index and with hope for stomaless operation.

Long-term survival outcomes following laparoscopic surgery for clinical stage 0/I rectal carcinoma

AIM

To clarify and evaluate the long-term outcomes of laparoscopic surgery for clinical stage 0/I rectal carcinoma patients.

METHODS

This single-arm phase II trial involved accredited surgeons from 43 Japanese institutions. Patients were registered preoperatively. The planned sample size was 490. The primary endpoint was overall survival, and long-term outcomes were evaluated.

RESULTS

A total of 495 patients were registered between February 2008 and August 2010. Eight patients (1.6%) required conversion to open surgery. Sphincter-preserving procedures were performed in 477 (97%) patients. Positive radial resection margin was found in two (0.4%) patients. Of 490 patients, 22, 314, 38, 115, and one patient had final pathological stages (p-stage) 0, I, II, III, and IV, respectively. Pathologically, 31.4% (154/490) of the patients did not have p-stage 0/I. The 5-year overall survival (OS) rates in p-stages 0, I, II, and III were 100%, 98%, 97%, and 94%, respectively. The 5-year OS of all patients at 96.6% (95% CI 94.6-97.9) was significantly better than the expected 5-year OS of 81.1% (P < .0001). The 5-year relapse-free survival in p-stages 0, I, II, and III were 100%, 93%, 81%, and 79%, respectively. The 5-year relapse-free survival of all patients was 90.1%. Fifty patients (10.2%) had recurrence; lung recurrence was found in 22 patients, local recurrence in 14, liver in seven, distant lymph node in nine, and bone in three.

CONCLUSIONS

Laparoscopic surgery for clinical stage 0/I rectal carcinoma has feasible long-term outcomes. (ClinicalTrials.gov No.NCT00635466.).

The comparison of mFOLFOXIRI with CAOX/SOX as neoadjuvant chemotherapy for locally advanced rectal cancer

51

Background: The standard therapy for the locally advanced rectal cancer (LARC) (Ra or Rb, T2Npsitive, T3/4Nany) is chemoradiotherapy (CRT) followed by surgery. The CRT prevents local recurrence, although problems such as complications or the improvement of distant recurrence still remain. Several studies about the neoadjuvant chemotherapy (NAC) without radiation showed favorable R0 resection rate and outcome, however the best regimen of NAC is unclear. The aim of this study is to investigate the efficacy and safety of mFOLFOXIRI and CAPOX/SOX as NAC. Methods: We examined the patients (pts) with LARC who were planned to receive mFOLFOXIRI (5FU 2400mg/m2/day1-2, leucovorin 200mg/m2, oxaliplatin 85mg/m2, irinotecan 150mg/m2, every 2 weeks) or CAPOX/SOX(capecitabine 2000mg/m2 or S-1 mg/m2 80day1-14, oxaliplatin 130mg/m2, day1, every 3weeks) for 8-12 weeks as NAC, retrospectively. Results: Forty-nine pts received mFOLFOXIRI and thirty-two pts received XELOX/SOX between Jan 2015 and Mar 2019. The characteristics of mFOLFOXIRI and XELOX/SOX were as follows; median age, 64 (37-80) and 65 (33-68); PS 0/1, 46(94%)/3(6%) and 14(44%)/18(56%); Ra/Rb-P, 4(8%)/45(92%) and 0/32; clinical T2/3/4, 4(7%)/27(55%)/19(39%) and 1(3%)/18(56%)/13(41%); clinical N0/1/2, 13(27%)/26(53%)/10(20%) and 7(22%)/17(53%)/8(25%). The pathological response rate which was defined as tumor affected area over one-third were 61.2% in mFOLFOXIRI and 65.6% in CAPOX/SOX including complete remission of 4.1% and 12.5%, respectively. Six of 49 pts withdrew from mFOLFOXIRI due to toxicities, whereas one of 32 pts from CAPOX/SOX. One pt received CRT after SOX because of lack of efficacy. The major grade 3/4 toxicities of mFOLFOXIRI were neutropenia (n = 22, 45%), thrombocytopenia and febrile neutropenia (n = 4, 8%) and anorexia (n = 3, 6%), whereas CAPOX/SOX neutropenia (n = 3. 9%), thrombocytopenia (n = 1, 3%) and hand-foot syndrome (n = 1, 3%). The one year of relapse free survival rate were 85.4% and 83.6%. Conclusions: Although the pathological response of mFOLFOXIRI was comparable with CAPOX/SOX, CAPOX/SOX was less toxic.The further investigation including 5 year overall survival rate rate was needed.

The Management of Recurrence within Six Months after Hepatic Resection for Colorectal Liver Metastasis

BACKGROUND

Hepatectomy is currently recommended as the most reliable treatment for colorectal liver metastases. However, the association between the choice of treatment for recurrence and the timing of recurrence remains controversial.

METHODS

Two-hundred ninety-five patients who underwent hepatectomy were retrospectively analyzed for the risk factors and the outcomes for early recurrence within 6 months. The remnant liver volumes (RLVs) and laboratory data were measured postoperatively using multidetector computed tomography on days 7 and months 1, 2, and 5 after the operation.

RESULTS

Early recurrence developed in 88/295 patients (29.8%). Colorectal cancer lymph node metastasis, synchronous liver metastasis, and multiple liver metastases were independent risk factors for the occurrence of early recurrence (p < 0.001, 0.032, and 0.019, respectively). Patients with early recurrence had a poorer prognosis than did patients who developed later recurrence (p < 0.001). Patients who underwent surgery or other local treatment had better outcomes. The changes in RLV and laboratory data after postoperative month 2 were not significantly different between the 2 groups.

CONCLUSION

Patients with early recurrence within 6 months had a poorer prognosis than did patients who developed later recurrence. However, patients who underwent repeat hepatectomy for recurrence had a better prognosis than did those who underwent other treatments, with good prospects for long-term survival.

Delta-like 3 localizes to neuroendocrine cells and plays a pivotal role in gastrointestinal neuroendocrine malignancy

Delta‐like 3 (DLL3) is a member of the Delta/Serrate/Lag2 (DSL) group of Notch receptor ligands. Five DSL ligands are known in mammals, among which DLL3 has a unique structure. In the last few years, DLL3 has attracted attention as a novel molecular targeting gene in neuroendocrine carcinoma of the lung due to its high expression. However, the expression pattern and functions of DLL3 in the gastrointestinal tract and gastrointestinal neuroendocrine carcinoma remain unclear. In this study, we examined the expression and role of DLL3 in the gastrointestinal tract, as well as in gastrointestinal neuroendocrine carcinoma. Immunohistochemical staining of the human normal gastrointestinal tract revealed that DLL3 localized in neuroendocrine cells. DLL3 showed intense staining in chromogranin A‐positive gastric cancer specimens. Real‐time quantitative RT‐PCR and western blotting analyses showed considerable upregulation of DLL3 in gastrointestinal neuroendocrine carcinoma cell lines. Immuno‐electron microscopy demonstrated abundant expression of DLL3 in neurosecretory granules in these cells. Furthermore, gene silencing of DLL3 caused significant growth inhibition through the induction of intrinsic apoptosis. Our findings suggest that DLL3 is expressed in neuroendocrine cells of the gastrointestinal tract and that it has a pivotal role in gastrointestinal neuroendocrine carcinoma cells. Based on these findings, further investigations are required to achieve a breakthrough in developing therapeutic strategies for gastrointestinal neuroendocrine carcinoma.

Novel technique with the IRIS U kit to prevent urethral injury in patients undergoing transanal total mesorectal excision

Background

Low anterior resection of the rectum with total mesorectal excision (TME) has been the gold standard for the surgical treatment of rectal cancer as it has the lowest recurrence rates. The key issue while performing transanal TME (TaTME) is avoiding iatrogenic urethral injury. We introduce our surgical technique for TaTME.

Surgical technique

Intraurethral indocyanine green injection using the IRIS U kit with subsequent visualization under NIR was safely utilized during the TaTME. We were able to easily detect and visualize the IRIS urethral kit. The prostatic segment of the urethra can be identified in real-time using the infrared illumination system urethral kit (IRIS U kit).

Benefits

The prostatic segment of the urethra was easily and quickly identified by the green fluorescence during TaTME.

Conclusion

Our TaTME technique is an easy and feasible approach that provides real-time urethral images.

•

New technique during TaTME.

•

IRIS U-kit is device to avoid the urethra injury.

Totally extraperitoneal approach to laparoscopic lateral lymph node dissection for patients with recurrent lateral pelvic lymph nodes after rectal cancer surgery: a novel technique-M TEP LLND

Lateral lymph node dissection (LLND) for recurrence of lateral pelvic lymph node metastasis after rectal cancer surgery is technically demanding because of the need for re-do surgery. We herein report a novel technique of laparoscopic LLND via a totally extraperitoneal (TEP) approach. Since October 2018, we have performed LLND based on a TEP approach, called "M TEP LLND", with two cases treated. By peeling in the caudal direction in the dorsal layer of the rectus abdominis muscle, a working space is created once the extraperitoneal space is reached, and LLND is performed. All lateral pelvic lymph node dissection procedures have been successfully completed, and there have been no intraoperative or postoperative complications. This procedure allows TEP-experienced colorectal surgeons to perform safe and complete LLND without any influence of intraperitoneal adhesion or intestinal obstruction. M TEP LLND is less invasive than the conventional intraperitoneal approach and appears to be useful, particularly for recurrence of lateral pelvic lymph node metastasis.

International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer

In recent years, natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer has attracted widespread attention. The potential benefits of NOSES including reduction in postoperative pain and wound complications, less use of postoperative analgesic, faster recovery of bowel function, shorter length of hospital stay, better cosmetic and psychological effect have been described in colorectal surgery. Despite significant decrease in surgical trauma of NOSES have been observed, the potential pitfalls of this technique have been demonstrated. Particularly, several issues including bacteriological concerns, oncological outcomes and patient selection are raised with this new technique. Therefore, it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery. After three rounds of discussion by all members of the International Alliance of NOSES, the consensus is finally completed, which is also of great significance to the long-term progress of NOSES worldwide.

Clinical impact of single-incision laparoscopic right hemicolectomy with intracorporeal resection for advanced colon cancer: propensity score matching analysis

BACKGROUND

Laparoscopic right hemicolectomy has become an acceptable treatment for right-sided colon cancer. Most centers use multiport laparoscopic right hemicolectomy extracorporeally (MRHE), whereas single-incision laparoscopic right hemicolectomy intracorporeally (SRHI) remains controversial. The aim of this study was to compare these two techniques using propensity score matching analysis.

METHODS

We analyzed the data from 111 patients who underwent laparoscopic right hemicolectomy between December 2015 and December 2016. The propensity score was calculated according to age, gender, body mass index, the American Society of Anesthesiologists score, previous abdominal surgery, and D3 lymph node dissection. Postoperative pain was evaluated using a visual analogue scale (VAS) and postoperative analgesic use was an outcome measure.

RESULTS

The length of skin incision in SRHI was significantly shorter than in MRHE [3 (3.5-6) versus 4 (3-6) cm, respectively; P = 0.007]. The VAS score on day 1 and day 2 after surgery was significantly less in SRHI than in MRHE [30 (10-50) versus 50 (20-69) on day 1, P = 0.037; 10 (0-50) versus 30 (0-70) on day 2, P = 0.029]. Significantly fewer patients required analgesia after SRHI on day 1 and day 2 after surgery [1 (0-3) versus 2 (0-4) on day 1, P = 0.024; 1 (0-2) versus 1 (0-4) on day 2, P = 0.035]. There were no significant differences in operative time, intraoperative blood loss, number of lymph nodes removed, and postoperative course between groups.

CONCLUSIONS

SRHI appears to be safe and technically feasible. Moreover, SRHI reduces the length of the skin incision and postoperative pain compared with MRHE.

Biohybrid catalysts for sequential one-pot reactions based on an engineered transmembrane protein

A two-step one pot reaction sequence consisting of artificial metalloprotein olefin metathesis and hydrogenation was performed yielding 1,2-diphenylethane derivatives.

A Concealed “Natural Orifice”: Umbilicus Anatomy for Minimally Invasive Surgery

Introduction. A recent development in minimally invasive surgery (MIS) is single-port surgery, where a single large multiport trocar is placed in the umbilicus. All medical schools require that students complete an anatomy course as part of the medical curriculum. However, there is limited instruction regarding the detailed parts of the “umbilicus.” In several famous anatomy atlases, the umbilicus is not dissected at all and is merely represented as a button. Until now, the true nature of the umbilicus has not been anatomically demonstrated. Methods. Five cadavers were obtained from the Osaka Medical College medical student anatomy class. The umbilicus was dissected in the anatomy laboratory, to demonstrate all the layers. A detailed dissection was performed, focusing on the exact center of the umbilicus, in order to ascertain whether there exists a “natural orifice” or a fascial defect. Results. In all cadavers, a small defect of fascia was identified just below the center of the umbilicus. Yellow fatty tissue was present just below the skin in the exact center of the umbilicus. A probe placed exactly in the middle of this defect passes easily through into the abdominal cavity. Conclusions. With the widespread use of MIS, umbilical incision is commonly used to reduce pain and improve cosmetic results. This study consistently revealed a natural defect of fascia in the center of the umbilicus. Therefore, the umbilicus can be called a concealed “natural orifice.” It is important to recognize and utilize this defect effectively to minimize unnecessary tissue trauma during MIS.

Peranal endoscopic myectomy (PAEM) for rectal lesions with severe fibrosis and exhibiting the muscle-retracting sign

BACKGROUND

Although endoscopic submucosal dissection has enabled complete tumor resection and accurate pathological assessment in a manner that is less invasive than surgery, the complete resection of lesions with severe fibrosis in the submucosal layer and exhibiting the muscle-retracting sign is often difficult. We have devised a new method, peranal endoscopic myectomy (PAEM), for rectal lesions with severe fibrosis, in which dissection is performed between the inner circular and outer longitudinal muscles, and have examined the usefulness and safety of this new technique.

METHODS

All of the patients who underwent PAEM in our hospital and affiliated hospitals between July 2015 and June 2017 were retrospectively reviewed.

RESULTS

10 rectal lesions were treated with PAEM. En bloc resection with a negative vertical margin was achieved in eight patients (80 %), whose lesions were mucosal (n = 2), shallow submucosal (n = 1), deep submucosal (n = 4), and muscle invasive (n = 1). The clinical course of all patients after PAEM was favorable. In patients who underwent additional surgery, anus preservation was achieved on the basis of the pathological results from PAEM.

CONCLUSIONS

PAEM for lesions with severe fibrosis exhibiting the muscle-retracting sign appears to be both safe and useful.

Nogo-B (Reticulon-4B) functions as a negative regulator of the apoptotic pathway through the interaction with c-FLIP in colorectal cancer cells

Nogo-B is a member of the Nogo/Reticulon-4 family and has been reported to be an inducer of apoptosis in certain types of cancer cells. However, the role of Nogo-B in human cancer remains less understood. Here, we demonstrated the functions of Nogo-B in colorectal cancer cells. In clinical colorectal cancer specimens, Nogo-B was obviously overexpressed, as determined by immunohistochemistry; and Western blot analysis showed its expression level to be significantly up-regulated. Furthermore, knockdown of Nogo-B in two colorectal cancer cell lines, SW480 and DLD-1, by transfection with si-RNA (siR) resulted in significantly reduced cell viability and a dramatic increase in apoptosis with insistent overexpression of cleaved caspase-8 and cleaved PARP. The transfection with Nogo-B plasmid cancelled that apoptosis induced by siRNogoB in SW480 cells. Besides, combinatory treatment with siR-Nogo-B/staurosporine (STS) or siR-Nogo-B/Fas ligand (FasL) synergistically reduced cell viability and increased the expression of apoptotic signaling proteins in colorectal cancer cells. These results strongly support our contention that Nogo-B most likely played an oncogenic role in colorectal cancer cells, mainly by negatively regulating the extrinsic apoptotic pathway in them. Finally, we revealed that suppression of Nogo-B caused down-regulation of c-FLIP, known as a major anti-apoptotic protein, and activation of caspase-8 in the death receptor pathway. Interaction between Nogo-B and c-FLIP was shown by immunoprecipitation and immunofluorescence studies. In conclusion, Nogo-B was shown to play an important negative role in apoptotic signaling through its interaction with c-FLIP in colorectal cancer cells, and may thus become a novel therapeutic target for colorectal cancer.

Formate complexes of titanium(iv) supported by a triamido-amine ligand

The terminal formate complex [(OCHO)Ti(N₃N)] (3) containing the trianionic triamido-amine ligand (Me₃SiNCH₂CH₂)₃N^3- (N₃N) was prepared via salt metathesis of [ClTi(N₃N)] (1) with sodium formate or alternatively by treatment of the alkyl complex [ⁿBuTi(N₃N)] (2) with ammonium formate [HNEt₃][OCHO]. Deprotonation of 3 with potassium hexamethyldisilazide gave a polymeric helical chain of the oxo complex {K[OTi(N₃N)]}_n (4). Reaction of 2 with the trityl salt [Ph₃C][B(3,5-Cl₂C₆H₃)₄] or the Brønsted acid [HNEt₃][B(C₆F₅)₄] gave [(Et₂O)Ti(N₃N)][BR₄] (6[BR₄]·Et₂O) with R = 3,5-Cl₂C₆H₃ or C₆F₅. The diethyl ether ligand was easily replaced by other L-type donor ligands such as tetrahydrofuran, pyridine, and 4-dimethylaminopyridine to give 6[BR₄]·L with L = thf, py, and dmap. Reaction of 6[BR₄]·Et₂O with a stoichiometric amount of CO₂ gave the dimeric, dicationic bis(carbamate)-bridged complexes [Ti{N(CH₂CH₂NSiMe₃)₂(CH₂CH₂NSiMe₃(μ-CO₂-ηO:ηO'))}]₂[BR₄]₂ (7[BR₄]₂) through insertion of one CO₂ into one of the titanium-amido bonds. Addition of pyridine to 7[B(C₆F₅)₄]₂ formed the monomeric carbamate complex [(py)Ti{((O₂C-κ²O,O')NSiMe₃CH₂CH₂)N(CH₂CH₂NSiMe₃)₂}][B(C₆F₅)₄] (8[B(C₆F₅)₄]·py). The cationic formate-bridged species [(Ti(N₃N))₂(μ-OCHO-ηO:ηO')][BR₄] (10[BR₄]) readily formed when the terminal formate complex 3 was reacted with the cationic 6[BR₄]. The reactivity of triamido-amine stabilized titanium(iv) complexes is shown to differ considerably from that of related titanium tris(anilide) complexes.

Intestinal endometriosis combined with colorectal cancer: a case series

BACKGROUND

Intestinal endometriosis is a common benign disease among menstruating women that affects the intestinal tract.

CASE PRESENTATION

This case report presents seven Japanese cases of intestinal endometriosis with colorectal cancer treated by laparoscopic surgery. Five of the seven cases reported here are women presenting with bowel obstruction due to colorectal endometriosis with colorectal cancer. It can be confused with serious lesions such as advanced colorectal cancer with peritoneal involvement or invasion of adjacent organs (T4).

CONCLUSIONS

Therefore, we should consider the probability that the cause of bowel obstruction is not T4 but intestinal endometriosis. For surgical treatment, we recommend laparoscopic surgery for colorectal resection because of its benefits of differential diagnosis of T4, preserving fertility, and preventing excessive surgical stress. We performed laparoscopic resection in seven patients with intestinal endometriosis and colorectal cancer. These cases demonstrate the difficulty of establishing a differential diagnosis of intestinal endometriosis with colorectal cancer from T4.

Intestinal endometriosis combined with colorectal cancer: a case series

Background

Intestinal endometriosis is a common benign disease among menstruating women that affects the intestinal tract.

Case presentation

This case report presents seven Japanese cases of intestinal endometriosis with colorectal cancer treated by laparoscopic surgery. Five of the seven cases reported here are women presenting with bowel obstruction due to colorectal endometriosis with colorectal cancer. It can be confused with serious lesions such as advanced colorectal cancer with peritoneal involvement or invasion of adjacent organs (T4).

Conclusions

Therefore, we should consider the probability that the cause of bowel obstruction is not T4 but intestinal endometriosis. For surgical treatment, we recommend laparoscopic surgery for colorectal resection because of its benefits of differential diagnosis of T4, preserving fertility, and preventing excessive surgical stress. We performed laparoscopic resection in seven patients with intestinal endometriosis and colorectal cancer. These cases demonstrate the difficulty of establishing a differential diagnosis of intestinal endometriosis with colorectal cancer from T4.

1,4-Dihydropyridyl complexes of magnesium: synthesis by pyridine insertion into the magnesium–silicon bond of triphenylsilyls and catalytic pyridine hydrofunctionalization

Magnesium triphenylsilyl complexes [Mg(SiPh₃)₂(THF)₂] and [(Me₃TACD)Mg(SiPh₃)] ((Me₃TACD)H = 1,4,7-trimethyl-1,4,7,10-tetraazacyclododecane) serve as precursors for 1,4-dihydropyridyl complexes of magnesium which are active in the hydroboration of pyridine.

Cyclotrimerization of phenylacetylene catalyzed by a cobalt half-sandwich complex embedded in an engineered variant of transmembrane protein FhuA

An (η⁵-cyclopentadienyl)cobalt(i) complex was covalently incorporated in an engineered variant of the β-barrel protein FhuA. The new biohydrid catalyst cyclotrimerized phenylacetylene to give regioisomeric triphenylbenzenes.

Risk factors for surgical site infection after stoma closure comparison between pursestring wound closure and conventional linear wound closure: Propensity score matching analysis

PURPOSE

Stoma closure has been associated with a high rate of surgical site infection (SSI) and the optimal skin closure method is still controversial. The aim of this study was to compare the short-term and long-term outcomes between the conventional linear closure (CC) and the persestring closure (PC) using propensity score matching analysis.

METHODS

We analysed the data of 360 patients who underwent stoma closure with CC or PC between January 2000 and December 2014. The propensity score was calculated from age, gender, body mass index, primary disease, type of stoma, diabetes mellitus, history of smoking, steroid use, the American Society of Anesthesiologists score, Prognostic Nutritional Index and modified Glasgow Prognostic Score.

RESULTS

There was no difference in operative variables between the two groups. The CC group and the PC group were comparable with regards to overall SSI (25.0 vs. 7.8%; P = 0.007), superficial SSI (21.9 vs. 4.7%; P = 0.003). Significant risk factor for SSI was conventional linear closure (OR, 4.14; 95% CI, 1.448-13.91).

CONCLUSION

Our study suggests that a pursestring stoma closure leads to less SSI.

Laparoscopic versus open resection for transverse and descending colon cancer: Short-term and long-term outcomes of a multicenter retrospective study of 1830 patients

INTRODUCTION

Previous randomized controlled trials demonstrated similar oncological outcomes between laparoscopic and open colectomies, except for cases involving transverse colon and splenic flexure colon cancer. The objective of this study was to confirm the oncological safety and advantages of the short-term results of laparoscopic surgery for transverse and descending colon cancer in comparison with open surgery.

METHODS

The study data were retrospectively collected from the databases of 45 hospitals. Patients with transverse or descending colon cancer who underwent laparoscopic or open R0 resection were registered. The primary end-points were the 3-year overall survival and relapse-free survival rates according to pathological stage. The secondary end-points were the short-term results, including blood loss, operative time, diet intake, hospital stay, and postoperative complications.

RESULTS

Of the 1830 eligible patients, 872 underwent open colectomy and 958 underwent laparoscopic colectomy. The median follow-up period was 38.4 months. The conversion rate to open resection was 4.5%. The 3-year overall survival rate of the laparoscopic group was significantly higher than that of the open group for stage I patients (96.2% vs 99.2%; P = 0.04); it was also higher for stage II (94.0% vs 95.5%) and stage III (87.4% vs 90.2%) patients, but there were no significant differences. The 3-year relapse-free survival rate of the laparoscopic group was significantly higher than that of the open group for stage I patients; there were no differences between the open and laparoscopic groups among the stage II and III patients. In the multivariate analyses, laparoscopic resection was a significant factor in relapse-free survival. Laparoscopic patients had significantly lower blood loss and a significantly longer operative time than the open groups. Also, postoperative hospital stay was significantly shorter and postoperative morbidity was significantly lower in the laparoscopic group.

CONCLUSION

Although this retrospective study has limitations, we can conclude that laparoscopic surgery for transverse and descending colon cancer is oncologically safe and yields better short-term results than open surgery.

The metabolic profile of a rat model of chronic kidney disease

Background

The kidney is always subjected to high metabolic demand. The aim of this study was to characterize metabolic profiles of a rat model of chronic kidney disease (CKD) with cardiorenal syndrome (CRS) induced by prolonged hypertension.

Methods

We used inbred male Dahl salt-sensitive (DS) rats fed an 8% NaCl diet from six weeks of age (high-salt; HS group) or a 0.3% NaCl diet as controls (low-salt; LS group). We analyzed function, pathology, metabolome, and the gene expression related to energy metabolism of the kidney.

Results

DS rats with a high-salt diet showed hypertension at 11 weeks of age and elevated serum levels of creatinine and blood urea nitrogen with heart failure at 21 weeks of age. The fibrotic area in the kidneys increased at 21 weeks of age. In addition, gene expression related to mitochondrial function was largely decreased. The levels of citrate and isocitrate increased and the gene expression of alpha-ketoglutaratedehydrogenase and succinyl-CoA synthetase decreased; these are enzymes that metabolize citrate and isocitrate, respectively. In addition, the levels of succinate and acetyl Co-A, both of which are metabolites of the tricarboxylic acid (TCA) cycle, decreased.

Conclusions

DS rats fed a high-salt diet were deemed a suitable model of CKD with CRS. Gene expression and metabolites related to energy metabolism and mitochondria in the kidney significantly changed in DS rats with hypertension in accordance with the progression of renal injury.

Risk factors for anastomotic leakage after laparoscopic surgery with the double stapling technique for stage 0/I rectal carcinoma: a subgroup analysis of a multicenter, single-arm phase II trial

PURPOSE

The aim of this study was to determine the risk factors for anastomotic leakage after laparoscopic rectal surgery.

METHODS

We conducted a prospective trial involving 395 patients with stage 0/I rectal carcinoma who underwent laparoscopic low anterior resection using a double stapling technique. Data concerning variables related to patient background, tumors and surgical factors were evaluated. The outcomes with respect to anastomotic leakage were recorded, and univariate and multivariate analyses were performed to identify relevant risk factors.

RESULTS

The overall anastomotic leakage rate was 8.4%. A univariate analysis showed male gender (P = 0.006) and preoperative blood sugar level (P = 0.0034) to be significantly associated with anastomotic leakage. The variables of gender, preoperative blood sugar level, American Society of Anesthesiologists (ASA) classification (P = 0.15), transanal decompression tube (P = 0.06) and number of stapler cartridges used for rectal transection (P = 0.18) were selected for the multivariate analysis because of their P values being <0.2. The multivariate analysis identified male gender (odds ratio 4.12, P = 0.006) and the absence of a transanal decompression tube (odds ratio 3.11, P = 0.0484) as independent risk factors predicting anastomotic leakage.

CONCLUSIONS

Male gender and the absence of a transanal decompression tube appeared to be independent risk factors for anastomotic leakage. Insertion of a transanal decompression tube may help prevent anastomotic leakage after low anterior resection, particularly in male patients.

[MINIMALLY INVASIVE SURGERY FOR COLORECTAL CANCER BASED ON VIRTUAL SURGICAL ANATOMY]

For advanced right colon cancer, we perform lymph node dissection exposing the so-called surgical trunk. For the resection of advanced distal sigmoid/rectal cancer, we routinely perform lymph node dissection around the root of the inferior mesenteric artery, preserving the left colic artery. To perform either of these procedures safely, it is important to know the precise vascular anatomy with individual variations. However, there are major issues in laparoscopic surgery, such as a lack of tactile sensation and limited visual field. To overcome these issues and identify the vascular anatomy of each patient accurately, we have applied integrated three-dimensional computed tomography (3D-CT) imaging as a preoperative simulation and for intraoperative navigation since July 2000. Integrated 3D-CT imaging appears to be useful, especially for cancer located around the left flexure of the transverse colon, where major variations in vascular anatomy occur. Using the no-touch technique appropriately with the precise determination of laparoscopic surgical anatomy based on simulation and navigation by integrated 3D-CT imaging for each patient, systematic lymphadenectomy in addition to lateral lymph node dissection with tailor-made vascular laparoscopic dissection for the treatment of advanced lower rectal cancer appears to be feasible and a more meticulous approach compared with conventional open surgery.

Molecular magnesium hydrides supported by an anionic triazacyclononane-type ligand

A dimeric magnesium hydride supported by a monoanionic TACN-type ligand is formed by an unusual rearrangement of an unstable mononuclear complex with a terminal Mg–H bond.

Clinical implications of preoperative chemoradiotherapy prior to laparoscopic surgery for locally advanced low rectal cancer

The present study aimed to evaluate whether preoperative chemoradiotherapy (CRT) has any adverse effects on laparoscopic surgery (LS) for locally advanced low rectal cancer (LARC). The study was performed at the Osaka Medical College Hospital, and included patients who were operated on between July 2006 and December 2013. The short-term outcomes in 156 patients who underwent surgery for LARC following CRT were evaluated, of whom 152 underwent LS. Among the patients who were followed for >40 months, 77 patients (the CRT group) were compared with 39 patients who underwent LS without CRT (the surgery-alone group) for long-term outcomes. The total number of patients who received sphincter-preserving surgery was 74%. No positive longitudinal resection margins were identified, and only 1.3% had identifiable positive circumferential resection margins. The complication rate was 14%, and no serious complications occurred. There were no significant differences between the CRT and the surgery-alone groups in terms of the 5-year relapse-free survival rate (70.1 vs. 61.5%; P=0.81) or the 5-year overall survival rate (88.3 vs. 69.2%; P=0.06). However, the 5-year local recurrence-free survival rate was significantly improved in the CRT group patients (96.1 vs. 79.5%; P=0.009). In conclusion, our results have demonstrated that LS with preoperative CRT appears to be feasible and safe, and may have beneficial effects on local recurrence.