Transanal total pelvic exenteration in the prone jackknife position for rectal cancer invading the bladder, seminal vesicles, and small intestine.

A 58-year-old man had rectal cancer directly invading the urinary bladder and small intestine, without distant metastasis. We successfully performed complete resection using a hybrid approach, including laparoscopic surgery and transanal total pelvic exenteration (TaTPE) with the patient in the prone jackknife (PJK) position. In the PJK position, gravity and pelvic morphology lead to a clear and wide surgical field. This case demonstrates that total pelvic exenteration using laparoscopic surgery and TaTPE in the PJK position provides a better surgical field than either TaTPE or laparoscopic surgery in the supine position. TaTPE in the PJK position may also be useful for curative surgery in locally advanced rectal cancer.

Transanal total mesorectal excision in the prone jackknife position without being conscious of the size of prostatic enlargement for lower rectal cancer.

In 1982, it was demonstrated that a total mesorectal excision alone could achieve low rectal cancer recurrence rates in the pelvis and high disease-free survival rates. Nowadays, the total mesorectal excision is the gold-standard surgery for rectal cancer. Currently, the transanal total mesorectal excision has attracted attention as a promising alternative to the anterior approach. The transanal approach is superior to the anterior approach, because it facilitates total mesorectal excisions of the lower rectum, improves visualization, and shortens the surgical time. Some factors are particularly favorable for the transanal approach, including lesions in the lower third of the rectum, a narrow pelvis, a large tumor, male sex, and a prostatic enlargement. The transanal total mesorectal excision is commonly performed in the Lloyd-Davies position. However, in the Lloyd-Davies position, the sacral bone prevents the mobilized rectum from moving away from the pelvic base. From the perspective of pelvic morphology, we reasoned that, in the prone jackknife position, the mobilized rectum could spontaneously move toward the head, due to gravity, and this would broaden the pelvic surgical field. Consequently, this position could facilitate the transanal total mesorectal excision. Here, we described a transanal total mesorectal excision performed in the prone jackknife position for treating lower rectal cancer with a prostatic enlargement.

Antimicrobial stewardship without infectious disease physician for patients with candidemia: A before and after study.

BACKGROUND: Little is known about the effects of antimicrobial stewardship team (AST) without infectious disease physician (IDP) on clinical outcome in patients with candidemia. METHODS: We conducted a before and after study involving patients with hospital-acquired candidemia at a tertiary hospital without IDPs. The AST consisted of physicians, pharmacists, nurse, microbiologist, and administrative staff. A candidemia care bundle was developed based on the Infectious Disease Society of America (IDSA) guideline. The non-IDP AST provided recommendations to the attending physicians whose patients developed candidemia during hospitalization. The primary outcome was 30-day all-cause mortality, while the secondary outcomes were adherence to the IDSA guidelines regarding the management of candidemia. Data of up to 3 years of preintervention and 3 years of intervention period were analyzed. RESULTS: By 30 days, 11 of 46 patients (23.9%) in the intervention group and 7 of 30 patients (23.3%) in the preintervention group died (adjusted hazard ratio for the intervention group: 0.68 [95% CI 0.24-1.91]). The non-IDP AST was associated with appropriate empirical antifungal therapy (100% vs 60.0%; proportion ratio 1.67 [95% CI 1.24-2.23]), appropriate duration of treatment (84.7% vs 43.3%; 1.96 [1.28-3.00]), removal of central venous catheters (94.4% vs 70.8%; 1.33 [1.02-1.74]), and ophthalmological examination (93.5% vs 63.3%; 1.48 [1.12-1.96]). CONCLUSIONS: Although we found no significant difference in 30-day mortality, the non-IDP AST was associated with improved adherence to guidelines for management of candidemia.

Laparoscopic radical lymph node dissection for advanced colon cancer close to the hepatic flexure.

INTRODUCTION: Complete mesocolic excision is currently recognized as a standard procedure for colon cancer. Gastroepiploic, infrapyloric, and superficial pancreatic head lymph node metastases in the gastrocolic ligament have been reported for colon cancer close to the hepatic flexure. We sought to investigate metastases in the gastrocolic ligament in colon cancer close to the hepatic flexure. METHODS: This was a single-center retrospective study. All patients with T2 or deeper invasive colon cancer in the relevant tumor location who underwent laparoscopic right hemicolectomy or extended right hemicolectomy at our institution between 1 April 2011 and 31 March 2015 were included. RESULTS: Lymph node dissection in the gastrocolic ligament was performed in 35 cases. Complications occurred in 11 patients (31%) and were grades I and II according to the Clavien-Dindo classification. Lymph node metastases in the gastrocolic ligament were found in only three patients (9%). Each metastasis was larger than 9 mm. CONCLUSIONS: Metastases in the gastrocolic ligament occurred in 9% of patients with T2 or deeper invasive colon cancer close to the hepatic flexure. Laparoscopy was feasible and useful during gastrocolic ligament resection. This study included a small sample and lacked an extended follow-up. Further studies are needed to determine the clinical relevance of this finding, particularly in terms of recurrence and long-term survival.

Single-access laparoscopic colectomy utilizing gravity in the lateral decubitus position.

BACKGROUND: Only a limited number of instruments can be used in single-access laparoscopic colectomy, and triangulation must be forfeited to avoid instrument collision. We investigated whether this problem could be overcome by performing laparoscopic colectomy by the use of the lateral decubitus position, making full use of gravity. OBJECTIVE: The aim of this study was to determine whether single-access laparoscopic colectomy could be achieved while maintaining patients in the lateral decubitus position. DESIGN: This was a prospective study. SETTING: This single-center study was conducted in a hospital. PATIENTS: Ten consecutive patients (4 men and 6 women) with stage II or III colon cancer were included. INTERVENTIONS: Each patient was placed in the lateral decubitus position. Single-port access to the abdomen was provided by a 3.0-cm incision at the umbilicus. The roots of the supplying or draining vessels were isolated and divided for lymphadenectomy. Next, the colon was dissected from a lateral approach, without the help of the assistant. The specimen was extracted from the single-access incision. Extracorporeal or intracorporeal anastomosis was performed. MAIN OUTCOME MEASURES: The primary outcome measured was the feasibility of single-access laparoscopic colectomy in the lateral decubitus position. RESULTS: There were no intraoperative complications and no need for conversions to conventional laparoscopic surgery, open surgery, or the supine position. The median total surgical time was 154 minutes (interquartile range, 135-220 minutes). Surgical blood loss was slight (<20 mL) in all patients. No postoperative complications occurred. The median postoperative hospital stay was 7 days (interquartile range, 5-7 days). LIMITATIONS: The sample size was small. CONCLUSIONS: Our results show that single-access laparoscopic colectomy in the lateral decubitus position is safe and feasible.

Molecular mechanisms of liver metastasis.

Colorectal cancer is the second most common cancer, and is the third leading cause of cancer-related death in Japan. The majority of these deaths is attributable to liver metastasis. Recent studies have provided increasing evidence that the chemokine-chemokine receptor system is a potential mechanism of tumor metastasis via multiple complementary actions: (a) by promoting cancer cell migration, invasion, survival and angiogenesis; and (b) by recruiting distal stromal cells (i.e., myeloid bone marrow-derived cells) to indirectly facilitate tumor invasion and metastasis. Here, we discuss recent preclinical and clinical data supporting the view that chemokine pathways are potential therapeutic targets for liver metastasis of colorectal cancer.

Single-access laparoscopic low anterior resection with vertical suspension of the rectum.

PURPOSE: Single-access laparoscopic surgery was first introduced for colectomy and later adapted for anterior resection. During single-access laparoscopic pelvic procedures, such as total mesorectal excision, it is often difficult to obtain an adequate operative field. By suspending the rectum vertically, we were able to execute a total mesorectal excision with single-access laparoscopy. We describe here the use of this new procedure to treat rectal cancer. METHODS: The selected 7 patients (1 male and 6 female) with stage II or III rectal cancer underwent the procedure. Single-port access to the abdomen was provided by a 3.0-cm incision at the right iliac fossa. The descending mesocolon was dissected by use of a medial approach, and a columnar magnet was placed on the surface of the abdominal wall to restore triangulation. The inferior mesenteric artery was skeletonized and the superior rectal artery divided during lymph node dissection. The total mesorectal excision extended to the pelvic floor and the rectum was vertically retracted with a suspending bar in collaboration with an extracorporeal magnet tool. The rectum was then transected below the reflection of the peritoneum. Intracorporeal anastomosis was performed with the double-stapling technique. Two pelvic drains were inserted through the single incision and the anus, respectively, for all patients. A defunctioning ileostomy was not created in any patient. RESULTS: Median total surgical time was 205 minutes (range, 175-245 min). Intraoperative blood loss was minimal in all patients (range, 1-20 mL). None of the cases required conversion to open surgery or addition of a second port. The only preoperative or postoperative complication occurred in one patient with clinical anastomotic leakage. CONCLUSION: Low anterior single-access laparoscopic resection seems safe and feasible when the rectum is suspended like a swing to ensure an adequate operative field.

Multimedia article. Radical lymphadenectomy for advanced colon cancer via separation of the mesocolon into two layers as in filleting fish.

BACKGROUND: Radical lymphadenectomy for advanced colon cancer performed via the medial approach improves oncologic outcomes. However, D3 radical lymphadenectomy possesses some unresolved problems such as the complicated vascular anatomy and concerns over surgical morbidity [1-5]. The authors present a simple and safe procedure for laparoscopic right or left hemicolectomy using a medial approach to overcome these problems. The key characteristic of their procedure is separation of the mesocolon into two layers along the superior or inferior mesenteric artery, showing the course of these branches under the mantle of the vascular sheath. This procedure resembles filleting fish into two pieces. METHODS: Between October 2009 and March 2010, 11 consecutive patients with advanced colon cancer underwent a curative laparoscopic right (n=5) or left (n=6) hemicolectomy via a medial approach by a single surgeon. The body mass image (BMI) for the 11 patients ranged from 22 to 32 kg/m2. With this procedure, the D3 lymphadenectomy procedure is performed first [6]. The mesocolon is dissected between the superficial layer of the fat tissue and the deep layer of the vascular sheath along the superior or inferior mesenteric artery. After the course of each branch is exposed, each supplying or draining vessel is transected at its root [7, 8]. The use of a laparoscope and a spatula-type electric cautery greatly contributes to this procedure [9]. Next, the bowel is mobilized, and the specimen is retrieved through the small incision. Finally, extra- or intracorporeal anastomosis is performed. RESULTS: No intraoperative complications occurred. The median number of retrieved lymph nodes was 23 (range, 13-52). The median total operative time was 220 min (range, 145-318 min), and the intraoperative blood loss was minimal (range, 0-70 g). The postoperative course was uneventful for all the patients. CONCLUSIONS: The authors consider the described method to be simple and safe for radical lymphadenectomy during a laparoscopic right or left hemicolectomy.

Single-access laparoscopic left and right hemicolectomy combined with extracorporeal magnetic retraction.

PURPOSE: In single-access laparoscopic colectomy, the number of forceps inserted through the umbilical incision is limited. To compensate for the single-access site, triangulation must be lost or instrument collision must be sustained. Extracorporeal magnetic retraction can overcome this problem. This report describes the use of this new procedure for colon cancer resection. METHODS: All patients had advanced cancer of the descending or the ascending colon. Single access to the abdomen was achieved with a 3.0- to 4.0-cm umbilical incision. Short vascular forceps and 2 rolls of gauze were inserted into the incision and a columnar magnet was placed on the surface of the abdominal wall. A specially made port access device was attached at the incision. The vascular forceps grasping the tissue were retracted by moving the magnet, enabling triangulation in cooperation with a second forceps. The mesocolon was dissected using a medial to lateral approach. The roots of the vascular pedicles were isolated and divided from the superior or the inferior mesenteric artery during lymph node dissection. Extracorporeal anastomosis was performed. RESULTS: There were no intraoperative complications, no need to convert to open surgery, and no need to add a second port. The median total surgical time was 255 (range, 220-315) minutes. Surgical blood loss was slight (range, 1-20 mL) in all patients. No postoperative complications occurred. The postoperative hospital stay was 7 days for each patient. CONCLUSIONS: This procedure can be safely and feasibly performed using extracorporeal magnetic retraction.

Single-access laparoscopic colectomy with a novel multiport device in sigmoid colectomy for colon cancer.

PURPOSE: Laparoscopic-assisted colectomy is a common procedure for colorectal disease, and laparoscopic colectomy from a single access point is rapidly evolving. This report describes the use of single-access laparoscopic colectomy (SALC) with a novel multiport device in sigmoidectomy for colon cancer. METHODS: Data were collected retrospectively on 5 patients who underwent the procedure for colon cancers in the period from November 2008 through January 2009. The abdomen was approached through a 3- to 4-cm incision via the umbilicus in every case. To ensure maintenance of the pneumoperitoneum, the procedure was performed with a specially developed multiport device enveloped by a glove containing 3 5-mm ports. In all 5 patients, the root of the inferior mesenteric artery was isolated and divided at the distal side where the left colic artery branched off. RESULTS: The median total surgical time was 185 (range, 176-210) minutes. In all patients, surgical blood loss was slight (range, 0-20 mL). Only one patient required conversion into laparoscopic-assisted colectomy by the addition of 2 ports, because the location adjacent to the descending colon made it necessary to mobilize the splenic flexure. The median number of harvested lymph nodes was 17 (range, 12-24). No postoperative complications occurred. The postoperative hospital stay was 7 days for every patient. CONCLUSIONS: Single-access laparoscopic sigmoidectomy seems to be feasible and safe when performed by experienced laparoscopic surgeons who are familiar with the unique principles of this procedure. Additional experience and continued investigations are warranted.

Acetylcholine receptor effects on accumbal shell dopamine-mediated turning behaviour in rats.

The nature of acetylcholine receptor effects on dopaminergic functions within the nucleus accumbens shell was studied in rats, using turning behaviour as read-out parameter. Unilateral injections of the acetylcholine receptor agonist, carbachol (1.0-5.0 microg), into the nucleus accumbens shell dose-dependently elicited contraversive circling. Unilateral injections of the combination of a fixed dose of the dopamine D(2) receptor agonist, quinpirole (10.0 microg), with increasing doses of the dopamine D(1) receptor agonist, SKF 38393 (1.0-5.0 microg), into the nucleus accumbens shell dose-dependently elicited contraversive pivoting. The same held for the combination of a fixed dose of SKF 38393 (5.0 microg) with increasing doses of quinpirole (5.0 and 10.0 microg), which was injected into the nucleus accumbens shell. The nicotinic acetylcholine receptor antagonist, mecamylamine (5.0 and 10.0 microg), injected into the nucleus accumbens shell, which alone did not elicit any turning behaviour, significantly suppressed both the contraversive circling induced by carbachol (5.0 microg) and the contraversive pivoting induced by the mixture of SKF 38393 (5.0 microg) and quinpirole (10.0 microg). The muscarinic acetylcholine receptor antagonist, methylscopolamine (1.0 and 2.5 microg), injected into the nucleus accumbens shell, which alone did not elicit any turning behaviour, significantly suppressed the contraversive circling induced by carbachol (5.0 microg), whereas it significantly increased the contraversive pivoting induced by both the mixture of SKF 38393 (1.0 microg) and quinpirole (10.0 microg) and the mixture of SKF 38393 (5.0 microg) and quinpirole (5.0 microg). Neither SKF 38393 (5.0 microg) nor quinpirole (10.0 microg) injected into the nucleus accumbens shell affected the contraversive circling induced by carbachol (5.0 microg). Carbachol (1.0 microg) injected into the nucleus accumbens shell caused a slight initial potentiation followed by an inhibition of the contraversive pivoting induced by the mixture of SKF 38393 (5.0 microg) and quinpirole (10.0 microg). These results confirm that stimulation of both nicotinic and muscarinic acetylcholine receptors in the nucleus accumbens shell is required for the accumbens-dependent, acetylcholine-mediated circling. The study provides the original evidence that stimulation of nicotinic acetylcholine receptors in the nucleus accumbens shell is required for the accumbens-dependent, dopamine-mediated pivoting. Finally, the present study shows that muscarinic acetylcholine receptors in the nucleus accumbens shell play an inhibitory role in the production of the accumbens-dependent, dopamine-mediated pivoting.

GABAA and GABAB receptors in the nucleus accumbens shell differentially modulate dopamine and acetylcholine receptor-mediated turning behaviour.

The ability of GABAA and GABAB receptors in the shell of the nucleus accumbens to modulate distinct types of turning behaviour was investigated in freely moving rats, using the unilateral injection technique. The GABAA receptor agonist muscimol and the GABAA receptor antagonist bicuculline did not produce turning behaviour; the same holds for the GABAB agonist baclofen and the GABAB antagonist 2-hydroxysaclofen. A mixture of the dopamine D1 receptor agonist SKF 38393 and the dopamine D(2/3) receptor agonist quinpirole has been found to elicit contraversive pivoting, when injected into the shell. This pivoting was dose-dependently inhibited by muscimol, and the inhibitory effect of muscimol was antagonised by bicuculline. Pivoting was also dose-dependently inhibited by baclofen; however, 2-hydroxysaclofen did not antagonise the inhibitory effect. The acetylcholine receptor agonist carbachol has been found to elicit contraversive circling, when injected into the shell. This carbachol-induced circling was inhibited by baclofen, and 2-hydroxysaclofen antagonised the inhibitory effect. Carbachol-induced circling was also partially inhibited by muscimol; however, the inhibitory effect of muscimol was not antagonised by bicuculline. It is concluded that mesolimbic GABAA receptors exert an inhibitory control on dopamine-dependent pivoting that can be elicited from the shell of the nucleus accumbens, and that GABAB receptors exert an inhibitory control on acetylcholine-dependent circling that can be elicited from the shell of the nucleus accumbens. This data extends the earlier reported findings that the neurochemical substrate in the shell of the nucleus accumbens that mediates dopamine-dependent pivoting is fundamentally different from the shell substrate that mediates acetylcholine-dependent circling.

Role of mu- and delta-opioid receptors in the nucleus accumbens in turning behaviour of rats.

The role of mu-, delta1- and delta2-opioid receptors in the nucleus accumbens in pivoting was investigated in freely moving rats. Unilateral injections of the mu-opioid receptor agonist, [D-Ala2,N-Me-Phe4,Gly5-ol]-enkephalin (DAMGO, 1 and 2 microg) and the delta2-opioid receptor agonist, deltorphin II (1 and 2 microg), but not the delta1-opioid receptor agonist, [D-Pen(2,5)]-enkephalin (DPDPE, 1-4 microg), into the shell or the core of the nucleus accumbens significantly induced contraversive pivoting. The pivoting induced by DAMGO (2 microg) and deltorphin II (2 microg) was inhibited significantly by the mu-opioid receptor antagonist, D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Phe-Thr-NH2 (CTOP, 0.1 and 1 microg), and the delta2-opioid receptor antagonist, naltriben (NTB, 0.1 and 1 mg/kg, i.p.), respectively. The DAMGO (2 microg)- or deltorphin II (2 microg)-induced pivoting was also inhibited significantly by co-administration of the dopamine D1/D2 receptor antagonist, cis(Z)-flupentixol (1 and 10 microg). The pivoting induced by unilateral injections of a mixture of dopamine D1 (SKF 38393, 5 microg) and D2 (quinpirole, 10 microg) receptor agonists into the shell was significantly inhibited by cis(Z)-flupentixol (1 and 10 microg) or NTB (1 and 3 mg/kg, i.p.), but not CTOP (1 microg) or delta1-opioid receptor antagonist, (E)-7-benzylidenenaltrexone (1 mg/kg, i.p.). The contraversive pivoting elicited by the cholinergic agonist, carbachol (5 microg), into the core was inhibited by co-administration of the muscarinic M1 antagonist, pirenzepine (1 microg), but not cis(Z)-flupentixol (1 microg). The results suggest that unilateral activation of mu- or delta2-opioid, but not delta1-opioid, receptors in the core and/or shell of the nucleus accumbens elicits contraversive pivoting that requires intact dopamine D1/D2 receptors in the shell, but not intact muscarinic M1 mechanism in the core. The study also shows that delta2-opioid, but not mu- and delta1-opioid, receptors in the core and/or shell modulate the shell-specific, dopamine D1/D2 receptor mechanisms involved in the production of pivoting.