Effectiveness of negative pressure wound therapy for the wound of ileostomy closure: a multicenter, phase II randomized controlled trial.

BACKGROUND: The American Society of Surgery and American Society for Surgical Infections issued guidelines for surgical site infections (SSIs) in December 2016. These guidelines recommend a purse-string suture (PSS) for stoma closure as it facilitates granulation and enables open wound drainage. This study investigated the effect of using negative pressure wound therapy (NPWT) along with standard PSS and aimed to determine the optimal period of NPWT use. METHODS: The patients were divided into three groups as follows: Group A, postoperative wound management alone with gauze exchange as the representative of conventional PSS; Group B, the performed management was similar to that of Group A plus NPWT for 1 week; and Group C, the performed management was similar to that of Group A plus NPWT for 2 weeks. Regarding objective measures, the wound reduction rate was the primary outcome, and the incidence of SSIs, length of hospital stay, and wound healing duration were the secondary outcomes. RESULTS: In total, 30 patients (male: 18, female: 12) were enrolled. The average age was 63 (range: 43-84) years. The wound reduction rate was significantly higher in Group B than in Group A on postoperative days (PODs) 7 (66.1 vs. 48.4%, p = 0.049) and 10 (78.6 vs. 58.2%, p = 0.011), whereas no significant difference was observed on POD 14. Compared with Group A, Group C (POD 7: 65.9%, POD 10: 69.2%) showed an increase in the wound reduction rate on POD 7, although the difference was not significant (p = 0.075). SSIs were observed in Groups B (n = 2) and C (n = 2) (20%) but not in Group A (0%). CONCLUSIONS: The most effective duration of NPWT use for ileostomy closure with PSS in terms of the maximum wound reduction rate was from PODs 3 to 10. However, NPWT did not shorten the wound healing duration. NPWT may reduce the wound size but should be used with precautions for SSIs. The small sample size (30 cases), the use of only one type of NPWT system, and the fact that wound assessment was subjective and not blinded were the limitations of this study. Further studies are needed to confirm our findings. TRIAL REGISTRATION: UMIN Clinical Trials Registry; UMIN000032174 (10/04/2018).

Site-specific risk factors for local recurrence after rectal cancer surgery.

BACKGROUND: Quite few studies examined risk factors for local recurrence after rectal cancer surgery with respect to local recurrence sites. METHODS: Local recurrence sites were categorized into axial, anterior, posterior, and lateral (pelvic sidewall), and axial, anterior, and posterior type were combined as the "other" type of local recurrence. Among 76 patients enrolled into our prospective randomized controlled trial to determine the indication for pelvic autonomic nerve preservation (PANP) in patients with advanced lower rectal cancer (UMIN000021353), multivariate analyses were conducted to elucidate risk factors for either lateral or the "other" type of local recurrence. RESULTS: Univariate analyses showed that tumor distance from the anal verge was significantly (p = 0.017), and type of operation (sphincter preserving operation (SPO) vs. abdominoperineal resection (APR)) was marginally (p = 0.065) associated with pelvic sidewall recurrence. Multivariate analysis using these two parameters showed that tumor distance from the anal verge was significantly and independently correlated with pelvic sidewall recurrence (p = 0.017). As for the "other" type of local recurrence, univariate analyses showed that depth of tumor invasion (p = 0.011), radial margin status (p < 0.001), and adjuvant chemotherapy (p = 0.037) were significantly associated, and multivariate analysis using these three parameters revealed that depth of tumor invasion (p = 0.004) and radial margin status (p < 0.001) were significantly and independently correlated with the "other" type of local recurrence. CONCLUSION: Risk factors for local recurrence after rectal cancer surgery were totally different with respect to the intra-pelvic recurrent sites. Site-specific probability of local recurrence can be inferred using these risk factors. TRIAL REGISTRATION NUMBER: UMIN000021353.

Changing Patterns of Distant Metastasis in Patients With Lower Rectal Cancer Undergoing Intraoperative Radiotherapy.

BACKGROUND/AIM: Local radiotherapy for primary tumors may increase the incidence of distant metastasis. However, the patterns of target organs have not been clarified yet. PATIENTS AND METHODS: In our randomized controlled trial examining the oncological efficacy of intraoperative radiotherapy (IORT) for advanced lower rectal cancer, the details of the metastatic organs were evaluated. RESULTS: In the IORT group (38 patients), 2 patients had metastasis in the liver and lung simultaneously, 9 in the liver, and 4 in the lung. In the control group (38 patients), 3 had metastasis in the lung, and 2 in the liver. The IORT group tended to have liver metastases more frequently (p=0.058). Among patients with liver metastases, distant metastasis-free intervals were significantly shorter in the IORT group, however, no significant difference was observed among patients with lung metastases. CONCLUSION: After curative rectal cancer surgery with IORT, liver metastasis may be increased and accelerated.

Intraoperative radiotherapy for resectable advanced lower rectal cancer-final results of a randomized controlled trial (UMIN000021353).

AIM: Pelvic autonomic nerve preservation (PANP) is useful to preserve voiding and sexual function after rectal cancer surgery. The aim of this study was to investigate the benefit of intraoperative radiotherapy (IORT) to have complete PANP without affecting oncological outcomes. METHODS: Patients undergoing potentially curative resection of the rectum were included. They were randomized to intraoperative radiotherapy of the completely preserved bilateral pelvic nerve plexuses (IORT group) or the control group without IORT, but with limited nerve preservation. The primary endpoint was pelvic sidewall recurrence. Moreover, patients' clinicopathologic parameters, postoperative complications, voiding function, and other oncologic outcomes were compared. RESULTS: From 79 patients, three were excluded from analysis, resulting in 38 patients in each group. Patients' demographic and pathological parameters were well balanced between the two groups. The trial was terminated prematurely in July 2017, because distant metastasis-free survivals were found to be significantly worse in the IORT group compared to the control group (odds ratio 2.554; 95% CI, 1.041 ~ 6.269; p = 0.041). Neither overall survival nor pelvic sidewall recurrence did differ between the two groups (overall survival: odds ratio 1.264; 95% CI, 0.523~3.051; p = 0.603/pelvic sidewall recurrence; odds ratio 1.350; 95% CI, 0.302~6.034; p = 0.694). Postoperative complications did not differ between the groups; however, the urinary function was significantly better in the IORT group in the short and long term. CONCLUSION: With the aid of IORT, complete PANP can be done without increase of pelvic sidewall recurrence; however, IORT may increase the incidence of distant metastases. Therefore, IORT cannot be recommended as a standard therapy to compensate less radical resection for advanced lower rectal cancer.

The impact of tumor location on the biological and oncological differences of colon cancer: Multi-institutional propensity score-matched study.

BACKGROUND: Several studies have reported some differences between right-sided and left-sided colon cancer. The aim was to analyze the differences in clinical and pathological features, recurrence, and prognostic impact of tumor location in patients with tumors truly located in the right and left side of the colon. PATIENTS: The study included 6790 stage I-III colon cancer patients who underwent curative resection. Patient characteristics were balanced using propensity score matching. RESULTS: Recurrence rates of stage I and II patients with left-sided colon cancer were higher than those in the right-sided group, indicating that recurrence free survival of left-sided colon cancer patients was significantly shorter than that of the right-sided patients. In stage III patients that experienced recurrence, cancer specific survival after recurrence of the right-sided colon cancer patients was significantly shorter than that of the left-sided patients (P = 0.003). CONCLUSIONS: In stage I-II patients, left-sided colon cancer was a significant risk factor for recurrence free survival, however, in stage III patients, right-sided colon cancer was a significant risk factor for after recurrence cancer specific survival.

Recent trends (2016-2017) in the treatment of inflammatory bowel disease.

Prevalence of inflammatory bowel disease (IBD), ulcerative colitis and Crohn's disease has dramatically increased in Asian countries in the last three decades. In this period, many new medical therapies were introduced for the treatment of IBD, such as immunosuppressants, anti-tumor necrosis factor agents, leukocyte apheresis, anti-integrin antibody, and so on, which have contributed to induce remission and to reduce complications in IBD. As for surgical techniques for Crohn's disease, a stapled functional end-to-end anastomosis and conventional end-to-end anastomosis have similar perianastomotic recurrence rate and reoperation rate. Prospective randomized controlled studies which compare Kono-S anastomosis and stapled side-to-side anastomosis are ongoing. Variant two-stage ileal pouch anal anastomosis (IPAA) and transanal IPAA are new concepts for surgical treatment of ulcerative colitis. Various endoscopic procedures, such as balloon dilation for stenosis or stricture, endoscopic fistulotomy, injection of filling agents, and clipping for fistulas or perforations will be new options in the treatment of Crohn's disease. Adverse effects of preoperative treatments on postoperative complications should also be taken into account to improve surgical outcomes in IBD patients.

Optimal Surveillance Protocols After Curative Resection in Patients With Stage IV Colorectal Cancer: A Multicenter Retrospective Study.

BACKGROUND: After patients with stage IV colorectal cancer undergo curative surgical resection, there is a large risk for recurrence. To establish optimal surveillance guidelines, an understanding of the temporal risk factors for recurrence is necessary. OBJECTIVE: The primary aim of our study was to determine predictors for early (within 1 year), middle (1-2 years), and late (2 years or later) recurrence following curative resection in patients with stage IV colorectal cancer. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at multiple institutions. PATIENTS: The retrospective cohort study comprised 1070 patients with stage IV colorectal cancer after an R0 resection for the primary and metastatic lesions in 19 institutions from January 1997 to December 2007. MAIN OUTCOME MEASURES: Risk factors for early, middle, and late recurrence were determined by logistic regression and Cox proportional hazards models. RESULTS: The overall recurrence rate was 73% (784/1070). Cancer-specific survival was 29.5 months, and recurrence-free survival was 8.9 months. Early recurrence occurred in 488 (62%), middle recurrence in 184 (24%), and late recurrence in 112 (14%). In multivariable analysis, early recurrence risk factors included rectum site, depth of tumor invasion (T4), increasing N-staging, venous invasion, and liver metastasis. Late recurrence risk factors were tumor size ≤50 mm, and peritoneal dissemination. LIMITATIONS: Because of the retrospective nature of this study, postoperative therapy was not standardized. CONCLUSIONS: Risk factors differ for early, middle, and late recurrences of stage IV colorectal cancer following curative resection. Early (within 1 year) recurrence factors were rectum site, T4, N-staging, venous invasion, and liver metastasis, whereas late (2 years or later) recurrence risk factors were small tumor size and peritoneal dissemination. Our study provides important data to guide a surveillance protocol following stage IV colorectal cancer curative resection. See Video Abstract at http://links.lww.com/DCR/A460.

Clinical pharmacology of daikenchuto assessed by transit analysis using radiopaque markers in patients with colon cancer undergoing open surgery: a multicenter double-blind randomized placebo-controlled study (JFMC39-0902 additional study).

BACKGROUND: This exploratory trial was conducted to investigate whether daikenchuto accelerates the recovery of gastrointestinal function in patients undergoing open surgery for sigmoid or rectosigmoid cancer. METHODS: Eighty-eight patients who underwent colectomy at one of the 11 clinical trial sites in Japan from January 2009 to June 2011 were registered in the study. Patients received either placebo or daikenchuto (15.0 g/day, 5 g three times a day) from postoperative day 2 to postoperative day 8. The study end points included the gastrointestinal tract transit time evaluated with radiopaque markers and the time to first flatus. The safety profile of daikenchuto was also evaluated until postoperative day 8. RESULTS: Seventy-one patients (daikenchuto, n = 38; placebo, n = 33) were statistically analyzed. Although the number of radiopaque markers in the anal side of the small intestine at 6 h was significantly greater in the daikenchuto group than in the placebo group (15.19 vs 10.06, p = 0.008), the total transit analysis results and the mean time to first flatus did not differ significantly between the two groups. CONCLUSIONS: Daikenchuto has a positive effect on the resolution of delayed gastric emptying, but has a limited effect on the resolution of postoperative paralytic ileus after open surgery in patients with sigmoid or rectosigmoid cancer. Daikenchuto may contribute to early oral intake in the postoperative course.

Efficacy of Gum Chewing on Bowel Movement After Open Colectomy for Left-Sided Colorectal Cancer: A Randomized Clinical Trial.

BACKGROUND: Prolonged intestinal paralysis can be a problem after gastrointestinal surgery. Several systematic reviews and meta-analyses have suggested the efficacy of gum chewing for the prevention of postoperative ileus. OBJECTIVE: The purpose of this study was to examine the efficacy of gum chewing for the recovery of bowel function after surgery for left-sided colorectal cancer and to determine the physiological mechanism underlying the effect of gum chewing on bowel function. DESIGN: This was a single-center, placebo-controlled, parallel-group, prospective randomized trial. SETTINGS: The study was conducted at a general hospital in Japan. PATIENTS: Forty-eight patients with left-sided colorectal cancer were included. INTERVENTIONS: The patients were randomly assigned to a gum group (N = 25) and a control group (N = 23). Four patients in the gum group and 1 in the control group were subsequently excluded because of difficulties in continuing the trial, resulting in the analysis of 21 and 22 patients in the respective groups. Patients in the gum group chewed commercial gum 3 times a day for ≥5 minutes each time from postoperative day 1 to the first day of food intake. MAIN OUTCOME MEASURES: The time to first flatus and first bowel movement after the operation were recorded, and the colonic transit time was measured. Gut hormones (gastrin, des-acyl ghrelin, motilin, and serotonin) were measured preoperatively, perioperatively, and on postoperative days 1, 3, 5, 7, and 10. RESULTS: Gum chewing did not significantly shorten the time to the first flatus (53 ± 2 vs. 49 ± 26 hours; p = 0.481; gum vs. control group), time to first bowel movement (94 ± 44 vs. 109 ± 34 hours; p = 0.234), or the colonic transit time (88 ± 28 vs. 88 ± 21 hours; p = 0.968). However, gum chewing significantly increased the serum levels of des-acyl ghrelin and gastrin. LIMITATIONS: The main limitation was a greater rate of complications than anticipated, which limited the significance of the findings. CONCLUSIONS: Gum chewing changed the serum levels of des-acyl ghrelin and gastrin, but we were unable to demonstrate an effect on the recovery of bowel function.

Laparoscopic Repair of Internal Transmesocolic Hernia of Transverse Colon.

Introduction. Internal hernias are often misdiagnosed because of their rarity, with subsequent significant morbidity. Case Presentation. A 61-year-old Japanese man with no history of surgery was referred for intermittent abdominal pain. CT suggested the presence of a transmesocolic internal hernia. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We found internal herniation of the small intestine loop through a defect in the transverse mesocolon, without any strangulation of the small intestine. We were able to complete the operation laparoscopically. The patient's postoperative course was uneventful and the patient was discharged on postoperative day 6. Discussion. Transmesocolic hernia of the transverse colon is very rare. Transmesocolic hernia of the sigmoid colon accounts for 60% of all other mesocolic hernias. Paraduodenal hernias are difficult to distinguish from internal mesocolic transverse hernias. We can rule out paraduodenal hernias with CT. Conclusion. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We report a case of a transmesocolic hernia of the transverse colon with intestinal obstruction that was diagnosed preoperatively and for which laparoscopic surgery was performed.

Hemoptysis and acute respiratory syndrome (ARDS) as delayed-type hypersensitivity after FOLFOX4 plus bevacizumab treatment.

As there have been many multidrug regimens introduced in colorectal cancer treatment, hypersensitivity is more often encountered than in the past. Though most allergic adverse events of oxaliplatin are mainly classified as type I reaction, a limited number of case reports of type IV reaction (delayed-type hypersensitivity) have been reported. A 73-year-old man was hospitalized for receiving the third cycle of FOLFOX4 plus bevacizumab. Forty-two hours after administration, he had dyspnea and hemoptysis. Acute respiratory distress syndrome was suspected, and the patient underwent mechanical ventilation and steroid pulse therapy. Delayed-type hypersensitivity is induced by induction of inflammation via IL-1, TNF-α and IL-6. The serum level of IL-6 in patients with advanced colorectal cancers is usually greater than the normal range. Therefore, delayed-type hypersensitivity may be easily induced in those patients. We should pay special attention to delayed-type hypersensitivity in advanced colorectal cancer patients undergoing FOLFOX treatment.

Modified Glasgow prognostic score in patients with incurable stage IV colorectal cancer.

BACKGROUND: The modified Glasgow prognostic score is an inflammation-based prognostic score. This study examined whether this score, measured before surgical procedures, could predict postoperative cancer-specific survival. METHODS: We retrospectively studied 79 colorectal cancer patients who underwent a surgical procedure for incurable stage IV disease. The modified Glasgow prognostic score (0 to 2) comprises C-reactive protein (≤10 vs >10 mg/L) and albumin (<35 vs ≥35 g/L) measurements. RESULTS: In terms of overall survival, univariate analysis revealed significant differences in the status of lung metastasis, peritoneal dissemination, distant metastasis, hemoglobin, C-reactive protein, albumin, tumor resection, adjuvant chemotherapy, and modified Glasgow prognostic score. Multivariate analysis revealed that hemoglobin (P = .019), adjuvant chemotherapy (P = .002), and modified Glasgow prognostic score (0 and 1, low; 2, high) (P = .0001) were significant predictive factors for postoperative mortality. CONCLUSIONS: The modified Glasgow prognostic score is simple to obtain and useful in predicting survival in incurable stage IV colorectal cancer patients undergoing surgery.

Inflammatory mass formation caused by gastric ectopic pancreas: report of a case.

Ectopic pancreas is a relatively rare condition that only occasionally causes the development of symptoms. This report presents a case of ectopic pancreas presenting as an inflammatory mass that formed in the gastric wall, which was successfully treated by surgical resection. A 32-year-old female was admitted due to a 3-year history of recurrent episodes of upper abdominal pain. Contrast-enhanced computed tomography showed an irregularly enhanced mass of heterogeneous density in the gastric antrum. Gastroscopy revealed a submucosally elevated mass with a central umbilication in the gastric antrum. These studies indicated the presence of a 3-cm ectopic pancreas associated with inflammatory changes. The patient underwent laparoscopic local resection of the stomach. Microscopic examination of the lesion revealed heterogenic pancreatic tissue containing islets, dilated pancreatic ducts, and massive fibrosis in the gastric wall, with acinar atrophy and inflammatory cell infiltration. These findings indicated the formation of an inflammatory mass in the ectopic pancreas.

Which is the preference of choice either life with a stoma or evacuatory disorder following rectal cancer surgery?

BACKGROUND/AIMS: Low anastomosis with covering stoma is the standard operation for low rectal carcinoma. Some patients experience severe anorectal disorder, which makes us consider whether stoma closure should be performed or not. There was no comparative study between life with a stoma and life with evacuatory disorder. METHODOLOGY: Covering stoma was closed at 4 to 6 months after ultra-low anterior resection. Forty-five patients were evaluated by questionnaire in terms of their bowel evacuation and anorectal manometry before ultra-low anterior resection and 6 months after stoma closure. They were also questioned about their subjective preference regarding the life before and after stoma closure. RESULTS: After stoma closure, frequency of daily bowel movement was significantly increased up to 5 times (range 2-15). Incontinence score was also significantly worsened from 0 to 8, postoperatively. All patients complained of any influence in their social life. Ninety-three percent (42/45) of the cases were dissatisfied with evacuation, postoperatively. Eighty-nine percent (40/45) of the cases had postoperative evacuatory disorder defined by the present study. Under these backgrounds, all patients replied that evacuation from the anus was superior to life with a stoma even during postoperative evacuatory disorder status. CONCLUSION: Even when patients had evacuatory disorder, they preferred life without a stoma according to their subjective opinion.

Peristalsis gap sign at cine magnetic resonance imaging for diagnosing strangulated small bowel obstruction: feasibility study.

PURPOSE: The aim of this study was to determine the feasibility of cine magnetic resonance imaging (MRI) for diagnosing strangulated small bowel obstruction (SBO). MATERIALS AND METHODS: This study included 38 patients with clinically confirmed SBO who had undergone cine MRI. Cine MRI scans were evaluated regarding the presence of the "peristalsis gap sign" (referring to an akinetic or severely hypokinetic closed loop), indicating strangulation. Computed tomography (CT) was performed in 34 of 38 patients with (n = 25) or without (n = 9) contrast enhancement. CT images were evaluated using a combination of criteria (presence of hyperattenuation, poor contrast enhancement, mesenteric edema, wall thickening, massive ascites) indicating strangulation. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of cine MRI and CT for the diagnosis of strangulation were calculated and compared using surgical findings and the clinical course as the reference standard. RESULTS: Sensitivity, specificity, PPV, and NPV of cine MRI were 100%, 92.9%, 83.3%, and 100%, respectively; and those of CT (of which 26.5% was performed without contrast enhancement) were 66.7%, 92.0%, 75.0%, and 88.5%, respectively. There was no significant difference in diagnostic accuracy between the two methods (P = 0.375). CONCLUSION: Cine MRI is a feasible and promising technique for diagnosing strangulation.

Recovery of upper gastrointestinal bowel movement after rectosigmoid cancer surgery: a pilot transit analysis.

Postoperative gastrointestinal bowel transit right after colorectal resection has not yet been clarified. Thirty patients with rectosigmoid cancer were treated in this pilot study. The nasogastric tube was removed on the first postoperative day. One Sitzmarks capsule was given to each patient on the second postoperative day. Abdominal X-rays were taken at 3, 6, 8, 24, 48, and 72 hours after capsule intake. Distribution of the remaining Sitzmarks capsules were counted on X-ray films to clarify postoperative gastrointestinal movement after bowel resection. All Sitzmarks capsules were observed in the stomach at 3 and 6 hours after capsule intake. At 8 hours (second postoperative day), the Sitzmarks capsules were distributed from the stomach to the small intestine. Sitzmarks capsules were distributed in the right side colon at 24 hours (third postoperative day) after intake. Although the main distribution was still in the right side colon, several patients had evacuations accompanied by the disappearance of the Sitzmarks capsules. In 50% of the patients, it took approximately 72 hours (fifth postoperative day) for the first defecation after intake of the capsules. However, the Sitzmarks capsules remained mainly in the right side colon. Eight hours after intake, the majority of the Sitzmarks capsules shifted to the small intestine. Therefore, medication or feeding should be safely possible starting on the second postoperative day. There was no particular impact of bowel resection on upper gastrointestinal transit in patients with rectosigmoid cancer.

Neurophysiologic investigation of anal function following double stapling anastomosis.

BACKGROUND AND AIM: Manual dilatation of the anal sphincter and transanal introduction of the circular stapling device are required for intraluminal stapling anastomosis. This procedure has been regarded as one of the causes of postoperative evacuatory disorder in low anterior resection. However, there has been no evidence of this matter. Therefore, we conducted this study to clarify the impact of the procedure of stapling anastomosis on postoperative anal function. METHODS: Twenty-five cases with sigmoid colon cancer underwent potentially curative sigmoid colectomy with stapling anastomosis (ST group) and 20 cases with hand-sewn anastomosis (non-ST group). The patients were questioned regarding the daily frequency of bowel movement, the presence of urgency and soiling, and Wexner's incontinence score. Anorectal manomatry and pudendal nerve terminal motor latency were also evaluated. The patients' questionnaire and physiologic examinations were prospectively obtained before, and 1 and 6 months after the operation. RESULTS: Postoperative bowel habit was graded as satisfied in 92% (23/25 patients) in the ST group and 90% (18/20 patients) in the non-ST group. There was no significant difference between the 2 groups in terms of presence of fecal incontinence, discrimination of gas and stool, and daily frequency of bowel movement. In anal manometry, there was no significant difference between the 2 groups regarding the resting and squeezing anal canal sphincter pressures at 1 and 6 months postoperatively. Pudendal nerve terminal motor latency showed their latency from 2.0 to 2.5 ms throughout the periods, and there was no difference between the 2 groups before, and 1 and 6 months after the operation. CONCLUSION: Stapling anastomosis does not affect anal function in the early postoperative period.

Quality assurance of pelvic autonomic nerve-preserving surgery for advanced lower rectal cancer--preliminary results of a randomized controlled trial.

BACKGROUND: Pelvic autonomic nerve-preserving (PANP) lateral node dissection (LLND) has been introduced in rectal cancer surgery in Japan, but quality assurance of this approach has not been tested by randomized controlled trials. METHODS: Patients with advanced lower rectal cancer were randomized either to complete PANP + LLND surgery combined with intraoperative radiotherapy (preserved group; n = 28) or to pelvic autonomic nerve resection + LLND surgery (resected group; n = 27). Operation-related parameters were compared statistically. RESULTS: Patient and tumor characteristics were well comparable. The incidence of anastomotic breakdown, intrapelvic abscess, and small bowel obstruction was not different between the two groups. In the preserved group, no patients had ureteral stenosis, pelvic bone fractures, or peripheral neuropathy due to intraoperative radiotherapy. Sphincter-preserving operation was possible with similar ratio in both groups. Adjuvant chemotherapy was given with similar ratio in both groups. The average operation time was 513 minutes in the preserved group and 409 minutes in the resected group, with a significant difference between the two groups. The average amount of hemorrhage was not different significantly between the preserved group (996 ml) and the resected group (970 ml). Circumferential resection margin status and operative curability were similar between the two groups. The average number of harvested and metastatic nodes in the mesentery and pelvic sidewall was not different significantly between the two groups. CONCLUSIONS: This study revealed, for the first time, that the surgical quality of PANP + LLND is the same as pelvic autonomic nerve resection + LLND.

Rationale of pelvic autonomic nerve preservation in rectal cancer surgery based on immunohistochemical study.

PURPOSE: Previous studies revealed that the incidence of cancer cell involvement along the pelvic autonomic nerves ranged from 4 to 14%. However, patients' profiles and methodologies differed among the studies. This study was conducted to clarify the incidence of cancer cell involvement in and around the pelvic autonomic nerves immunohistochemically. METHODS: Immunohistochemical staining was performed on pelvic autonomic nerve specimens resected from 17 patients with p-Stage I-III lower rectal cancers. Antibodies used were pan-cytokeratin (AE1/AE3) for staining cancer cells, S-100 for autonomic nerves, and D2-40 for lymphatic vessels. Lymphatic permeation around the pelvic autonomic nerves was defined as present when AE1/AE3-positive cells were detected in D2-40-stained lymphatic vessels. The presence of metastasis to the interstitial tissue or contaminants was also recorded. RESULTS: TNM staging was stage I in 1, stage II in 5, and stage III in 11 cases, respectively. No cases had lymphatic permeation or metastasis to the interstitial tissue in and around the pelvic autonomic nerves. Cancer cell contaminants were seen in four cases (23%). In three cases (18%), metastatic nodes were located at the root of the middle rectal artery, very close to the pelvic autonomic nerves. CONCLUSIONS: Cancer cell involvement was not seen in and around the pelvic autonomic nerves, suggesting that complete pelvic autonomic nerve preservation may be feasible, unless nerves are invaded by the tumor. In some cases, however, metastatic nodes were seen very close to the nerves. Meticulous lymph node dissection along the pelvic autonomic nerves is mandatory.

Comparison of functional and clinical outcomes: colonic J-pouch vs. coloplasty in patients with low rectal cancer.

BACKGROUND/AIMS: Coloplasty has been reported as substitution to colonic J-pouch when it is difficult to fashion. However, previous studies showed conflicting results with reference to functional outcome. METHODOLOGY: Forty-seven patients with low rectal cancer were involved in this study from July 2000 to December 2006. Coloplasty was performed when colonic J-pouch was hard to construct due to technical difficulty such as short masenterium and narrow pelvis. Clinical and functional evaluations were performed before the operation and 12 months after stoma closure. RESULTS: Colonic J-pouch was abandoned in 12 of 37 cases (26%) due to short colon and mesenterium in 8 cases and narrow pelvis in 4 cases. Frequency of daily bowel movement was significantly increased in both groups but no difference between the groups. Anal sphincter tones were maintained even after the operation. Moreover, no difference was noted between the groups. Anal canal length and sensory factor were also maintained. Volumetric factors such as maximum tolerable volume and neo-rectal capacity showed significant changing before and after the operation. However, there was no significant difference between the groups. CONCLUSIONS: Coloplasty could be a possible substitution to colonic J-pouch in patients with low rectal cancer from functional point of view.