[A case of ulcerative colitis complicated by disseminated intravascular coagulation that improved markedly after surgery].

A 57-year-old man presenting with severe ulcerative colitis (UC) complicated by disseminated intravascular coagulation (DIC) was referred to our hospital. Since it was difficult to improve DIC immediately with any medical treatment, total proctocolectomy, ileoanal canal anastomosis, and ileostomy were performed on the patient. Soon after the surgery, his platelet count and coagulability improved, and he recovered from DIC. Thus, when the cause of DIC is probably UC itself, and medical treatment has limited efficacy in improving the DIC, surgery should be performed as soon as possible to eliminate the cause of DIC, considering the general condition of the patient.

[Surgical treatment for ulcerative colitis in patients over 70 years of age].

The clinical course of 104 patients with ulcerative colitis who underwent primary surgery at ≥70 years was retrospectively examined. Pre- and postoperative patient conditions determined the choice of surgical procedure. Approximately half of the patients underwent restorative proctocolectomy, resulting in relatively good defecation function. In addition, the long-term outcomes of patients who underwent permanent ileostomy were favorable. However, the postoperative complication and mortality rates were high in all patients, including those with low preoperative performance status due to long-term hospitalization. In this patient population, surgery should be conducted before decreased performance status due to long-term hospitalization.

Postoperative results and complications of fecal diversion for anorectal Crohn's disease.

PURPOSE: Fecal diversion is a less-invasive technique that can alleviate symptoms in patients with refractory anorectal Crohn's disease. However, complications, including recurrence of residual anorectal Crohn's disease, may develop. We aimed to evaluate the postoperative results and complications associated with fecal diversion in patients with refractory anorectal Crohn's disease. METHODS: We enrolled 1218 Crohn's disease patients who underwent laparotomy at our institute. We retrospectively analyzed the clinical features of 174 patients who underwent fecal diversion for refractory anorectal Crohn's disease, complications of the diverted colorectum, and the incidence and risk factors for proctectomy after fecal diversion. RESULTS: After fecal diversion, 74% of patients showed improved symptoms. However, bowel continuity restoration was successful in four patients (2.2%), and anorectal Crohn's disease recurred in all patients. Seventeen patients developed cancer with a poor prognosis. The rate of conversion to proctectomy after fecal diversion was 41.3%, and the risk factors included rectal involvement (p = 0.02), loop-type stoma (p < 0.01), and the absence of treatment with biologics after fecal diversion (p = 0.03). CONCLUSION: Fecal diversion for refractory anorectal Crohn's disease can improve clinical symptoms. Patients with rectal involvement or loop-type stoma have a greater risk of requiring proctectomy following fecal diversion. The administration of biologic may decrease the rate of proctectomy.

[A case of a patient with Crohn's disease who had vaginal delivery after abdominoperineal resection for severe anorectal complications].

We report the case of a young female patient with Crohn's disease case who had vaginal delivery after abdominoperineal resection for severe perianal disease. The patient had Crohn's disease with anorectal complications for 13 years and underwent abdominoperineal resection for anorectal stenosis, complex anal fistula, and rectovaginal fistula in her early twenties. Seven years later, she got pregnant and gave birth to a healthy boy by vaginal delivery. No recurrence of Crohn's disease was observed during the perinatal period. There is no curative treatment for severe anorectal complications, which may be necessary for young patients to undergo abdominoperineal resection. Further studies are needed to determine the effects of Crohn's disease with anorectal complications on pregnancy and childbirth in affected patients.

A Study of the Right Colonic Vascular Anatomy: Correlations between Veins and Arteries.

OBJECTIVES: Few studies have examined the correlations between the arteries and veins of the right colon. In this study, we aimed to use high-resolution CT scans to understand the vascular anatomy of Henle's gastrocolic trunk and review the terminology describing the arteries and veins of the right colon. METHODS: This retrospective study has examined patients who underwent laparoscopic colectomy for right colon cancer in a single institution in Japan. Scans from consecutive patients who underwent surgery between October 2017 and March 2020 (n = 165) were examined. Preoperative CT images were used to create multiplanar reformation images and volume rendering images. RESULTS: Among the 139 patients with Henle's gastrocolic trunk (GCT) present, arteries accompanying the accessory right colic vein (ARCV) were most common on the right branch of the middle colic artery (MCA) (71.2%), followed by the right colic artery (RCA) (19.4%); meanwhile, 9.4% of the patients had no accompanying arteries. Of patients with no accompanying arteries to the ARCV, RCA was present in 15.4%. Among the 26 patients with no GCT, the right colic vein (RCV) existed in 15 patients, with the artery accompanying the RCV most commonly being the right branch of the MCA (66.6%), followed by the RCA (33.3%). CONCLUSIONS: Irrespective of the presence of GCT, approximately 70% of the arteries accompanying the drainage vein from the right colon were the right branch of the MCA. We suggest that vascular branch formation be considered preoperatively in surgical management for right colon cancer.

[Pregnancy and delivery in patients with Crohn's disease who had a history of abdominal surgery].

OBJECTIVE: A few studies have focused on pregnancy and childbirth in patients with Crohn's disease (CD) who had a history of abdominal surgery. The objective of this study is to analyze the problems of pregnant patients with CD with a history of abdominal surgery. METHODS: The rates of pregnancy-related complications and adverse birth outcomes were retrospectively analyzed in 29 patients with CD (45 pregnancies) with previous intestinal surgery. RESULTS: In this study, the following outcomes were observed:normal births occurred in 55.6% of the pregnancies, preterm births in 13.3%, and spontaneous abortions in 20.0%. The vaginal birth and cesarean section rates were 45.7% and 40.0%, respectively. The rate of low-birth weight infants was 14.3%. CONCLUSION: Overall, patients with CD with previous abdominal surgery can conceive and give birth. However, care needs to be taken to avoid preterm birth, spontaneous abortion, low birth weight, and cesarean delivery.

Subtotal colectomy for refractory ulcerative colitis with COVID-19 infection; a first case report in Japan.

We report a 60-year-old male who was transferred to our hospital for the operation because of refractory ulcerative colitis (UC). He was diagnosed to be infected with COVID-19 for SARS-CoV-2 PCR test positive at the time of transfer. We determined emergency operation because his general condition was poor such as malnutrition and ADL decline due to exacerbation of UC and air embolization by central venous catheter removal. He underwent subtotal colectomy with a sigmoid mucous fistula and ileostomy. He was well postoperatively. This is a first case report in Japan who underwent an operation for UC with COVID-19 infection.

Clinicopathological and prognostic evaluations of anorectal cancer after fecal diversion for patients with Crohn's disease.

PURPOSE: Colorectum diversion with a proximal stoma is often the preferred surgical approach in patients with Crohn's disease-related anorectal lesions or refractory colitis. To date, few studies have assessed the incidence and prognosis of cancer in the diverted anorectal segments. This study aimed to evaluate the clinical characteristics and prognosis of anorectal cancer associated with Crohn's disease following fecal diversion. METHODS: This was a retrospective study based on medical records of patients diagnosed with Crohn's disease between 1999 and 2020. It was conducted at Yokohama Municipal Citizen's Hospital. Patients diagnosed with anorectal cancer following fecal diversion were identified, and their prognosis was the primary outcome measure. RESULTS: Among 1615 patients, 232 patients (14%) underwent colorectum diversion. Of those 232 patients, 11 were diagnosed with anorectal cancer following fecal diversion, ten were diagnosed with advanced cancer, 10 underwent abdominoperineal resection, and eight died. 1 could not undergo resection due to multiple lung metastasis and died. The overall five-year survival rate in patients diagnosed with anorectal cancer following fecal diversion was 20%. CONCLUSION: Crohn's disease-associated anorectal cancer following fecal diversion was challenging to diagnose early, and patients had a poor prognosis even after curative resection. Early abdominoperineal resection may be considered for patients with Crohn's disease who cannot benefit from cancer screening and surveillance due to difficulty accessing the anorectal stricture via endoscopy.

Laparoscopic Surgery for Colorectal Cancer in Patients on Hemodialysis: A Propensity Score-matched Analysis.

BACKGROUND/AIM: Surgery on hemodialysis patients requires special attention, as the tissue of these patients is vulnerable and hemorrhagic. This study explored the feasibility of laparoscopic surgery for colorectal cancer in hemodialysis patients. PATIENTS AND METHODS: This was a retrospective study of patients who underwent laparoscopic surgery for colorectal cancer in a single institute from April 2007 to December 2016. RESULTS: A total of 2668 patients were included: 24 (0.9%) were on hemodialysis, and 2644 (99.1%) were not. After 1:1 propensity score matching, there were no significant differences in the short-term postoperative results, the disease-free survival rate (p=0.0813) or the cancer-specific survival rate (p=0.555). However, the overall survival rate was significantly lower in hemodialysis patients than in non-hemodialysis patients (p=0.0135). CONCLUSION: Standard laparoscopic operative procedures can be safely performed for hemodialysis patients, and there was no marked difference in the long-term oncological outcomes between the two groups.

The Significance of Lateral Lymph Node Metastasis in Low Rectal Cancer: a Propensity Score Matching Study.

BACKGROUND: The indications for lateral lymph node dissection (LLND) in rectal cancer have been controversial. The purpose of this study was to clarify the significance of lateral lymph node metastasis in low rectal cancer. METHODS: This was a retrospective study at a high-volume cancer center in Japan. In this study, 40 patients with pathologically positive LLN (LLN+) were matched with 175 negative (LLN-) patients by propensity score matching (PSM). COX regression analysis was used to identify independent risk factors related to prognosis. The relapse-free survival rate (RFS) and overall survival rate (OS) of the 2 groups before and after matching were analyzed. RESULTS: Of the 64 patients undergoing LLND, 40 (62.5%) patients had LLN+ disease. The LLN+ patients showed deeper infiltration of the primary tumor than the LLN- patients (T3-T4: 87.5% vs. 72.0%; p = 0.044), a greater number of metastatic lymph nodes (N2: 75.0% vs. 35.4%; p < 0.001), and a higher rate of local recurrence (30% vs. 9.1%; p < 0.001). Adjuvant chemotherapy was more common in the 40 LLN+ patients than in the 175 LLN- patients (70.0% vs. 46.8%; p = 0.008). After relapse, the rate of first-line chemotherapy administration for LLN+ patients was higher than that for the LLN- patients (62.5% vs. 29.5%; p = 0.005). The RFS of LLN+ patients was shorter than that of the LLN- patients (p = 0.005). After PSM, although more LLN+ patients received adjuvant chemotherapy than the LLN- patients (70.0% vs. 40.0%; p = 0.007), the local recurrence rate remained higher (30% vs. 10%; p = 0.025). The differences between RFS (p = 0.655) and OS rates (p = 0.164) of the 2 patient groups were not significant. CONCLUSION: Even after LLND, patients with LLN+ low rectal cancer still showed an elevated local recurrence rate. Controlling local recurrence by adjuvant chemotherapy alone is difficult, and the additional strategic treatments are needed.

Does signet ring cell carcinoma component signify worse outcomes for patients with colorectal cancer?

AIM: The purpose of this study was to elucidate the differences in clinical pathology and prognosis between signet ring cell carcinoma component and adenocarcinoma in colorectal cancer. MATERIALS AND METHODS: From April 2007 to December 2016, a total of 4348 patients with colorectal cancer underwent surgery, of which 3283 were included in the study. One patient was diagnosed with signet ring cell carcinoma (SRCC); 16 were diagnosed with signet ring cell carcinoma component (SRCCc); and 3266 patients were diagnosed with adenocarcinoma (ADC). We matched SRCCc and ADC with a propensity score of 1:3 and analyzed overall survival rates (OS) and cancer-specific survival rate (CSS) between the 2 groups before and after matching. RESULTS: Before matching, patients in the SRCCc group had more advanced cancer (stage III-IV: 87.5% vs 45.6%; P < .001), more perineural invasion (75.0% vs 44.2%; P = .013), and higher lymphatic invasion (87.5% vs 42.4%; P < .001) than those in the ADC group. Consequently, the OS (P < .001) and CSS (P = .049) of the SRCCc group were worse than the ADC group. Peritoneal metastasis was found in 4 (57%) patients with stage IV disease. However, after tumor staging and all background factors were matched, there were no significant differences in prognosis for OS (P = .127) and CSS (P = .932) between the 2 groups. CONCLUSION: SRCCc is more likely to be associated with lymphatic invasion and perineural infiltration than ADC, leading to significantly poorer survival outcomes. However, when all background factors are matched with ADC, the prognosis of SRCCc is not worse than ADC. Improving the treatment outcomes of peritoneal metastasis may be pivotal in the treatment of SRCCc.

Prognostic Utility of Apical Lymph Node Metastasis in Patients With Left-sided Colorectal Cancer.

BACKGROUND: Unlike the tumor nodes metastasis (TNM) lymph node classification, based solely on counts of nodal metastases, the Japanese system of classifying colorectal carcinoma (CRC) focuses on regional lymph node spread. In this study, we explored the prognostic utility of inferior mesenteric artery (IMA) apical lymph node (APN) metastasis. PATIENTS AND METHODS: This was a retrospective study of patients with stage III left-sided CRC. All enrollees were subjected to D3 resection between April 2007 and December 2016 at the International Medical Center of Saitama Medical University and then stratified by histologic presence (APN+ group) or absence (APN- group) of tumor in APNs examined postoperatively. Ultimately, propensity score matching was invoked (1:2) and COX regression analysis was conducted, determining group rates of relapse-free survival (RFS) and cancer-specific survival (CSS). RESULTS: A total of 498 patients were studied, grouped as APN+ (19/498, 3.8%) or APN- (479/498, 96.2%). Prior to matching, the APN+ (vs. APN-) group showed significantly more lymphatic involvement (73.7% vs. 47.8%; p=0.023), deep (T3/T4) tumor infiltration (100% vs. 78.9%; p=0.024), and nodal metastasis (N2: 84.2% vs. 27.6%; p<0.001). In addition, para-aortic nodal recurrences were significantly increased (15.7% vs. 2.0%; p<0.001), conferring worse RFS (p<0.001) and CSS (p=0.014) rates. Once baseline factors were matched, the two groups appeared similar in RFS (p=0.415) and CSS (p=0.649). Multivariate regression analysis indicated that elevated carcinoembryonic antigen (CEA) level and deep tumor infiltration were independent risk factors for RFS, whereas postoperative complications and tumor-positive node counts were independent risk factors for CSS. APN+ status was not a significant risk factor for RFS or CSS. CONCLUSION: APN positivity may thus constitute a regional rather than systemic manifestation. The TNM staging based on the number of metastatic lymph nodes seems to be more reasonable than the regional lymph node classification method.

E-PASS Scoring System May Be Useful for Prediction of Postoperative Complications in Super Elderly Colorectal Cancer Surgery Patients.

OBJECTIVES: Japan is facing an aging society. Elderly individuals are generally more prone to comorbidities and have weaker immune defenses, with ominous prognostic implications if postoperative complications arise. The aim of this study was to explore scoring systems for predicting postoperative morbidity risk in super elderly patients (≥85 years old) after colorectal surgery for cancer. METHODS: A population of elderly patients (n = 145) surgically treated for primary colorectal cancer within our department between April 2007 and December 2018 was examined retrospectively, assessing the capacities of various indices, such as Estimation of Physiologic Ability and Surgical Stress (E-PASS), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), prognostic nutritional index (PNI), and modified Glasgow Prognostic Score (mGPS), to predict postoperative complications. RESULTS: NLR, PLR, and mGPS did not differ significantly in the presence or absence of complications, whereas PNI tended to be lower if complications developed. The E-PASS system showed no group-wise differences in preoperative risk score (PRS), but the surgical stress score (SSS) and the comprehensive risk score (CRS; a composite of PRS and SSS) was significantly higher in patients with complications. Based on the cutoff value calculated from the Receiver operating curve (ROC) for the E-PASS CRS (-0.0580), patients were stratified into low-scoring and high-scoring (HSG) groups. Although not significantly different, the overall survival in the HSG tended to be lower by comparison. CONCLUSIONS: The E-PASS scoring system may be a useful predictor of postoperative complications in super elderly patients requiring colorectal cancer surgery.

Better Cancer-specific Survival in Younger Patients With Stage III Colorectal Cancer: A Propensity Score Matching Study From Japan.

BACKGROUND/AIM: The purpose of this study was to explore the perioperative, short-term, and long-term prognostic differences in colorectal cancer (CRC) between young and older patients. PATIENTS AND METHODS: A total of 3095 patients were divided into young (≤45 years; n=139) and older (>45 years; n=2956) groups. Then, propensity score matching was performed for patients in stage I to III according to a ratio of 1:1. The clinicopathological factors and prognosis of the two groups were studied. RESULTS: Young patients with CRC account for 4.49% of the total number of patients with CRC. Younger patients with CRC in stage I to III showed better cancer-specific survival (CSS). Older age was an independent risk factor for CSS prognosis. The CSS of the younger group was significantly better in stage I to III as a whole, but there was no difference in stage I and II subgroups - only in stage III. The proportion of young patients with stage III disease receiving first-line adjuvant chemotherapy was significantly higher. When young patients relapsed, they were more likely to receive second-line adjuvant chemotherapy or reoperation than older patients. CONCLUSION: Younger patients with stage III colorectal cancer had better CSS rates.

Grade 3 well-differentiated neuroendocrine tumor of the rectum: a case report.

BACKGROUND: The 2019 revised World Health Organization (WHO) classification of tumors of endocrine organs classifies grade 3 gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN G3) into well-differentiated tumors (NET G3) and poorly differentiated carcinomas (NEC G3). There are few reported cases of NET G3 occurring in the rectum. CASE PRESENTATION: A 71-year-old man complained of bright red blood in his stool. Total colonoscopy revealed a mass in the lower rectum. Pathologic examination yielded a diagnosis of group 1. Computed tomography revealed swollen paraintestinal lymph nodes and multiple liver metastases. We performed laparoscopic abdominoperineal resection not only to avoid the unbearable symptoms caused by tumor growth but to make a pathological diagnosis. The tumor measured 3.5 × 2.8 cm, and the pathological diagnosis was stage IV neuroendocrine carcinoma. He underwent chemotherapy with irinotecan plus cisplatin, followed by carboplatin plus etopside, but his disease did not respond to either regimen. Twenty-seven months after surgery, he died of his disease. Upon re-examination of the surgical specimen, the tumor was consistent with the 2019 WHO classification of NET G3.6 CONCLUSION: A definite diagnosis of NET G3 or NEC G3 must be made to determine the appropriate treatment strategy for patients with GEP-NEN G3. Further case reports and case series are needed to establish the optimal therapy.

The role of apical lymph node metastasis in right colon cancer.

BACKGROUND: The role of apical lymph node (APN) metastasis in colorectal cancer remains controversial. The main purpose of this study is to explore the prognostic value of APN metastasis in patients with right colon cancer. METHODS: This is a retrospective study of patients with stage III right colon cancer between April 2007 and December 2016. Patients who underwent resection of right colon cancers with D3 lymph node dissection were divided into APN-positive (APN+) and APN-negative (APN-) groups according to the postoperative pathological presence or absence of APN metastasis. Relapse-free survival (RFS) and overall survival (OS) between groups were compared after Cox regression analysis and 1:1 propensity score matching (PSM). RESULTS: A total of 254 patients were included in this study: 28 (11.0%) were APN+ and 226 (89.0%) were APN-. Before matching, the rates of elevated carcinoembryonic antigen (CEA), T3-4 tumor invasion, and N2 lymph node metastasis were significantly higher in the APN+ group (CEA ≥ 5 ng/mL, 53.6% vs. 37.6%, p < 0.001; T3-4, 92.9% vs. 85.4%, p < 0.001; N2 metastasis, 57.1% vs. 20.4%, p < 0.001), and APN+ tumors were associated with significantly higher postoperative relapse rates (39.3% vs. 21.2%; p = 0.03), especially with lung metastases (14.3% vs. 4.0%; p = 0.019), which conferred worse RFS (p = 0.013), although OS was similar (p = 0.078). However, after PSM, there were no apparent between-group differences in RFS (p = 0.29) or overall survival rate (p = 0.637). The Cox regression analysis indicated that lymphatic vessel infiltration and depth of invasion were independent risk factors for OS, while APN+ status was not a significant predictor for RFS or OS. CONCLUSIONS: APN metastasis was not a prognostic indicator for RFS or OS in right colon cancer. However, APN+ patients with elevated CEA levels and deeper tumor invasion should be closely monitored for lung metastasis during postoperative follow-up.

A first case of ileocecal resection using a Senhance Surgical System in Japan.

BACKGROUND: Several manufacturers are in the process of developing various innovative systems and expect more options in the robot market. One of the latest systems, the Senhance® platform (TransEnterix Surgical Inc, Morrisville, NC, USA), has already been introduced in Europe and has also been approved for clinical use in Japan. We report the first case of colorectal resection using Senhance in Japan. CASE PRESENTATION: The patient was a 79-year-old Japanese man who visited a previous physician for positive fecal occult blood. Upon close inspection, the preoperative diagnosis was cT2N0M0 stage I. We performed surgery using Senhance. The operation time was 198 min, and the estimated amount of bleeding was 10 g. He was discharged after surgery without any major complications. However, it is also true that the operability of the conventional port arrangement was poor during the surgical operation. CONCLUSION: We report the first Senhance-assisted ileocecal resection for colorectal cancer in Japan. In the future, we would like to find more ways to use it by accumulating more cases.

[A case of ulcerative colitis in an 86-year-old woman undergoing restorative proctocolectomy with ileal pouch-anal canal anastomosis].

An 86-year-old woman was diagnosed with ulcerative colitis (UC) in the 1970s. A colonoscopy performed 40 years thereafter revealed a 0-Is lesion in the upper rectum, and pathological examination showed well-differentiated adenocarcinoma. The lesion was diagnosed as colitic cancer based on the pathological findings and the 40-year interval since the diagnosis of total colitis type of UC. The patient was in good overall health with good anal function, based on the clinical examination and manometric study;she wished to undergo sphincter-preserving operation. Restorative proctocolectomy with ileal pouch-anal canal anastomosis that preserved the anal canal mucosa was performed. The postoperative course was good, with a defecation frequency of 4-5 times/day without fecal incontinence, and the patient resumed her preoperative lifestyle with very few alterations. Even in elderly patients aged >80 years who have UC, restorative proctocolectomy is feasible for those in good general health and with relatively good anal function, determined based on the daily defecation activity and anal manometry.

Intestinal endometriosis treated by laparoscopic surgery: case series of 5 patients.

BACKGROUND: Intestinal endometriosis is rare and most frequently involves the rectum and sigmoid colon. CASE PRESENTATION: Here, we report a case series of 5 patients who underwent laparoscopic resection for intestinal endometriosis. None of the patients developed postoperative complications, and all were discharged at 5-8 days after surgery. The diagnosis of intestinal endometriosis is difficult to obtain before surgery. Only 2 of 5 patients were diagnosed preoperatively. Among 1 of the 2 patients, the symptoms at the time of menstruation were obvious. In patients with submucosal tumors, the preoperative diagnosis can be difficult. Additional imaging examinations at the time of menstruation might be useful for obtaining a diagnosis. D2 dissections were performed for 3 patients, because malignancy could not be ruled out as a preoperative diagnosis. The surgical findings of 1 patient did not appear to be endometriosis. Surgery for intestinal endometriosis usually encounters advanced pelvic adhesions and fibrosis. For patients undergoing sigmoidectomy, the mean operative time was 152 min and mean blood loss was 10 mL. For patients undergoing rectal resection, the mean operative time was 282 min and mean blood loss was 17 mL. Two cases had severe pelvic adhesions, and the residual rectum could not be straightened. Therefore, side-to-side anastomosis was performed. For intestinal endometriosis surgery, flexible planning for the anastomosis method used for residual intestine should be undertaken. CONCLUSION: Laparoscopic surgery for intestinal endometriosis was safe but technically difficult, because of fibrosis and adhesions. An accurate diagnosis should be attempted based on the clinical symptoms, imaging findings, and intraoperative findings. The method used for anastomosis should be decided on a case-by-case basis.