Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan.

BACKGROUND: Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS: Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS: In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION: This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

Extraperitoneal colostomy in robotic surgery for rectal cancer using a tip-up fenestrated grasper.

INTRODUCTION: Although extraperitoneal colostomy could reduce the risk for parastomal hernia formation, it is often technically demanding to dissect the extraperitoneal route laparoscopically. Here, we demonstrate our original surgical technique for extraperitoneal tunneling using a robotic instrument. MATERIALS AND SURGICAL TECHNIQUE: After total mesorectal excision (TME) and before specimen retrieval, the edge of the outer leaf of the parietal peritoneum was elevated by the grasper in the left hand and the tip-up fenestrated grasper (Tip-Up) in the right hand. The extraperitoneal tissue was opened using the scissor forceps (right hand). Then, extraperitoneal tunneling (inner tunnel) was performed using a Tip-Up with a width of approximately 4 cm that could reach adjacent to the lateral border of the abdominal rectus muscle. A round incision was made at a preoperatively marked site on the skin. The anterior rectal sheath was cut in a cruciate fashion. The abdominal rectus muscle was split, and then the posterior rectus sheath was cut longitudinally not just below the stoma marking site but also at a slant on the lateral side. The peritoneum was dissected with care to avoid opening the peritoneum. The outer side of the tunnel was broken through to the inner tunnel using an easy blunt dissection with two fingers. Kelly forceps were introduced through the extraperitoneal tunnel along with the fingers, and the stump of the sigmoid colon was grasped and exteriorized through this tunnel. DISCUSSION: Robotic retroperitoneal tunneling using a Tip-Up is easy and useful for preventing parastomal hernia.

Spontaneous regression of advanced transverse colon cancer with remaining lymph node metastasis.

BACKGROUND: The observation of spontaneous regression (SR) has been well documented for many cancer types, including renal cell carcinoma, non-Hodgkin's lymphoma, leukemia, neuroblastoma, and malignant melanoma. However, the SR frequency in colorectal cancer is very rare. Therefore, the accumulation of SR colorectal cancer cases might contribute to find the regression mechanism. CASE PRESENTATION: A 67-year-old woman received colonoscopy due to being positive for fecal occult blood testing and was diagnosed as having a transverse colon cancer at a local hospital. She was admitted to our institution for surgical treatment of the colon cancer. The colonoscopy revealed a type 2 tumor of 13 mm in diameter at the hepatic flexure of the transverse colon. The enhanced computed tomography (CT) showed an enlarged lymph node in the intermediate lymph node region. The 18F-fluorodeoxyglucose positron emission tomography/CT showed no abnormal accumulation on the transverse colon; however, an abnormal accumulation was found at the enlarged lymph node. The patient was preoperatively diagnosed as having advanced transverse colon cancer with lymph node metastasis and underwent laparoscopic right hemicolectomy with D3 lymph node dissection. Pathological examination showed only a scar-like tissue and no cancerous lesion in the transverse colon, while a metastatic lymph node was histologically confirmed in the intermediate lymph node region. Loss of MLH1 and PMS2 expression was observed in the cancer cells of both biopsy specimens and resected lymph nodes. No recurrence was seen for 5 years after surgery. CONCLUSIONS: We reported a rare case of SR of the primary transverse colon cancer without regression of the metastatic regional lymph node. We considered that colorectal cancer with SR should be resected because even if SR of the primary lesion occurs, lymph node metastasis might have an inconsistent behavior as shown in the present case.

A case of perihilar cholangiocarcinoma with bilateral ligamentum teres hepatis treated with hepatopancreatoduodenectomy.

BACKGROUND: Bilateral ligamentum teres (BLT) hepatis is a very rare anomaly defined as the connection of the bilateral fetal umbilical veins to both sides of the paramedian trunk, and it has never been reported in the English literature. CASE PRESENTATION: A 72-year-old man who presented with obstructive jaundice was referred to our hospital. Contrast-enhanced computed tomography revealed that the patient had right-sided ligamentum teres (RSLT) and left-sided ligamentum teres (LSLT). The umbilical portion of the left portal vein, which the LSLT connected, became relatively atrophic in this patient. The RSLT attached to the tip of the right anterior pedicle and formed the umbilical portion of the right portal vein. The patient was diagnosed with perihilar cholangiocarcinoma which had invaded the root of the posterior branch of the bile duct, LHD, and intrapancreatic bile duct. The central bisectionectomy, in which the liver parenchyma was resected along the RHV on the right side and the LSLT on the left side, and caudate lobectomy combined with pancreatoduodenectomy were performed. The presence of the patient with BLT is important for ascertaining the mechanism of the development of RSLT. Two umbilical veins are present initially during the embryonic stage. In general, the right-sided vein disappears, and the atrophic left-sided vein remains connected to the left portal vein originating from the vitelline vein. Several papers on the mechanism of the development of RSLT have been published. Some authors have mentioned that a residue of the right umbilical vein and the disappearance of the left umbilical vein are the causes of RSLT. On the other hand, some authors have asserted that RSLT is the result of atrophy of the medial liver area. The presence of BLT in patients indicates that the mechanism of the development of RSLT is characterized by a residue of the right umbilical vein and the disappearance of the left umbilical vein. CONCLUSIONS: The mechanism and origin of RSLT can be understood through cases of BLT, and surgeons must pay attention to anomalies of the portal and hepatic veins in patients with abnormal ligamentum teres.

Global metabolic reprogramming of colorectal cancer occurs at adenoma stage and is induced by MYC.

Cancer cells alter their metabolism for the production of precursors of macromolecules. However, the control mechanisms underlying this reprogramming are poorly understood. Here we show that metabolic reprogramming of colorectal cancer is caused chiefly by aberrant MYC expression. Multiomics-based analyses of paired normal and tumor tissues from 275 patients with colorectal cancer revealed that metabolic alterations occur at the adenoma stage of carcinogenesis, in a manner not associated with specific gene mutations involved in colorectal carcinogenesis. MYC expression induced at least 215 metabolic reactions by changing the expression levels of 121 metabolic genes and 39 transporter genes. Further, MYC negatively regulated the expression of genes involved in mitochondrial biogenesis and maintenance but positively regulated genes involved in DNA and histone methylation. Knockdown of MYC in colorectal cancer cells reset the altered metabolism and suppressed cell growth. Moreover, inhibition of MYC target pyrimidine synthesis genes such as CAD, UMPS, and CTPS blocked cell growth, and thus are potential targets for colorectal cancer therapy.

Local control of sphincter-preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis.

Sphincter-preserving procedures (SPPs) for surgical treatment of low-lying rectal tumors have advanced considerably. However, their oncological safety for locally advanced low rectal cancer compared with abdominoperineal resection (APR) is contentious. We retrospectively analyzed cohort data of 1500 consecutive patients who underwent elective resection for stage II-III rectal cancer between 2010 and 2011. Patients with tumors 2-5 cm from the anal verge and clinical stage T3-4 were eligible. Primary outcome was 3-year local recurrence rate, and confounding effects were minimized by propensity score matching. The study involved 794 patients (456 SPPs and 338 APR). Before matching, candidates for APR were more likely to have lower and advanced lesions, whereas SPPs were carried out more often following preoperative treatment, by laparoscopic approach, and at institutions with higher case volume. After matching, 398 patients (199 each for SPPs and APR) were included in the analysis sample. Postoperative morbidity was similar between the SPPs and APR groups (38% vs 39%; RR 0.98, 95% CI 0.77-1.27). Margin involvement was present in eight patients in the SPPs group (one and seven at the distal and radial margins, respectively) and in 12 patients in the APR group. No difference in 3-year local recurrence rate was noted between the two groups (11% vs 14%; HR 0.77, 95% CI 0.42-1.41). In this observational study, comparability was ensured by adjusting for possible confounding factors. Our results suggest that SPPs and APR for locally advanced low rectal cancer have demonstrably equivalent oncological local control.

Influence of previous abdominal surgery on surgical outcomes between laparoscopic and open surgery in elderly patients with colorectal cancer: subanalysis of a large multicenter study in Japan.

BACKGROUND: The aim of the present study was to examine the technical and oncological feasibility of laparoscopic surgery (LAP) in elderly patients with a history of abdominal surgery. METHODS: We conducted a propensity score-matched case-control study of colorectal cancer (CRC) patients aged ≥80 years that were treated at 41 hospitals between 2003 and 2007. We included 601 patients who had a history of abdominal surgery and underwent curative and elective surgery for stage 0 to III CRC. After the matching procedure, 153 patients were included in each cohort. The surgical outcomes of LAP and open surgery (OS) were compared. P-values of <0.05 were considered statistically significant. RESULTS: LAP resulted in a significantly longer surgical time (220 vs. 170 min, p < 0.001), but significantly less intraoperative blood loss (39 vs. 100 ml, p < 0.001). A number of postoperative recovery-related parameters, including the length of the hospitalization period (12 vs. 14 days, p = 0.002), and the days to the resumption of fluid (2 vs. 3 days, p < 0.001) and solid food intake (4 vs. 5 days, p < 0.001), were significantly better in the LAP group. Moreover, the overall morbidity rate (43 vs. 66 %, p = 0.009) and the frequency of postoperative ileus (7 vs. 19 %, p = 0.023) were significantly lower in the LAP group, while the frequencies of other morbidities did not differ significantly between the groups. In the survival analyses, overall survival and disease-free survival did not differ between the two groups. CONCLUSIONS: In this population, LAP can be performed safely in elderly CRC patients with a history of abdominal surgery, and LAP resulted in a lower postoperative morbidity rate than OS.

Follow-up of asymptomatic adult diaphragmatic hernia: should patients with this condition undergo immediate operation? A report of two cases.

BACKGROUND: Asymptomatic diaphragmatic hernia is generally thought to be rare among adults. We present two different types of asymptomatic diaphragmatic hernia diagnosed with computed tomography (CT) and discuss treatment strategies. CASE PRESENTATION: Case 1: A 37-year-old woman was diagnosed with catamenial pneumothorax in the right diaphragm. Partial resection of the diaphragm and lung was performed using a linear stapler. She was asymptomatic after the operation and gave birth 2 years later. After delivery, she experienced recurrent pneumothorax, and CT revealed a right diaphragmatic defect with herniation of a part of the liver into the thorax. An iatrogenic diaphragmatic hernia was diagnosed. There has been no change in the size of the hernia and no symptoms due to the diaphragmatic hernia for more than 3 years after it was diagnosed. Case 2: A 75-year-old woman was previously diagnosed with rectal cancer and had undergone surgery after chemoradiotherapy. One year after surgery, herniation of a 3 × 1.3-cm section of retroperitoneal fat tissue into the left thoracic cavity was observed incidentally at a follow-up CT and was diagnosed as an adult Bochdalek hernia (BH). We reviewed the patient's past CT findings and confirmed that the same finding had been present since the first scan. A wait-and-see approach was chosen because there had been no change in the size of hernia, there were no symptoms, the patient was elderly, and there was a high risk of recurrence of the rectal cancer. She has had no symptoms to date, and careful follow-up has been performed. CONCLUSIONS: There are few reports of asymptomatic adult diaphragmatic hernia. Although symptomatic diaphragmatic hernia is generally treated surgically, there are cases in which a wait-and-see approach has been applied, such as our asymptomatic cases.

Relationship between tissue tension and thermal diffusion to peripheral tissue using an energy device.

The aim of the study was to assess the relationship between tissue tension and thermal diffusion to peripheral tissues using an electric scalpel, ultrasonically activated device, or a bipolar sealing system. The mesentery of pigs was excised with each energy device (ED) at three tissue tensions (0, 300, 600 g). The excision time and thermal diffusion area were monitored with thermography, measured for each ED, and then histologically examined. Correlations between tissue tension and thermal diffusion area were examined. The excision time was inversely correlated with tissue tension for all ED (electric scalpel, r = 0.718; ultrasonically activated device, r = 0.949; bipolar sealing system, r = 0.843), and tissue tension was inversely correlated with the thermal diffusion area with the electric scalpel (r = 0.718) and bipolar sealing system (r = 0.869). Histopathologically, limited deep thermal denaturation occurred at a tension of 600 g with all ED. We conclude that thermal damage can be avoided with adequate tissue tension when any ED is used.

Multiple gastric gastrointestinal stromal tumors treated by laparoscopic-endoscopic cooperative surgery: A case report.

The typical treatment of choice for gastrointestinal stromal tumors (GIST) is surgical resection. Here we report a case of three GIST lesions resected safely by laparoscopic-endoscopic cooperative surgery (LECS). A 78-year-old woman was referred to our hospital for further treatment of an enlarging gastric submucosal tumor. Esophagogastroduodenoscopy and endoscopic ultrasonography revealed two gastric submucosal tumors. Endoscopic ultrasonography-guided fine needle aspiration was subsequently performed. The patient underwent LECS in accordance with therapeutic guidelines for GIST. Assisted by a laparoscope and using three trocars, a full-thickness resection was performed endoscopically for the 3-cm lesion and its nearby submucosal tumor, which was newly detected intraoperatively. The other lesion was also resected with an autosuture device under laparoscopy. No intraoperative or postoperative complications were observed. In LECS, endoscopic observation and resection can minimize gastric deformation and preserve gastric function. To the best of our knowledge, this is the first case of LECS performed on multiple GIST.

Perforation in an intestinal malignant lymphoma case.

BACKGROUND: The gastrointestinal tract is a relatively common involvement site in lymphoma and, in such cases, intestinal perforation is a concern before and during chemotherapy. The prediction of intestinal perforation prior to chemotherapy is difficult, and there is no standard strategy to minimize the frequency of severely adverse gastrointestinal events in lymphoma cases. CASE PRESENTATION: The 61-year-old female patient had a history of primary central nervous system lymphoma (PCNSL), diagnosed histologically as diffuse large B cell lymphoma (DLBCL). We administered six courses of intensive chemotherapy consisting of high-dose methotrexate and sequential whole-brain irradiation (40.5 Gy). After a 3-year remission of the PCNSL, the patient's lymphoma recurred, involving the small intestine. (18)F-FDG-PET/CT upon the recurrence before chemotherapy showed multiple nodular lesions in the patient's gastrointestinal tract. Central nervous system lesions were not detected. We administered intensive salvage chemotherapy consisting of cyclophosphamide, high-dose AraC, methyl-prednisolone, etoposide, and rituximab. The response was a rapid partial response, but on day 10 after the initiation of salvage chemotherapy, she complained of abdominal pain with tenderness. The contrast-enhanced (CE)-CT revealed transmural ischemia of the intestine. On the 7th day after the onset of urgent abdominal symptoms, follow-up CE-CT showed that the ischemic lesion had become thin. We conducted elective surgery after waiting for the complete recovery of the patient's white blood cell count. The pathological findings of resected intestine confirmed the elimination of the majority of lymphoma cells and concomitant partial necrotic tissue. CONCLUSIONS: We were able to avoid the neutropenic period and safely conducted the surgical treatment for the subclinical perforation by using CE-CT. The combination of (18)F-FDG-PET/CT before chemotherapy and CE-CT scanning for the targeted involvement site helped us evaluate the surgical indications and optimal timing of surgery in a lymphoma patient with gastrointestinal involvement.

Beneficial effect of D-allose for isolated islet culture prior to islet transplantation.

BACKGROUND: Pretransplant restoration of islets damaged during isolation remains to be solved. In this study, we examined the effect of D-allose on islets isolated from rat pancreata prior to islet transplantation. METHODS: Rat islets isolated from fresh pancreata were cultured overnight in Roswell Park Memorial Institute 1640 solution in the absence (group 1) or presence (group 2) of D-allose. Then we assessed stimulation index of insulin, and cure rate after islet transplantation to diabetic nude mice. We also measured malondialdehyde level and caspase 3 activity of islets after the overnight culture for assessment of the oxidative stress and the apoptosis. RESULTS: D-allose significantly improved insulin secretion of islets. The stimulation index in group 2 was significantly higher than in group 1. Cure rate after transplantation in group 2 was higher than in group 1 especially in the first week. The malondialdehyde level in group 2 was significantly lower than in group 1. But the caspase 3 activities in both groups did not differ. CONCLUSIONS: D-allose treatment of isolated islet culture prior to transplantation restored islet function and increased successful transplant rate. The results of this study suggested that D-allose improved function of damaged islets through its anti-oxidative activity.

Morphological study of the neurovascular bundle to elucidate nerve damage in pelvic surgery.

PURPOSE: Postoperative sexual and urinary dysfunction may occur after rectal cancer surgery involving the pelvis, but this problem cannot be solved. The aim of this study was to examine the nerve morphology of the neurovascular bundle in cadavers to determine possible causes of nerve damage during surgery. METHODS: Twenty-two formalin-fixed cadavers were used in the study. The cadavers were donated to the Tokyo Medical University. The study comprised histological evaluation of paraffin-embedded bilateral neurovascular bundle specimens from the cadavers. Four slides of 3-cm thick were made every 1 cm in a plane perpendicular to the rectum towards the pelvic floor from the peritoneal reflection in bilateral neurovascular bundles in 22 cadavers. The number of nerves, the mean nerve area, and the mean nerve diameter were measured in each slide. RESULTS: The results were categorized into cases with high (group H) and low (group L) positions of the pelvis 1 cm above and 2 cm below the peritoneal reflection, respectively. There was no significant difference in the number of nerves between these groups. The nerve area and nerve diameter were significantly smaller in group L, and these characteristics were more marked in males. CONCLUSIONS: Our results show that the nerves of the neurovascular bundle became smaller in the deep pelvis. This may cause these nerves to be more susceptible to injury, resulting in nerve damage in the deep pelvis that leads to postoperative dysfunction. Particularly, this type of nerve damage may be a cause of postoperative sexual dysfunction in males.

Internal inguinal hernia on the transplant side after kidney transplantation: a case report.

The patient was a 52-year-old man who presented with right inguinal swelling and pain. He had undergone kidney transplantation in 2005 and bypass surgery using a vascular prosthesis from the left axillary artery to the bilateral femoral arteries in 2008. The vascular prosthesis had invaded the right inguinal canal ventrally. The transplanted ureter had a hazy appearance on a non-enhanced abdominal CT scan. A Lichtenstein operation was performed under a diagnosis of inguinal hernia. A skin incision with pulling of tissue and subcutaneous fat was devised to avoid exposure of the vascular prosthesis. The inguinal canal and spermatic cord were found to have coalesced. The hernia was diagnosed as a supravesical hernia, class II-1. This case shows that a Lichtenstein operation is a suitable procedure for avoidance of damage to the transplanted ureter in treatment of a transplant-side inguinal hernia in a kidney transplant recipient.

Predictors of postoperative complications in elderly and oldest old patients with gastric cancer.

BACKGROUND: The incidence of gastric cancer has been increasing among elderly persons in Japan. This study aimed to clarify risk factors for postoperative complications in oldest old patients with gastric cancer. METHODS: One-hundred ninety patients more than 75 years old with gastric cancer underwent gastrectomy between 2000 and 2011. Patients were classified into two groups: group A included 29 patients who were 85 years or older (oldest old patients), and group B included 161 patients who were 75-84 years of age. Perioperative parameters associated with complications were compared in each group. RESULTS: The preoperative estimated glomerular filtration rate was significantly lower in group A (p = 0.03). The two groups significantly differed in performance status (p = 0.018). Patients in group A received a lesser extent of lymph node dissection and had fewer lymph nodes excised. As a result, the duration of the operation was significantly shorter in group A. There were no significant differences in the frequency or grade of total complications or mortality between the two groups. Operative hemorrhage (>300 ml) and Hiroshima POSSUM (predicted morbidity risk >40) were risk factors in both groups A and B; the risk factors of preoperative serum albumin level and prognostic nutritional index (PNI) were specific to group A. CONCLUSIONS: Adjustments to the extent of surgery among oldest old patients most likely reduces the incidence of postoperative complications in this group. Preoperative serum albumin level and PNI are significant predictors of postoperative complications in oldest old patients with gastric cancer.

Pancreatic thickness as a predictive factor for postoperative pancreatic fistula after distal pancreatectomy using an endopath stapler.

PURPOSE: No consistent risk factor has yet been established for the development of pancreatic fistula (PF) after distal pancreatectomy (DP) with a stapler. METHODS: A total of 31 consecutive patients underwent DP with an endopath stapler between June 2006 and December 2010 using a slow parenchymal flattening technique. The risk factors for PF after DP with an endopath stapler were identified based on univariate and multivariate analyses. RESULTS: Clinical PF developed in 7 of 31 (22 %) patients who underwent DP with a stapler. The pancreata were significantly thicker at the transection line in patients with PF (19.4 ± 1.47 mm) in comparison to patients without PF (12.6 ± 0.79 mm; p = 0.0003). A 16-mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve; the area under the ROC curve was 0.875 (p = 0.0215). Pancreatic thickness (p = 0.0006) and blood transfusion (p = 0.028) were associated with postoperative PF in a univariate analysis. Pancreatic thickness was the only significant independent factor (odds ratio 9.99; p = 0.036) according to a multivariate analysis with a specificity of 72 %, and a sensitivity of 85 %. CONCLUSION: Pancreatic thickness is a significant independent risk factor for PF development after DP with an endopath stapler. The stapler technique is thus considered to be an appropriate modality in patients with a pancreatic thicknesses of <16 mm.

Extraperitoneal colostomy in laparoscopic abdominoperineal resection using a laparoscopic retractor.

Although extraperitoneal colostomy is often performed to prevent postoperative parastomal hernia formation following an open abdominoperineal resection of lower rectal cancer, it has not been widely employed laparoscopically because of the difficulty associated with the extraperitoneal route. This paper describes a laparoscopic extraperitoneal sigmoid colostomy using the Endo Retract™ Maxi instrument. This surgical technique is easy, and helps to prevent the development of parastomal hernias.