Hideki Nishibori

Impact of visceral obesity on surgical outcome after laparoscopic surgery for rectal cancer

In laparoscopic colorectal surgery, the influence of obesity on surgical outcome remains controversial1,2. Although body mass index (BMI) is widely used for the assessment of general obesity, a large accumulation of visceral adipose tissue (visceral obesity) may complicate surgical procedures, particularly laparoscopic rectal surgery. Furthermore, visceral obesity is more directly associated with metabolic and cardiovascular co-morbidity than general obesity3,4. The aim of this study was to examine the association between visceral obesity and the outcome of laparoscopic rectal surgery.

Laparoscopic surgery for recurrent Crohn's disease†

The aim of this study was to assess the feasibility of laparoscopic surgery for recurrent Crohns disease, and the role of repeated laparoscopy in reoperation.

Laparoscopic Restorative Proctocolectomy for Patients with Ulcerative Colitis

BACKGROUND Significant concern continues about the feasibility of laparoscopic restorative proctocolectomy (RP) with an ileal J pouch anal anastomosis in the surgical treatment of patients with ulcerative colitis (UC). The aim of this study was to clarify the feasibility of laparoscopic RP at a single institution where the surgical routine of laparoscopic colorectal surgery has already been established. PATIENTS AND METHODS Between July 1994 and December 2001, 18 patients with UC underwent laparoscopic RP. The median age was 30 (range, 18-51) years, and the median follow-up was 20 (range, 5-89) months. Five trocars were placed. After the entire colon and rectum were mobilized and the vessels were divided intracorporeally, the rectum was divided with use of a laparoscopic linear stapler. A pouch anal anastomosis was fashioned with use of a double stapling technique. A diverting loop ileostomy was fashioned. RESULTS There were no conversions to the open procedure. The median operative time and median blood loss were 360 (range, 290-500) minutes and 105 (range, 10-586) mL, respectively. Six postoperative complications occurred (wound sepsis, 2; bowel obstruction, 1; anastomotic stricture, 2; pouchitis, 1). In one patient, a bowel obstruction developed 3 months after the operation, which was managed conservatively. The median length of the hospital stay was 9 (range, 7-21) days. CONCLUSIONS The laparoscopic RP is safe and feasible in selected patients with UC. New laparoscopic instrumentation, such as a linear stapler, and a more reliable laparoscopic coagulating and dividing tool should be designed, which would make it possible to perform this procedure more frequently in the surgical treatment of UC.

Gene expression in colorectal cancer and in vitro chemosensitivity to 5‐fluorouracil: A study of 88 surgical specimens

To predict the sensitivity of colorectal cancer to 5‐fluorouracil (5‐FU), we compared the gene expression of surgically obtained colorectal cancer specimens with chemosensitivity to 5‐FU as detected by 3‐(4,5‐dimethylthiazol‐2‐yl)‐2,5‐diphenyl‐2H tetrazolium bromide (MTT) assay. Eighty‐eight patients with advanced and/or metastatic colorectal cancer provided written informed consent and entered the trial from September 2000 to October 2001. Fresh surgical specimens were used for the MTT assay, and sensitivity to 5‐FU was evaluated at a cutoff concentration of 50 μg/ml and 48‐h incubation time. Frozen samples were stored at −80°C until mRNA analysis of thymidylate synthetase (TS), dihydropyri‐midine dehydrogenase (DPD), thymidine phosphorylase (TP), es‐nucleoside transporter (NT), and E2F1 by real‐time RT‐PCR. The correlations between the variables were analyzed, and the predictive value of these mRNAs was assessed statistically using a receiver operating characteristic (ROC) curve. NT and DPD, TP and DPD, and TP and NT mRNA expression levels correlated significantly, while TS and E2F1 showed no correlations. High NT expression was associated with low sensitivity to 5‐FU (P<0.013), as were high DPD and E2F1 expression (P<0.022 for both). High TP mRNA expression correlated with low sensitivity to 5‐FU (P<0.034), although high TS mRNA expression did not. ROC curves indicated that DPD and NT mRNAs were possible predictors of sensitivity to 5‐FU, with cutoff values of 0.6 and 0.4, respectively. The sensitivity of colorectal cancer to 5‐FU may be regulated by DPD, the rate‐limiting enzyme of catabolism, and NT, an important transmembrane transporter of nucleosides.

Increased ubiquitin immunoreactivity in hepatocellular carcinomas and precancerous lesions of the liver

BACKGROUND/AIMS Ubiquitin covalently attaches to abnormal and short-lived proteins, thus marking them for ATP-dependent proteolysis in eukaryotic cells. Increased ubiquitin immunoreactivity was recently observed immunohistochemically in human malignant tumors. To clarify the change in protein metabolism during hepatocarcinogenesis, we studied ubiquitin immunoreactivity in hepatocellular carcinomas (HCCs) and precancerous lesions using immunohistochemistry and immunoblot analysis. METHODS A total of 72 HCCs (37 advanced, 19 early, 16 early-advanced (advanced HCC component in early HCC nodule) type HCCs) and 18 precancerous lesions (8 atypical adenomatous hyperplasias (AAHs), 10 adenomatous hyperplasias (AHs)) were studied immunohistochemically. Immunoblot analysis was also performed in advanced HCC and early HCC cases. RESULTS Non-tumorous hepatocytes were either immunonegative or weakly stained in their nuclei. Advanced HCCs showed strong immunoreactivity in most cases, while early HCCs showed relatively weaker immunoreactivity. In 14 of 16 early-advanced type tumors, the inner portion of the nodules, which corresponds to advanced HCC, showed stronger immunoreactivity than the outer low-grade portion. In 8 of 8 AAHs and 7 of 10 AHs, positive but weak staining was found. Immunoblot analysis showed an increase in 42 kDa ubiquitinated protein(s) in 8 of 16 advanced HCC cases (50%) and in 1 of 6 early HCC cases (16.7%), as well as an increase in several other bands in tumor tissues. CONCLUSIONS The intensity of ubiquitin staining appeared to increase in a stepwise manner from AH to advanced HCC, and the results suggest a possible correlation between changes in the ubiquitinated proteins and multistep hepatocarcinogenesis.

Indications for laparoscopic surgery for Crohn's disease using the Vienna Classification

Objective  The aim of this study was to investigate the clinical outcome of laparoscopic surgery for Crohns disease and clarify the indications using the Vienna Classification.

The application of a new stapling device for open surgery (Contour™ Curved Cutter Stapler) in the laparoscopic resection of rectal cancer

Anastomotic leakage is a serious problem in the laparoscopic resection of rectal cancer. Although stapling devices and techniques for colorectal or coloanal anastomosis have been improved, laparoscopic anastomosis is still technically difficult and the rate of leakage is high. To resolve this problem, a new stapling device (the ContourTM Curved Cutter Stapler) for open surgery was applied to the laparoscopic resection of rectal cancer. After intracorporeal mobilization and vessel ligation, a 6-cm Pfannenstiel incision was made to insert the device into the peritoneal cavity, and a hand access device was placed on the site. The head of the device was put through a cutoff of the middle finger of a surgical glove, after which the wrist of the glove was attached to the hand access device. To prevent leakage of CO2 gas through the gap between the shaft and the glove, the shaft covered by the glove was tied, and the gap was filled with bone wax. After re-creation of the pneumoperitoneum, the rectum was transected with the stapling device, and the anastomosis was accomplished by the double stapling technique. This technique enabled a reliable transection of the rectum because of the easy handling of the device and the wide laparoscopic view of the lower rectum in the deep pelvis.

A metastatic model of human colon cancer constructed using cecal implantation of cancer tissue in nude mice

COL-2-JCK, a human colon cancer xenograft line able to be transplanted into nude mice, was implanted in the subserosal layer of the cecum, either as cancer tissue or as a single cell suspension. When cancer tissue was used for the cecal implantation, 100% extensive local tumor growth and a high incidence of metastases to the regional lymph nodes, peritoneum, liver, and lung was observed. In contrast, when the cell suspension of this line was injected into the cecal wall, no metastases were observed, with significantly reduced local tumor growth. The use of cancer tissue maintaining the original cancer tissue structure is therefore considered imperative for allowing full expression of the biological characteristics of cancer cells. This nude mouse model using the cecal implantation of cancer tissue should thus prompt further study on the biology of human colon cancer.

Short- and midterm outcomes of laparoscopic surgery compared for 131 patients with rectal and rectosigmoid cancer

BackgroundThis study aimed to clarify and compare the short- and midterm surgical outcomes of laparoscopic surgery for rectal and rectosigmoid cancer.MethodsBetween June 1992 and December 2004, 131 selected patients with cancer of the rectum (n = 60) and rectosigmoid (n = 71) underwent laparoscopic surgery. The indications for laparoscopy included a preoperative diagnosis of T1/T2 tumor in the rectum and T1–T3 tumors in the rectosigmoid.ResultsThe mean follow-up period was 42 months. The procedures included anterior resection for 117 patients, abdominoperineal resection for 11 patients, Hartmann’s procedure for 1 patient, and restorative proctocolectomy for 1 patient. Conversion to an open procedure occurred for four patients (3.1%). Postoperative complications developed in 29 patients (22.1%), including anastomotic leakage in 14 patients (11.8%). The length of hospital stay for the rectal cases was significantly longer than for the rectosigmoid cases (10 vs 7 days; p = 0.0049). The tumor node metastasis (TNM) stages included 0 (n = 14), I (n = 72), II (n = 15), III (n = 29), and IV (n = 1). Recurrences were experienced by 13 patients, including local recurrence (n = 7) and recurrences involving the liver ((n = 2), lung (n = 3), and distant lymph nodes (n = 1). The 5-year disease-free and overall survival rates were, respectively 91.7% and 97.9% for stage I, 86.7% and 90.9% for stage II, and 77.1% and 90.0% for stage III.ConclusionsLaparoscopic surgery is feasible and safe for selected patients with rectal or rectosigmoid cancer. The selected patients in this study experienced favorable short- and midterm outcomes.

Long-term outcome of per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer

Objective  The authors have performed per anum intersphincteric rectal dissection. With direct coloanal anastomosis for cases of lower rectal cancer in which the distal surgical margin is difficult to secure by the double stapling technique. The aim of this study was to evaluate the long‐term outcome and to clarify the surgical indications for this operation.