Hirotoshi Hasegawa

Randomized controlled trial of laparoscopic versus open colectomy for advanced colorectal cancer

Background: After confirming a favorable outcome of laparoscopic surgery for early colorectal cancer, we conducted a randomized controlled trial to compare short-term outcomes of laparoscopic and open colectomy for advanced colorectal cancer. Methods: Fifty-nine patients with T2 or T3 colorectal cancer were randomized to undergo laparoscopic (n = 29) or open (n = 30) colectomy. Median follow-up was 20 months (range, 6–34 months). Results: Operative time was longer (p <0.0001) and blood loss (p = 0.0034) and postoperative analgesic requirement were less in the laparoscopic group than in the open group. An earlier return of bowel motility and earlier discharge from the hospital (p = 0.0164) were observed after laparoscopic surgery. Serum C-reactive protein levels on postoperative days 1 (p <0.0001) and 4 (p = 0.0039) were lower in the laparoscopic group than in the open group. Postoperative complications did not differ between the two groups. Conclusion: Laparoscopic surgery for advanced colorectal cancer is feasible, with favorable short-term outcome.

Overexpression of leucine-rich repeat-containing G protein-coupled receptor 5 in colorectal cancer

Leucine‐rich repeat‐containing G protein‐coupled receptor 5 (LGR5) is a 7‐transmembrane receptor reportedly expressed in stem cells of the intestinal crypts and hair follicles of mice. Overexpression of LGR5 is observed in some types of cancer; however, there has been no specific assessment in colorectal tumorigenesis. We performed quantitative RT‐PCR for LGR5 expression in 37 representative cancer cell lines, and showed that LGR5 mRNA was frequently overexpressed in colon cancer cell lines. Moreover, LGR5 expression was higher in colon cancer cell lines derived from metastatic tumors compared with those from primary tumors. In clinical specimens, there was significant overexpression of LGR5 in 35 of 50 colorectal cancers (CRCs), and in seven of seven sporadic colonic adenomas, compared with matched normal mucosa. This suggests up‐regulation of LGR5 from the early stage of colorectal tumorigenesis. LGR5 expression showed marked variation among CRC cases and correlated significantly with lymphatic invasion, vascular invasion, tumor depth, lymph node metastasis, and tumor stage (IIIC vs. IIIB). In addition to cancer cells, crypt base columnar cells of the small intestine and colon were shown by in situ hybridization to express LGR5. This is the first report suggesting the involvement of LGR5, not only in early events but also in late events in colorectal tumorigenesis. (Cancer Sci 2010)

Stapled Versus Sutured Closure of Loop Ileostomy: A Randomized Controlled Trial

OBJECTIVE To compare the outcome after conventional sutured loop ileostomy closure with stapled ileostomy closure. SUMMARY BACKGROUND DATA A defunctioning loop ileostomy is now widely used in colorectal surgery. Subsequent closure may be associated with early complications, particularly bowel obstruction. The results of a preliminary nonrandomized study suggested that there was no significant difference in the rate of complications between sutured and stapled closure of loop ileostomy. METHODS One hundred forty-one consecutive patients who underwent loop ileostomy between 1993 and 1998 were randomized before surgery to either sutured or stapled loop ileostomy closure. Seventy-one patients had stapled closure and 70 had sutured closure. RESULTS Both groups were comparable in terms of age, sex, original operation, duration after original operation, and level of operating surgeon. Postoperative bowel obstruction occurred in 10/70 (14%) patients after sutured closure compared with 2/71 (3%) patients after stapled closure. Subgroup analysis of ileostomy closure in patients having an ileal pouch showed no significant difference in bowel obstruction between stapled and sutured closure (2/30 vs. 7/29). The incidence of other complications, readmissions, and reoperations did not differ between the two groups. The stapled closure was only 4 minutes quicker than sutured closure. The mean total hospital stay tended to be shorter after the stapled closure than the sutured closure, but this did not reach statistical significance. CONCLUSIONS Bowel obstruction occurred less frequently after stapled closure, but the mean hospital stay and readmission and reoperation rate did not significantly differ between the two groups.

Body Mass Index Category as a Risk Factor for Colorectal Adenomas: A Systematic Review and Meta-Analysis

OBJECTIVES:The association between increasing body weight and colorectal adenoma prevalence has been suggested to follow a similar pattern to excess weight and colorectal cancer, although the magnitude of this relationship has not been validated. The objective of this study was to quantify the association and dose–response relationship between body mass index (BMI) and colorectal adenoma prevalence in clinical trials.METHODS:We systematically reviewed 23 studies (168,201 participants), which compared the prevalence of colorectal adenomas according to World Health Organization BMI categories. We assessed the effects of each BMI category on colorectal adenomas where odds ratio (OR) was used as a surrogate for effect size, and applied multivariate meta-analysis as a method of sensitivity analysis to evaluate the robustness of our findings and to analyze adenoma prevalence by multiple BMI categories simultaneously to assess for a dose–response relationship. Heterogeneity and publication bias were assessed.RESULTS:Subjects with a BMI of ≥25 had a significantly higher prevalence of colorectal adenomas (OR=1.24 (95% confidence interval (CI): 1.16–1.33), P<0.01) when compared with those with BMI<25. Multivariate meta-analysis also confirmed a positive association between higher BMI categories and the prevalence of colorectal adenoma (BMI: 25–30 vs. BMI<25; OR=1.21 (95% CI: 1.07–1.38), P<0.01; BMI≥30 vs. BMI<25; OR=1.32 (95% CI: 1.18–1.48), P<0.01) and revealed a dose–response relationship.CONCLUSIONS:The positive association between obesity and colorectal adenoma prevalence demonstrates an underlying dose–response relationship according to BMI. Colorectal centers may benefit from the timely screening of obese patients for colorectal adenomas in addition to clarifying the biological role of adiposity on colorectal tumor initiation and progression.

Cyclooxygenase-2 expression as a new marker for patients with colorectal cancer.

PURPOSE: Epidemiologic studies indicate that the use of nonsteroidal anti-inflammatory drugs, which inhibit cyclooxygenase activity, reduce the risk of colorectal cancer. In addition, several studies demonstrate increased expression of cyclooxygenase-2 in human colorectal cancer tissues. However, the role of cyclooxygenase-2 expression in colorectal cancer has not yet been fully established. The aim of this study was to clarify the clinicopathologic significance of cyclooxygenase-2 expression in human colorectal cancer. METHODS: A total of 232 surgically resected colorectal cancer specimens were analyzed immunohistochemically with the use of a murine anti-human cyclooxygenase-2 monoclonal antibody. Cyclooxygenase-2 expression was then compared with clinicopathologic background and survival outcome. RESULTS: Cyclooxygenase-2 was expressed in the cytoplasm of the cancer cells but not in normal epithelium. Cyclooxygenase-2 expression was noted in 71.6 percent (166/232) of the cancer patients and correlated significantly with histologic type (P = 0.033), depth of invasion (P = 0.016), pathologic stage (P = 0.020), and metachronous liver metastasis (P = 0.001). Multivariate analysis for factors associated with metachronous liver metastasis showed that cyclooxygenase-2 expression was one of the independent risk factors, second only to lymph node metastasis. Patients with cyclooxygenase-2 expression showed a significantly poorer outcome compared with those without cyclooxygenase-2 expression (P = 0.002). CONCLUSION: Cyclooxygenase-2 expression in the primary lesion may be a useful marker for evaluating prognosis and liver metastasis in patients with colorectal cancer.

Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer

Rectal resection with total mesorectal excision is perhaps the most technically challenging of laparoscopic procedures, and the purpose of this study was to show that laparoscopic ultralow anterior resection is feasible for lower rectal cancer. Seven patients with lower rectal cancer were treated in this way with a satisfactory outcome in each case, and on the basis of this limited study, we suggest that extension of laparoscopy to the treatment of very low rectal lesions may be of advantage.

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.

Prospective evaluation of laparoscopic surgery for rectosigmoidal and rectal carcinoma.

AbstractPURPOSE: This study was designed to examine the shortterm results of laparoscopy in the treatment of curative cases of rectosigmoidal and rectal carcinoma. METHODS: A review was performed of a prospective registry of 70 patients who underwent curative laparoscopic resection for rectosigmoidal and rectal carcinoma between July 1993 and April 2001. Before 1997, only patients with early (Tis or T1) cancers located in the rectosigmoid and upper rectum that required bowel resection were candidates for laparoscopy. In 1997, we expanded the application of laparoscopy to include T2 cancers located anywhere in the rectum. Mesorectal transection was performed at least 5 cm below the tumor for rectosigmoidal and upper rectal lesions, and total mesorectal excision was performed for lower tumors. Primary anastomosis was performed by a double-stapling technique, or a per anum handsewn coloanal anastomosis was performed. Patient demographics and outcomes were recorded prospectively. RESULTS: The median follow-up was 23 months. An anastomosis was performed in 92.9 percent of the operations. Oral intake was started on median postoperative Day 1, and the median length of hospitalization was 8 days. Two patients needed conversion to conventional open surgery. A total of 15 postoperative complications occurred in 13 patients (18.6 percent), including anastomotic leakage in 6 (8.6 percent) and bowel obstruction in 3 (4.3 percent). Reoperation was required in six patients. Two patients developed recurrence of cancer at the anastomotic site. The expected 5-year survival and disease-free survival rates were 100 and 92.1 percent, respectively. CONCLUSION: The findings of the present study demonstrate the feasibility and safety of laparoscopic surgery for selected patients with rectal carcinoma. Morbidity and mortality rates and oncologic outcome appear to be comparable with conventional 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.

Results of a multicenter study of 1,057 cases of rectal cancer treated by laparoscopic surgery

BackgroundThe aim of this study was to clarify the feasibility of laparoscopic surgery for rectal cancer retrospectively in 28 centers throughout Japan.MethodsBetween May 1994 and February 2006, 1,057 selected patients with rectal cancer underwent laparoscopic surgery. All the data regarding the patient details, and operative and postoperative outcome were collected retrospectively.ResultsMean follow-up was 30 months. Procedures included anterior resection in 938, abdominoperineal resection in 107, Hartmann’s procedure in 10, and others in two patients. Conversion to open procedures occurred in 77 patients (7.3%). Postoperative surgical complications developed in 235 patients (22.2%), including anastomotic leakage in 84 (9.1%). Median length of postoperative hospital stay was 15 days (7–271 days). Patients with upper rectal cancer had shorter hospital stay than those with lower rectal cancer (14 versus 18 days, p < 0.01). Tumor–node–metastases (TNM) stage included 83(7.9%) stage 0, 495 (46.8%) stage I, 197 (18.6%) stage II, 230 (21.8%) stage III, and 52 (4.9%) stage IV. Recurrence was developed in 67 patients (6.6%) of the 1,011 curatively treated patients. Local recurrence occurred in 11 patients (1.0%). There was no port-site metastasis. Of the 1,011 curatively treated patients, the 3-year disease-free survival rate was 100% in stage 0, 94.6% in stage I, 82.1% in stage II, and 79.7% in stage III.ConclusionsLaparoscopic surgery is feasible and safe in selected patients with rectal cancer, with favorable short-term and mid-term outcome.