Keiichiro Ohta

The effect of Daikenchuto on postoperative intestinal motility in patients with right-side colon cancer

PurposeDaikenchuto (DKT) has a stimulant effect on intestinal motility and reportedly has a positive effect on postoperative intestinal motility in patients with sigmoid colon cancer. In this study, we investigated the effects of DKT in patients with right-side colon cancer.MethodsThis retrospective study included 88 patients with right-side colon cancer. We orally administered 7.5xa0g of DKT in the DKT group and did not administer any DKT to patients in the no-DKT group. All patients ingested radiopaque markers 2xa0h before surgery, which were used to assess intestinal motility. The postoperative intestinal motility was radiologically assessed by counting the numbers of residual markers in the large and small intestines.ResultsThe DKT and no-DKT groups showed no marked differences in the total number of residual markers or number of residual markers in the small intestine. However, in the elderly subgroup, the total number of residual markers in the DKT group was significantly less than in the no-DKT group.ConclusionAlthough DKT had some small effect on the postoperative intestinal motility for most patients, it may have positive effects in elderly patients.

Oxaliplatin-induced increase in splenic volume; irreversible change after adjuvant FOLFOX

Oxaliplatin can cause hepatic sinusoidal obstruction syndrome (SOS). SOS can cause chemotherapy‐related adverse effects or morbidity after liver resection. Conventionally, SOS is diagnosed using liver biopsy. Recently, it was reported that increased splenic volume (SV) can be used to detect SOS. In this study, we evaluated the changes in SV during adjuvant chemotherapy.

Intestinal hemorrhage caused by Meckel’s diverticulum with ectopic gastric mucosa on polypoid lesion: a case report

Meckel’s diverticulum may sometimes present as an intraluminal polypoid mass causing small bowel obstruction; however, gastrointestinal bleeding due to Meckel’s diverticulum with a polypoid lesion is rare. A 14-year-old girl presented with tarry stool and syncope in our hospital. Laboratory examination showed iron-deficiency anemia with a low hemoglobin level of 5.8xa0g/dl. The bleeding site was detected by neither upper gastrointestinal endoscopy nor colonoscopy. Transanal double-balloon enteroscopy showed a diverticulum with an ulceration at a site approximately 50xa0cm from the ileocecal valve and a polypoid lesion inside of the diverticulum. Histopathological examination of a polypoid lesion revealed an ectopic gastric mucosa of the fundic type. Furthermore, technetium-99m pertechnetate scintigraphy showed a hot spot in her lower right abdomen. On the basis of these findings, she was diagnosed as having hemorrhagic Meckel’s diverticulum. Single-incision laparoscopy-assisted segmental bowel resection of the ileum was performed. The patient recovered well, and she was discharged from the hospital on postoperative day 7. She was doing well 6xa0months later without evidence of reoccurrence. In this report, we describe a case of Meckel’s diverticulum with a polypoid lesion; hemorrhage may have occurred owing to the ulceration of the ileal mucosa with which the polypoid lesion directly came in contact. We consider this case to be of interest to gain insight into the site and mechanism of ulceration associated with Meckel’s diverticulum.

Feasibility of Neoadjuvant FOLFOX Therapy Without Radiotherapy for Baseline Resectable Rectal Cancer

Background/Aim: The combination of oxaliplatin, leucovorin and fluorouracil (FOLFOX) has been established as postoperative adjuvant chemotherapy for stage III colon cancer. However, the safety and efficacy of neoadjuvant FOLFOX in patients with rectal cancer are still controversial. This prospective pilot study aimed to evaluate the feasibility of neoadjuvant FOLFOX therapy without radiation for baseline resectable rectal cancer (RC). Patients and Methods: The study included 30 patients with clinical stage II/III RC between February 2012 and December 2015. The patients were treated with six cycles of FOLFOX followed by elective surgery. The primary endpoint was the R0 resection rate. The secondary endpoints were the scheduled treatment completion rate, adverse events, pathological response and the disease-free survival (DFS) rate. Results: All the patients underwent elective R0 resection after neoadjuvant FOLFOX therapy. The completion rate of the 6-cycle regimen was 93.3% (28/30 patients). Grade 3-4 adverse events occurred in seven patients (23.3%). Pathological complete response was noted in two patients (6.7%). The 3-year DFS rate was 77.5% (95% confidence interval, 61.4%-93.7%). Conclusion: Neoadjuvant FOLFOX therapy without radiation is a feasible therapeutic strategy for baseline resectable RC.

Negative Effects of Mechanical Bowel Preparation on the Postoperative Intestinal Motility of Patients with Colorectal Cancer

Several processes can occur as a reaction to surgery, including postoperative intestinal hypoperistalsis, which normally recovers over several hours to days. Postoperative ileus (POI), a transient impairment of bowel motility after abdominal surgery, is characterized by nausea, vomiting, inability to tolerate oral diet, abdominal distension, and delayed passage of flatus and stool. The pathophysiology of POI is multifactorial, but the detailed underlying mechanisms are unknown. This complication should be prevented; however, no single technique or agent has been found to prevent POI effectively. A multidirectional approach is therefore needed to prevent POI. Operative management following the enhanced recovery after surgery (ERAS) approach, including minimally invasive methods, optimal pain control, aggressive postoperative rehabilitation, and early oral nutrition, reportedly exerts a positive effect on the recovery speed of gastrointestinal motility after colon surgery. Although, traditionally, mechanical bowel preparation (MBP) has been thought to decrease the prevalence of surgical site infection and anastomotic leakage, no benefit of MBP has been reported in clinical trials. Some studies have associated MBP with polyethylene glycol (PEG) with poor anastomosis healing and decreased intestinal motility. We showed that MBP with PEG negatively affects motility of the small intestines after both open and laparoscopic colon surgeries. As nutrient absorption occurs in the small intestines, it is important to promote its prompt recovery. In the ERAS approach, omission of MBP is recommended and may be the most important element of ERAS, allowing for early small intestinal motility recovery.

Preoperative Bowel Preparation in ERAS Program: Would-Be Merits or Demerits

For over a century, surgeons have used preoperative mechanical bowel preparation (MBP) to decrease fecal mass within the large bowel. However, over the past 2 decades, several randomized trials and a large meta-analysis have failed to demonstrate reduced rates of surgical site infection (SSI) after elective colorectal surgery in patients who received MBP alone. It was reported in 1971 that MBP removed gross feces but did not alter the number of microorganisms in the colonic lumen. MBP with oral antibiotics, but not alone, reduces the prevalence of SSI. MBP does not affect the prevalence of anastomotic leakage in colon surgery. However, we should not equate rectal surgery with colon surgery because the rate of anastomotic leakage is higher in the former. Also, omitting MBP may be a risk factor for anastomotic leakage in elderly patients. MBP does not reduce morbidity, including SSI, in patients undergoing digestive tract surgery (not for colorectal cancer), such as esophagocoloplasty, hepatectomy or pancreaticoduodenectomy. MBP can negatively affect intestinal motility after surgery. Of note, omission of MBP may negatively affect long-term survival; however, this hypothesis is controversial.

Primary small intestinal volvulus after laparoscopic rectopexy for rectal prolapse: Volvulus after laparoscopic rectopexy

Primary small intestinal volvulus is defined as torsion in the absence of congenital malrotation, band, or postoperative adhesions. Its occurrence as an early postoperative complication is rare. A 40‐year‐old woman presented with rectal prolapse, and laparoscopic rectopexy was uneventfully performed. She could not have food on the day after surgery. She started oral intake on postoperative day 3 but developed abdominal pain after the meal. Contrast‐enhanced CT revealed torsion of the small intestinal mesentery. An emergent laparotomy showed small intestinal volvulus, without congenital malformation or intestinal adhesions. We diagnosed it as primary small intestinal volvulus. The strangulated intestine was resected, and reconstruction was performed. The patient recovered uneventfully after the second surgery. To the best of our knowledge, this is the first report of primary small intestinal volvulus occurring after rectopexy for rectal prolapse. Primary small intestinal volvulus could be a postoperative complication after laparoscopy.

Modified Marionette Technique for Laparoscopic Colorectal Surgery

INTRODUCTIONnSingle-port laparoscopic surgery has some technical limitations with respect to control of the forceps inserted through the single-access site, which results in increased internal collisions due to coaxial alignment of the instruments, as well as and decreased range of motion and visualization. To overcome these limitations, we employ a modified marionette technique as a way to carry out laparoscopic colorectal surgery. Materials and Surgical Technique: The procedures for the modified marionette technique are performed as follows: An Internal Organ Retractor (IOR)™ and an atraumatic clip designed to firmly grasp tissue, with 1-0 nylon thread, are inserted through a 12-mm trocar and secured in place where adequate visualization and traction for cutting with a radio knife is required. A looped 1-0 nylon thread put through an 18-gauge injection needle is pierced through the abdominal wall, the looped nylon extruded, and the nylon attached to the IOR is pulled out by threading the looped nylon thread. This allows for adequate traction from outside the body through the abdominal wall and appropriate placing adjustments.nnnCONCLUSIONnThe modified marionette technique using IOR introduced here is an easy, economical, effective and safe traction technique for colorectal surgeries. This technique will be a useful tool for performing both reduced port and multiport laparoscopic colorectal surgeries.

Comparison of Postoperative Pain Following Laparoscopic Versus Open Gastrostomy/Jejunostomy in Patients with Complete Obstruction Caused by Advanced Esophageal Cancer

BACKGROUNDnWhen percutaneous endoscopic gastrostomy is not feasible, a gastrostomy tube may be inserted for enteral access by a laparoscopic or open technique. The aim of this study was to compare the postoperative pain of laparoscopic versus open gastrostomy in patients with complete obstruction caused by advanced esophageal cancer.nnnMETHODSnFifteen patients who had undergone either a reduced port access laparoscopic gastrostomy/jejunostomy (LGJ, n=7) or open gastrostomy/jejunostomy (OGJ, n=8) between July 2011 and December 2015 were retrospectively studied. Variables examined comprised age, sex, body mass index (BMI), operative time, blood loss volume, and American Society of Anesthesiologist physical status (ASA-PS) scores. The degree of postoperative pain was also assessed in both groups during the first seven postoperative days.nnnRESULTSnThe patients in the two groups were comparable in age, sex, BMI, ASA-PS scores, intraoperative blood loss or postoperative complication rates. Operative time was shorter in the LGJ group than the OGJ group. No patients in the LGJ group required conversion to open laparotomy. Tube feedings were started on postoperative Day 1 in both groups; there were no postoperative complications. The duration of rescue nonopioid analgesic use was significantly shorter in the LGJ than the OGJ group (1.3 versus 3.5 days; P=0.0005). There was a significant difference in frequency of postoperative nonopioid analgesic use: 7.9 times in the LGJ group versus 17.9 times in the OGJ group (P=0.0219).nnnCONCLUSIONSnLGJ is associated with less postoperative pain than OGJ in patients with complete obstruction caused by advanced esophageal cancer.

Abstract 3134: Prediction of early recurrence after resection of metastatic liver tumors from colorectal cancer using circulating cell-free DNA

Background: We have reported that the amount of total circulating cell-free DNA (ccfDNA) increases with tumor growth and decreases upon tumor shrinkage. However, adverse effects of drugs and surgical stress can increase total ccfDNA because ccfDNA is derived from both normal and cancer cells. Thus, the ability to determine how much ccfDNA is derived from cancer cells is a critical issue. It has been reported that the length of ccfDNA derived from cancer cells is greater than 200 bp while that from normal cells undergoing apoptosis is less than 200 bp. Furthermore, the ratio of ccfDNA to β-globin reflects the amount of mitochondrial DNA derived from normal cells undergoing stress-induced apoptosis. We developed a new biomarker readout, the LINE-1 long fragment (longer than 200 bp) to β-globin ratio (LBR), based on this principle. In this study, we evaluated the clinical utility of the LBR to detect early recurrence of liver metastasis from colorectal cancer after liver resection. Methods: We enrolled 20 patients who underwent curative liver resection of metastatic liver tumors from colorectal cancer. Total ccfDNA and LBR were measured pre-surgery, and at 1 week and 1 month post-surgery. ccfDNA was purified from 1 mL serum using the QIAamp Circulating Nucleic Acid Kit. Total ccfDNA was measured using Qubit Fluorometer. LINE-1 long fragment and β-globin in ccfDNA were measured using real time PCR. The Ethics Review Committee of our institution approved the study protocol. Written informed consent was obtained from each patient. Results: We completed 1-year follow-up in 13 of 20 patients. Recurrence was detected in 7 patients and no signs of recurrence were detected in the other 6. Total ccfDNA increased 1 week after surgery in all 13 patients, which could have been caused by surgical stress. Total ccfDNA 1 month after surgery increased in 5 of 7 patients with recurrence. Total ccfDNA 1 month after surgery increased in 3 of 6 patients without recurrence. The 3 patients with increased ccfDNA had post-operative complications or drug-induced liver dysfunction. Notably, LBR increased in the 7 patients with recurrence and decreased in the 6 patients without recurrence 1 month post-surgery. Conclusion: LBR has potential as a novel biomarker readout for early detection of recurrence after liver resection of metastatic liver tumors from colorectal cancer. Citation Format: Takuma Iwai, Takeshi Yamada, Hayato Kan, Michihiro Koizumi, Seiichi Shinji, Yasuyuki Yokoyama, Goro Takahashi, Shiro Kitano, Masato Nakayama, Zenya Naito, Keiichiro Ohta, Eiji Uchida. Prediction of early recurrence after resection of metastatic liver tumors from colorectal cancer using circulating cell-free DNA. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3134.