Ryo Inada

Risk factors for anastomotic leakage after laparoscopic surgery for rectal cancer using a stapling technique.

Purpose: This study evaluated the risk factors for anastomotic leakage after laparoscopic surgery for rectal cancer using a stapling technique. Methods: The total prospective registry of 111 patients with rectal cancer who initially underwent laparoscopic low anterior resection using a stapling technique was reviewed. Univariate and multivariate analyses were carried out to identify relevant risk factors. Results: Overall anastomotic leakage rate was 5.4% (6/111). Univariate analysis demonstrated that body mass index (BMI) (P=0.0377) was significantly associated with anastomotic leakage. After univariate analysis, the variables of BMI and the size of the circular stapler (P=0.0923) were selected for multivariate analysis, as their P values were <0.2, and multivariate analysis demonstrated that BMI was independently predictive of developing anastomotic leakage (P=0.0458). Conclusions: Laparoscopic surgery for rectal cancer using a stapling technique can be performed safely without increasing the risk of anastomotic leakage, and increased BMI might be a potential risk factor for anastomotic leakage.

Short-Term Outcomes of Laparoscopic Intersphincteric Resection for Lower Rectal Cancer and Comparison with Open Approach

Background/Aims: To evaluate the short-term surgical outcomes of laparoscopic intersphincteric resection (ISR) for lower rectal cancer, and to compare them with a case-control series of open ISR. Methods: Between July 2002 and March 2011, 29 patients with lower rectal cancer underwent laparoscopic ISR, and 22 of 29 patients who underwent laparoscopic ISR were compared with the control open ISR group of patients matched for age, gender, operative procedure and pathological stage. Results: There was no perioperative mortality, 8 complications occurred in 7 patients, and the morbidity rate was 24.1% (7/29). Leakage occurred in 1 patient (3.4%) in the laparoscopic ISR group. Regarding the matched case-control study, the operative time was significantly longer (p = 0.0007), but blood loss was significantly lower (p = 0.0003) in the laparoscopic ISR group. The median postoperative hospital stay was 8 days in the laparoscopic ISR group, which was significantly shorter than in the open ISR group (14 days). Postoperative complication rates were similar. In the laparoscopic ISR group, the levels of C-reactive protein on postoperative days 1–3 were significantly lower than in the open ISR group. Conclusions: Laparoscopic ISR for lower rectal cancer provides benefits in the early postoperative period without increasing morbidity or mortality.

ARID1A expression in gastric adenocarcinoma: Clinicopathological significance and correlation with DNA mismatch repair status

AIM To analyze the mismatch repair (MMR) status and the ARID1A expression as well as their clinicopathological significance in gastric adenocarcinomas. METHODS We examined the expressions of MMR proteins and ARID1A by immunohistochemistry in consecutive 489 primary gastric adenocarcinomas. The results were further correlated with clinicopathological variables. RESULTS The loss of any MMR protein expression, indicative of MMR deficiency, was observed in 38 cases (7.8%) and was significantly associated with an older age (68.6±9.2 vs 60.4±11.7, P<0.001), a female sex (55.3% vs 31.3%, P=0.004), an antral location (44.7% vs 25.7%, P=0.021), and a differentiated histology (57.9% vs 39.7%, P=0.023). Abnormal ARID1A expression, including reduced or loss of ARID1A expression, was observed in 109 cases (22.3%) and was significantly correlated with lymphatic invasion (80.7% vs 69.5%, P=0.022) and lymph node metastasis (83.5% vs 73.7%, P=0.042). The tumors with abnormal ARID1A expression more frequently indicated MMR deficiency (47.4% vs 20.2%, P<0.001). A multivariate analysis identified abnormal ARID1A expression as an independent poor prognostic factor (HR=1.36, 95%CI: 1.01-1.84; P=0.040). CONCLUSION Our observations suggest that the AIRD1A inactivation is associated with lymphatic invasion, lymph node metastasis, poor prognosis, and MMR deficiency in gastric adenocarcinomas.

Intussusception due to rectal adenocarcinoma in a young adult: A case report

An intussusception due to colonic adenocarcinoma has sometimes been reported. However, to the best of our knowledge, reports of intussusception due to rectal adenocarcinoma are extremely rare. In this report, the case of a young man with rectal adenocarcinoma causing intussusception is described. A 24-year-old man visited a hospital complaining of abdominal pain, and an upper rectal cancer was diagnosed by colonoscopy. Computed tomography showed intussusception caused by a large tumor in the pelvis and absence of distant metastases. Locally advanced rectal cancer causing intussusception was diagnosed, and a low anterior resection was performed. Intraoperatively, repair of the invagination could not be accomplished easily; therefore, the repair was abandoned. Instead, the tumor was removed en bloc to avoid dissemination of the cancer. Histopathologically, the tumor was diagnosed as a poorly differentiated adenocarcinoma, pStage IIA. The patient has no evidence of recurrence at 10 mo after the operation.

Laparoscopic resection of synchronous colorectal cancers in separate specimens

Laparoscopic approaches are increasingly being used in patients with colorectal cancer, but the feasibility of laparoscopic resection of synchronous colorectal cancers in separate specimens remains unknown. In such cases, it is necessary to consider the site of port placement, sequence of dissection, choice of specimen extraction sites, specimen handling, and extracorporeal anastomosis sites. Moreover, the need for complete mesenteric dissection in two areas, removal of two separate specimens containing malignancies, and two anastomoses elicit unique questions related to technical considerations. The aim of this study was to determine the feasibility of laparoscopic resection of two separate specimens containing malignancies for multiple synchronous colorectal cancers.

Clinical outcomes of women with ovarian metastases of colorectal cancer treated with oophorectomy with respect to their somatic mutation profiles

We clarified the clinical prevalence of ovarian metastases from colorectal cancers (CRCs) in 296 female patients with CRC and evaluated clinical outcomes with relation to their mutational profiles, such as BRAF/KRAS mutation and microsatellite instability (MSI) status. The female CRCs were categorised into three subsets: CRCs with ovarian metastases [6.4% (n = 19), 5-year overall survival (OS) = 24.7%], CRCs with extra-ovarian metastases only [32.4% (n = 96), 5-year OS = 34.5%] and CRCs without any recurrence or metastasis [61.2% (n = 181), 5-year OS = 91.3%]. All patients with ovarian metastases underwent oophorectomy; of these, 9 who received preoperative chemotherapy had measurable metastases to extra-ovarian sites and the ovaries. Although 5 of 9 (56%) achieved partial response or complete response at extra-ovarian sites, no patient archived objective response at ovarian sites. Regarding the mutation profiles, in CRCs with extra-ovarian metastases only, the median survival time (MST) after initial treatments to progression to stage IV or recurrence was 13 [95% confidence interval (CI): 7–16 months] in BRAF-mutant and 34 months (95% CI: 22–58 months) in BRAF wild-type (P = 0.0033). Although ovarian metastases demonstrated poor response to systemic chemotherapy in CRCs with ovarian metastases, the MST after initial treatments to progression to stage IV or recurrence was 22 (95% CI: 21–25 months) in BRAF-mutant and 38 months (95% CI: 24–42 months) in BRAF wild-type (P = 0.0398). The outcomes of patients with ovarian metastases could be improved by oophorectomy regardless of their mutation profiles.

BRAF V600E mutation is a predictive indicator of upfront chemotherapy for stage IV colorectal cancer

In stage IV colorectal cancer (CRC), initial resection of the primary tumor is considered to be an important strategy for improving disease outcome. However, there is no consensus on the timing as to when the surgical intervention of the primary tumor should occur. The present study hypothesizes that genetic profiles in CRC may indicate the appropriate treatment strategies for patients with stage IV CRC, and a cohort of 113 patients with stage IV CRC resected primary lesions at various periods were analyzed for the presence of mutations in the KRAS, exon 2, and BRAF genes, exon 15, and for the microsatellite instability status of the tumor. These data were additionally correlated with various clinicopathological features. Although BRAF-mutant was revealed to be an independent negative prognostic factor in stage IV CRC (HR, 8.42; 95% confidence interval, 2.72–26.02), BRAF-mutant samples exhibited better prognoses if they were treated with chemotherapy prior to tumor resection. Thus, the presence of BRAF mutations provides a compelling rationale for the establishment of intensive upfront chemotherapy to improve survival in stage IV CRC.

Comparison of outcomes between symptomatic and asymptomatic patients with colorectal cancer: a propensity score-matched analysis of surgical invasiveness, medical costs and oncological outcomes

Background and aims Whether asymptomatic patients with colorectal cancer (CRC) who are treated in hospitals show better outcomes than symptomatic patients with CRC still remains unknown. The aim of this study was to evaluate differences in clinical benefits following treatment in asymptomatic and symptomatic patients with CRC. Methods This study was a retrospective cohort analysis with data obtained from records. A cohort of 145 asymptomatic and 123 symptomatic patients who underwent CRC surgery between January 2009 and December 2011 was enrolled. To reduce bias in comparing outcomes, propensity score (PS) analysis was used for matching of patients in the symptomatic and asymptomatic groups based on clinicopathological factors. Surgical invasiveness, medical costs and oncological outcomes were examined by unadjusted and PS-matched analysis. Results Tumours in the symptomatic group were more often diagnosed in advanced stages compared with tumours in the asymptomatic group. Therefore, fewer symptomatic group patients underwent minimally invasive surgery. Short-term outcomes, including amount of blood loss, duration of postoperative hospital stay and perioperative medical costs, were significantly better in the asymptomatic group. Although overall survival was significantly better in the asymptomatic group, there was no significant difference between the groups when the patients were adjusted on the basis of PS. Conclusions Though this study was limited by the retrospective nature and small sample size, favourable outcomes in asymptomatic patients were due to the higher proportion of patients in this group who were diagnosed with CRC in earlier stages, due to participation in CRC screening programmes.

Staple-Line Reinforcement of the Duodenal Stump With Intracorporeal Lembert's Sutures in Laparoscopic Distal Gastrectomy With Roux-en-Y Reconstruction for Gastric Cancer.

Purpose: We report a duodenal stump reinforcement procedure in laparoscopic distal gastrectomy with Roux-en-Y reconstruction. Methods: We retrospectively reviewed the data of 223 patients who underwent laparoscopic distal gastrectomy with Roux-en-Y reconstruction for gastric cancer. We compared 2 groups: group NR (not reinforced, n=102, June 2009 to December 2011) when we did not perform reinforcement of the duodenal stump, and group R (reinforced, n=121, January 2012 to July 2014) when we did the reinforcement. The duodenum was divided with an endoscopic linear stapler. In group R, the duodenal staple line was reinforced by hand-sewn Lembert’s sutures. Results: There were no significant differences between group NR and R in patients’ characteristics. Duodenal stump leakage occurred in 2 patients in group NR (2.0%). By contrast, in R group, no patients had duodenal stump leakage or fistula. Conclusions: Duodenal stump leakage can be avoided by using reinforcement with Lembert’s sutures.

Successful Laparoscopic Treatment for Refractory Rectovaginal Fistula of Behçet's Disease: A Case Report and Review of the Literature

Abstract Abstract Introduction: Rectovaginal fistula caused by BehA§ets disease is extremely rare, and the clinical course is very unfavorable. We describe rectovaginal fistula of BehA§ets disease with successful laparoscopic treatment, and review the literature. Case presentation: A 30-year-old woman with BehA§ets disease was diagnosed with rectovaginal fistula, and treated medically after fecal diversion colostomy. However, the fistula remained, and she underwent radical surgery. Laparoscopically, after mobilization of the rectum, the fistula was removed. The rectum was transected on the anal side of the fistula, and removed after extraction through the vaginal incision. The vaginal incision was repaired by suturing, and rectal anastomosis was performed using a double-stapling technique. The omentum was fixed between the rectum and vagina, and the operation was completed. Six months after the laparoscopic surgery, no evidence of fistula recurrence has been seen on colonoscopy. Conclusion: We have rep...