Takefumi Yoshida

Challenges in staging systems for colorectal cancer: clinical significance of metastatic lymph node number in colorectal cancer and mesorectal extension in rectal cancer.

In many countries, treatment for cancer is performed based on staging systems in which the degree of cancer development is defined objectively. A common staging system is thus needed to compare outcomes. The staging system for colorectal cancer in Japan has been made to enhance consistency with the TNM classification, and the categorization of metastatic lymph nodes and depth of invasion have been revised in recent years. Although these are important factors that determine disease stage, relationships between each factor and recurrence have shown differing prognoses. In our retrospective study, the prognosis of a group with only one metastatic lymph node was significantly better compared to a group with ≧2 metastatic lymph nodes. In addition, rectal cancer with mesorectal extension >5 mm showed low relapse-free survival rates and high recurrence rates. The validity of staging systems should thus be inspected from various perspectives.

Bowel obstruction caused by an internal hernia that developed after laparoscopic subtotal colectomy: a case report

IntroductionLaparoscopic surgery is a minimally invasive approach with good treatment outcomes and is currently the standard surgery for colorectal cancer in Japan. Mesenteric closure is considered unnecessary in laparoscopic colorectal surgery because it can damage the bowel and blood vessels. However, an internal hernia may develop if the mesentery is not repaired.Case presentationWe report a case of internal hernia in a 61-year-old male of Japanese ethnicity. The patient had advanced sigmoid colon cancer, early-stage transverse colon cancer, and multiple adenomatous polyposis, and underwent laparoscopically-assisted subtotal colectomy. Bowel obstruction developed six days postoperatively and did not improve with conservative treatment. Abdominal computed tomography detected an internal hernia, prompting emergency surgery in which the ileum protruding into the mesenteric defect and an anastomotic stricture were detected. Reanastomosis, mesentery closure, and ileostomy were performed after hernia repair.ConclusionIn this case, open surgery was necessary due to bowel obstruction after laparoscopic colectomy. This outcome indicated that mesenteric closure should have been performed. Thus, the benefits of mesenteric closure require assessment in future cases.

The Impact of Body Mass Index on Perioperative Outcomes After Laparoscopic Colorectal Surgery.

Laparoscopic colorectal surgery has gained increasing attention during the past 20 years. Surgeons today are more often confronted with obese patients. Therefore, it is timely to investigate the feasibility and safety of laparoscopic surgery for colorectal disease in obese patients. This study included 65 patients with colorectal disease who underwent laparoscopic surgery, between January 2009 and January 2014, at Kurume University Hospital. We divided the patients in this study into two groups based on their body mass index (BMI): <25 kg/m(2) (non-obese group) and ≥ 25 kg/m(2) (obese group). We assessed baseline characteristics and surgical outcomes, and these were compared between the non-obese group and the obese group. There were 53 patients in the non-obese group, and 12 patients in the obese group. There was no significant difference between the two groups of patients with regard to age, sex, co-morbidity, tumor location, tumor node metastasis (TNM) stage, tumor size and serum carcinoembryonic antigen (CEA) level. The duration of the operation was longer (by about 49 mins) for obese patients than non-obese patients. The conversion rate, amount of blood loss, number of lymph nodes resected, and duration of postoperative hospital insertion were each similar between the two groups. There was no significant difference between the two groups with regard to the overall incidence of postoperative complications; however, the incidence of incisional hernia tended to be more frequent in obese patients. There was no mortality in the two groups. Laparoscopic colorectal surgery is technically feasible and safe for obese patients. However, obesity is associated with longer duration and with higher risk of incisional hernia. Our findings suggest that BMI may not be an accurate estimate of visceral fat, and further studies may be useful for understanding the impact of obesity.

Fecoflowmetric analysis of anorectal motor function in postoperative anal-preserving surgery patients with low rectal cancer comparison with the wexner score and anorectal manometry.

The aim of this study was to elucidate whether fecoflowmetry (FFM) could evaluate more detailed evacuative function than anorectal manometry by comparing between FFM or anorectal manometric findings and the clinical questionnaires and the types of surgical procedure in the patients who received anal-preserving surgery. Fifty-three patients who underwent anal-preserving surgery for low rectal cancer were enrolled. The relationships between FFM or the manometric findings and the clinical questionnaires and the types of procedure of anal-preserving surgery were evaluated. There were significant differences between FFM markers and the clinical questionnaire and the types of the surgical procedure, whereas no significant relationship was observed between the manometric findings and the clinical questionnaire and the types of the surgical procedure. FFM might be feasible and useful for the objective assessment of evacuative function and may be superior to manometry for patients undergoing anal-preserving surgery.

External sphincter resection for lower rectal and anal canal adenocarcinoma: achieving anal preservation with oncological and functional satisfaction

Intersphincteric resection (ISR) has recently been performed for very low rectal cancer, whereas abdominoperineal resection (APR) is typically reserved for cancers extremely close to the anal verge and/or when the depth of tumor invasion is suspected to involve the intersphincteric space. This is because impairment of anal function is considered unavoidable if the external sphincter (ES) is excised. We describe our technique of ISR with ES resection and discuss its outcomes. This surgical technique may offer major clinical advantages to selected patients and should be considered as an alternative to APR, although careful consideration of anal function is required.

Extraanatomic Aortic Bypass for Repair of Aortic Coarctation

Abstract  We describe two adult patients who underwent extraanatomic ascending aorta‐to‐descending thoracic aorta bypass grafting for repair of aortic coarctation through a median sternotomy and posterior pericardial approach. Of the two patients, one presented with coarctation and concurrent cardiovascular disorders, and the other, with residual coarctation. Cardiopulmonary bypass was established with double arterial cannulation in the aorta or axillary artery and the femoral artery ensure adequate perfusion proximal and distal to coarctation and bicaval cannulation. The heart was retracted cephalic and superiorly, and the descending thoracic aorta was exposed through the posterior pericardium. After achieving distal anastomosis, the graft was directed anterior to the inferior vena cava and lateral to the right atrium, and anastomosed to the right lateral aspect of the ascending aorta. A 14‐mm graft was used. In one patient receiving concomitant procedures, mitral valve repair and replacement of the ascending aorta was performed after the distal anastomosis.

Technical tips for intersphincteric resection: how to take out the rectum

Intersphincteric resection (ISR) is an ideal technique that preserves the anus, regardless of whether the internal anal sphincter is removed. However, it is difficult to dissect the anterior wall of the rectum from the adjacent organs. We herein describe a safe and useful ISR technique which draws out the rectum through the anus. The intersphincteric space (ISS) between the internal and external anal sphincter muscles was first transabdominally dissected. Next, the transanal dissection was advanced into the ISS bilaterally from the posterior side without dissecting the anterior wall of the anal canal, and the sigmoid colon and rectum were drawn out through the anus. Dissection between the anterior wall of the rectum and prostate/vagina could be easily performed under direct vision. This technique enables the dissection without any risk of a positive surgical margin or unexpected bleeding, and avoids injury to adjacent organs. This technique seems to be a safe and useful dissection technique for approaching the anterior wall of the anal canal.

Increased Expression of Claudin-1 Contributes to Tumorigenesis in Ulcerative Colitis-Associated Colorectal Cancer

G A A b st ra ct s CRC cases diagnosed between 1990 and 2006 in 7 tertiary referral centers in the Netherlands were selected using a nationwide pathology database (PALGA). This database was also used to identify IBD controls matched for our referral setting. Controls had to have a closed rectal stump, but no neoplasia. Follow-up started at the date of subtotal colectomy with formation of a closed rectal stump. The following variables were collected at t=0: gender, type of IBD, disease duration until date of subtotal colectomy, concomitant primary sclerosing cholangitis (PSC), medication use, smoking behaviour, dysplasia in the colectomy specimen, presence of pseudopolyps, and extent and severity of inflammation before subtotal colectomy. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated for patient variables using Cox regression analysis. End points were advanced neoplasia and end of follow-up (proctectomy, end of study or lost to follow-up). Results: We identified 12 patients with high grade dysplasia (HGD) (n=1) or CRC (n=11) of the rectal stump and 19 without neoplasia served as controls. Univariate analysis showed an association between advanced neoplasia and PSC (HR 8.3; 95%CI 1.9-36.3), dysplasia in the original subtotal colectomy specimen (HR 6.7; 95%CI 1.2-37.5) and disease duration until subtotal colectomy (HR per year 1.09; 95%CI 1.03-1.16). Multivariate analysis showed that only disease duration was significantly associated with advanced neoplasia (HR 1.09; 1.01-1.17). Conclusion: This relatively small casecontrol study shows that risk factors for HGD/CRC in the rectal stump after subtotal colectomy show similarities to those of the complete colon in IBD.