Takuro Ushigome

Umbilical Incision Laparoscopic Surgery with One Assist Port for Anterior Resection

Background: A high surgical technique is required for laparoscopic anterior resection using single-incision laparoscopic surgery such as multiport surgery. We report a novel surgical technique of umbilical incision laparoscopic surgery with one assist port which could be performed like conventional multiport surgery. Methods: With the patient in the lithotomy position, a 3-cm longitudinal skin incision is made at the umbilicus and carried down to the peritoneum. A 12-mm and two 5-mm trocars are placed through the incision. Another 12-mm trocar is placed for the insertion of laparoscopic coagulation shears and a stapler in the right lower quadrant. After surgery, the trocar in the right lower quadrant is removed and a drain is replaced through the insertion site. The operator mainly uses two trocars, a 5-mm trocar placed at the umbilicus and a 12-mm trocar in the right lower quadrant, making it like conventional laparoscopic surgery. Results: The median operation time was 195 (range 180–205) min, intraoperative blood loss was 20 (range 0–60) ml, and none of the 3 patients had any complications postoperatively. Conclusion: As opposed to surgery with only three ports, so-called single-incision laparoscopic surgery, this operation can be performed much more comfortably if another port is inserted in the right lower quadrant.

Lateral pelvic lymph node dissection using latero-vesical approach with aspiration procedure for advanced lower rectal cancer.

BACKGROUND/AIMS The aim of this study was to evaluate the impact of complete dissection of areolar tissue surrounding lymph nodes in lateral pelvic lymphadenectomy on the outcome of advanced rectal cancer at or below the peritoneal reflection. METHODOLOGY From 1995 to 2004, lateral pelvic lymph node dissection was performed in 141 consecutive patients with advanced rectal cancer at or below the peritoneal reflection by open surgery in our hospital. They were divided into two groups according to the techniques used for lymph node dissection, i.e. conventional method (CM) and our original method, latero-vesical approach with aspiration procedure (LVA), which eliminates not only lymph nodes but also the tissue surrounding the lymph nodes. RESULTS The number of dissected lateral pelvic lymph nodes by LVA was significantly higher than that by CM. In patients without lateral pelvic lymph node metastasis, no significant difference in the outcome was observed between the two groups. On the contrary, among the patients with lateral pelvic lymph node metastasis, five-year survival rates of the group with CM or with LVA was 50% and 70% respectively. CONCLUSIONS For patients with lateral pelvic lymph node metastasis, lateral pelvic lymphadenectomy, complete dissection of areolar tissue surrounding lymph nodes, may contribute to improve the prognosis of advanced rectal cancer at, or below, the peritoneal reflection.

Feasibility study of adjuvant chemotherapy with S-1 (TS-1; tegafur, gimeracil and oteracil potassium) for colorectal cancer.

BACKGROUND/AIMS The aim of this study is to evaluate feasibility and safety of 3-week method (3-week administration and 1-week withdrawal) for colorectal cancer as adjuvant chemotherapy with an oral anticancer drug, S-1. METHODOLOGY Forty-two patients with stage II or III colorectal cancer who underwent curative resection in our hospital during a one year period in 2005 were enrolled in the preliminary pilot study. Between 2006 and 2007, 104 patients with stage II or III colorectal cancer who underwent curative resection in our hospital were chosen and were randomly divided into two groups, 3-week method or 4-week method (4-week administration and 2-week withdrawal) for a prospective randomized trial. RESULTS The one-year completion rate in the 3-week method group was 98% (50/51) which was significantly better than that in the 4-week method group, 68% (36/53) (p=0.035). There were no grade 3 or 4 adverse reactions in both laboratory and clinical findings in the pilot study and in the prospective randomized trial. CONCLUSIONS Three-week method of S-1 administration had good feasibility, easily manageable toxicity, high accumulated dose in one year and good compliance. The 3-week method with S-1 may be a standard adjuvant chemotherapy schedule for colorectal cancer.

Colorectal anastomosis using retroperitoneal window after wide colorectal resection.

After wide colorectal resection, some patients require colostomy due to the difficulty with performing primary colorectal anastomosis. For such patients, we have devised a novel technique of coloproctostomy or coloanal anastomoses through an extra-anatomical route, the retroperitoneal window (RPW), as a reconstruction route. The peritoneum over the inferior margin of the horizontal portion of the duodenum is incised, and the retroperitoneal route is dilated dorsal to the ileocolic artery and vein from the incision below the duodenum towards the right ventral aspect of the aortic bifurcation in the retroperitoneal space. This route is called RPW. After colorectal resection, the proximal stump of the colon is delivered through the RPW, and coloproctostomy or coloanal anastomoses is performed. Nine patients underwent this procedure during a three-year period from December 2007 to November 2010. This technique allowed coloproctostomy was performed in six and coloanal anastomoses in three patients. Without any complications, none of the nine patients required temporary colostomy. By using RPW, the necessity of colostomy would be reduced in patients who require wide colorectal resection.

Safety and Efficacy of Trifluridine-Tipiracil Hydrochloride Oral Combination (TAS-102) in Patients with Unresectable Colorectal Cancer.

Aim: To retrospectively examine efficacy and safety of oral combination of trifluridine and tipiracil hydrochloride (TAS-102) as the second-line therapeutic agent for unresectable colorectal cancer. Patient and Methods: Treatment outcomes of 17 patients who had received TAS-102 at our Institution from January 2015 to January 2017 were analyzed. The indications for second-line TAS-102 treatment were intolerance to other multi-drug combination (four patients) or patient refusal of the standard second-line therapy (13 patients). Results: Among 17 patients who received TAS-102 as second-line therapy, partial response was observed in two (12%) and stable disease in two (12%). Outcomes of TAS-102 given as second-line therapy were: median overall survival of 5 months, response rate of 12% and disease control of 24%. Overall, no adverse events other than neutropenia were noted. Conclusion: Our findings suggest a beneficial role of TAS-102 in second-line therapy for unresectable colorectal carcinoma.

Possibility of sandwiched liver surgery with molecular targeting drugs, cetuximab and bevacizumab on colon cancer liver metastases: a case report

A 31-year-old man with sigmoid colon cancer with concomitant simultaneous multiple liver metastases had received FOLFIRI (leucovorin, fluorouracil and irinotecan) and FOLFOX6 (leucovorin, fluorouracil and oxaliplatin) after an ordinary sigmoidectomy. However, his serum carcinoembryonic antigen (CEA) level increased rapidly during the fifteen months after the operation while he was on FOLFOX6. Abdominal computed tomography revealed expanding multiple liver tumors. As the third line chemotherapy, a combination therapy of cetuximab with irinotecan was given, which markedly reduced his levels of serum CEA, and the size and number of liver tumors. He underwent lateral segmentectomy of the liver and microwave coagulation of the liver metastases in the remnant liver. Thereafter, a good quality of life with tumor dormancy was obtained for 6 months. However, his serum CEA started to rise again in the absence of liver tumors. Therefore, FOLFOX6 with bevacizumab was chosen as the fourth line chemotherapy, and the serum CEA was reduced with tumor dormancy. A good quality of life was obtained again at 3 years after the first surgery. This report indicates the effectiveness of sandwiched liver surgery with the molecular targeting drugs cetuximab and bevacizumab on multiple liver metastases of colon cancer, and suggests the possibility of a regimen consisting of bevacizumab following cetuximab.

Single-incision laparoscopic ileoproctostomy for chronic constipation.

A 56-year-old woman who had undergone cesarean section thirty-five years ago and appendectomy forty years ago was referred to our department for surgical treatment of chronic constipation of over thirty years duration. She underwent laparoscopic ileoproctostomy using a single incision laparoscopic surgery (SILS) in July 2009. After laparoscopic mobilization of the ileocecal portion, the terminal ileum was transected by a stapler. Ileoproctostomy was performed by a circular stapler inserted transanally after the placement of an anvil on the ileal stump. The duration of the operation was 90 minutes and perioperative blood loss was less than 10mL. Her postoperative course was uneventful and she was discharged ten days after the operation. After discharge her bowel habits have been regular without any laxatives. SILS has been performed since the late 1990s for a wide variety of surgical procedures. To our knowledge however, this is the first report of ileoproctostomy using SILS for chronic constipation.

Usefulness of one suprapubic assist port in umbilical incision laparoscopic surgery for right-side colon cancer.

BACKGROUND/AIMS Although single incision laparoscopic surgery (SILS) has been performed for right-side colon cancer, it cannot always be completed by only umbilical incisional ports. One suprapubic assist port in SILS for right-side colon cancer is useful for such cases. METHODOLOGY Seventeen patients underwent SILS for right-side colon cancer between September 2009 and August 2010. Six patients (35%) who could not complete the procedure with only umbilical incisional ports for right-side colon cancer were evaluated. RESULTS All six patients could not be operated on with only the umbilical incisional ports because the root of the ileocolic artery and vein could not be dissected because of obesity or difficulty with controlling the intestine. However, they could undergo laparoscopic surgery when only one suprapubic assist port was inserted. The mean operation time was 192.2 minutes (range 128-230), the mean intraoperative blood loss was 26.7mL (range 0-90) and the mean postoperative hospital stay was 9.2 days (range 9-10). Postoperatively, none of the six patients had any complications. CONCLUSIONS One suprapubic assist port in SILS for right-side colon cancer seems to be useful for patients who cannot be operated on with only umbilical incisional ports.

Retrograde Single Stapling Technique for Laparoscopic Ultralow Anterior Resection

A highly effective surgical technique is required for laparoscopic low rectal transection without sufficient distal margins when ultralow anterior resection (ULAR) with a stapler is a technical challenge for laparoscopic surgery. We report a retrograde single stapling technique (RSST) for laparoscopic ULAR. Total mesorectal excision is performed laparoscopically. After the anal side of the tumor has been closed transanally, the distal line in the right lateral wall of the rectum is partially transected with laparoscopic coagulation shears (LCS). The distal line in the rectum is transected circularly with LCS after detecting the cutting part in the right lateral wall of the rectum laparoscopically. The end of the distal rectum is closed by a purse-string suture using 2-0 prolene transanally. Intestinal resection is performed extracorporeally through a suprapubic incision. After an anvil is placed in the proximal end of the colon over a purse-string suture, it is introduced to the anal canal transabdominally. The purse-string suture is tied to the anvil shaft before connecting it to the center shaft of the circular stapler; the instrument is then fired to create end-to-end anastomosis. For the prevention of anastomotic leakage, a 24-french balloon catheter which decompresses the anastomosis is inserted through the anus.