Yoshiya Fujimoto

Factors affecting the difficulty of laparoscopic total mesorectal excision with double stapling technique anastomosis for low rectal cancer

BACKGROUND Although the laparoscopic approach is accepted for the treatment of colon cancer, its value for low rectal cancer is unknown. The purpose of this study was to evaluate the influence of patient and tumor factors, particularly pelvic dimensions, on the difficulties in laparoscopic total mesorectal excision (TME) for low rectal cancer. METHODS Seventy-nine consecutive patients underwent laparoscopic TME with intracorporeal rectal transection and double stapling technique (DST) anastomosis for low rectal cancer. Gender, body mass index (BMI), tumor diameter, tumor depth, tumor distance from the anal verge, preoperative chemoradiotherapy, and 5 pelvic dimensions (pelvic inlet, pelvic outlet, length of sacrum, interspinous distance, and intertuberous distance) were analyzed as variables affecting the difficulties of laparoscopic TME. The dependent variables were pelvic operative time, which was defined as the time required for dissection of the rectum from the pelvis, intracorporeal transaction, and anastomosis. Other dependent variables were intraoperative blood loss, overall postoperative morbidity, and anastomotic leakage. Univariate and multivariate analyses were performed to determine the predictive significance of variables. RESULTS Multivariate analysis showed that BMI (P < .0001), tumor distance from the anal verge (P = .0003), tumor depth (P = .0021), and pelvic outlet (P = .0362) were independently predictive of pelvic operative time. Pelvic operative time was related to intraoperative blood loss (P < .0001). The tumor distance from the anal verge (P = .0333, odds ratio [OR]: 1.06) was related to postoperative morbidity, and pelvic outlet was related to anastomotic leakage (P = .0305, OR: 1.13). CONCLUSION BMI, tumor distance from the anal verge, tumor depth, and pelvic outlet were independent predictors for operative time and morbidity. These factors should be taken into account when planning laparoscopic TME.

Incidence of and risk factors for anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer

BACKGROUND Laparoscopic rectal cancer surgery involving rectal division with intracorporeal stapling devices is technically difficult. This study aimed to identify risk factors for anastomotic leakage associated with laparoscopic anterior resection for rectal cancer. METHODS We studied 363 patients who underwent laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique (DST) anastomosis for rectal cancer between July 2005 and February 2010. Twenty-two independent clinical variables were examined by univariate and multivariate analyses. The outcome of interest was clinical anastomotic leakage. RESULTS Anastomotic leakage was identified in 13 (3.6%) patients. Multivariate analysis identified middle/lower rectal cancer (odds ratio, 9.446) and lack of pelvic drain (odds ratio, 3.814) as independent predictive factors for anastomotic leakage. The number of cartridges used for rectal division had no significant impact on anastomotic leakage. CONCLUSIONS Laparoscopic anterior resection involving intracorporeal rectal transection and DST anastomosis is safe if performed using an appropriate technique.

Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection.

BackgroundRectal transection and anastomosis at the lower rectum is the most challenging part of laparoscopic low anterior resection. Therefore, some have demonstrated that rectal transection should be performed using instruments for open surgery with small laparotomy. In our institute, however, rectal transection using a currently available endostapler followed by anastomosis with a double stapling technique is usually performed.MethodsThe important points of our technique are as follows: trocar placement, optimal device choice, harmonious movement between the operator and assistant for rectal transection, optimal point of piercing with the center rod of the circular stapler, and ideal positioning of the proximal colon.ResultsSeventy-eight patients underwent low anterior resection using this technique. There were no conversions to open surgery. All rectal transections were completed laparoscopically with an available endostapler. A diverting ileostomy was created in six cases. Anastomotic leakage occurred in only two patients (2.6%) and rectovaginal fistula in only one patient (1.3%).ConclusionsOur standardized technique is considered to be safe and feasible for rectal transection and anastomosis using the double stapling technique (DST).

Abdominal sacral resection for posterior pelvic recurrence of rectal carcinoma: analyses of prognostic factors and recurrence patterns.

BackgroundLocal recurrence of rectal cancer presents challenging problems. Although abdominal sacral resection (ASR) provides pain control, survival prolongation, and possibly cure, reported morbidity and mortality are still high, and survival is still low. Thus, appropriate patient selection and adjuvant therapy based on prognostic factors and recurrence patterns are necessary. The purpose of this study was to evaluate the results of ASR for posterior pelvic recurrence of rectal carcinoma and to analyze prognostic factors and recurrence patterns.MethodsForty-four patients underwent ASR for curative intent in 40 and palliative intent in 4 cases. All but one could be followed up completely. Multivariate analyses of factors influencing survival and positive surgical margins were conducted.ResultsMorbidity and mortality were 61% and 2%, respectively. Overall 5-year survival was 34%. The Cox regression model revealed a positive resection margin (hazard ratio, 10 [95% confidence interval, 3.8–28]), a local disease–free interval of <12 months (4.2 [1.8–9.8]), and pain radiating to the buttock or further (4.2 [1.6–11]) to be independently associated with poor survival. The logistic regression model showed that macroscopic multiple expanding or diffuse infiltrating growths were independently associated with a positive margin (7.5 [1.4–40]). Of the patients with recurrence, 56% had failures confined locally or to the lung.ConclusionsASR is beneficial to selected patients in terms of survival. To select patients, evaluation of the resection margin, the local disease–free interval, pain extent, and macroscopic growth pattern is important. To improve survival, adjuvant treatment should be aimed at local and lung recurrences.

Second Hepatectomy for Recurrent Colorectal Liver Metastasis: Analysis of Preoperative Prognostic Factors

BackgroundSecond hepatectomy is a potentially curative treatment for patients with hepatic recurrence of colorectal cancer. However, there is still no consensus about the patient selection criteria for second hepatectomy under these circumstances, and the factors affecting prognosis after second hepatectomy remain uncertain.MethodsClinicopathologic data for 111 consecutive patients with colorectal liver metastasis who underwent second hepatectomy at a single institution between 1985 and 2004, and for whom complete clinicopathologic reports were available, were subjected to univariate and multivariate analyses.ResultsThe morbidity and mortality rates were 14% and 0%, respectively, and the overall 5-year survival rate was 41%. Multivariate analysis revealed that synchronous resection for the first liver metastasis (hazard ratio, 1.8), more than three tumors at the second hepatectomy (1.9), and histopathological involvement of the hepatic vein and/or portal vein by the first liver metastasis (1.7) were independently associated with poor survival. We used these three risk factors to devise a preoperative model for predicting survival. The 5-year survival rates of patients without any risk factors, and with one, two, or three risk factors, were 62%, 38%, 19%, and 0%, respectively.ConclusionsSecond hepatectomy is beneficial for patients without any risk factors. Before second hepatectomy, chemotherapy should be considered for patients with any of these risk factors, especially with two or three factors, in the adjuvant or neoadjuvant setting to prolong survival. These results need to be confirmed and validated in another data set or future prospective trial according to the scoring scheme we outline.

Effect of body mass index on short-term outcomes of patients undergoing laparoscopic resection for colorectal cancer: a single institution experience in Japan.

Background: The impact of body mass index (BMI) on laparoscopic surgery for colorectal cancer in Asian countries is unclear, partly because obesity is less common in Asia than in western countries. The purpose of this study was to evaluate the association between BMI and short-term outcomes after laparoscopic resection for colorectal cancer in Japanese patients. Methods: A cohort of 1194 patients who underwent laparoscopic resection for colorectal cancer at Cancer Institute Hospital between July 2005 and February 2010 were enrolled in this prospective study. Outcomes were analyzed according to BMI category: nonobese (BMI<25), obese I (25⩽BMI<30), and obese II (BMI≥30). Results: A total of 926 patients (78%) were classified as nonobese, 243 (20%) were obese I, and 25 (2%) were obese II. Mean operating time (214 min vs. 244 min vs. 293 min) and mean estimated blood loss (23 mL vs. 42 mL vs. 88 mL) increased significantly with increasing BMI (P<0.0001, respectively). The rate of postoperative complications was significantly higher in obese II patients than in nonobese and obese I patients (24% vs. 9.2% vs. 9.1%, P=0.0428). Multivariate analysis showed that a BMI in the obese II range was an independent predictive factor for developing anastomotic leakage (odds ratio: 10.27, 95% confidence interval, 1.98-53.44). Conclusions: Laparoscopic surgery for colorectal cancer is technically more demanding in Japanese obese II patients than in nonobese or obese I patients. Special care is required because of the increased risk of developing postoperative complications.

Simultaneous Resection of Colorectal Cancer and Synchronous Liver Metastases: Initial Experience of Laparoscopy for Colorectal Cancer Resection

Background/Aims:Although laparoscopy is accepted for treatment of colorectal cancer, there is no established consensus for its use when resection of synchronous liver metastases is performed simultaneously. The purpose of this study was to evaluate whether laparoscopic colorectal resection with simultaneous resection of synchronous liver metastases was technically feasible and whether it may be a therapeutic option. Methods: Ten patients underwent laparoscopic resection for primary colorectal cancer, combined with synchronous resection of liver metastases. Results: The primary tumor location was in the sigmoid colon in 3 patients and the rectum in 7. All laparoscopic colorectal resections were successful, with no conversion to open surgery. Simultaneously, there were 7 conventional open and 3 laparoscopy-assisted liver resections. The median total operating time was 446 (range 300–745) min, including 222 (range 152–313) min for colorectal resection. The median total estimated blood loss was 175 (range 30–1,200) ml, including 10 (range 0–550) ml for colorectal resection. There was no major morbidity, except 1 patient who developed decubitus. Conclusion: This preliminary report suggests that laparoscopic resection for sigmoid colon and rectal cancer, combined with synchronous resection of liver metastases, is a safe and feasible procedure in selected patients.

Treatment of colorectal carcinoids: A new paradigm

It is often difficult to evaluate the grade of malignancy and choose an appropriate treatment for colorectal carcinoids in clinical settings. Although tumor size and depth of invasion are evidently not enough to stratify the risk of this rare tumor, the present guidelines or staging systems do not mention other clinicopathological variables. Recent studies, however, have shed light on the impact of lymphovascular invasion on the outcome of colorectal carcinoids. It has been revealed that the presence of lymphovascular invasion was among the strongest risk factors for metastasis along with tumor size and depth of invasion. Furthermore, tumors smaller than 1 cm, within submucosal invasion and without lymphovascular invasion, carry minimal risk for metastasis with 100% 5-year survival in the studies from Japan as well as from the USA. This would suggest that these tumors could be curatively treated by endoscopic resection or transanal local excision. On the other hand, colorectal carcinoids with either lymphovascular invasion or tumor size larger than 1 cm carry the risk for metastasis equivalent to adenocarcinomas. Therefore, it should be emphasized that histological examination of lymphovascular invasion is mandatory in the specimens obtained by endoscopic resection or transanal local excision, as this would provide useful information for determining the need for additional radical surgery with regional lymph node dissection. Although the present guidelines or TNM staging system do not mention the impact of lymphovascular invasion, this would be among the next promising targets in order to establish better guidelines and staging systems, particularly in early-stage colorectal carcinoids.

Colon cancer in the splenic flexure: comparison of short-term outcomes of laparoscopic and open colectomy.

Background: Laparoscopic surgery for colon cancer in the splenic flexure (SF cancer) is technically demanding and has not been evaluated in randomized clinical trials. This study aimed to evaluate the safety and feasibility of laparoscopic surgery for SF cancer. Methods: Thirty-three patients undergoing laparoscopic surgery for SF cancer (LAC group) were retrospectively compared with 22 patients undergoing open surgery for SF cancer (OC group) between April 2003 and June 2010. Results: Left hemicolectomy was the most performed procedure in both groups (79% vs. 82%). Median operating time was significantly longer (209 vs. 178 min) and estimated blood loss was significantly lower (15 vs. 113 mL) in the LAC group than in the OC group. Conversion to open surgery was needed for 1 (3%) patient because of bleeding near the pancreas. Tumor stage was more advanced in the OC group than in the LAC group, but N stages were similar between groups. The median number of lymph nodes harvested was significantly higher in the LAC group than in the OC group (16 vs. 12). The rate of postoperative complications was significantly lower in the LAC group than in the OC group (6% vs. 36%). Time to flatus (1 vs. 3 d), time to liquid diet (2 vs. 5 d), and hospital stay (12 vs. 16 d) were significantly shorter in the LAC group than in the OC group. Conclusions: Laparoscopic surgery for SF cancer is feasible.

Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer

Total pelvic exenteration (TPE) may be the only procedure that can cure T4 rectal cancer that directly invades the urinary bladder or prostate. Here, we describe our experience of laparoscopic TPE with en bloc lateral lymph node dissection for advanced primary rectal cancer. A 62‐year‐old man diagnosed with advanced lower rectal cancer (T4bN0M0) underwent laparoscopic TPE with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy. Ligation of the dorsal vein complex was performed under direct visualization through the perineal approach, and the large perineal defect was reconstructed using bilateral V‐Y advancement of the gluteus maximus musculocutaneous flaps. The ileal conduit was constructed extracorporeally through an extended umbilical port that was extended to 4 cm. The total operative time was 831 min and estimated blood loss was 600 mL. Laparoscopic TPE appears to be safe and feasible in selected patients.