Yuichiro Yoshioka

Neoadjuvant Oxaliplatin and Capecitabine and Bevacizumab without Radiotherapy for Poor-risk Rectal Cancer: N-SOG 03 Phase II Trial

OBJECTIVE This Phase II trial was designed to evaluate the safety and efficacy of neoadjuvant oxaliplatin and capecitabine and bevacizumab without radiotherapy in patients with poor-risk rectal cancer. METHODS Patients with magnetic resonance imaging-defined poor-risk rectal cancer received neoadjuvant oxaliplatin and capecitabine and bevacizumab followed by total mesorectal excision or more extensive surgery. RESULTS Between February 2010 and December 2011, 32 patients were enrolled in this study. The completion rate of the scheduled chemotherapy was 91%. Reasons for withdrawal were refusal to continue therapy in two patients and disease progression in one, with two of these three patients not undergoing surgery. Among the 29 patients who completed the scheduled chemotherapy, one refused surgery within 8 weeks after the completion of chemotherapy, which was the period stipulated by the protocol, and another had rectal perforation, requiring urgent laparotomy. As a result, the completion rate of this experimental treatment was 84%. Of the 30 patients who underwent surgery, the R0 resection rate was 90% and a postoperative complication occurred in 43%. A pathological complete response was observed in 13% and good tumor regression was exhibited in 37%. CONCLUSIONS Neoadjuvant oxaliplatin and capecitabine plus bevacizumab for poor-risk rectal cancer caused a high rate of anastomotic leakage and experienced a case with perforation during chemotherapy, both of which were bevacizumab-related toxicity. Although the short-term results with the completion rate of 84.4% and the pathological complete response rate of 13.3% were satisfactory, we have to reconsider the necessity of bevacizumab in neoadjuvant chemotherapy (UMIN number, 000003507).

“Supraportal” Right Posterior Hepatic Artery: An Anatomic Trap in Hepatobiliary and Transplant Surgery

BackgroundA supraportal right posterior hepatic artery (RPHA), which runs cranially to the right portal vein and goes to the liver, has never been described.MethodsThe course of the RPHA to the right portal vein was evaluated, using (1) computed tomography (CT) arteriography and portography in 300 patients who underwent multidetector row CT (radiologic study) and (2) operative records in 203 patients who underwent left-sided hepatectomy for perihilar cholangiocarcinoma (surgical study).ResultsIn the radiologic study, an infraportal type RPHA was observed in 239 (79.7%) patients, a supraportal type in 35 (11.7%), and a combined type in 26 (8.7%). In the surgical study, an infraportal type was observed in 179 (88.2%) patients, a supraportal type in 11 (5.4%), and a combined type in 13 (6.4%). In two patients with the combined type RPHA, the supraportal hepatic artery of the right posterior superior segment (A7) was injured during surgery. In another two patients with advanced carcinoma involving the supraportal PRHA, combined hepatic artery resection and reconstruction was necessary. Overall, in 4 (17.4%) of the 24 hepatectomized patients with supraportal or combined type RPHA, iatrogenic injury during surgery or cancer invasion of the hepatic artery occurred due to the course of the RPHA itself. In contrast, 179 hepatectomized patients with infraportal type RPHA did not have such course-dependent complications.ConclusionsThe supraportal RPHA runs just beneath the right hepatic duct, which may function as an anatomic trap during hepatobiliary and transplant surgery.

Pedicled Ileal Flap to Repair Large Duodenal Defect After Right Hemicolectomy for Right Colon Cancer Invading the Duodenum

Although right-sided colon cancer occasionally invades the second part of the duodenum, there is no standard procedure for reconstructing a large duodenal defect after resection. This report describes a new approach we recently devised. After resecting the right hemicolon and the involved duodenum, a segment of terminal ileum was isolated on the vascular pedicle, sacrificing the adjacent ileum. We created a flap by opening the segment along the antimesenteric border, and used this flap to cover the defect. This method does not create a nonanatomical bypass and fewer intestinal anastomoses are required than for Roux-en-Y reconstruction.

Conversion Chemotherapy Using Cetuximab plus FOLFIRI Followed by Bevacizumab plus mFOLFOX6 in Patients with Unresectable Liver Metastases from Colorectal Cancer

Recently, in patients with unresectable colorectal liver metastasis, liver resection sometimes becomes possible by intensive systemic chemotherapy, i.e. conversion therapy. However, among cases that do not respond well to first-line chemotherapy, it is rare that second-line chemotherapy results in a marked response allowing liver resection. We consider that the liver resection rate may be increased by initiating second-line treatment at an earlier stage before progression subsequent to first-line chemotherapy. We are conducting a multicentre Phase II study to evaluate the efficacy and safety of sequential chemotherapy using six cycles of cetuximab plus FOLFIRI (5-fluorouracil, folinic acid and irinotecan) followed by six cycles of bevacizumab plus FOLFOX (5-fluorouracil, folinic acid and oxaliplatin) as conversion chemotherapy. The primary endpoint is the liver resection rate during the bevacizumab + FOLFOX phase. Fifty patients are required for this study.

Continuous mattress suture for all hand-sewn anastomoses of the gastrointestinal tract

BACKGROUND The continuous vertical mattress technique for anastomoses in the gastrointestinal or colorectal surgery has not been well reported in literature. METHODS We used the technique for all hand-sewn anastomoses with double-armed monofilament absorbable suture (Glycomer 631). RESULTS In the 266 consecutive anastomoses in 242 cases, there were 4 anastomotic leakages (1.5%) and 1 anastomotic stenosis (0.4%). CONCLUSIONS The technique was feasible, time-saving, economical and with satisfactory results.

Locally Recurrent Rectal Cancer Successfully Treated by Total Pelvic Exenteration with Combined Ischiopubic Rami Resection: Report of a Case

A combined ischiopubic rami resection is extremely rare in the field of gastroenterologic surgery. We report a case of a locally recurrent rectal cancer that was successfully treated by total pelvic exenteration with combined ischiopubic rami resection. A 58-year-old male with locally recurrent rectal cancer and liver metastases was referred to our hospital. Computed tomography and magnetic resonance imaging showed a perineal tumor, which had invaded the prostate, urethra, and obturator internus muscle, and two liver metastases. Because the perineal tumor was very close to the dorsal vein complex and the pubic symphysis, it was considered difficult to approach and divide the dorsal vein complex, and still retain oncologic safety. To achieve R0 resection, total pelvic exenteration with ischiopubic rami resection, total emasculation and partial liver resection were performed. Pathological examination revealed that surgical margins were negative for cancer cells. Although reconstruction of the pelvic ring was not performed, his ambulatory function had recovered to an almost normal status at 6 months after the operation.

Extraluminal GI stromal tumor of the jejunum diagnosed by EUS at double-balloon endoscopy

A 65-year-old man underwent contrast-enhanced CT to follow up a pancreatic duct dilated because of chronic pancreatitis. An enhanced mass of approximately 2-cm diameter was observed in the upper abdominal cavity during both the arterial and venous phases. The patient underwent videocapsule endoscopy (VCE), which demonstrated only a tortuous and dilated vessel in the jejunum (A). Antegrade double-balloon endoscopy (DBE, EN-450T5/W) was then performed and revealed the same abnormality as did VCE (B), but DBE could not distinguish any mass effect on air insufflation. Because the dilated vessel was assumed to be associated with an extraluminal lesion, EUS with a 12-MHz US catheter probe was performed during DBE. The procedure revealed a submucosal tumor under the vessel, which was hypoechoic, with multiple anechoic areas. The tumor was localized to the muscle layer (C). These findings suggested GI stromal tumor (GIST) with malignant potential. The tumor was resected by singleincision laparoscopic surgery. It was found to be attached to the small-bowel wall by a very small area (D), suggesting an extraluminal growth pattern. The surgical specimen was histopathologically confirmed to be a GIST.

Optimal schedule of adjuvant chemotherapy with S-1 for stage III colon cancer: study protocol for a randomized controlled trial

BackgroundAlthough, in Western countries, oxaliplatin-based regimens have been established as a gold standard treatment for patients with stage III or high risk stage II colon cancer after curative resection, in Japan fluorouracil-based regimens have been widely accepted and recommended in the guidelines for adjuvant settings in patients with stage III colon cancer. S-1, an oral preparation evolved from uracil and tegafur, has equivalent efficacy to uracil and tegafur/leucovorin for treating patients with advanced colorectal cancer and might be a suitable regimen in an adjuvant setting. However, the completion rate of the standard six-week cycle of the S-1 regimen is poor and the establishment of an optimal treatment schedule is critical. Therefore, we will conduct a multicenter randomized phase II trial to compare six-week and three-week cycles to establish the optimal schedule of S-1 adjuvant therapy for patients with stage III colon cancer after curative resection.Methods/DesignThe study is an open-label, multicenter randomized phase II trial. The primary endpoint of this study is three-year disease-free survival rate. Secondary endpoints are the completion rate of the treatment, relative dose intensity, overall survival, disease-free survival, and incidence of adverse events. The sample size was 200, determined with a significance level of 0.20, power of 0.80, and non-inferiority margin of a 10% absolute difference in the primary endpoint.DiscussionAlthough S-1 has not been approved yet as a standard treatment of colon cancer in an adjuvant setting, it is a promising option. Moreover, in Japan S-1 is a standard treatment for patients with stage II/III gastric cancer after curative resection and a promising option for patients with colorectal liver metastases in an adjuvant setting. However, a six-week cycle of treatment is not considered to be the best schedule, and some clinicians use a modified schedule, such as a three-week cycle to keep a sufficient dose intensity with few adverse events. Therefore, it will be useful to determine whether a three-week cycle has an equal or greater efficacy and tolerance to side-effects compared with the standard six-week cycle schedule, and thus may be the most suitable treatment schedule for S-1 treatment.Trial registrationThe University Hospital Medical Information Network (UMIN) Clinical Trials Registry UMIN000006750.

Rectal duplication cyst successfully treated by laparoscopic total mesorectal excision using the prolapsing technique

Congenital alimentary tract duplication is a rare disease. It most frequently occurs in the ileum, with the rectum being the rarest site. Herein, we report a 38‐year‐old woman who was referred to our hospital because of severe anal pain. On digital examination, a smooth, round, rubbery mass was palpable; it was located 5 cm from the anal verge in the posterior rectal wall. A CT scan demonstrated a 5‐cm cystic lesion located anterior to the sacrum that was displacing the rectum anteriorly. Spontaneous remission of the tumor was evident; however, after 5 months of follow‐up, the patient experienced the same severe anal pain. MRI demonstrated a recurrent cystic lesion. To prevent further complications and to confirm or deny malignancy, laparoscopic total mesorectal excision using the prolapsing technique was performed. Pathologically, the cystic lesion was diagnosed as a rectal duplication cyst. This is the first report of a rectal duplication cyst successfully treated by laparoscopic total mesorectal excision.

Abdominal Aortic Blood Flow Disturbance Due to Binge Eating

A 38-year-old man visited our emergency department with symptoms of abdominal distention (Fig. 1). He suffered from anorexia nervosa, repeatedly refusing food and overeating. He said that he had more than 10 meals at lunch. His abdominal distention was prominent and cyanosis of the lower limb was observed (Fig. 2). An abdominal contrast-enhanced computed tomography scan indicated that the descending aorta was pressed by the expanded stomach, and blockage of blood flow was observed (Fig. 3). Free gas was also found in the peritoneal cavity. Therefore, we performed an urgent laparotomy and punctured the stomach to reduce the pressure; however, pulseless ventricular fibrillation occurred during surgery. He died after resuscitation was not successful in restoring his normal heart rate. His blood potassium was 10.3 mEq/l. Aortic compression and occlusion secondary to acute gastric dilatation was initially reported in 2006 involving a 22year-old female anorexic patient who developed acute gastric dilatation following a binge episode. In this case, there was a rapid return of the circulation after decompression of the stomach, the bowel appeared viable and the abdomen was closed. Unfortunately, the patient died 36 h after developing severe metabolic acidosis and disseminated intravascular coagulation secondary to reperfusion injury. In a similar case, there is report of survival by performing several intestinal resections after the initial gastric decompression surgery. We believe that it would have been difficult to save him. However, artificial dialysis or percutaneous cardiopulmonary support should have been instated. Fig. 1 Patient with a prominent abdominal distension