Yuki Mizumoto

Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery

Defaecatory function is often poor after anterior resection. Denervation of the neorectum following high ligation of the inferior mesenteric artery (IMA) is a possible cause of impaired defaecatory function. The purpose of this randomized clinical trial was to clarify whether the level of ligation of the IMA in patients with rectal cancer affects defaecatory function.

Oncological Outcomes following Rectal Cancer Surgery with High or Low Ligation of the Inferior Mesenteric Artery

Background: The level of inferior mesenteric artery (IMA) ligation for anterior resection of rectal cancer has several considerations concerning oncological outcomes. The primary endpoint of this randomized controlled trial (RCT) was to assess bowel function between high and low ligation. This study was intended to clarify oncological outcome as the secondary endpoint. Objective: The aim of this study was to assess in a prospective RCT whether the ligation level of the IMA in rectal cancer influences oncological outcomes. Methods: Between February 2008 and December 2011, 100 patients who underwent anterior resection for rectal cancer were randomized to perform either high or low ligation of the IMA. Oncological outcomes was the secondary endpoint of this RCT, whereas assessing bowel function was the primary endpoint. This RCT was registered at clinicaltrials.gov (NCT00701012). Results: There were no differences between the groups in terms of clinical data except for tumor stage. There were more advanced-stage patients in the high ligation group (p = 0.046). There were no lymph node (LN) metastases in the root of the IMA in the high ligation group. The average number of harvested LNs for the high and low ligation groups was 16.7 and 14.9, respectively. There was no difference in disease-free survival (DFS), site of first recurrence, and overall survival (OS). When patients were in stage III, there was also no difference in DFS and OS. Conclusions: The ligation level of the IMA in rectal cancer may not influence oncological outcomes. However, further large-scale RCTs are needed to conclude this issue.

Successful laparoscopic resection for cap polyposis: case report, literature review

BackgroundCap polyposis is a rare gastrointestinal disease with endoscopically and pathologically distinctive features. Its exact etiology has not been fully elucidated. In a few cases, there was recurrence after inadequate treatment. Efficacy of Helicobacter pylori eradication therapy, however, has been shown in some published research.Case presentationA 70-year-old female patient developed intermittent mucous diarrhea with loss of body weight and visited a physician. Total colonoscopy showed multiple sessile polyps which were partially coadunated from the rectum to the sigmoid colon. Histopathological finding was tubular adenoma with mild atypia. The patient stayed for observation. Worsening symptoms following protein-losing enteropathy demanded surgical treatment because malignancy could not be ruled out. Laparoscopic resection was performed, and the surgical specimens revealed that the polypoid lesion mainly consisted of mild adenomatous glands which were covered with purulent granulation tissues. We made final diagnosis of cap polyposis and saw rapid improvement of her symptoms. Long-term observation is required after surgery.ConclusionsWe reported a case of successful laparoscopic resection of cap polyposis with protein-losing enteropathy (170 words).

Horizontal rectal transection using an endolinear stapler for laparoscopic low anterior resection

Multiple firings with multiple cartridges for rectal transection have been reported as potential causes of anastomotic leakage in laparoscopic low anterior resection with the double-stapling technique [1]. Here we demonstrate an effective new method for horizontal transection of the rectum that we have used for laparoscopic low anterior resection, using a large endovascular clip for rectal alignment. The patient is placed in the head-down lithotomy position with the right side tilted down and the surgeon on the patient’s right. Five-port trocars including two 12-mm ports, two 5-mm ports, and a blunt port were introduced (Fig. 1). Pneumoperitoneum is created using carbon dioxide, and laparoscopic exploration is performed. After complete mobilization of the rectum to the levators, the surgeon inserts the linear stapler through the right lower quadrant port (Fig. 2a, b). The assistant through the left upper quadrant port pulls the rectum forward and cranially rolling it in a counterclockwise direction. The surgeon through the right upper quadrant port also rolls the rectum in a counterclockwise direction to align the horizontal line of the rectum with the linear staple insertion line (Fig. 2c, d). A 70-mm endovascular clip (B. Braun Aesculap Co., Tokyo, Japan) is introduced through the right lower quadrant port aligning, and the rectal wall is clamped below the tumor (Figs. 2e, 3a). Figure 3b shows the 70-mm endovascular clip. A distal rectal washout is performed using 1000 ml of 5% povidone-iodine solution. An endolinear stapler (Echelon FLEX 60 ; Ethicon EndoSurgery, Cincinnati, OH, USA) is inserted through the right lower quadrant port and then applied at the rectal wall parallel and caudal to the 70-mm endovascular clip (Fig. 3c). The assistant forceps in the left lower quadrant port pushes the distal rectum to the right, and the endolinear stapler with opened jaws is simultaneously pushed deeper into the left side space. The jaws are then closed at a position that enabled transection of the rectum with one firing using a single cartridge (Fig. 3d). Figure 3e shows Fig. 1 Port sites