Yusuke Suwa

Real-Time Indocyanine Green Fluorescence Imaging-Guided Complete Mesocolic Excision in Laparoscopic Flexural Colon Cancer Surgery.

INTRODUCTION: Laparoscopic surgery for colon cancer located in the hepatic flexure or splenic flexure is not standardized, because lymphatic drainage at this site may vary and the precise site of lymphatic dissection is uncertain. TECHNIQUE: Indocyanine green was injected into the submucosal layer around the tumor at 2 points with a 23-gauge localized injection before lymph node dissection and the lymph flow was observed using a near-infrared camera system 30 minutes after injection. In addition, a complete mesocolic excision with central vascular ligation guided the region where the lymph flow was fluorescently observed. RESULTS: A total of 20 consecutive patients (hepatic flexure, 10 patients; splenic flexure, 10 patients) were enrolled in this study. All of the procedures were safely performed without any complications. The lymph flow was visualized in 19 patients (95%) intraoperatively. Modification of the operative methods was required for 5 patients (modification in the separation line of the mesocolon and vessel selection for central vascular ligation) because the area of lymph flow observed during surgery differed from that of the preoperative diagnosis. CONCLUSION: Intraoperative real-time visualization of the lymph flow using indocyanine green fluorescence imaging during laparoscopic colon cancer surgery, especially flexural colon cancer surgery, is feasible and a helpful technique for identifying appropriate central vessels to be dissected and for determining an appropriate separation line of the mesentery.

IL-7 and procalcitonin are useful biomarkers in the comprehensive evaluation of the severity of acute cholangitis.

The incidence of biliary tract infection (BTI), especially healthcare‐associated cholangitis, is increasing. However, there are few reports concerning biomarkers of acute cholangitis. We therefore performed an exhaustive investigation of several biomarkers.

Clinicopathological and Prognostic Evaluations of Mixed Adenoneuroendocrine Carcinoma of the Colon and Rectum: A Case-Matched Study

BACKGROUND: Mixed adenoneuroendocrine carcinoma of the colon and rectum is a very rare type of tumor. OBJECTIVE: The aim of the present study was to evaluate the clinicopathological characteristics and prognosis of mixed adenoneuroendocrine carcinomas of the colon and rectum. DESIGN: This was a retrospective case-matched analysis (from March 2007 to December 2013). SETTINGS: This study was conducted at Yokosuka Kyosai Hospital. PATIENTS: One thousand three hundred six consecutive patients with a preoperative diagnosis of colorectal cancer and who underwent tumor resection were enrolled in the present study. Each patient diagnosed with mixed adenoneuroendocrine carcinoma was 1:2 matched with 2 counterparts who had been diagnosed with adenocarcinoma. INTERVENTION: Immunohistochemical staining for neuroendocrine markers (chromogranin A, synaptophysin, and CD56) was performed. Cases in which the neuroendocrine component accounted for >30% of the tumor were diagnosed as mixed adenoneuroendocrine carcinomas. RESULTS: Among 1306 patients, 42 patients (3.2%) were diagnosed with mixed adenoneuroendocrine carcinoma and were compared with 84 patients with adenocarcinoma who had been randomly case matched. The average Ki-67–labeling index value was 78.0% (range, 30.0%–99.0%). Chromogranin A, synaptophysin, and CD56 positivity were observed in 42.9% (18/42), 81.0% (34/42), and 33.3% (14/42) of the tumors. Both the disease-free survival and overall survival were significantly worse for mixed adenoneuroendocrine carcinoma than for adenocarcinoma. Ten patients underwent treatment with oxaliplatin-based chemotherapy. The response rate was 40.0%; the median progression-free survival and overall survival were 6.3 months and 18.1 months. LIMITATIONS: This was a retrospective single-institution study that included a limited number of cases. The treatment regimens used included different types of oxaliplatin-based chemotherapy. CONCLUSION: Mixed adenoneuroendocrine carcinoma of the colon and rectum has a poor prognosis after curative resection and should be distinguished from adenocarcinoma.

Late cardiac metastasis from colorectal carcinoma 15 years after surgery.

Late recurrence of malignant tumors in the heart more than 10 years after surgery is quite rare, especially for colorectal carcinoma. Here, we report a case of late cardiac metastasis from a primary colorectal carcinoma, which occurred more than 15 years after the initial surgery. To our knowledge, this is the first such reported case.

Single-Incision Laparoscopic Anterior Resection Using a Curved Stapler.

INTRODUCTION:Single-incision laparoscopic colectomy is technically limited because of such factors as instrument crowding, in-line viewing, and insufficient countertraction. In particular, it is technically difficult to cut the distal rectum from the umbilicus using an articulating linear stapler in single-incision laparoscopic anterior resection. TECHNIQUE:After treating the mesorectum, the 5-mm trocar is replaced with a 12-mm trocar. The cartridge of the curved stapler is mounted while the shaft of the stapler is inserted into the 12-mm port extracorporeally. The curved stapler is inserted through the umbilical incision with the cartridge. A multichannel port is then mounted, and the abdominal cavity is reinsufflated. The curved stapler can then be operated intracorporeally. This procedure facilitates the vertical dissection of the rectum from the umbilicus. RESULTS:A total of 27 consecutive patients were analyzed in this study. All the procedures were safely performed without any complications. The median distance from the peritoneal reflection to the transection point of the distal bowel in single-incision laparoscopic anterior resection was 5.0 cm (range, –2.0 to 15.0). One stapler firing was required to achieve distal bowel division in 26 patients (96.3 %), whereas 2 firings were required in 1 patient (3.7 %). The median distal margin was 7.0 cm (range, 3.0–13.0). The time from the insertion of the stapler to transection was 180 seconds (range, 100–420). There were no cases of anastomotic leakage. CONCLUSIONS:In single-incision laparoscopic anterior resection, it is feasible to perform rectal transection from the umbilicus by using a curved stapler. This technique may allow for the omission of 1 trocar from the operation.

The maximum chemiluminescence intensity predicts severe neutropenia in gemcitabine-treated patients with pancreatic or biliary tract cancer

PurposeTo assess the predictive ability of the maximum chemiluminescence intensity (CImax) for severe neutropenia (SN) during neoadjuvant chemo(radio)therapy [NAC(RT)] in patients with advanced pancreatic or biliary tract cancer.MethodsClinicopathological variables and blood test data before NAC(RT) were evaluated in 64 patients with advanced pancreatic or biliary tract cancer who received gemcitabine plus tegafur/gimeracil/oteracil as NAC(RT).ResultsThirty-nine patients (60.9%) developed Grade 3–4 SN. The median time between commencing NAC(RT) and the onset of SN was 15 (range 10–36) days. SN occurred during the NAC period, not the RT period. The CImax, neutrophil count, serum interleukin-6 level, C-reactive protein level, complement C3 titer, serum complement titer, and 50.0% hemolytic unit of complement before NAC(RT) were significantly lower in patients with SN than in those without SN (P < 0.05). Multivariate analysis confirmed the CImax to be the sole independent predictor of SN (P < 0.05). The optimal threshold for the CImax was 46,000 RLU/s. The sensitivity and specificity were 46.2% and 80.0%, respectively. Majority of the patients (81.8%) with a low CImax before NAC(RT) experienced SN during NAC(RT).ConclusionsCImax before NAC(RT) predicts SN during NAC(RT) in patients with advanced pancreatic or biliary tract cancer.

Detection of gas components as a novel diagnostic method for colorectal cancer

The fecal occult blood test (FOBT) is widely accepted as the most economic and non‐invasive screening method for colorectal cancer (CRC). However, the FOBT is inconvenient because it requires a fecal sample and shows limited accuracy. Alternatively, we hypothesized that fecal gas compounds from bowel movements may be a non‐invasive biomarker for CRC.

Midterm follow-up of a randomized trial of open surgery versus laparoscopic surgery in elderly patients with colorectal cancer

BackgroundLaparoscopic surgery has been widely accepted for the treatment of colorectal cancer; however, long-term outcomes in elderly patients remain controversial. The midterm results of a randomized trial comparing open surgery with laparoscopic surgery in elderly patients with colorectal cancer are presented.MethodsThis was a randomized trial comparing open surgery with laparoscopic surgery in elderly patients with colorectal cancer. The primary outcome was complication rate, and secondary outcomes included 3-year recurrence-free survival and overall survival. A total of 200 patients were randomly assigned to open surgery or laparoscopic surgery between 2008 and 2012. The main study objective was to compare the midterm outcomes of open surgery with those of laparoscopic surgery in elderly patients with colorectal cancer. This trial is registered with Clinical Trials.gov (NCT01862562).ResultsThere were no differences between the laparoscopic surgery group and open surgery group in the 3-year overall survival rate (91.5% for laparoscopic surgery vs. 90.6% for open surgery, p = 0.638) or the 3-year recurrence-free survival rate (84.8% for laparoscopic surgery vs. 88.2% for open surgery, p = 0.324). The local recurrence rate was significantly higher in the laparoscopic surgery group than in the open surgery group in rectal cancer (13.8% for laparoscopic surgery vs. 0% for open surgery, p = 0.038). In subgroup analysis according to tumor location, there were no significant differences in the 3-year overall survival rate or 3-year recurrence-free survival rate between the two treatment groups.ConclusionThe midterm outcomes of laparoscopic surgery are similar to those of open surgery in elderly patients with colorectal cancer.

The safety of preoperative amino acid (Elental®) loading in colon cancer surgery: prospective cohort study.

Abstract Objective: The aim of this prospective study was to evaluate the safety of preoperative amino acid plus CHO drink (Elental®) loading in colon cancer surgery. Summary of Background Data: Prolonged preoperative fasting increases insulin resistance and current evidence recommends carbohydrate drinks 2 hours before surgery. Methods: We prospectively enrolled consecutive patients with a preoperative diagnosis of colon cancer who underwent surgery. The patients received 600 ml of Elental® the night before surgery and 300 ml of Elental® 3 h prior to induction of anaesthesia. Primary endpoint was the safety of preoperative amino acid (Elental®) loading in colon cancer surgery. Safety measurement was anastomotic leakage and aspiration pneumonia. Secondary endpoints were incidence rate of incisional surgical site infection, recovery of bowel movement, length of hospital stay, postoperative nutritional status and insulin resistance. Results: A total of 80 consecutive patients were enrolled in this study fro...

The novel diagnostic method for colorectal cancer: Detection of methyl mercaptan from flatus.

529 Background: Fecal occult blood test screening for colorectal cancer (CRC) reduces cancer specific mortality through the detection of early stage disease. However, medical examination rate is very low in Japan because of the inconvenience of sampling of stool. On the other hand, it is reported that dogs can be trained to distinguish breath samples of patients with lung and breast cancer from those of control. It is unclear that odour materials become effective tools in CRC screening. The aims of this study were to evaluate the gas components in the flatus of CRC patients and to compare with healthy controls. Methods: Thirty-two patient before elective colorectal surgery in Yokohama City University and 13 healthy controls were enrolled in this study.The apparatus for gas sampling was placed in the toilet. Defecation gas from a patient in a toilet stool was collected in a 25L sampling bag. A fan (50 L / min ) was arranged to aspirate air in the toilet stool. Defecation gas components were collected as fo...