BACKGROUND: Objective assessment of surgical technical skills is essential for ensuring patient safety and maintaining high-quality surgical care. Although the Endoscopic Surgical Skill Qualification (ESSQ) System of the Japan Society for Endoscopic Surgery (JSES) has contributed to the standardization of endoscopic surgery, factors associated with pass-fail outcomes in the certification examination have not been systematically evaluated. METHODS: This retrospective observational study included applicants who underwent the colorectal endoscopic surgical skill qualification examination between 2020 and 2024. Applicant-, institutional-, patient-, tumor-, surgical-, and reviewer-related variables registered at the time of application were analyzed. Associations with pass-fail outcomes were assessed using uni- and multivariable analyses. RESULTS: A total of 1945 applications were analyzed. The overall pass rate during the study period was 33.2%, with robot-assisted cases showing comparable results, although the number of robot-assisted cases was limited. Primary reviewers agreed in 68.1% of cases, and the overall Cohen's kappa was 0.336. Multivariable analysis identified fewer application attempts, larger institutional bed capacity, 3D scope use, shorter operative time, and lower blood loss as independent predictors of successful qualification (all p < 0.05). Reviewer demographics showed no associations. CONCLUSIONS: This study provided the first comprehensive evaluation of factors associated with pass-fail outcomes in the ESSQ Examination of the JSES. Certification results were influenced by applicant- and institution-related characteristics, as well as operative performance indicators, whereas reviewer demographic factors showed no measurable impact.

BACKGROUND: Anastomotic leakage (AL) remains a major postoperative complication after rectal cancer surgery, even with advances in minimally invasive techniques. Indocyanine green (ICG) fluorescence imaging is widely used to assess bowel perfusion, but conventional methods rely heavily on subjective visual interpretation. The SPY-QP software enables quantitative evaluation of ICG fluorescence, potentially improving the accuracy of perfusion assessment. METHODS: The SPECTACLE study is a multicenter, prospective, single-arm trial designed to evaluate whether SPY-QP-based quantitative blood flow assessment can reduce AL rates compared with historical controls from the EssentiAL study. Perfusion assessment is performed according to an algorithm we developed based on our previous retrospective analysis. We plan to enroll 400 patients undergoing laparoscopic or robotic rectal cancer resection with anastomosis. The primary endpoint is the incidence of AL (Grades A-C) within 30 days postoperatively. Secondary endpoints include changes in surgical strategy based on perfusion findings, operative time, intraoperative complications, and other postoperative outcomes. DISCUSSION: This study aims to provide robust evidence on whether objective perfusion assessment using SPY-QP can reduce AL after rectal cancer surgery, potentially leading to broader adoption of quantitative imaging in colorectal surgery. TRIAL REGISTRATION: Japan Registry of Clinical Trials: jRCTs032230212.

The management of lateral pelvic lymph nodes in locally advanced lower rectal cancer remains controversial. The sentinel lymph node (SLN) mapping can potentially enhance patient selection for lateral pelvic lymph node dissection. The current mapping agent, indocyanine green dye cannot be externally imaged prior to surgery and is not retained after entering the SLN. This study evaluated the ability of tilmanocept, a receptor-specific SLN mapping agent, to provide preoperative PET cross-sectional imaging and sustained intraoperative fluorescence images during rectal cancer surgery. Tilmanocept was labeled with gallium-68, technetium-99m, and a near-infrared fluorophore. Four pigs were studied. Tilmanocept was injected into the submucosal layer of the rectal wall followed 1 h later by PET/CT images of the pelvis, which identified ten SLNs, one of which was a pudendal artery regional SLN. Approximately 45 h after administration, SLN dissection was guided by fluorescence imaging during robotic surgery. The tenth SLN was excised by open surgery. The radioactive and fluorescent intensities of all ten excised SLNs were significantly higher than the non-SLNs. The ability of dual-labeled tilmanocept to provide preoperative SLN imaging can potentially reduce morbidity and operation time by identifying patients who will not require lateral pelvic lymph node dissections.

BACKGROUND: Pouchitis is a prevalent complication following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) and significantly impacts patient outcomes. The identification of risk factors and development of predictive models would help to guide perioperative management. METHODS: This multicentre retrospective study analysed data from 1136 UC patients who underwent IPAA between 2005 and 2019 as part of the Clinical Outcome of Surgery for Ulcerative Colitis (COSUC) study. Potential risk factors, including demographic, clinical and surgical variables, were assessed using univariable and multivariable logistic regression. A predictive model was developed and validated using separate cohorts, with performance evaluated via receiver operating characteristic (ROC) curve analysis. RESULTS: Pouchitis occurred in 67 patients (5.9%). Univariable analysis identified younger age (<40 years), lower body mass index (BMI) and preoperative use of steroids and immunosuppressants as significant risk factors. Multivariable analysis confirmed preoperative steroid use as the only independent predictor (HR 1.98, p = 0.016). The predictive model achieved an area under the curve (AUC) of 0.63 in the training cohort and 0.67 in the validation cohort. Using a 9.6% probability cut-off, the model demonstrated moderate sensitivity and high specificity in identifying high-risk patients. CONCLUSION: Preoperative corticosteroid use was identified as the only independent risk factor for pouchitis after IPAA in UC patients. A risk model incorporating age, BMI and immunosuppressive therapy was developed and may aid in perioperative risk stratification. However, given the study's retrospective design and limited variable scope, further validation in prospective cohorts is necessary to confirm its clinical utility.

We report a case of a 51‒year‒old man who presented with right lower abdominal pain. On physical examination, a palpable, tender mass was detected in the right lower abdomen. Contrast‒enhanced computed tomography (CT) revealed a 15‒cm mass in the right lower abdominal wall, supplied by the right inferior epigastric artery, with internal hemorrhage and necrotic areas. Radiological findings were inconclusive for malignancy. As there was no evidence of distant metastasis or invasion into adjacent organs, the tumor was considered resectable, and surgical resection was performed. Histopathological examination confirmed the diagnosis of synovial sarcoma. Given the high risk of recurrence and metastasis associated with synovial sarcoma, adjuvant chemotherapy was administered postoperatively. The patient remains alive without recurrence 1 year after surgery.

BACKGROUND: The purpose of this study was to compare outcomes and adverse events between three-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) in patients undergoing long-course neoadjuvant radiation therapy (NA-RT) for locally advanced rectal adenocarcinoma (LARC). METHODS: We retrospectively analyzed a total of 47 consecutive patients who received NA-RT for LARC between January 2011 and September 2022. Seven and 40 patients were diagnosed with clinical stages II and III, respectively. The prescribed dose per fraction was 1.8 Gy for total doses of 45 or 50.4 Gy. Seventeen and 30 patients received 3D-CRT and IMRT, respectively. NA-RT was delivered with concurrent chemotherapy of oral administration of S-1. RESULTS: Planned NA-RT was completed without any treatment interruption in 43 of the 47 patients. Two patients experienced treatment interruption, and two patients discontinued due to grade ≥ 3 toxicities. No significant differences were observed between patients receiving 3D-CRT and IMRT in local control, progression-free survival, and overall survival (P = 0.488, 0.259, and 0.636, respectively). Patients receiving IMRT showed significantly fewer non-hematological grade ≥ 2 acute toxicities than those receiving 3D-CRT (33.3% vs. 70.6%, P = 0.018). In addition, patients who received IMRT tended to have less intestinal toxicity of grade ≥ 2 than those who received 3D-CRT (P = 0.057). CONCLUSION: IMRT significantly reduced grade ≥ 2 acute toxicities without compromising oncologic outcomes compared to 3D-CRT. Therefore, IMRT may be considered as a current standard treatment in the total neoadjuvant therapy era.

The patient was a 72-year-old woman with a history of surgery for uterine, bladder, left breast, and rectal cancers. The patient was admitted to the emergency department due to abdominal pain and vomiting. Abdominal and pelvic computed tomography showed a mass lesion and bowel obstruction at the end of the ileum, and positron emission tomography showed a mass lesion with accumulation in the same area of the pelvis. The patient was referred to our department for surgical treatment. The tumor at the end of the ileum invaded the ileal conduit, abdominal wall, right-sided colon, and mouth of the ileum, and a right hemicolectomy of the colon was performed. Another mass was palpated in the pelvic jejunum during examination, and partial resection of the small intestine was performed simultaneously. The tumor at the end of the ileum was diagnosed as diffuse large B-cell lymphoma, whereas the jejunal tumor was diagnosed as tubular adenocarcinoma. Synchronous double cancer of malignant lymphoma of the ileum and carcinoma of the jejunum is rare. Herein, we report this case and review the relevant literature.

当院で外科的治療を行った後腹膜脂肪肉腫25例(男性16例、女性9例、年齢中央値66歳)の手術成績と再発リスク因子について検討した。その結果、全症例の5年OSは59.8%で、根治度別ではR0:76.2%、R1:50.0%、R2:0%であった。初回手術後の5例と3回目切除後の1例の計6例が現在無再発生存中である。一方、局所再発リスク因子は分割切除と組織型であり、再発率は分割切除例で100%、WDLPS以外の組織型で91.7%と高率であった。また、組織型は独立した予後因子であり、WDLPSはそれ以外の組織型に比して予後良好であった。

A 59-year-old man presented with abdominal mass and weight loss. Computed tomography revealed a 20 cm mass in the vicinity of the left kidney. A tumor biopsy was performed and diagnosed with leiomyosarcoma. We performed tumor resection. The tumor invaded the surrounding tissues, and a lumpectomy with resection of the left kidney and left adrenal gland was performed. Pathologically, there was a slight suspicion of tumor exposure, so radiotherapy was administered to the dissected surface. There was no evidence of local recurrence or metastasis after 12 months.

Lesser omental hernias are rare; however, they should be considered in symptomatic bowel obstruction subsequent to a subtotal or total colectomy. This report describes two cases of recurrent bowel obstruction secondary to lesser omental hernias after laparoscopic total colectomies for ulcerative colitis. Initially, these patients had been treated conservatively; however, due to symptom recurrence, surgical intervention was decided on. In both cases, laparoscopic surgery revealed lesser omental hernias. The small bowel, which had entered from the dorsal aspect of the stomach, was returned to the original position, and the lesser omentum was closed. The patients were discharged uneventfully, with no recurrent bowel obstruction during the follow-up period. These cases highlight the importance of including internal hernias in the differential diagnosis relative to recurrent bowel obstruction, in patient subpopulations with a prior history of a subtotal or total colectomy. Confirmation by computed tomography is preferable.

BACKGROUND: The potential benefits of robotic-assisted compared with laparoscopic surgery for locally advanced cancer have not been sufficiently proven by prospective studies. One factor is speculated to be the lack of strict surgeon criteria. The aim of this study was to assess outcomes for robotic surgery in patients with locally advanced rectal cancer with strict surgeon experience criteria. METHODS: A criterion was set requiring surgeons to have performed more than 40 robotically assisted operations for rectal cancer. Between March 2020 and May 2022, patients with rectal cancer (distance from the anal verge of 12 cm or less, cT2-T4a, cN0-N3, cM0, or cT1-T4a, cN1-N3, cM0) were registered. The primary endpoint was the rate positive circumferential resection margin (CRM) from the pathological specimen. Secondary endpoints were surgical outcomes, pathological results, postoperative complications, and longterm outcomes. RESULTS: Of the 321 registered patients, 303 were analysed, excluding 18 that were ineligible. At diagnosis: stage I (n = 68), stage II (n = 84) and stage III (n = 151). Neoadjuvant therapy was used in 56 patients. There were no conversions to open surgery. The median console time to rectal resection was 170 min, and the median blood loss was 5 ml. Fourteen patients had a positive CRM (4.6%). Grade III-IV postoperative complications were observed in 13 patients (4.3%). CONCLUSION: Robotic-assisted surgery is feasible for locally advanced rectal cancer when strict surgeon criteria are used.

OBJECTIVE: To investigate the oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer and risk factors for local recurrence (LR). BACKGROUND: A high LR rate with a multifocal pattern early after TaTME has been reported in Norway and the Netherlands, causing controversy over the oncological safety of this technique. METHODS: Twenty-six member institutions of the Japan Society of Laparoscopic Colorectal Surgery participated in this retrospective cohort study. A total of 706 patients with primary rectal cancer who underwent TaTME between January 2012 and December 2019 were included for analysis. The primary endpoint was the cumulative 3-year LR rate. RESULTS: A total of 253 patients had clinical stage III disease (35.8%) and 91 (12.9%) had stage IV. Intersphincteric resection was performed in 318 patients (45.0%) and abdominoperineal resection in 193 (27.3%). There was 1 urethral injury (0.1%). A positive resection margin (R1) was seen in 42 patients (5.9%). Median follow-up was 3.42 years, and the 2- and 3-year cumulative LR rates were 4.95% (95% confidence interval: 3.50-6.75) and 6.82% (95% confidence interval: 5.08-8.89), respectively. A multifocal pattern was observed in 14 (25%) of 56 patients with LR. Tumor height from the anal verge, pathological T4 disease, pathological stage III/IV, positive perineural invasion, and R1 resection were significant risk factors for LR in multivariable analysis. CONCLUSIONS: In this selected cohort in which intersphincteric resection or abdominoperineal resection was performed in more than half of cases, oncological outcomes were acceptable during a median follow-up of more than 3 years.

PURPOSE: Recently, a new certification system called the Endoscopic Surgical Skill Qualification System (ESSQS) has been launched in Japan to improve surgical safety. This study aimed to determine whether ESSQS-qualified surgeons affect the short- and long-term outcomes of laparoscopic right hemicolectomy. METHODS: A total of 187 colon cancer patients who underwent laparoscopic right hemicolectomy at Kindai University Hospital between January 2016 and December 2020 were enrolled. These patients were divided into two groups based on surgeries performed by ESSQS-qualified surgeons (QS group) and non-ESSQS-qualified surgeons (NQS group). The short- and long-term outcomes were compared between the two groups before and after propensity score matching (PSM). RESULTS: After PSM, 43 patients from each group were included in the matched cohort. In the short-term outcomes, the total operative time was significantly longer in the NQS group than in the QS group (229 vs. 174 min, p < 0.0001). However, there were no significant differences in the two groups regarding blood loss (0 vs. 0 ml, p = 0.7126), conversion (0.0% vs. 7.0%, p = 0.0779), Clavien-Dindo ≥ 2 complications (9.3% vs. 7.0%, p = 0.6933), mortality (2.3% vs. 0.0%, p = 0.3145), and postoperative hospital stay (9 vs. 9 days, p = 0.5357). In the long-term outcomes, there were no significant differences between the two groups in the 3-year overall survival (86.6% vs. 83.0%, p = 0.8361) and recurrence-free survival (61.7% vs. 72.0%, p = 0.3394). CONCLUSION: Laparoscopic right hemicolectomy performed by ESSQS-qualified surgeons contributed to shorter operative time. Under the supervision of ESSQS-qualified surgeons, almost equivalent safety and oncological outcomes are expected even in surgeries performed by non-ESSQS-qualified surgeons.

With the development of surgical technology, indocyanine green (ICG) fluorescence navigation systems may be useful in various areas of colorectal surgery, including tumor location confirmation, bowel perfusion, ureter identification, and lymph node mapping. This review provides an overview of the current status of ICG-based navigation surgery in colorectal surgery, emphasizing its role in lymphatic flow mapping. This state-of-the-art approach will allow for appropriate oncological surgeries in the field of colorectal cancer and improve the patient's prognosis.

Anastomotic leakage is one of the most dreaded complications of colorectal surgery and is strongly associated with tissue perfusion. Indocyanine green fluorescence angiography (ICG-FA) using indocyanine green and near-infrared systems is an innovative technique that allows the visualization of anastomotic perfusion. Based on this information on tissue perfusion status, surgeons will be able to clearly identify colorectal segments with good blood flow for safer colorectal anastomosis. The results of several clinical trials indicate that ICG-FA may reduce the risk of AL in colorectal resection; however, the level of evidence is not high, as several other studies have failed to demonstrate a reduction in the risk of AL. Several large-scale RCTs are currently underway, and their results will determine whether ICG-FA is, indeed, useful. The major limitation of the current ICG-FA evaluation method, however, is that it is subjective and based on visual assessment by the surgeon. To complement this, the utility of objective evaluation methods for fluorescence using quantitative parameters is being investigated. Promising results have been reported from several clinical trials, but all trials are preliminary owing to their small sample size and lack of standardized protocols for quantitative evaluation. Therefore, appropriately standardized, high-quality, large-scale studies are warranted.

AIM: There have been no reports of searching for metastases to lymph nodes along the accessory middle colic artery (aMCA). The aim of this study was to investigate the metastasis rate of the aMCA for splenic flexural colon cancer. METHODS: Patients with histologically proven colon carcinoma located in the splenic flexure, clinically diagnosed as stage I-III were eligible for this study. Patients were retrospectively and prospectively enrolled. The primary endpoint was frequency of lymph node metastasis to the aMCA (station 222-acc and 223-acc). The secondary endpoint was the frequency of lymph node metastasis to the middle colic artery (MCA) (station 222-lt and 223) and left colic artery (LCA) (station 232 and 253). RESULTS: Between January 2013 and February 2021, a total of 153 consecutive patients were enrolled. The location of the tumor was 58% in the transverse colon and 42% in the descending colon. Lymph node metastases were observed in 49 cases (32%). The presence of aMCA rate was 41.8% (64 cases). The metastasis rates of stations 221, 222-lt, and 223 were 20.0%, 1.6%, and 0%, and stations 231, 232, and 253 were 21.4%, 1.0%, and 0%, respectively. The metastasis rates of stations 222-acc and 223-acc were 6.3% (95% confidence interval: 1.7%-15.2%) and 3.7% (95% confidence interval: 0.1%-19%), respectively. CONCLUSIONS: This study identified the distribution of lymph node metastases from splenic flexural colon cancer. If the aMCA is present, this vessel should be targeted for dissection, taking into account the frequency of lymph node metastasis.

BACKGROUND: The Biocartis Idylla™ platform is a fully automated, real-time PCR-based diagnostic system. The Idylla™ KRAS and NRAS-BRAF Mutation Tests have been developed for the qualitative detection of mutations in KRAS, NRAS and BRAF genes, facilitating the genomic profiling of patients with colorectal cancer. The aim of the present study was to evaluate clinical performances of these tests in Japan. METHODS: The RAS and BRAF mutation statuses of 253 formalin-fixed paraffin-embedded (FFPE) colorectal cancer tissues were analyzed using the Investigational Use Only Idylla™ KRAS Mutation Test and the Idylla™ NRAS-BRAF Mutation Test and an in vitro diagnostics (IVD) kit (MEBGEN RASKET™-B kit). RESULTS: The success rate for obtaining a valid mutational data without retest of the Idylla tests was 97.6% (247/253): 111 KRAS mutations (43.8%), 9 NRAS mutations (3.6%), and 36 BRAF V600E mutations (14.2%) were detected using the Idylla tests. Compared with the MEBGEN RASKET-B results, the positive concordance rate was 97.4%, the negative concordance rate was 95.7%, and the overall concordance rate was 95.3% (κ = 0.919, 95% CI 0.871-0.967). The average turnaround time to Idylla™ KRAS and NRAS-BRAF Mutation Test was 5.6 working days (range: 3-11 days). CONCLUSION: This result demonstrates a high concordance between the Idylla™ KRAS and NRAS-BRAF Mutation Tests and an existing IVD kit. In this manner, the Idylla™ mutation tests were validated for the detection of clinically significant KRAS, NRAS, and BRAF mutations in FFPE samples from colorectal cancer patients.

Anal canal cancer (ACC) has been reported to be an uncommon cancer in Japan, as in the USA, Europe, and Australia. This retrospective multi-institutional study was conducted to clarify the characteristics of ACC in Japan. First, the histological ACC type cases treated between 1991 and 2015 were collected. A detailed analysis of the characteristics of anal canal squamous cell carcinoma (SCC) cases was then conducted. The results of the histological types revealed that of the 1781 ACC cases, 435 cases (24.4%) including seven cases of adenosquamous cell carcinomas were SCC and 1260 cases (70.7%) were adenocarcinoma. However, the most common histological type reported in the USA, Europe, and Australia is SCC. Most ACC cases are adenocarcinomas and there is a low incidence of SCC in Japan which is different from the above-mentioned countries. Moreover, we reclassified T4 into the following two groups based on tumor size: T4a (tumor diameter of 5 cm or less) and T4b (tumor diameter of more than 5 cm). The results of the TNM classification of SCC revealed that the hazard ratio (HR) to T1 of T2, T3, T4a, and T4b was 2.45, 2.28, 2.89, and 4.97, respectively. As T4b cases had a worse prognosis than T4a cases, we propose that T4 for anal canal SCC in Japan be subclassified into T4a and T4b.

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

Matrix metalloproteinase 14 (MMP14) expression is implicated in progression of colorectal cancer, but its role in the tumor microenvironment (TME) has been unclear. The relevance of MMP14 to colorectal cancer progression was explored by analysis of transcriptomic data for colorectal adenocarcinoma patients (n = 592) in The Cancer Genome Atlas. The role of MMP14 in the TME was investigated in a retrospective analysis of tumor samples from 86 individuals with stage III colorectal cancer by single cell-based spatial profiling of MMP14 expression as performed by 12-color multiplex immunohistochemistry (mIHC). Analysis of gene expression data revealed that high MMP14 expression was associated with tumor progression and implicated both cancer-associated fibroblasts (CAFs) and tumor-associated macrophages in such progression. Spatial profiling by mIHC revealed that a higher percentage of MMP14+ cells among intratumoral CAFs (MMP14+ CAF/CAF ratio) was associated with poorer relapse-free survival. Multivariable analysis including key clinical factors identified the MMP14+ CAF/CAF ratio as an independent poor prognostic factor. Moreover, the patient subset with both a high MMP14+ CAF/CAF ratio and a low tumor-infiltrating lymphocyte density showed the worst prognosis. Our results suggest that MMP14+ CAFs play an important role in progression of stage III colorectal cancer and may therefore be a promising therapeutic target.

INTRODUCTION: Cirrhosis is a significant determinant of postoperative morbidity and mortality. Patients with severe liver cirrhosis are substantially contraindicated for surgical treatment of inguinal hernia because of the substantial recurrence rate and high postoperative morbidity and mortality. However, hernia with incarceration and strangulation, which could become life-threatening, should be repaired urgently even for patients with severe liver cirrhosis. No clear surgical guidelines have been established regarding the treatment strategy for inguinal hernia in patients with cirrhosis. PRESENTATION OF CASE: A 62-year-old man with a history of chronic C-type liver cirrhosis (Child-Pugh classification C) and hepatocellular carcinoma was referred to us for surgical treatment of an irreducible right inguinal hernia. An abdominal computed tomography (CT) scan revealed that the small intestine had herniated into the scrotum and severe abdominal wall varicose veins due to liver cirrhosis. We performed a hybrid method that combines examination laparoscopy and Lichtenstein's technique to observe the abdominal cavity and to avoid the risks due to severe varicosis of the inferior epigastric vein. DISCUSSION: There have been some reports of inguinal hernia with cirrhosis and ascites, but no reports of incarcerated inguinal hernia with abdominal wall varicose veins. In the present case, we chose a laparoscopic approach to observe the abdominal cavity to confirm intestinal necrosis. Hybrid surgery using laparoscopy and Lichtenstein's technique for incarcerated inguinal hernia could be performed safely. CONCLUSION: Hybrid surgery using laparoscopy and Lichtenstein's technique may be an effective method for patients with incarcerated inguinal hernia with end-stage cirrhosis and severe abdominal varicosis.

BACKGROUND: Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices. METHODS: We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017. RESULTS: Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis. CONCLUSIONS: Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon's skill. The appropriate indications must be established with more case registries because our experience is limited.

BACKGROUND: Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure. METHODS: We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients. RESULTS: Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7-14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10-16 days). CONCLUSION: The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

INTRODUCTION AND IMPORTANCE: We describe the case of a patients with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was treated by laparoscopic repair. CASE PRESENTATION: An 82-years-old man with history of HCC with hepatitis C virus-related liver cirrhosis (Child-Pugh B). The patient was treated RFA to HCC for segment 4, 5, 6, 8. After 16 months from latest RFA for segment 8, the patient was admitted to our hospital because of mild dyspnea. Computed tomography revealed a diaphragmatic herniation of bowel loops into the right thoracic cavity. The patients electively underwent laparoscopic repair of the diaphragmatic hernia. The patient was discharged from hospital without any post-operative complications. CLINICAL DISCUSSION: The only treatment to diaphragmatic hernia is surgery, but liver cirrhosis patients limits this possibility. For the surgical treatment of patients with severe cirrhosis, the operation should be carefully assessed. We believe that a laparoscopic approach should be used for repairing diaphragmatic hernia. In the present case, we considered that a laparoscopic approach was safer and more feasible than open laparotomy. CONCLUSION: Diaphragmatic hernia is a rare late-onset complication associated with RFA for HCC. And patients with HCC often have severe liver dysfunction and cirrhosis. A laparoscopic approach is safe and minimally invasive for sever cirrhosis patients.

Intraoperative visualization of lymphatic flow could guide surgeons performing laparoscopic colon cancer surgery on the extent of intestinal resection required. The purpose of this study was to investigate indocyanine green fluorescence imaging for intraoperative detection of lymphatic flow and nodes in such patients. All patients undergoing elective laparoscopic surgery for colorectal cancer from October 2016 to July 2017 were included in this study. Indocyanine green was injected submucosally around the tumors via a colonoscope and lymphatic flow assessed with a laparoscopic near-infrared camera system intraoperatively. Lymphatic flow was visualized perioperatively in 43 of 57 patients (75.4%). The rate of visualized lymphatic flow was significantly higher in patients with a lower clinical stage than in those with a higher clinical stage (p = 0.0103). Among the 14 patients in whom lymphatic flow was not visualized, 10 (71.4%) had cStage III or IV cancer. Our results indicate the potential role of intraoperative navigation in colon cancer surgery in early-stage colon cancers. This method allows the surgeon to clearly identify lymphatic flow during surgery and allows the determination and individualization of the lymph node dissection range.

We report a relatively rare case of cecal cancer with dermatomyositis. An 81-year-old man was diagnosed with dermatomyositis associated with the symptoms of eruption, limb muscle weakness, and difficulty swallowing. Colonoscopy revealed a type 2 tumor in the cecum. The patient underwent laparoscopic ileocecal resection. Although it was impossible for the patient to stand before the surgery, he could stand 10 days after the surgery and walk without assistance 14 days after the surgery. In addition, the eruption disappeared, and the preoperatively high creatine kinase(CK)value normalized. Dermatomyositis with malignant tumor has been reported to be associated with poor prognosis. Symptoms related to dermatomyositis may be improved by the resection of the associated tumor. Therefore, it is important to treat the malignant tumor when the patient's condition permits.

A solitary fibrous tumor is a ubiquitous mesenchymal fibroblastic tumor that was previously considered limited to the pleural cavity. Here, we report a rare case of a large solitary fibrous tumor of the mesorectum, which was successfully resected laparoscopically. A 56-year-old woman was referred to our hospital for a giant pelvic mass. Pelvic MRI showed a well-circumscribed mass, 12 cm in diameter, with heterogeneous signal intensity on T2 -weighted images. It was diagnosed as a benign mesorectal tumor of unknown origin. We successfully resected the entire tumor laparoscopically. Histological examination revealed it to be an extrapleural solitary fibrous tumor. For large tumors in the pelvis, the laparoscopic approach is preferable in terms of intraoperative hemorrhage, as long as they do not invade surrounding tissues.

We conducted a phase II clinical trial involving patients with stage III CRC. All enrolled patients whose human leukocyte antigen (HLA)-A status was double-blinded were administered the same regime of a peptide vaccine and UFT/LV chemotherapy. The primary objective of the study was the comparison of relapse-free survival (RFS) in patients with HLA-A*2402 versus those without HLA-A*2402. A total of 46 patients were enrolled in the study. Three-year RFS was not significantly different between HLA-A*2402 matched and unmatched groups. Three-year RFS was significantly better in patients with positive CTL responses in the HLA-A*2402 matched group compared with those without. In conclusion, vaccination-induced immune responses combined with UFT/LV are positively associated with survival benefit in patients with HLA-A* 2402-positive stage III CRC.

FOLFOX (folic acid, 5-FU and oxaliplatin) therapy is widely used to treat patients with metastatic colorectal cancer. This study was conducted to elucidate the impact of gains or losses at specific regions of chromosomes on the outcome of FOLFOX therapy. DNA copy changes were analyzed on the genomic DNA extracted from tumor and non-tumor tissues obtained at the time of surgery who had synchronous liver metastases using single nucleotide polymorphism array. Tumors with retained long arm of chromosome 8 and lost long arm of chromosome 18 showed poorer survival. Tumors with 10 or more aberrant chromosomes also showed poor survival. In conclusion, patients with complex chromosomes showed poor outcome after FOLFOX therapy.

本研究は膵・消化管内分泌腫瘍の腫瘍起源細胞・腫瘍幹細胞を同定することと、膵・消化管内分泌腫瘍の腫瘍化メカニズムの解明を目的としたものであった。今年度の研究成果を以下に記載する。 (1)消化管内分泌腫瘍における腫瘍幹細胞の同定:PDX-1, somatostatin, serotonin, gastrinの発現を免疫染色、蛍光多重染色により検討した結果、より分化度の低い腫瘍幹細胞を含む細胞集団を同定することができた。現在、これまでの結果をまとめた論文を執筆中である。(2)消化管内分泌腫瘍の腫瘍化の検討:膵ガストリノーマの起源細胞は膵管上皮に存在するとの仮説に基づき、siRNAによるMEN1 geneノックダウン膵上皮細胞株を作成し、検討を行った。MEN1 geneノックダウン株と野性株との間に、細胞増殖・細胞形態などの点で明らかな変化を認めず、gastrin、Insulin, glucagons、E-cadherin、b-catenin, chromograninA, CDX2の発現においても差を認めなかった。そこで、新たにPDX-1を導入することで内分泌腫瘍化が誘導される可能性があると考え、現在PDX-1遺伝子の導入を試みている。(3)ヒト膵・消化管内分泌腫瘍の長期培養株の樹立:われわれの施設ではガストリノーマの腫瘍株化に成功している。ヒト膵・消化管内分泌腫瘍に対する研究には長期培養株は不可欠で、その樹立により、基礎研究分野に大きな伸展が期待できる。しかし、昨年度より標本からの培養を試みているが、長期培養株の樹立に至っていない。ガストリノーマは非常に稀な疾患で、細胞培養可能な適格症例が今年度はなかった。引き続き細胞培養の試みを継続する。