Search

Multidisciplinary treatment for locally advanced rectal cancer requires an accurate assessment of the risk of metastasis to the lateral lymph nodes (LNs). We herein aimed to stratify the risk of pathological metastasis to lateral LNs based on the preoperatively detected malignant features. All patients with rectal cancer who underwent surgery from January 2016 to July 2020 were identified. We recorded the TNM factors; perirectal and lateral LN sizes; and MRI findings, including mesorectal fascia involvement, extramural vascular invasion (EMVI), tumor site, and tumor distance from the anal verge. 101 patients underwent rectal resection with lateral lymph node dissection, of whom 16 (15.8%) exhibited pathological metastases to the lateral LNs. Univariate analyses demonstrated that lateral LN metastasis was significantly correlated with mrEMVI positivity (p = 0.0023) and a baseline lateral LN short-axis length of ≥ 5 mm (p

A new technique that allows visualization of whole pelvic organs with high accuracy and usability is needed for preoperative simulation in advanced rectal cancer surgery. In this study, we developed an automated algorithm to create a three-dimensional (3D) model from pelvic MRI using artificial intelligence (AI) technology.This study included a total of 143 patients who underwent 3D MRI in a preoperative examination for rectal cancer. The training dataset included 133 patients, in which ground truth labels were created for pelvic vessels, nerves, and bone. A 3D variant of U-net was used for the network architecture. Ten patients who underwent lateral lymph node dissection were used as a validation dataset. The correctness of the vascular labelling was assessed for pelvic vessels and the Dice similarity coefficients calculated for pelvic bone.An automatic segmentation algorithm that extracts the artery, vein, nerve, and pelvic bone was developed, automatically producing a 3D image of the entire pelvis. The total time needed for segmentation was 133 seconds. The success rate of the AI-based segmentation was 100% for the common and external iliac vessels, but the rates for the vesical vein (75%), superior gluteal vein (60%), or accessory obturator vein (63%) were suboptimal. Regarding pelvic bone, the average Dice similarity coefficient between manual and automatic segmentation was 0.97 (standard deviation 0.0043).Though there is room to improve the segmentation accuracy, the algorithm developed in this study can be utilized for surgical simulation in the treatment of advanced rectal cancer.

Circumferential resection margin (CRM) is essential for oncological quality assessment in rectal cancer surgery. CRM represents a surrogate parameter for oncological outcomes and is important for stratifying treatment strategies in Western nations. In Japan, the mesentery is removed for specimen processing in order to extract as many lymph nodes (LNs) as possible; consequently, CRM cannot be measured. Given the diversification of treatment strategies for rectal cancer, the lack of measurement of CRM to assess surgical outcomes is a crucial issue that must be resolved. Therefore, it is necessary to establish a method enabling measurement of CRM while enjoying the advantages of the Japanese method. In the method we developed, the mesentery is removed from the rectum more than 2 cm away from the tumor, and the vicinity of the tumor is circularized. It is necessary to investigate the usefulness of this method prospectively in a multi-center study.

BACKGROUND Transperineal abdominoperineal excision (TpAPE) is an emerging approach for low rectal cancers but is technically challenging. Based on an anatomical study we conducted previously, we have standardized the TpAPE procedure. Here, we aimed to validate the feasibility of the standardized TpAPE by investigating the short-term outcomes. METHODS From January 2018 to November 2020, a total of 405 patients underwent laparoscopic or robotic rectal resection for rectal cancer in our institution. For the current study, we analyzed data for the 31 patients who underwent TpAPE. The abdominal phase was performed synchronously with the perineal phase using either a laparoscopic or robotic approach. Short-term outcomes included operative and pathological results. RESULTS Of the 31 cases, we identified anterior quadrant tumor invasion in 21. Most of the cases were advanced, with 6 staged as cT3 and 20 as T4. Of the 27 cases not involving distant metastasis, neoadjuvant therapy was performed in 19. No inadvertent rectal perforation or urethral injury was found intraoperatively. The median procedural duration to specimen removal was 250 min (interquartile range, 204-287), and the median intraoperative blood loss was 10 ml (interquartile range, 5-40). Regarding postoperative complications, perineal wound infection developed in 11 cases. A positive circumferential resection margin was found in 3, corresponding to the positive rate of 9.7%. These three cases were among the first 12 cases involving standardized TpAPE. CONCLUSIONS The current results indicate that TpAPE can be performed safely and might represent a useful option for low rectal cancer resection.

Introduction Transperineal minimally invasive abdominoperineal excision (TpAPE) may help minimize surgical invasiveness and make it possible to perform two-team surgery, although this procedure is regarded as difficult. The anatomical structures are complicated and have not been clearly defined, particularly on the anterior side of the anorectal junction in men. We investigated the anatomical configuration around the anterior wall of the anorectal junction, focusing on the structure of the striated muscles, to establish a standard procedure for TpAPE. Methods We scrutinized the T2 -weighted MRI scans of 106 men, and two male cadavers were used to examine the muscular structure surrounding the anorectal junction. We established our standardized procedure for TpAPE based on these anatomical studies. We also analyzed the clinicopathological findings from five men who had undergone TpAPE at our institution. Results Using MRI, we detected band-like muscles bilaterally, just medial to the puborectal muscle in all analyzed patients, which we termed the rectal anterolateral muscle. We also detected the muscles that may correspond to the rectal anterolateral muscle when inspecting the cadavers. The standardized TpAPE procedures were carried out uneventfully for the five cases, and intraoperative complications such as urethral injury and inadvertent rectal perforation did not occur. Conclusion We standardized the TpAPE procedure based on anatomical examination of the muscular structure around the anal canal. The findings can contribute to safe implementation of TpAPE.

To investigate the safety and efficacy of mucous fistula refeeding (MFR) in low-birth-weight infants. Between December 2006 and December 2018, medical records of low-birth-weight infants who underwent small bowel enterostomy formation in the neonatal period and subsequent stoma closure at our institution were retrospectively reviewed. Patients were assigned to “refeeding” (RF) and “non-refeeding” (NRF) groups, which were compared for patient characteristics and clinical outcomes. We also cultured the proximal stoma output over time in the RF group and reviewed changes in the flora to evaluate the safety of refeeding. In the RF group, compared with that before refeeding, there was significantly more rapid weight gain after refeeding (17.7 vs 10.6 g/day; P = 0.002). Median total time of parenteral nutrition (PN) was 25 and 87 days in the RF and NRF groups, respectively (P = 0.001). The number of patients who developed PN-associated liver disease (PNALD) was smaller in the RF group (P = 0.12). No complications of MFR were noted and no pathogenic bacteria were cultured. MFR was able to diminish the need for PN, which potentially decreased the incidence of PNALD, and was safe as there were no complications of the refeeding process.

Background Extremely low birth weight (ELBW) is a risk factor for various gastrointestinal complications. In the recent decades, advances in medicine have increased the survival of ELBW infants with necrotizing enterocolitis (NEC). To our knowledge, there have been no reports of neonates or infants developing simultaneous gastric and duodenal perforations and later developing NEC. We report a case of an extremely low birth weight infant (ELBWI) who developed both gastric and duodenal perforations at the same time and developed NEC after operation for gastric and duodenal perforations. Case presentation The patient was a female infant with ELBW who developed both gastric and duodenal perforations at the same time and developed NEC after operation for gastric and duodenal perforations. After birth, endotracheal intubation was performed. However, barotrauma occurred during positive pressure ventilation, resulting in a large area of emphysema in the left lower lung field, leading to collapse of the left lung. This giant bulla may have compressed the pulmonary vein, possibly resulting in pulmonary venous thrombosis (PVT). This episode could have triggered simultaneous gastric and duodenal perforations. In addition, we hypothesized that PVT caused acute arterial ischemia, leading to the development of NEC. The infant was started on heparin for anticoagulation. Later, the infant developed non-immunoglobulin E (IgE)-mediated gastrointestinal food allergies (non-IgE-GI-FAs). The giant bulla associated with barotrauma might have caused PVT, resulting in arterial emboli and multiple simultaneous gastrointestinal perforations. Conclusions Anticoagulation therapy with heparin for acute arterial thrombosis is effective for preventing the development of short bowel syndrome. Duodenal and intestinal surgery probably acted as risk factors for the subsequent development of non-IgE-GI-FAs. The infant had been stabilized at the time of writing this report.

We aimed at investigating the incidence and risk factors of non-IgE-mediated gastrointestinal food allergies (non-IgE-GI-FAs) in neonates and infants. A total of 126 infants who underwent neonatal gastrointestinal surgeries were grouped into those with (n = 13) and those without an onset of non-IgE-GI-FAs (n = 113). The characteristics of the two groups (e.g., birth weight, delivery type, small intestinal surgeries, and pre-/postoperative nutrition) were compared. Small intestinal surgeries were classified into those with and those without full-layer invasion of the small intestine. For the statistical analysis, postoperative nutrition was classified into breast milk only, formula milk, and elemental diet only. Except for full-layer surgical invasion of the small intestine and the period of parenteral nutrition, no significant differences were found between the two groups. Surgery with full-layer invasion was a risk factor of non-IgE-GI-FAs (odds ratio (OR) 10.70, 95% confidence interval (95% CI) 2.11–54.20; p = 0.004). Formula milk after surgery was a risk factor of non-IgE-GI-FAs when compared to breast milk (OR 5.65, 95% CI 1.33–24.00; p = 0.019). Neonates undergoing gastrointestinal surgery have a higher incidence of non-IgE mediated gastrointestinal food allergies. We recommend that formula milk should not be administered to newborns who underwent neonatal gastrointestinal surgeries with full-layer invasion of the small intestine.