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Aims: Whether rotation of a diverting loop ileostomy during rectal cancer surgery, for reducing the catastrophic effect of an anastomotic leakage, affects the incidence of small-bowel obstruction has not been fully investigated. The purpose of this study is to explore whether technical maneuvers in diverting loop ileostomy creation, including its rotation, are associated with increased incidence of small-bowel obstruction in rectal tumor surgery., Methods: This multicenter prospective study was conducted by the Clinical Study Group of Osaka University, which comprises 24 major institutions. Patients with rectal adenocarcinoma scheduled for laparoscopic/robotic low anterior resection or intersphincteric resection with a diverting loop ileostomy were included. A total of 451 patients were prospectively enrolled between July 2015 and April 2021. The primary endpoint was the relevance of loop ileostomy rotation to the incidence of small-bowel obstruction; the secondary endpoints included the origin of the small-bowel obstruction and length of hospital stay., Results: Small-bowel obstruction was observed in 10.8% in the nonrotated group and 12.3% in the rotated group, with no significant difference (P > .99). The only risk factor identified for small-bowel obstruction was distance from the ileocecal valve, with a significant difference in 16 patients (7.3%) with a distance of ≤30 cm and 16 patients (15.4%) in a distance of >30 cm (P = .028)., Conclusion: Rotation of the diverting loop ileostomy had no significant effect on the incidence of small-bowel obstruction., Competing Interests: Conflict of Interest/Disclosure The authors have no conflict of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

In May 2023, the Hugo RAS system obtained pharmaceutical approval for use in gastroenterological surgery in Japan. It is expected to be particularly effective in rectal cancer surgery, which require the manipulation of the deep pelvic cavity and communication with surgeons operating from the intraperitoneal and anal approaches. A 68-year-old woman presented to our hospital with bloody stools and was diagnosed with cStage I (cT2N0M0) rectal cancer and underwent abdominoperineal resection employing the Hugo RAS system. Two arm carts were placed on the left and right lateral sides with an interleg space, and trocars were placed in a straight line between the right superior iliac spine and umbilicus. Herein, we report the first abdominoperineal resection for rectal cancer using the Hugo RAS system., (© 2024 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Purpose: To assess pain management in patients post-sacrectomy, focusing on opioid use, and to identify the factors associated with postoperative pain., Methods: Patients who underwent resection of locally recurrent rectal cancer (LRRC) with concomitant sacrectomy at one of two hospitals between 2007 and 2020 were reviewed retrospectively. We examined the use of opioids preoperatively and postoperatively. Patients were classified into high and low sacrectomy groups based on the sacral bone resection level passing through the S3 vertebra., Results: Sixty-four patients were enrolled. Opioid use was significantly higher in the high sacrectomy group than in the low sacrectomy group at all times assessed: on postoperative days 7, 14, 30, 90, 180, and 365. Opioid use 3 months after locally recurrent rectal cancer surgery was significantly higher in patients with local re-recurrence of the tumor than in those without re-recurrence (p < 0.05), and the median morphine-equivalent opioid use 3 months postoperatively was significantly higher in the high sacrectomy group (30 vs. 0 mg/day; p < 0.05)., Conclusions: Opioid use after concomitant sacrectomy for LRRC was higher in the high sacrectomy group. Prolonged postoperative pain or increasing pain was associated with local recurrence., (© 2022. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: First-line treatment with FOLFOXIRI plus bevacizumab (BEV) is highly effective and regarded as one of the standards-of-care for patients with metastatic colorectal cancer (mCRC), despite the high incidence of neutropenia and diarrhea as side effects. AXEPT, an Asian phase III study, showed that modified CAPIRI+BEV [capecitabine (CAP: 1600 mg/m 2 ), irinotecan (IRI: 200 mg/m 2 ), and BEV (7.5 mg/m 2 )] was non-inferior to FOLFIRI+BEV as a second-line therapy for mCRC patients and was associated with a lower incidence of hematologic toxicities. Thus, a reduced dose of the CAP and IRI regimen in combination with oxaliplatin (OX) and BEV (CAPOXIRI+BEV) may be more feasible than FOLFOXIRI+BEV, without compromising efficacy., Methods: QUATTRO-II is an open-label, multicenter, randomized phase II study. In Step 1, the recommended doses of OX and IRI will be investigated as a safety lead-in. In Step 2, patients will be randomized to the recommended dose of either CAPOXIRI+BEV or FOLFOXIRI+BEV. Induction triplet chemotherapy plus BEV treatments will be administered for up to 4 months followed by fluoropyrimidine plus BEV maintenance. The primary endpoint is progression-free survival (PFS). The similarity in PFS between the two arms will be evaluated by observing whether the point estimate of hazard ratio (HR) for PFS falls between 0.80 and 1.25. Ensuring a 70% probability that the observed HR will be "0.8 < HR < 1.25" under the assumption of the true HR of 1.0, and 100 patients will be evaluated during the 3-year study period. Secondary endpoints include overall survival, overall response rate, safety, and patient reported outcome (PRO) (FACT/GOG-Ntx4)., Discussion: Considering the lower incidence of hematologic toxicities with modified CAPIRI+BEV than with FOLFIRI+BEV, CAPOXIRI+BEV may be a promising treatment option if sufficient efficacy and lower hematologic toxicities are indicated in this study. Additionally, a lower incidence of peripheral sensory neuropathy (PSN) reported following CAPEOX treatment compared to that after FOLFOX in ACHIEVE, an adjuvant phase III trial, suggest that CAPOXIRI+BEV can mitigate OX-induced PSN., Trial Registration: Clinicaltrials.gov NCT04097444 . Registered September 20, 2019, https://clinicaltrials.gov/ct2/show/study/NCT04097444 / Japan Registry of Clinical Trials jRCTs041190072. Registered October 9, 2019.

Background: Fashioning an ileostomy in the umbilicus and combining the trauma from extraction of colorectum with that from ileostomy should be less invasive and lead to improved cosmetic outcomes. However, there are only a few reports regarding umbilical ileostomy., Methods: We retrospectively collected data for 121 consecutive patients with rectal tumor who underwent elective laparoscopic rectal resection with diverting loop ileostomy between 2010 and 2015 at Osaka University Hospital, Japan. The safety and feasibility of umbilical diverting loop ileostomy and its influence on stoma care were investigated., Results: A total of 83 patients were included in this study; of these, 30 underwent umbilical diverting loop ileostomy and 53 underwent conventional diverting loop ileostomy, which was created in the right lower quadrant of the abdomen. The umbilical and conventional groups showed similar rates of postoperative and stoma-related complications (26.7 vs. 32.1%, p = 0.804 and 3.3 vs. 3.8%, p = 1.000, respectively). Level of parastomal dermatitis was evaluated by DET score at three time points (stoma self-management establishment, first outpatient review post-discharge, and just before stoma closure). DET scores at any time points did not differ significantly between the two groups., Conclusions: Umbilical diverting loop ileostomy is comparable to conventional ileostomy with regard to safety and feasibility. Our methods for umbilical ileostomy using the umbilical skin flap were less invasive and did not have a negative impact on stoma care and parastomal dermatitis. Umbilical ileostomy may be a promising alternative to conventional ileostomy in selected cases.

A 70-year-old man presenting with melena was referred to our clinic. A clinical examination revealed a bulky tumor in the lower rectum. After ileostomy, 4 courses of capecitabine plus oxaliplatin (XELOX) therapy were administered as neoadjuvant chemotherapy. Computed tomography (CT) revealed significant reduction of the tumor. Laparoscopic super-low anterior resection with lateral lymph node dissection was performed. The pathological examination revealed no residual cancer cells, and a diagnosis of pathological complete response was made. The patient has been disease-free for 1 year after the operation. Neoadjuvant chemotherapy with XELOX might be promising for patients with locally advanced rectal cancer.

A man in his fifties with rectal cancer underwent low anterior resection in another Hospital in January 2006. He was finally diagnosed with Stage III a (pA, pN1, H0, P0). The patient who had postoperative complication such as ruptured suture left the hospital in May 2006, when he was detected with multiple liver metastases and was referred to our hospital for systemic chemotherapy. Systemic chemotherapy with mFOLFOX6 was performed from May 2006. Grade 3 diarrhea and grade 2 peripheral neuropathy, nausea and vomiting were observed. After 6 courses of mFOLFOX6, MRI revealed metastasis had been disappeared and levels of CEA and CA19-9 were decreased below normal. The treatment has been discontinued. Recurrence was not observed for 30 months.