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Background Some studies have reported that adhesion prevention barriers (APBs) reduce adhesion after abdominal surgery; however, evidence showing that APBs reduce the incidence of postoperative small bowel obstruction (SBO), one of the most serious complications after abdominal surgery, is little. One concern is that APBs are usually applied only under the midline incision, although adhesion can occur at any place in the peritoneum where an incision is made during surgery. INTERCEEDⓇ is an APB that reportedly prevents postoperative SBO after surgery. This study aims to assess the clinical utility of INTERCEEDⓇ for the prevention of SBO after laparoscopic colorectal cancer surgery and determine whether the application site of INTERCEEDⓇ affects the incidence of SBO. Methods/Design This study is a prospective, multicenter, observational study conducted in Japan. The primary end point is the incidence of postoperative SBO 2 years after laparoscopic colorectal cancer surgery. The secondary end points include whether the site of the application of INTERCEEDⓇ affects the incidence of SBO. Each surgeon selects one of the following three procedures: 1) INTERCEEDⓇ is placed only under the midline incision; 2) INTERCEEDⓇ is placed at the site of bowel mobilization and/or lymph node dissection, but not under the midline incision; and 3) INTERCEEDⓇ is placed at both sites. Discussion This is the first study to assess whether the placement of APBs affects the incidence of SBO. The study results may lead to a subsequent randomized study.

Several studies have demonstrated that diverse systemic inflammatory-based prognostic parameters predict a poor prognosis in patients with gastric cancer. However, few studies have focused on the relationships between postoperative complications and systemic inflammatory-based prognostic parameters after curative gastrectomy. We investigated the relationships between postoperative complications and these parameters and assessed the clinical utility of the parameters as predictors of postoperative complications in patients with stage I–III gastric cancer. We retrospectively reviewed 300 patients who underwent curative gastrectomy for stage I–III gastric cancer. All postoperative complications were classified as infectious or noninfectious. We evaluated the relationships between postoperative complications and clinical factors, including systemic inflammatory-based prognostic parameters. In total, 101 patients (33.7%) had postoperative Clavien–Dindo grade II–IV complications, and 54 (18.0%) patients developed infectious complications including pancreatic fistula, pneumonia, anastomotic leak, intra-abdominal abscess, and cholecystitis. The relationships between postoperative complications and systemic inflammatory-based prognostic parameters were evaluated by the areas under the receiver operating characteristic curves. Postoperative pneumonia was identified as the most sensitive complication to the systemic inflammatory-based prognostic parameters. Multivariate analysis revealed that preoperative neutrophil-to-lymphocyte ratio (odds ratio, 14.621; 95% confidence interval, 1.160–184.348; p = 0.038) was an independent predictor of pneumonia. Preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of postoperative pneumonia in patients with stage I–III gastric cancer after curative gastrectomy.

Aim Appendicitis is divided into two categories: complicated appendicitis (CA) and uncomplicated appendicitis (UA). In pediatric patients with CA, the use of interval appendectomy (IA), which is non‐operative management followed by elective surgery, has decreased the number of postoperative complications. Before discussing the merit of IA for adult patients, we need to clarify whether the frequency and seriousness of the complication rate after emergency surgery is higher for CA than for UA. Methods This retrospective cohort study included adult patients who underwent appendectomy and who were registered in the National Clinical Database (NCD) from 2014 to 2016. Patients with CA who underwent emergency appendectomy comprised the CA group. Patients with UA comprised the UA group. Patients with chronic or recurrent appendicitis who underwent elective appendectomy comprised the elective appendectomy (EA) group. Primary outcomes were all morbidity, serious morbidity, and mortality within 30 days after appendectomy. Results We included 109 256 patients in the study: 14 798 CA, 86 876 UA, and 7582 EA patients. Compared with the UA group, the rates of all morbidity, serious morbidity, and mortality were significantly higher in the CA group. All morbidity, serious morbidity, and mortality rates were significantly lower in the EA group than in the other two groups. Conclusions We confirmed that emergency surgery for CA places the patient at relatively higher risk. We also showed that the risk associated with EA is significantly lower than that for the other methods., This retrospective cohort study included adult patients who underwent appendectomy and who were registered in the National Clinical Database from 2014 to 2016. Compared with the uncomplicated appendicitis group, the rates of all morbidity, serious morbidity, and mortality were significantly higher in the complicated appendicitis group. All morbidity, serious morbidity, and mortality rates were significantly lower in the elective appendectomy group than in the other two groups.

TAS-102 improved the overall survival of metastatic colorectal cancer (CRC) patients with a median progression-free survival (PFS) in the RECOURSE trial. Subsequently, the combination of TAS-102 and bevacizumab was shown to extend the median PFS (C-TASK FORCE study). However, the study included patients who received second- and third-line treatment. Our study exclusively examined patients receiving this combination as a third-line treatment to investigate the clinical impact beyond cytotoxic doublets. This investigator-initiated, open-label, single-arm, multi-centered phase II study was conducted in Japan. Eligible CRC patients were refractory or intolerant to fluoropyrimidine, irinotecan, and oxaliplatin in first- and second-line therapy. TAS-102 (35 mg/m2) was given orally twice daily on days 1–5 and 8–12 in a 4-week cycle, and bevacizumab (5 mg/kg) was administered by intravenous infusion every 2 weeks. The primary endpoint was PFS and the secondary endpoints were time-to-treatment failure, response rate, overall survival (OS), and safety. Between June 2016 and August 2017, 32 patients were enrolled. All patients previously received bevacizumab. The median PFS was 4.5 months; the median overall survival was 9.3 months. Partial response was observed in two patients. The most common adverse events above grade 3 were neutropenia followed by thrombocytopenia. There were no non-hematological adverse events above grade 3 and no treatment-related deaths occurred. This study met its primary endpoint of PFS, which is comparable to the results of the C-TASK FORCE study. The TAS-102 and bevacizumab combination has the potential to be a therapeutic option for third-line treatment of metastatic CRC.

To systematically review the effects of surgeon fatigue on postoperative mortality and postoperative complications after elective and non-elective surgeries. A database search was conducted for original articles published in PubMed between 2000 and 2020 with the keywords: “surgeon,” “sleep deprivation,” “sleep deprived,” “fatigued,” “mortality,” “morbidity,” and “outcomes.” We selected articles that disclosed actual numbers of patients who underwent surgery by fatigued or rested surgeons, rates of postoperative mortality, or total postoperative complications. Of the 1427 articles identified, 16 met the selection criteria and were included. Eight of the 16 also included total postoperative complications. Analysis revealed no significant differences in the rates of postoperative mortality after elective and non-elective surgeries or total postoperative complications of elective surgeries or non-elective surgeries performed by fatigued vs. rested surgeons. The relative risks were 1.03 [95% confidence interval (CI), 0.86–1.24], 1.08 (95% CI, 0.85–1.38), 0.99 (95% CI, 0.95–1.04), and 0.93 (95% CI, 0.67–1.28), respectively. Surgeon fatigue does not affect the rates of postoperative mortality or total postoperative complications after elective surgeries and may have little to no effect on the rates of postoperative mortality or total postoperative complications after non-elective surgeries.

Anastomotic leak is one of the most serious postoperative complications, and intraoperative adequate perfusion plays a key role in preventing its development in gastric cancer surgery. This study aimed to investigate the relationships between anastomotic leak and the parameters defined by an assessment of intraoperative anastomotic perfusion using a near-infrared indocyanine green (ICG) fluorescence system and to evaluate the usefulness of this ICG fluorescence assessment in gastric cancer surgery. We retrospectively reviewed data of 100 patients who underwent gastric cancer surgery. In a visual assessment based on fluorescence intensity, we classified ICG fluorescence image patterns as homogeneous, heterogeneous, or faint. In a chronological assessment, the first or second time point of ICG fluorescence appearance on one or the other side of the anastomosis was defined as FT or ST, respectively. The time difference in ICG fluorescence appearance between FT and ST was defined as TD. The relationships between anastomotic leak and the evaluated clinical factors, including the parameters identified by the ICG fluorescence assessment, were evaluated using univariate or multivariate analysis. Although no signs of leak were found by surgeons’ subjective judgments, four patients developed postoperative anastomotic leak of Clavien–Dindo grade III or IV. Multivariate analysis revealed that TD was an independent predictor of anastomotic leak (odds ratio 35.361, 95% confidence interval 1.489–839.923, p = 0.027). A novel parameter identified using near-infrared ICG fluorescence assessment may be useful to predict anastomotic leak in gastric cancer surgery. UMIN Clinical Trials Registry: #UMIN000030747 ( https://www.umin.ac.jp/ctr/index.htm ).

The present study was performed to compare postoperative pain following transinguinal preperitoneal repair (TIPP) and transabdominal preperitoneal repair (TAPP) performed by a single surgeon with adequate experience in each procedure.Adult patients who underwent herniorrhaphy for elective unilateral primary inguinal hernia repair from April 2013 to October 2019 were identified. After propensity score matching, a numeric rating scale was used to compare postoperative pain scores at 1 day, 1 week, and 1 month between patients who underwent TAPP and TIPP.Among 784 patients who underwent herniorrhaphy during the study period, 354 were analyzed by propensity score matching (TAPP, TAPP is preferable to TIPP in patients undergoing elective unilateral primary inguinal hernia repair in terms of reducing short-term pain.

Regorafenib significantly improves overall survival in previously treated metastatic colorectal cancer patients. However, various toxicities, such as hand-foot skin reaction (HFSR), fatigue, and liver dysfunction have limited the use of regorafenib. These toxicities appear soon after treatment initiation. The ReDOS study demonstrated the effectiveness of a weekly dose-escalation therapy of regorafenib starting with a lower daily dose; however, its usefulness in Asian subjects is unknown. We conducted a phase II study to evaluate the safety and survival benefit of regorafenib dose-escalation therapy for Japanese patients.Patients with sufficient organ function, who had previously received more than two lines of chemotherapy were included. Regorafenib was started at 80 mg/day and escalated to 120 mg/day in Week 2 and 160 mg/day in Week 3, if no severe drug-related toxicities were observed. The primary endpoint was cancer progression-free survival (PFS). Tumor response and progression were assessed radiologically every 8 weeks. This study was registered in the University Hospital Medical Information Network (UMIN#UMIN000028933).57 patients were enrolled and all started regorafenib at 80 mg/day. 32 patients (56.1%) were subsequently escalated to 120 mg/day and 19 (33.3%) to 160 mg/day. Only 8 patients (14.0%) discontinued treatment because of adverse events. Median PFS was 1.9 months. Median overall survival was 8.9 months, the response rate was 0%, and the disease control rate was 31.6%. The most frequent adverse event greater than grade 3 was hypertension (19.3%), followed by HFSR (14.0%).Regorafenib dose-escalation therapy is well tolerated with PFS-like regorafenib standard therapy.

We herein describe a case of laparoscopic surgery for an esophageal duplication cyst using a near‐infrared indocyanine green fluorescence system. A 64‐year‐old woman with a cystic tumor adjacent to the esophagogastric junction was referred to our hospital for treatment. Esophagogastroduodenoscopy and abdominal CT revealed a 70‐mm submucosal tumor derived from the abdominal esophagus. We performed laparoscopic resection and then evaluated the tissue perfusion of the abdominal esophagus by using a near‐infrared indocyanine green fluorescence system. A Dor fundoplication was performed to prevent postoperative gastroesophageal reflux disease and reinforce the mucosal layer defect. The postoperative course was uneventful, and pathological evaluation confirmed that the tumor was an esophageal duplication cyst. The patient did not develop recurrence in the 24 months after surgery. We have demonstrated that laparoscopic resection of an esophageal duplication cyst may be performed effectively with intraoperative assessment of tissue perfusion using a near‐infrared indocyanine green fluorescence system.

A phase II trial was conducted to investigate the benefit of oxaliplatin-based adjuvant chemotherapy in Japanese stage III colon cancer patients. Eligible patients were scheduled to receive 12 cycles of mFOLFOX6 or 8 cycles of CAPOX in adjuvant settings. The primary endpoint was the 3-year disease-free survival (DFS). Cox proportional hazards regression was performed to identify risk factors for a worse DFS. A total of 130 patients, including 73 patients receiving mFOLFOX6 and 57 patients receiving CAPOX, were enrolled from 16 institutions between April 2010 and April 2014. The 3-year DFS was 82.2%, exceeding the expected primary endpoint of 81.7%. The 3-year DFS tended to be higher in patients receiving mFOLOFOX6 than in those receiving CAPOX (mFOLFOX6, 86.3%; CAPOX, 76.9%; P = 0.06). The 3-year DFS rates did not differ markedly based on the risk stratification (T1/T2/T3 N1 vs. T4 or N2) indicated by the IDEA COLLABORATION study (P = 0.22). In the multivariate analysis, stage IIIC (P = 0.046) and early discontinuation (P

Low anterior resection syndrome (LARS) commonly develops after an anal sphincter-preserving operation (SPO). The etiology of LARS is not well understood, as the anatomical components and physiological function of normal defecation, which may be damaged during the SPO, are not well established. SPOs may damage components of the anal canal (such as the internal anal sphincter, longitudinal conjoint muscle, or hiatal ligament), either mechanically or via injury to the nerves that supply these organs. The function of the rectum is substantially impaired by resection of the rectum, division of the rectococcygeus muscle, and/or injury of the nervous supply. When the remnant rectum is small and does not function properly, an important functional role may be played by the neorectum, which is usually constructed from the left side of the colon. Hypermotility of the remnant colon may affect the manifestation of urge fecal incontinence. To develop an SPO that minimizes the risk of LARS, the anatomy and physiology of the structures involved in normal defecation need to be understood better. LARS is managed similarly to fecal incontinence. In particular, management should focus on reducing colonic motility when urge fecal incontinence is the dominant symptom.

Background: There are no standardised criteria for the determination of the ‘regional’ pericolic node in colon cancer surgery, which represents a major cause of the international uncertainty regarding the optimal bowel resection margin. This prospective cohort study aimed to determine ‘regional’ pericolic nodes based on detailed mapping for feeding arteries and lymph nodes. Methods: In all, 2,996 patients with stages I–III colon cancer who underwent curative surgery between June 2013 and December 2017 at 25 institutions in Japan were included. The anatomical distributions of the feeding artery and lymph nodes were determined in resected fresh surgical specimens based on in vivo measurements of the bowel. Findings: The mean number of retrieved pericolic nodes was 20·9 per patient. In all patients except seven (0·2%), the primary feeding artery was distributed within 10 cm of the primary tumour. The metastatic pericolic node location most distant from the primary tumour was within 3 cm in 837 patients, 3–5 cm in 130 patients, 5–7 cm in 39 patients and 7–10 cm in 34 patients. Only four patients (0·1%) had pericolic lymphatic spread beyond 10 cm; all of whom had T3/4 tumours accompanying extensive mesenteric lymphatic spread, and three developed systemic recurrence. The positive pericolic node distance from the primary tumour did not differ depending on the primary tumour location or the distribution of the feeding arteries. Postoperatively, none of the 2996 patients developed recurrence in the remaining pericolic nodes. Interpretation: Based on the distribution of metastatic lymph nodes and prognostic outcomes, the pericolic nodes designated as ‘regional’ were those located within 10 cm of the primary tumours. Despite the fact that surgeons tend to prefer complete mesocolic excision, these findings should be fully considered when determining the bowel resection margin. Funding: Japanese Society for Cancer of the Colon and Rectum Declaration of Interest: All authors declare no competing interests. Ethical Approval: This study was conducted according to the Declaration of Helsinki and comparable Japanese ethical standards. The study was approved by the Institutional Review Boards of the JSCCR and each participating institution. Written informed consent was obtained from all study participants

We previously reported the first evidence of oncological benefits from a Japanese phase II trial of oxaliplatin-based adjuvant chemotherapy in patients with stage III colon cancer (the FACOS study). We herein report the long-term survival and persistent oxaliplatin-related peripheral sensory neuropathy (PSN) for patients enrolled in this trial. Patients were scheduled to receive the mFOLFOX6 or CAPOX regimen in the adjuvant setting. The five-year overall survival (OS) rate and persistent PSN were evaluated. A total of 130 patients (mFOLFOX6, n = 73; CAPOX, n = 57) were eligible. The 5-year OS rate was 91.4%. No significant difference in the OS rate was observed between regimens (mFOLFOX6, 94.4%; CAPOX, 87.4%; P = 0.25). The incidence of PSN during adjuvant treatment was 55.4% in grade 1 (G1), 30.0% in G2, and 4.6% in G3. No patients showed G3 PSN at 12 months, but G1 or G2 residual PSN after 5 years was observed in 21.8% (G1, 20%; G2, 1.8%). Updated results from the FACOS study support the benefits of oxaliplatin-based adjuvant chemotherapy in terms of the long-term survival among Japanese patients with stage III colon cancer. However, long-term persistent PSN occurs in about 20% of survivors, counterbalancing the favorable OS.

Background: the novel severe acute respiratory syndrome coronavirus 2 virus that emerged in December 2019 causing coronavirus disease 2019 (COVID-19) has led to the sudden national reorganization of health care systems and changes in the delivery of health care globally. The purpose of our study was to use a survey to assess the global effects of COVID-19 on colorectal practice and surgery. Materials and methods: a panel of International Society of University Colon and Rectal Surgeons (ISUCRS) selected 22 questions, which were included in the questionnaire. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in the ISUCRS database and was advertised on social media sites. The questionnaire remained open from April 16 to 28, 2020. Results: a total of 287 surgeons completed the survey. Of the 287 respondents, 90% were colorectal specialists or general surgeons with an interest in colorectal disease. COVID-19 had affected the practice of 96% of the surgeons, and 52% were now using telemedicine. Also, 66% reported that elective colorectal cancer surgery could proceed but with perioperative precautions. Of the 287 respondents, 19.5% reported that the use of personal protective equipment was the most important perioperative precaution. However, personal protective equipment was only provided by 9.1% of hospitals. In addition, 64% of surgeons were offering minimally invasive surgery. However, 44% reported that enough information was not available regarding the safety of the loss of intra-abdominal carbon dioxide gas during the COVID-19 pandemic. Finally, 61% of the surgeons were prepared to defer elective colorectal cancer surgery, with 29% willing to defer for ≤ 8 weeks. Conclusion: the results from our survey have demonstrated that, globally, COVID-19 has affected the ability of colorectal surgeons to offer care to their patients. We have also discussed suggestions for various practical adaptation strategies for use during the recovery period. We have presented the results of a survey used to assess the global impact of coronavirus disease 2019 (COVID-19) on the delivery of colorectal surgery. Despite accessible guidance information, our results have demonstrated that COVID-19 has significantly affected the ability of colorectal surgeons to offer care to patients. We have also discussed practical adaptation strategies for use during the recovery phase., NA

Chemotherapy with oxaliplatin is known to induce sinusoidal obstruction syndrome (SOS). In a previous single-center study, we reported that oxaliplatin-induced increase in splenic volume (SV) is strongly indicative of SOS, and that this increase in SV persisted for 1 year after completing chemotherapy. The aim of this study was to confirm the oxaliplatin-induced SV change in a multicenter study in patients with stage III colon cancer in Japan.We enrolled 59 patients who underwent curative resection for stage III colon cancer in the FACOS study in a phase II multi-center clinical study. Participants received mFOLFOX6 or CAPOX as adjuvant chemotherapy. SV change was assessed three times by computed tomographic volumetry: before surgery, on completion of adjuvant chemotherapy, and 1 year after completing adjuvant chemotherapy.SV on completing and 1 year after chemotherapy was significantly higher than that before surgery (P 0.001). Oxaliplatin-induced SOS persisted for 1 year after the completion of adjuvant chemotherapy in half of the patients. There was no difference in 3-year disease-free survival with respect to the presence or absence of increased SV. An increase in SV was observed in 72% of patients treated with mFOLFOX6 and 94% of patients treated with CAPOX (P = 0.13).This study can be verified the findings observed in our previous single-center study, oxaliplatin-based adjuvant chemotherapy was associated with an increase in SV. Furthermore, this increase can persist for 1 year. The continuous presence of SOS may have a negative impact on prognosis in patients that develop recurrent disease.

Diverticular disease of the colon occurs quite frequently in developed countries, and its prevalence has recently increased in Japan. The appearance of diverticulosis increases with age, although mostly remaining asymptomatic. Approximately 20% of cases require treatment. As the Western lifestyle and number of elderly people increase, the need for medical treatment also increases. Computed tomography (CT) is the gold standard for diagnosing diverticulitis. Complicated diverticulitis is classified by the size and range of abscess formation and the severity of the peritonitis. Each case should be classified based on clinical and computed tomography (CT) findings and then treated appropriately. Most patients with uncomplicated diverticulitis (stages 0–Ia) can be treated conservatively. Diverticulitis with a localized abscess (stages Ib–II) is generally resolved with conservative treatment. If the abscess is larger or conservative treatment fails, however, percutaneous drainage or surgery should be considered. Operative treatment is considered standard therapy for severe diverticulitis with perforation and generalized peritonitis (stages III–IV). Colonic diverticulitis treated conservatively frequently recurs. Elective surgery after recovery should be considered carefully and decisions made on a case‐by‐case basis. Because cases of colonic diverticulitis will undoubtedly increase in Japan, it is likely that we will be confronted with increasing numbers of treatment decisions. We therefore need to have a systematic strategy for treating the various stages of colonic diverticulitis appropriately. We herein review the management of complicated diverticulitis.

BACKGROUND Liver metastases from colorectal cancer (CRC) are best managed using multiple modalities, but the role of chemotherapy prior to resection of marginally resectable liver metastases remains unsettled. PATIENTS AND METHODS Consecutive patients treated for marginally resectable CRC liver metastases were matched using a propensity-score analysis based on the probability of a patient having up-front surgery or prehepatectomy chemotherapy followed by surgery. RESULTS The study group consisted of 70 propensity-matched patients undergoing up-front surgery or prehepatectomy chemotherapy followed by surgery. Groups were similar in terms of baseline characteristics. Median estimated blood loss (605 ml vs. 957 ml, p=0.006), number of patients requiring transfusion (5 vs. 14, p=0.016) and median postoperative hospital stay (13 vs. 17 days, p=0.005) were significantly less in the prehepatectomy chemotherapy group. CONCLUSION Hepatic resection after prehepatectomy chemotherapy for patients with marginally resectable CRC liver metastases can lead to favorable short-term outcomes.

Aim To evaluate whether the congested area that develops in associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) contributes to rapid future liver remnant (FLR) hypertrophy. Patients and methods Eight patients undergoing liver partition and right portal vein (RPV) ligation within the FLR in the first operation of ALPPS were compared with eight patients undergoing RPV embolization in the FLR as the first operation of classical two-stage (CTS) hepatectomy. Results Extrapolated kinetic growth of the FLR in ALPPS was 32.7±18.7 ml/day, 7.8-times that in CTS (4.2±2.0 ml/day, p=0.001). Extrapolated kinetic reduction in volume of the ventral aspect of the right paramedian sector, which became congested after the first procedure in ALPPS, was 19.8±11.6 ml/day, 11-times that in CTS (1.8±1.3 ml/day, p=0.001). Conclusion Production of a congested area within the deportalized liver may contribute importantly to rapid FLR hypertrophy during ALPPS.

We compared histologic findings in nonneoplastic portions of liver resected during surgery associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) with those from hepatectomy after portal vein embolization (PVE).Effects of congestion and ischemia in ALPPS on hepatocyte regeneration are incompletely understood, as are those on hepatocyte maturity.Specimens obtained from 8 patients treated with ALPPS and from 14 patients treated with hepatectomy after PVE were examined by light and electron microscopy.Extrapolated kinetic growth of the future liver remnant (FLR) for ALPPS was 14.4 ± 4.8 mL/d, which was faster than for PVE (3.6 ± 2.2 mL/d; P.001). Microscopically, the FLR showed greater hepatocyte cell density and smaller hepatocyte size in ALPPS than in PVE (P.01 for each). Bright-appearing hepatocytes and sinusoidal narrowing were more frequent in ALPPS (50% and 50%) than in PVE (0% and 8.3%; P = .025 for each). In the deportalized ventral aspect of the anterior section, hepatocyte atrophy, hepatocyte degeneration or necrosis, sinusoidal dilation, fibrosis, and congestion were more frequent in ALPPS than in PVE (P = .001, P = .002, P.001, and P.001, respectively). Electron microscopy frequently showed vacant-appearing hepatocytic cytoplasm filled with glycogen granules in the FLR in ALPPS. Fewer cytoplasmic organelles and lipofuscin granules were observed in ALPPS than in PVE.In the FLR, regenerative hepatocytes in ALPPS were morphologically immature compared with PVE. ALPPS should be performed with caution, considering limited functional increase in the FLR reflecting immaturity of the regenerative hepatocytes.

After major liver resections, infections and liver insufficiency are the most common complications; these may coincide. We performed a randomized clinical trial to clarify ability of early enteral nutrition to prevent infectious complications and liver failure following major hepatectomy. We prospectively allocated consecutive patients who underwent major liver resection into either an early enteral nutrition group in which such nutrition was initiated on the first postoperative day or a nonenteral nutrition group. The primary study endpoint was rate of infectious complications. Thirty-two patients were randomly allocated to the enteral nutrition group, while 31 were assigned to the nonenteral nutrition group. No significant difference in rate of infection complications was evident between enteral (9.4%) and nonenteral group (22.6%, P = 0.184). However, complications of grade III severity or worse were significantly less frequent in the enteral (9.4%) than in the nonenteral group (32.3%, P = 0.031). Further, postoperative serum concentrations of pre-albumin and reduced-state albumin were greater in the enteral than in the nonenteral group. Early enteral nutrition did not significantly improve prevention of infectious complications, but some effectiveness in preventing severe complications and improving nutritional status was demonstrated.

While adjuvant chemotherapy is preferable for colon cancer, treatment duration is controversial. This phase III trial is investigated optimal duration of adjuvant chemotherapy for Stage IIB/III colon cancer. Eighteen-month treatment with UFT/LV did not improve DFS compared with 6-month UFT/LV treatment. This study suggests that 6 months treatment duration is enough for Stage IIB/III colon cancer., Background While adjuvant chemotherapy is preferable for high-risk colon cancer, treatment duration is controversial. Oral uracil and tegafur (UFT)/leucovorin (LV) is widely used as a standard adjuvant chemotherapy for colon cancer in Japan. We conducted a phase III trial to investigate the optimal duration of adjuvant chemotherapy for stage IIB/III colon cancer. Patients and methods Patients with curatively resected stage IIB/III colon cancer were eligible for enrollment in this trial. Patients were registered within 6 weeks after surgery and were randomly assigned to receive UFT/LV for 28 of 35 days for 6 months in the control group or for 5 consecutive days per week for 18 months in the study group. The primary end point was the disease-free survival (DFS), and the secondary end points were overall survival (OS) and safety. Result A total of 1071 patients were registered from 233 centers. A statistically significant difference in DFS was not observed between the study group and the control group; the 5-year DFS was 69% in the study group and 69% in the control group. The 5-year OS was 85% in the study group and 85% in the control group. Conclusion Eighteen-month treatment with UFT/LV did not improve DFS or OS compared with 6-month UFT/LV treatment in patients with stage IIB/III colon cancer. The important finding from this study is that not 18 months but 6 months of treatment is enough for postoperative UFT/LV for stage IIB/III colon cancer. Clinical trial number UMIN-CTR C000000245.

The clinical outcomes of patients who have undergone total pelvic exenteration (TPE) for locally advanced primary colorectal cancer have not been satisfactory. For the last 13 years, we have performed layer-oriented, en bloc resection of tumor for which TPE is indicated, in the hope of improving postoperative outcomes. The clinical outcomes of these cases were retrospectively analyzed.A total of 54 patients who underwent TPE from 1986 to 2013 were retrospectively analyzed. Since 2002, a layer-oriented removal for clinical T4 colorectal cancer, as in T3 or less invasive tumors removed by total mesorectal excision, was applied to 23 cases for which TPE was indicated. Postoperative mortality, morbidity, overall survival (OS), and disease-free survival (DFS) were evaluated.On univariate analysis, good postoperative OS and DFS were associated with the layer-oriented operative maneuver, blood loss less than 2000 mL, negative nodal metastasis, and no preoperative radiation therapy. Male sex was the marginal determinant correlated with good OS and DFS. Depth of invasion to T3 was the marginal determinant correlated with good DFS. On multivariate analysis using the 4 factors identified on univariate analyses, the layer-oriented operative procedure was a significant determinant for both good OS and DFS, together with negative nodal metastases. Postoperative mortality and morbidity in the layer-oriented excision were acceptable.For primary colorectal cancers for which TPE is indicated, layer-oriented excision was a safe and effective procedure, and it may be recommended as one of the standard surgical approaches in TPE.

This exploratory trial was conducted to investigate whether daikenchuto accelerates the recovery of gastrointestinal function in patients undergoing open surgery for sigmoid or rectosigmoid cancer. Eighty-eight patients who underwent colectomy at one of the 11 clinical trial sites in Japan from January 2009 to June 2011 were registered in the study. Patients received either placebo or daikenchuto (15.0 g/day, 5 g three times a day) from postoperative day 2 to postoperative day 8. The study end points included the gastrointestinal tract transit time evaluated with radiopaque markers and the time to first flatus. The safety profile of daikenchuto was also evaluated until postoperative day 8. Seventy-one patients (daikenchuto, n = 38; placebo, n = 33) were statistically analyzed. Although the number of radiopaque markers in the anal side of the small intestine at 6 h was significantly greater in the daikenchuto group than in the placebo group (15.19 vs 10.06, p = 0.008), the total transit analysis results and the mean time to first flatus did not differ significantly between the two groups. Daikenchuto has a positive effect on the resolution of delayed gastric emptying, but has a limited effect on the resolution of postoperative paralytic ileus after open surgery in patients with sigmoid or rectosigmoid cancer. Daikenchuto may contribute to early oral intake in the postoperative course.

Background We compared clinical outcomes of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) against those of classical 2-stage hepatectomy in treating metastatic liver disease. Methods Short-term outcomes, serial changes in volume of the future liver remnant (FLR), functional FLR volume, and tumor growth activity during the treatment period, were compared between our first 11 consecutive patients treated with ALPPS and 54 patients treated with classical 2-stage hepatectomy. Results Mortality in the ALPPS group (9%) tended to be higher than in the classical 2-stage group (2%, P = 0.341). The FLR hypertrophy ratio (FLR volume after vs. before the procedure) 1 week after the first operation in the ALPPS group (1.54 ± 0.18) exceeded that in the classical 2-stage group (1.19 ± 0.29, P = 0.005), being similar to the ratio at 3 weeks after the first procedure in the classical 2-stage group (1.40 ± 0.43). However, functional volume of the FLR in the ALPPS group 1 week after the first procedure (52.1%) tended to be smaller than that in the classical group 3 weeks after the first procedure (59.2%). Conclusions ALPPS should be used with extreme caution, giving special attention to postoperative complications and grade of functional liver regeneration.

Background Although intraoperative peritoneal lavage is often performed routinely with the aim of reducing peritoneal contamination, little evidence of lavage benefits in elective liver resection without bile duct resection is available. We addressed the issue with a randomized clinical trial. Methods We prospectively and randomly assigned consecutive patients undergoing liver resection to a lavage group or a non-lavage group. Peritoneal lavage was performed at the end of operation for patients in the lavage group. The primary endpoint was the rate of surgical site infection. Results Ninety-six patients were assigned to the lavage group and 97 to the non-lavage group. When superficial/deep incisional infection and organ/space infection were considered together, no significant difference in surgical site infection rate was evident between lavage (21.9%) and non-lavage groups (13.4%, P = 0.135). However, organ/space infection was significantly more frequent in the lavage group (16.7%) than the non-lavage group (7.2%, P = 0.048). Peritoneal lavage was identified as a risk factor for organ/space infection by multivariate analysis (relative risk, 2.977; confidence interval, 1.094 to 8.100; P = 0.033). Conclusion Intraoperative peritoneal lavage does not reduce overall incidence of surgical site infection and may increase risk of organ/space infection.

Background: Although a ‘liver-first' approach recently has been advocated in treating synchronous colorectal metastases, little is known about how results compare with those of the classical approach among patients with similar grades of liver metastases. Methods: Propensity-score matching was used to select study subjects. Oncologic outcomes were compared between 10 consecutive patients with unresectable advanced and aggressive synchronous colorectal liver metastases treated with the reverse strategy and 30 comparable classically treated patients. Results: Numbers of recurrence sites and recurrent tumors irrespective of recurrence sites were greater in the reverse group then the classic group (p = 0.003 and p = 0.015, respectively). Rates of freedom from recurrence in the remaining liver and of freedom from disease also were poorer in the reverse group than in the classical group (p = 0.009 and p = 0.043, respectively). Among patients treated with 2-stage hepatectomy, frequency of microvascular invasion surrounding macroscopic metastases at second resection was higher in the reverse group than in the classical group (p = 0.011). Conclusions: Reverse approaches may be feasible in treating synchronous liver metastases, but that strategy should be limited to patients with less liver tumor burden.

Ryohei Itagaki, Keiji Koda, Masato Yamazaki, Kiyohiko Shuto, Chihiro Kosugi, Atsushi Hirano, Hidehito Arimitsu, Risa Shiragami, Yukino Yoshimura, Masato Suzuki Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan Purpose: Serotonin (5-hydroxytryptamine [5-HT])3 receptor antagonists are effective for the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D), in which exaggerated intestinal/colonic hypermotility is often observed. Recent studies have suggested that the motility disorder, especially spastic hypermotility, seen in the neorectum following sphincter-preserving operations for rectal cancer may be the basis of the postoperative defecatory malfunction seen in these patients. We investigated the efficacy of 5-HT3 receptor antagonists in patients suffering from severe low anterior resection syndrome. Patients and methods: A total of 25 male patients with complaints of uncontrollable urgency or fecal incontinence following sphincter-preserving operations were enrolled in this study. Defecatory status, assessed on the basis of incontinence score (0–20), urgency grade (0–3), and number of toilet visits per day, was evaluated using a questionnaire before and 1 month after the administration of the 5-HT3 antagonist ramosetron. Results: All the parameters assessed improved significantly after taking ramosetron for 1 month. The effect was more prominent in cases whose anastomotic line was lower, ie, inside the anal canal. Defecatory function was better in patients who commenced ramosetron therapy within 6 months postoperatively, as compared to those who were not prescribed ramosetron for more than 7 months postoperatively. Conclusion: These results suggest that 5-HT3 antagonists are effective for the treatment of low anterior resection syndrome, as in diarrhea-predominant irritable bowel syndrome. The improvement in symptoms is not merely time dependent, but it is related to treatment with 5-HT3 antagonists. Keywords: low anterior resection syndrome, serotonin receptor antagonist, ISR, defecatory malfunction

Postoperative anastomotic leaks and subsequent mediastinal abscess are serious complications. The purpose of this study was to assess the efficacy of naso-esophageal extraluminal drainage after thoracic esophagectomy with gastric conduit reconstruction using a posterior mediastinal route. About 50 of 365 patients (13.7%) with esophageal cancer and postoperative anastomotic leak after curative esophagectomy was investigated. Beginning in June 2009, naso-esophageal extraluminal drainage by inserting a naso-esophageal aspiration tube into the abscess cavity when percutaneous abscess drainage was introduced which was ineffective or technically impossible. Twenty-five patients underwent naso-esophageal extraluminal drainage concomitantly with enteral nutrition. Twenty-one (84%) patients had major leaks, one (4%) minor leak and three (12%) had endoscopically proven conduit necrosis. None of the naso-esophageal extraluminal drainage cases (100%) required reintervention or reoperation and all experienced complete cure (100%) during hospitalization. Endoscopic balloon dilatation was performed for four patients after discharge because of anastomotic stricture. Patients with leaks were divided into two groups: current group (n = 32), treated after June 2009, and preceding group (n = 18), treated prior to the introduction of naso-esophageal extraluminal drainage. Significantly more patients in the preceding group suffered respiratory failure (28% vs. 61%, p = 0.024), and higher reoperation rate (0% vs. 17%, p = 0.042) and hospital mortality (0% vs. 22%, p = 0.013). In the current group, 31 (97%) patients experienced complete cure during hospitalization. Naso-esophageal extraluminal drainage and concomitant enteral nutritional support are less invasive, and effective and powerful methods to treat even major leakage after esophagectomy. These methods may be an alternative management to improve mortality for patients with esophageal cancer.

Massive postoperative ascites remains a major threat that can lead to liver failure and other fatal complications, especially in patients with poor liver function. Branched-chain amino acid (BCAA) administration increases biosynthesis and secretion of albumin by hepatocytes and increases oncotic pressure by elevating blood albumin concentration, thereby decreasing peripheral edema, ascites, and pleural effusion. We randomly allocated consecutive patients undergoing major liver resection for hepatocellular carcinoma to either a group where oral BCAA administration was initiated 3 weeks before liver resection, or a non-BCAA group. The primary study endpoint was development of postoperative ascites. Overall, 39 patients were allocated to the BCAA group, while 38 were assigned to the non-BCAA group. No significant difference in the rate of refractory ascites, considered alone, was evident between the BCAA (5.1 %) and non-BCAA groups (13.2 %; p = 0.263). However, the occurrence of refractory ascites and/or pleural effusion was significantly less frequent in the BCAA group (5.1 %) than in the non-BCAA group (21.1 %; p = 0.047). Furthermore, the postoperative serum concentration of reduced-state albumin was greater immediately after liver resection in the BCAA group than in the non-BCAA group. Preoperative administration of BCAA did not significantly improve prevention of refractory ascites, but significant effectiveness in preventing ascites, pleural effusion, or both, as well as improving metabolism of albumin, was demonstrated [University Hospital Medical Information Network (UMIN) reference number 000004244].

Background Details of postoperative damage to anal sphincter tonus following sphincter-preserving operation for rectal cancer remain unclear. Methods Postoperative anal tonus was measured using 3-dimensional (3D) vector manometry in 56 patients. Anal length with pressure from any direction was defined as total length (TL). Length with circular pressure (LCP), which is only measurable using 3D manometry, was also evaluated. Results In operations associated with low anastomosis, both TL and LCP at rest were significantly shortened when compared with control (high interior resection [HAR]). In particular, degraded LCP at rest was obvious. Anal lengths in squeezing state were preserved except in cases with intersphincteric resection (ISR). Postoperative incontinence score inversely correlated with functional anal length at rest. Conclusions Although the sphincter muscles are mechanically preserved, function of the internal sphincter and subsequent defecatory function can be degraded in cases with operative procedures including surgical maneuvers at the pelvic floor.

Background: Breast-conserving surgery after primary systemic therapy (PST) has become a widely acceptable procedure for locally advanced breast cancers. Sometimes it is difficult to determine the appropriate resection-line at the time of surgical operation because of tumor size reduction or indistinct boundary of the tumor. Moreover we cannot detect tumors in cases with complete response. That was why we developed a new navigation technique using real-time image reconstruction. Materials and methods: Multi-detector row computed tomography (MD-CT) has been performed for all breast cancer patients in our institute. DICOM images of MD-CT were analyzed by image processing software ‘OsiriX'. OsiriX is an open source software which anyone can download from website (http://www. osirix-viewer.com). OsiriX has been specifically designed for navigation and visualization of multimodality and multidimensional images. We used 3D volume rendering images. At the time of surgery, pre-PST volume rendering images ware superimposed directly on the patients’ skin from projector which was connected to a personal computer in the operating room. Results: We could see ‘real-time’ rendering images (from skin to organ by layer to layer) on the patient's body. By using pre-PST imaging data, we could recognize precise tumor area and could perform breast conserving surgery safer and easier than before. Conclusion: Using 3D reconstruction MD-CT images which were obtained before PST, ‘real-time’ virtual navigation was helpful to determine the resection-line for clear surgical margin in breast-conserving surgery after PST. This new technique does not need some expensive equipments and easily performed by surgeon. Ordinary personal computer and projector make it possible to demonstrate a new environment in surgical operation. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-10-11.

Background Right hepatectomy (RH) is the standard surgical procedure for perihilar cholangiocarcinoma (PHC) with right-sided predominance in many centers. Although left trisectionectomy (LT) is aggressively performed for PHC with left-sided predominance in high-volume centers, the surgical and survival outcomes of LT are unclear. Therefore, this study aimed to compare the outcomes of LT and RH for PHC. Methods Consecutive patients who underwent surgical resection for PHC at Chiba University Hospital from 2008 to 2016 were retrospectively reviewed. The outcomes of patients with PHC who underwent LT were compared with those who underwent RH following one-to-one propensity score matching. Results Of 171 consecutive PHC resection patients, 111 were eligible for the study; 41 (37%) underwent LT, and 70 (63%) underwent RH. In a matched cohort (LT: n = 27, RH: n = 27), major complication rates (67% vs. 52%; p = 0.42), 90-day mortality rates (15% vs. 0%; p = 0.11) and R0 resection rates (56% vs. 44%; p = 0.58) were similar in both groups. The 3-year recurrence-free survival rates (27% vs. 47%; p = 0.27) and overall survival rates (45% vs. 60%; p = 0.17) were also similar in both groups. Conclusions In patients with PHC, LT could achieve similar surgical and survival outcomes as RH.

We applied a new concept of “image overlay surgery” consisting of the integration of virtual reality (VR) and augmented reality (AR) technology, in which dynamic 3D images were superimposed on the patient’s actual body surface and evaluated as a reference for surgical navigation in gastrointestinal, hepatobiliary and pancreatic surgery. We carried out seven surgeries, including three cholecystectomies, two gastrectomies and two colectomies. A Macintosh and a DICOM workstation OsiriX were used in the operating room for image analysis. Raw data of the preoperative patient information obtained via MDCT were reconstructed to volume rendering and projected onto the patient's body surface during the surgeries. For accurate registration, OsiriX was first set to reproduce the patient body surface, and the positional coordinates of the umbilicus, left and right nipples, and the inguinal region were fixed as physiological markers on the body surface to reduce the positional error. The registration process was non-invasive and markerlesss, and was completed within 5 min. Image overlay navigation was helpful for 3D anatomical understanding of the surgical target in the gastrointestinal, hepatobiliary and pancreatic anatomies. The surgeon was able to minimize movement of the gaze and could utilize the image assistance without interfering with the forceps operation, reducing the gap from the VR. Unexpected organ injury could be avoided in all procedures. In biliary surgery, the projected virtual cholangiogram on the abdominal wall could advance safely with identification of the bile duct. For early gastric and colorectal cancer, the small tumors and blood vessels, which usually could not be found on the gastric serosa by laparoscopic view, were simultaneously detected on the body surface by carbon dioxide-enhanced MDCT. This provided accurate reconstructions of the tumor and involved lymph node, directly linked with optimization of the surgical procedures. Our non-invasive markerless registration using physiological markers on the body surface reduced logistical efforts. The image overlay technique is a useful tool when highlighting hidden structures, giving more information.

Transgastric access is a major route in natural orifice translumenal endoscopic surgery (NOTES); gastrotomy should be performed unless it would damage surrounding organs in the peritoneal cavity. This article describes a novel rendezvous gastrotomy technique over a direct percutaneous endoscopic gastrostomy (PEG). In six live porcines, the gastrotomy involved applying a direct PEG through the abdominal wall into the stomach and exchanging to a needle trocar. An endoscopic balloon catheter was passed through the trocar by rendezvous technique. Then the inflated balloon and endoscope were advanced to the peritoneal cavity through the gastrotomy. Transgastric cholecystectomy was performed with a hybrid needle grasper through the same percutaneous site and the gastrotomy was closed with endoscopic clips. The rendezvous gastrotomy technique could reduce guidewire exchange. The success rate was 100% (6/6). Mean times for transgastric peritoneoscopy and cholecystectomy were 25.5 and 83.5 min. Mortality and morbidity was 0%. The addition of the extra trocar was unnecessary in all procedures. The advantage of this introduction system includes the creation of controlled gastric perforation, which is easier to close. It provides reliable transgastric access and increases safety. It simplifies transgastric NOTES and provides less invasive hybrid NOTES procedure.

潰瘍性大腸炎の手術症例54例中，大腸癌を合併した4例を報告する．症例1: 25歳女性．発症8年目にSD移行部のIspポリープに対し内視鏡的粘膜切除術を施行し，病理診断が腺癌のため手術を施行した．症例2: 36歳男性．発症17年目にdysplasiaを2病変認め手術を施行した．病理診断は高分化型腺癌であった．症例3: 48歳女性．発症16年目の大腸内視鏡検査で穿孔し緊急手術を施行した．上行結腸に3型の中分化型腺癌，多発するIIa+IIc病変を認めた．症例4: 48歳女性．発症24年目に巨大結腸症の診断で紹介受診した．大腸亜全摘術を施行したが直腸は切除不能であった．術後の直腸生検で印環細胞癌の診断であった．これらの症例のように炎症の活動性が低い場合でも，罹病期間が長い潰瘍性大腸炎では発癌リスクが高く，効率的なサーベイランスが望まれる．

はじめに：鼠径ヘルニア根治手術は若い外科医が基本手技を鍛錬する場であり，外科手術の入門編として位置していた．現在，初期研修医制度が実施され，外科系診療科志望でない研修医も外科をローテーションするカリキュラムが組まれている．今回，我々は鼠径ヘルニア根治術を初期研修医に執刀させる是非を検討する．方法：2005年4月から2007年12月に根治手術を施行した139例を対象とした．134例にmesh plug法が，5例にPROLENE hernia system法が行われた．初期研修医執刀例は72例（R群），外科医執刀例は67例（S群）だった．R群とS群において，患者背景，術中，術後因子を検討した．結果：患者背景においてR群とS群で有意差はなかった．術中因子として手術時間においてR群：S群に有意差を認めた（88.0分：64.2分，p＜0.001）．術後因子は，入院期間（3.8±2.1日：4.9±8.3日，p=0.14），合併症（9.8％：6.6％，p=0.64）に統計学的に有意差はなかったが，再発はR群7例（9.7％），S群1例（1.5％）で有意にR群において高かった（p=0.04）．考察：入院期間，合併症には有意差はなく，再発率は初期研修医術者が外科医と比較し有意に高かったが，助手として外科専門医が指導することで，再発率が抑えられる．よって，現在の研修医制度において外科系研修カリキュラムの手術執刀についての指導指診作成が望まれる．

This study used postoperative defecography to characterize morphological features of defecatory disorders in patients following rectal resection. We also evaluated differences in dynamic defecatory condition depending on reconstruction methods for sphincter-saving surgery.Subjects comprised 62 patients (male/female, 41/21; mean age, 61 years) who underwent defecography after sphincter-saving surgery for rectal cancer. Semisolid barium (100 ml) was introduced into the rectum, and images were taken in a sitting position. Characteristic dynamic findings in defecography were evaluated according to operative methods and were compared with symptoms of defecatory disorders.Defecographic findings closely associated with postoperative defecatory disorder were as follows: (1) low volume of neorectum in patients with worse incontinence grade (p0.05), (2) low evacuation fraction in patients with significantly impaired function such as soiling, urgency, and worsened incontinence score (p0.05), (3) minor alteration of anorectal angle at evacuation in patients with major soiling and worsened incontinence score (p0.05), and (4) barium shadow in the anal canal at rest in patients with urgency (p0.05). By reconstruction method, the J-pouch displayed a larger volume than straight anastomosis but a significantly wider anorectal angle than high anterior resection (HAR). Side-to-end anastomosis offered a moderate volume and a sharp anorectal angle as in HAR.Defecography is useful for visualizing and characterizing defecatory disorders following rectal resection. Based on defecography, J-pouch reconstruction offers advantageous volume, while side-to-end anastomosis provides a more acute anorectal angle for patients who have received rectal resection with low anastomosis. A new reconstruction method offering both advantages was discussed.