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Although laparoscopic surgery for colon cancer is accepted in the treatment guidelines, the laparoscopic approach for rectal cancer is recommended only in clinical trials. Thus far, several trials have shown favorable short-term results such as early recovery and short hospital stay, but long-term results remain a critical concern for laparoscopic rectal cancer surgery. To date, no randomized control trials have shown an increased local recurrence after laparoscopic surgery for rectal cancer. Additionally, according to previous studies, open conversion, which is more frequent in laparoscopic rectal surgery than in laparoscopic colon surgery, may affect short-term and long-term survival. The evidence on male sexual function has been contradictory. Long-term results from ongoing multicenter trials will be available within several years. Based on accumulated evidence from well-organized clinical trials, laparoscopic surgery will likely be accepted as a treatment choice for rectal cancer. In the future, extended laparoscopic rectal surgery might be feasible for additional procedures such as laparoscopic lateral pelvic lymph node dissection and laparoscopic total pelvic exenteration for rectal cancer invading the adjacent pelvic organ. [ABSTRACT FROM AUTHOR]

Background: Lateral lymph node (LLN) dissection contributes to a decrease in local recurrence and prolongs survival in locally advanced lower rectal cancer patients as compared with total mesorectal excision (TME) alone [1, 2]. However, this procedure is also accompanied by increased bleeding and postoperative complications [3, 4]. Recently, laparoscopic TME has become a safe and feasible approach for lower rectal cancer even after preoperative chemoradiation [5-7]. Laparoscopic LLN dissection could be the next promising approach and could not only provide a survival benefit but also minimize bleeding and postoperative complications with enhanced visualization, as reported in gynecological and urological malignancies [8, 9].Methods: A total of 14 patients underwent laparoscopic LLN dissection with TME after preoperative chemoradiation. Our standardized procedure for LLN dissection is seen in the video. After completion of TME, as described previously [5, 6], the obturator nerve is identified between the external and internal iliac arteries and the obturator lymph nodes are dissected along this nerve to reach the obturator foramen. The internal iliac lymph nodes are dissected along the surface of the internal iliac vein, carefully preserving the pelvic nerve plexus.Results: The procedure was successfully accomplished in all cases without conversion to laparotomy. The median amount of bleeding and operative time were 25 (range=5-1190) ml and 413 (range=277-596) min, respectively. The median number of retrieved lymph nodes was 23 (range=14-33), and eight cases had metastasis in the retrieved LLNs. Postoperative recovery was excellent, with median time to flatus of 1 (range=1-2) day. Postoperative complications included three wound infections, one anastomotic leakage, and one presacral abscess, and all recovered without surgical intervention. There was no urinary dysfunction. After a mean follow-up of 17 (range=8-43) months, all 14 patients were alive without recurrence.Conclusions: Laparoscopic LLN dissection can be safely conducted with minimal postoperative complications. [ABSTRACT FROM AUTHOR]

Background: Prioritizing patient health is essential, and given the risk of mortality, surgical techniques should be objectively evaluated. However, there is no comprehensive cross-disciplinary system that evaluates skills across all aspects among surgeons of varying levels. Therefore, this study aimed to uncover universal surgical competencies by decomposing and reconstructing specific descriptions in operative performance assessment tools, as the basis of building automated evaluation system using computer vision and machine learning-based analysis., Methods: The study participants were primarily expert surgeons in the gastrointestinal surgery field and the methodology comprised data collection, thematic analysis, and validation. For the data collection, participants identified global operative performance assessment tools according to detailed inclusion and exclusion criteria. Thereafter, thematic analysis was used to conduct detailed analyses of the descriptions in the tools where specific rules were coded, integrated, and discussed to obtain high-level concepts, namely, "Skill meta-competencies." "Skill meta-competencies" was recategorized for data validation and reliability assurance. Nine assessment tools were selected based on participant criteria., Results: In total, 189 types of skill performances were extracted from the nine tool descriptions and organized into the following five competencies: (1) Tissue handling, (2) Psychomotor skill, (3) Efficiency, (4) Dissection quality, and (5) Exposure quality. The evolutionary importance of these competences' different evaluation targets and purpose over time were assessed; the results showed relatively high reliability, indicating that the categorization was reproducible. The inclusion of basic (tissue handling, psychomotor skill, and efficiency) and advanced (dissection quality and exposure quality) skills in these competencies enhanced the tools' comprehensiveness., Conclusions: The competencies identified to help surgeons formalize and implement tacit knowledge of operative performance are highly reproducible. These results can be used to form the basis of an automated skill evaluation system and help surgeons improve the provision of care and training, consequently, improving patient prognosis., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Intensive local treatment comprising total mesorectal excision (TME) with selective lateral pelvic lymph node dissection (LPND) after neoadjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC) has received attention among clinicians treating rectal cancer. It remains unclear whether adjuvant chemotherapy (ACT) after intensive local treatment is beneficial for these patients. We evaluated the oncologic benefit of ACT for patients with LARC who received intensive local treatment., Materials and Methods: This international multicentre retrospective cohort study included 737 patients treated in Japan and Korea between 2010 and 2017. The effectiveness of ACT on recurrence-free survival (RFS) was evaluated using univariable and multivariable Cox proportional hazards models, with subgroup analyses to identify subpopulations potentially benefiting from ACT., Results: The median follow-up was 49 months; the 5-year RFS and local recurrence rates for the entire cohort were 72.1% and 4.9%, respectively; 514 patients (69.7%) received adjuvant chemotherapy, without an oncologic benefit (hazard ratio, 1.14; 95% confidence interval [CI]: 0.79-1.68) demonstrated in the multivariable Cox regression analysis. In subgroup analyses, the distributions of the 95% CI in patients aged ≥70 years and those with ypStage 0 tended to place a disproportionate emphasis that favoured the non-ACT treatment strategy., Conclusion: Despite achieving good local control with intensive local treatment strategy, the effectiveness of ACT for the LARC patients with CRT followed by TME with selective LPND was not proved. Elderly patients and those with ypStage0 may not receive benefit from ACT after CRT and TME ± LPND., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

The aim of this study was to clarify the clinical impact of inferior mesenteric lymph node (IMLN) metastasis from cancer of the sigmoid colon or rectum. A total of 952 patients underwent curative surgery with IMLN dissection for either sigmoid colon cancer or rectal cancer from January 2000 to August 2018. Of these, 26 (2.7%) were pathologically diagnosed with IMLN metastasis. Excluding 1 patient, 25 patients were retrospectively investigated for clinicopathological characteristics and long-term outcomes. Specifically, the clinical course of patients with recurrence was meticulously scrutinised. Of the 25 patients, 14 (56%) had recurrence during the follow-up period. The 5-year recurrence-free survival was 31.2%, and 5-year overall survival was 59.7%. No serious morbidity, such as anastomotic leakage, was observed. Of the 14 patients with recurrence, 6 underwent secondary surgery with curative intent and 5 of the 6 patients remained cancer-free. In contrast, 8 patients were treated with chemotherapy, radiotherapy or best supportive care. Although IMLN metastasis was strongly associated with recurrence, long-term survival could be expected in most cases. Furthermore, there could be a chance for complete cure in patients with recurrence if secondary surgery is successfully carried out., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© Indian Association of Surgical Oncology 2021, corrected publication 2021.)

Background: The local recurrence of rectal cancer classifies 4 types, anterior, posterior, lateral compartment and anastomotic site. This study evaluates outcome of laparoscopic lateral lymph node dissection(LLND)against the lateral lymph node recurrence., Method: Five patients were diagnosed as the lateral lymph node recurrence and underwent laparoscopic LLND. We diagnosed the lateral lymph node recurrence by CT, MRI and PET-CT. All cases revealed abnormal uptake on PET-CT., Result: The median of age is 63. Three patients are male. About primary tumor, 4 patients had tumor below peritoneal reflection and one patient above it. Two patients received neoadjuvant(chemo)radiotherapy(RT group)and one of them underwent laparoscopic LLND at the first operation. The median period from operation to recurrence was 25 months. Before re-operation, 3 patients received chemotherapy. Pathological assessments confirmed pathological complete response(pCR) in all three cases. The median of operation time and bleeding were 257 min and 0 mL, respectively. No complications, more than Grade III(Clavien-Dindo classification)happened. The median follow-up period from re-operation was 34 months. Four patients have no recurrence and one presents lung metastasis. All 5 patients are alive., Conclusion: Laparoscope magnifies various pelvic structures. Therefore we perform operation more exactly and safety. In the case of local recurrence, especially lateral compartment, tumor is easy to invade adjacent structures. Then, it is often difficult to do R0 resection. If we find the recurrence lesions earlier and induce neoadjuvant chemotherapy, we can improve R0 resection rate.

We present a case of bilateral lymph node metastases of rectal cancer treated with chemotherapy and surgery. The patient was a 65-year-old man with upper rectal cancer. Laparoscopic low anterior resection(LAR)was performed. Pathological findings were tub2>por>muc, pT3, ly2, v3, pN2, pM0. Six months after surgery, the CEA level was elevated. CT and PET-CT confirmed bilateral metastasis to the lymph nodes. Five courses of FOLFOX4 plus bevacizumab were administered, and then, we performed laparoscopic bilateral lymph node dissection. Pathological assessments confirmed scarring and fibrosis, that is, a pathological complete response(pCR)was achieved. Two years and 6 months after surgery, no recurrence was detected. After chemotherapy or chemoradiotherapy, we should perform surgery to prevent local recurrence, especially to the lateral lymph nodes.

Objective: To perform a retrospective analysis of UFT and oral leucovorin combination adjuvant chemotherapy for Stage III colon cancer patients over 76 years old, in order to evaluate both treatment efficacy and toxicity., Subjects: Between 2002 and 2011, 333 Stage III colon cancer patients had surgery performed in our institute, and we studied 25 of them on our chemotherapy regimen., Results: Patients'median age was 78 years old, with 12 men and 13 women. Of all the patients, 19 had Stage IIIa and 6 had Stage IIIb. The 3-year disease-free survival rates for Stage III and Stage IIIa patients were 65. 1% and 83. 1%, respectively, and the 3-year overall survival rate for Stage III was 79. 9%. With regard to toxicity, liver function disorder was observed in 8% of the patients, being the adverse event that occurred the most, but there was no Grade 3 or 4 toxicity., Conclusion: UFT and oral leucovorin combination adjuvant chemotherapy for Stage III colon cancer patients over 76 years showed a good response, especially for Stage III a.

Objective: To perform a retrospective analysis of UFT and oral leucovorin plus PSK combination adjuvant chemotherapy for stage III colon cancer in order to evaluate both treatment efficacy and toxicity., Subjects: Between 2003 and 2009, 273 stage III colon cancer patients underwent surgery in our institute, and we studied 156 of them., Results: Patients' median age was 72 years old; 87 men and 69 women. Of all patients, 119 had stage IIIa and 37 had stage IIIb. The 3-year disease, free survival rates for stage III, stage IIIa and stage IIIb patients were 73. 9%and 80. 6%and 51. 4%, respectively, and the 3-year overall survival rates for stage III was 97. 6%. With regard to toxicity, liver function disorder was observed in 9. 6%of the patients as the most frequent adverse event, but there was no grade 3 or 4 toxicity., Conclusion: UFT and oral leucovorin plus PSK combination adjuvant chemotherapy for stage III colon cancer showed a good response especially for stage III a.

It is often difficult to evaluate the grade of malignancy and choose an appropriate treatment for colorectal carcinoids in clinical settings. Although tumor size and depth of invasion are evidently not enough to stratify the risk of this rare tumor, the present guidelines or staging systems do not mention other clinicopathological variables. Recent studies, however, have shed light on the impact of lymphovascular invasion on the outcome of colorectal carcinoids. It has been revealed that the presence of lymphovascular invasion was among the strongest risk factors for metastasis along with tumor size and depth of invasion. Furthermore, tumors smaller than 1 cm, within submucosal invasion and without lymphovascular invasion, carry minimal risk for metastasis with 100% 5-year survival in the studies from Japan as well as from the USA. This would suggest that these tumors could be curatively treated by endoscopic resection or transanal local excision. On the other hand, colorectal carcinoids with either lymphovascular invasion or tumor size larger than 1 cm carry the risk for metastasis equivalent to adenocarcinomas. Therefore, it should be emphasized that histological examination of lymphovascular invasion is mandatory in the specimens obtained by endoscopic resection or transanal local excision, as this would provide useful information for determining the need for additional radical surgery with regional lymph node dissection. Although the present guidelines or TNM staging system do not mention the impact of lymphovascular invasion, this would be among the next promising targets in order to establish better guidelines and staging systems, particularly in early-stage colorectal carcinoids.

Extended pelvic lymphadenectomy (EPL) with total mesorectal excision (TME) has been reported to provide oncological benefit in lower rectal cancer in Japan. In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation (CRT) followed by TME has been established as a standard treatment for decreasing local recurrence. Recently, several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan. A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone. Considering that almost 45% survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes (LLNs), EPL performed by experienced surgeons definitely contributes to decrease local recurrence. On the other hand, a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT. On this point, preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs. For future treatment, it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis. Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups, further studies would lead to the next great step towards future improvement in treating lower rectal cancer.

Background/aims: Although laparoscopy is accepted for treatment of colon cancer, its use for rectal cancer still has technical limitations. Whether a laparoscopic approach for rectal cancer is safe and beneficial remains unknown when simultaneous open upper major abdominal surgery is planned., Methodology: Eight patients underwent laparoscopic rectal resection for primary rectal cancer combined with open upper major abdominal surgery., Results: All laparoscopic rectal resections were successful, with no conversion to open surgery. Surgical procedures included two anterior, four low or super-low anterior, and two abdominoperineal resections. There were five simultaneous liver resections for suspected synchronous liver metastasis and three gastrectomies for advanced gastric cancer. Mean operating time was 517 (377-745) min, including 235 (165-330) min for rectal resection. Mean estimated blood loss was 398 (45-1200) mL, including 78 (0-550) mL for rectal resection. There was no postoperative morbidity. Overall morbidity was lower (0 vs. 47%) and time to flatus and liquid diet was faster (2.1 vs. 3.4 and 3.5 vs. 5.6 days, respectively) in the laparoscopic resection group compared with the open group with synchronous open upper major abdominal surgery., Conclusions: This preliminary report suggests that laparoscopic rectal resection for rectal cancer combined with open upper major abdominal surgery is a safe and feasible option in selected patients.

Laparoscopy-assisted surgery for rectal surgery has been shown to be both technically feasible and a safe alternative to laparotomy. It can be combined with preoperative chemoradiation and sphincter preserving operation for advanced low rectal cancer. We report a case of advanced lower rectal cancer, which was treated with laparoscopy-assisted total mesorectal excision and intersphincteric resection (abdomino-anal resection with coloanal anastomosis) following preoperative chemoradiation. In this patient, preoperative chemoradiation was very effective and no cancer cells remained in resected specimens.

Laparoscopic surgery is increasingly applied to the treatment of gastrointestinal disease. However, the insertion of secondary trocars following pneumoperitoneum carries the risk of serious complications such as major vascular and bowel injuries. Such injury can arise when the force required for the trocar insertion is such that it causes the operator to have impaired control over the entry. There is a need for a procedure of secondary trocar insertion that is safe and easy to perform for training clinicians in laparoscopic surgery. We have developed the "cut-and-screw" insertion method for secondary trocar insertion using a specially developed laparoscopic cannula with a sharp edge and housing. Our procedure is simple, rapid, and safe. In this chapter, we describe the technique and present our initial clinical results.

To proceed with more patient-oriented cancer medicine, the development of a new medical system is necessary in Japan. In Ariake Hospital of the Japanese Foundation for Cancer Research, a new medical system has been developed, which is composed of a common outpatient clinic and a conference system. The core conference system is called "Cancer Board". The practice of patient-oriented medicine in gastroenterological cancer has been introduced as a sample of the Cancer Board system in our hospital.

The outcome after resection of hepatic metastases from colorectal cancer is influenced not only by factors of metastatic lesions but also those of primary disease. To clarify whether primary disease factors are predictive of post-resection outcome of colorectal liver metastases, 180 patients (male : female = 114 : 66; 61.1 +/-10.5 yrs; synchronous: metachronous = 95 : 85; colon: rectum = 124 : 56 who underwent surgery of colorectal liver metastases in Cancer Institute Hospital from 1995 to 2005 were recruited for analysis. Post-resection outcome of the patients with colorectal liver metastases was significantly influenced by 1) depth of invasion, 2) grade of lymph node metastasis , 3) number of metastatic lymph nodes and 4) Dukes stage of primary disease. The patients with lymph node metastases further than grade 3 showed median survival time of less than 2 years and did not survive longer than 5 years. Thus such condition seemed not warrant resective treatment for liver metastases. In case of synchronous metastatic disease, primary disease information, such as lymph node metastases, depth of invasion, and Dukes stage, were significant predictive factors after hepatectomy. Meanwhile, such factors did not show significant influence in the patients with metachronous liver metastases. In conclusion, influence of primary disease factors should be considered for deciding the indication of hepatectomy for colorectal liver metastases, especially when patients have synchronous lesions.