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The efficacy of laparoscopic multivisceral resection (Lap-MVR) has been reported by several experienced high-volume centers. The Endoscopic Surgical Skill Qualification System (ESSQS) was established in Japan to improve the skill of laparoscopic surgeons and further develop surgical teams. We examined the safety and feasibility of Lap-MVR in general hospitals, and evaluated the effects of the Japanese ESSQS for this approach. We retrospectively reviewed 131 patients who underwent MVR between April 2016 and December 2019. Patients were divided into the laparoscopic surgery group (LAC group, n = 98) and the open surgery group (OPEN group, n = 33). The clinicopathological and surgical features were compared between the groups. Compared with the OPEN group, BMI was significantly higher (21.9 vs 19.3 kg/m2, p = 0.012) and blood loss was lower (55 vs 380 ml, p

Background/aim Perforation and postoperative complications have a negative effect on long-term outcomes in patients with colorectal cancer (CRC). The aim of this study was to evaluate the clinical factors with special reference to postoperative complications predicting the long-term outcome in those for whom curative resection for perforated CRC was performed. Patients and methods Patients who underwent curative resection for perforated CRC at stage II or III from April 2003 to March 2020 were included. Clinical factors were retrospectively analyzed. Results Forty-four patients met the selection criteria. The 30-day mortality rate was 4.5% and the complication rate was 47.7%. Excluding 30-day mortality, five-year recurrence-free survival (RFS) and overall survival (OS) were 62.3% and 73.6%, respectively. Multivariate analysis showed that postoperative complications (p=0.005) and pT4 pathological factor (p=0.009) were independent prognostic factors for RFS. Only postoperative complications (p=0.023) were an independent prognostic factor for OS. Conclusion Postoperative complications were significantly associated with RFS and OS, and pT4 was associated with RFS. The prevention and management of postoperative adverse events may be important for perforated CRC.

Objective Resection is usually recommended for locally recurrent rectal cancer (LRRC) for which R0 resection is possible, but its suitability varies by individual patient risk. Here, we report outcomes of resected LRRC in our hospital. Methods We retrospectively evaluated short- and long-term results of 33 patients who underwent resections for LRRC from January 2003 to December 2019. Results At the initial surgeries for these 33 patients, their disease stages at that time were Stage I: n=2, Stage II: n=12, Stage III: n=11, Stage IV: n=6, and unknown: n=2. Patients with Stage IV disease at their initial surgeries underwent radical one-step or two-step procedures. Metastasis to other organs was observed in 5 patients at the their initial LRRC diagnoses. At the LRRC surgeries, 7 patients received palliative surgeries; 26 received intent-to-treat resections, of which 17 were R0 resections. All-grade postoperative complications were observed in 11 patients, including 1 surgery-related death. Five-year overall survival rates were all cases: 38.4%; R0 group: 52.3%, R1 or R2 group: 19.4%, and palliative surgery group: 0%. The R0 group thus had significantly better prognosis than other patients (P = 0.0012). Eleven patients in the R0 group (64.7%) suffered re-recurrences but some patients achieved long-term survival through chemotherapy, radiation therapy, and surgery for metastasis to other organs, even after re-recurrence. Conclusion Long-term prognosis after surgery for LRRC was significantly better for patients with R0 margins. Multimodal treatments may greatly improve survival for patients who suffer re-recurrences after local recurrence resections.

Background Hemostasis is very important for a safe surgery, particularly in endoscopic surgery. Accordingly, in the last decade, vessel-sealing systems became popular as hemostatic devices. However, their use is limited due to thermal damage to organs, such as intestines and nerves. We developed a new method for safe coagulation using a vessel-sealing system, termed flat coagulation (FC). This study aimed to evaluate the efficacy of this new FC method compared to conventional coagulation methods. Methods We evaluated the thermal damage caused by various energy devices, such as the vessel-sealing system (FC method using LigaSure™), ultrasonic scissors (Sonicision™), and monopolar electrosurgery (cut/coagulation/spray/soft coagulation (SC) mode), on porcine organs, including the small intestine and liver. Furthermore, we compared the hemostasis time between the FC method and conventional methods in the superficial bleeding model using porcine mesentery. Results FC caused less thermal damage than monopolar electrosurgery’s SC mode in the porcine liver and small intestine (liver: mean depth of thermal damage, 1.91 ± 0.35 vs 3.37 ± 0.28 mm; p = 0.0015). In the superficial bleeding model, the hemostasis time of FC was significantly shorter than that of electrosurgery’s SC mode (mean, 19.54 ± 22.51 s vs 44.99 ± 21.18 s; p = 0.0046). Conclusion This study showed that the FC method caused less thermal damage to porcine small intestine and liver than conventional methods. This FC method could provide easier and faster coagulation of superficial bleeds compared to that achieved by electrosurgery’s SC mode. Therefore, this study motivates for the use of this new method to achieve hemostasis with various types of bleeds involving internal organs during endoscopic surgeries.

The C-reactive protein to albumin ratio (CAR) is a simple and useful score for predicting the outcomes of patients with various cancers. The aim of this study was to evaluate the CAR and short-term outcomes in oldest-old patients with colorectal cancer. A total of 126 patients aged 85 years and older with colorectal cancer who underwent resection for primary colon cancer from April 2015 to December 2018 were included. The preoperative cutoff value of the CAR for predicting postoperative complications was 0.19 on receiver operating characteristic curve analysis. Clinical characteristics and inflammation-based scores were compared between patients with a high CAR (CAR ≥ 0.19, n = 44) and a low CAR (CAR

Highlights • Extremely rare case of appendiceal metastasis of squamous cell carcinoma of the lung. • Metastatic appendiceal tumor tend to perforate. • Surgery is recommended. • CT and PET-CT are useful for diagnosis., Introduction Lung cancer is one of the most common cancers. On the other hand, lung cancer metastasis to the appendix is extremely rare, and in many cases it has been diagnosed with the onset of acute perforating appendicitis. Presentation of case An 85-year-old man with fever and abdominal pain visited our hospital. He had a history of squamous cell carcinoma of the left upper and lower lobes, metastasis to the ipsilateral lung and femur. CT showed that a finding of acute perforating appendicitis, emergency cecal resection was performed. Examination of the resected specimen showed that the appendix was thickened overall, with a white nodular structure at the root and a perforation in the middle. The final diagnosis was acute perforating appendicitis caused by metastatic squamous cell carcinoma from the lung. The patient had no particular problems during the postoperative course. Discussion A PubMed search was performed, this appears to be the first reported case of appendiceal metastasis of squamous cell carcinoma of the lung. Since squamous cell carcinoma of the lung has a stronger tendency for local extension than other histological types, perforating appendicitis due to distant metastasis to the abdominal organs and metastasis to the appendix was reported as a very valuable case. Conclusion Because the progression of concomitant or secondary appendicitis is rapid, we recommend frequent imaging modalities, prophylactic appendectomy be considered for patients who also have lung cancer and imaging findings show suspected metastasis to the appendix.

Background/Aim: We aimed to assess the risk factors for postoperative complications and long-term outcome of patients aged ≥80 years after curative resection for gastric cancer (GC). Patients and Methods: Patients aged ≥80 years who underwent curative gastrectomy for stage I-III GC between 2013 and 2020 were included. Clinical factors were retrospectively analyzed. Results: Of all 109 patients, 29 (26.6%) had 33 postoperative complications (Clavien–Dindo grade ≥2). The rate of postoperative complications was higher in those with greater blood loss (≥170 ml, p

Persistent descending mesocolon (PDM) represents a failure of fusion of the descending mesentery, leading to anatomical abnormalities. This study aimed to examine the effects of anatomical features of PDM on laparoscopic surgical outcomes.Patient backgrounds, surgical outcomes, anatomical characteristics, and operative findings were retrospectively compared between 186 patients classified into PDM and non-PDM groups who underwent primary resection for left-sided colon and rectal cancer at our hospital from January 2019 to December 2020.PDM was diagnosed in nine patients (4.8%). The operative time (337 ± 165 vs 239 ± 107 min, p = 0.010) was significantly different between PDM and non-PDM groups, but bleeding loss was not different (108 ± 97 ml vs 53 ± 142 ml, p = 0.259). In PDM patients, in addition to abnormal fixation of the sigmoid-descending colon junction, adhesion of the mesentery of the colon and small intestine in 100%, and adhesion between the mesocolon in 33% patients was confirmed intraoperatively. Ileus was more common in the PDM group (two cases, 22%) and in the non-PDM group (10 cases, 5.6%), but there was no significant difference in overall postoperative complications between the two groups (p = 0.215). The duration of postoperative hospital stay (28 ± 20 vs 16 ± 11 days, p = 0.002) was significant between the two groups. The left colonic artery (LCA) could not be preserved in six patients in the PDM group, one of whom had anastomotic leakage and two of whom required additional resections due to intraoperative intestinal blood flow failure.PDM prolonged operative times and duration of postoperative stay in laparoscopic surgery for left-sided colon and rectal cancer. Division of the LCA in PDM patients should be considered an intraoperative risk factor for injury to the marginal artery.

Schwannomas that occur in the retroperitoneal cavity are rare. We herein report a patient who underwent safe laparoscopic resection by using a preoperative 3D computed tomography (CT) image and a fluorescent ureteral stent during the surgery. A 47-year-old man presented with left lower abdominal pain. CT showed a 10-cm continuous retroperitoneal tumor originating at the third lumbar nerve in the lower left abdomen. Schwannoma was suspected. We underwent laparoscopic resection of the tumor guided by 3D images obtained preoperatively. A fluorescent ureteral stent was implanted during the surgery to improve visibility and protect the left ureter. The resection was completed without injury of other organs and vessels. The patient was discharged on postoperative Day 5. By performing a preoperative simulation using 3D CT images, we could anticipate the anatomical findings and easily identify them intraoperatively. In addition, the fluorescent ureteral stent provided visual support, thereby contributing to safe surgery.

Anastomotic leakage after right-sided colon cancer surgery is a serious complication that affects postoperative mortality. The Charlson comorbidity index (CCI) has been reported to be a useful predictor of postoperative complications.A total of 593 cases of right-sided colon cancer resections performed from 2016 to 2020 were examined. The patients were divided into two groups according to the presence or absence of anastomotic leakage (AL, n = 28; no-AL, n = 565); clinicopathological and surgical characteristics were compared between the groups.The AL group patients had a higher comorbidity rate (96.4% vs. 66.9%, p 0.001), higher CCI score (p 0.001), higher blood loss (42 mL vs. 23 mL, p = 0.046), and longer hospital stay (30 days vs. 12 days, p 0.001) than the no-AL group patients. The percentages of chronic pulmonary disease (14.3% vs. 3.9%, p = 0.029), cerebrovascular disease (14.3% vs. 1.9%, p = 0.022), connective tissue disease (39.3% vs. 3.2%, p 0.001), leukemia (3.6% vs. 0%, p = 0.042), and moderate to severe liver disease (7.1% vs. 0%, p = 0.002) were significantly higher in the AL group. In the multivariate analysis, CCI ≥ 2 was identified as an independent predictor of postoperative anastomotic leakage (hazard ratio 4.91, 95% confidence interval 2.23-10.85, p 0.001).CCI could predict anastomotic leakage after right-sided colon cancer surgery.

Single-incision laparoscopic surgery (SILS) has the potential to improve perioperative outcomes, including less postoperative pain, shorter operation time, less blood loss, and shorter hospital stay. However, SILS is technically difficult and needs a longer learning curve. Between April 2016 and September 2019, a total of 198 patients with clinical stage I/II right colon cancer underwent curative resection. In the case of the SILS approach, an organ retractor was usually used to overcome SILS-specific restrictions. The patients were divided into two groups by surgical approach: the SILS with organ retractor group (SILS-O, n = 33) and the conventional laparoscopic surgery group (LAC, n = 165). Clinical T status was significantly higher in the LAC group (p = 0.016). Operation time was shorter and blood loss was lower in the SILS-O group compared to the LAC group (117 vs. 197 min, p = 0.027; 10 vs. 25 mL, p = 0.024, respectively). In the SILS-O group, surgical outcomes including operation time, blood loss, number of retrieved lymph nodes, and postoperative complications were not significantly different between those performed by experts and by non-experts. Longer operation time (p = 0.041) was significantly associated with complications on univariate and multivariate analyses (odds ratio 2.514, 95%CI 1.047–6.035, p = 0.039). SILS-O was safe and feasible for right colon cancer. There is a potential to shorten the learning curve of SILS using an organ retractor.

Background/objective With increased life expectancy, the incidence of colorectal cancer in oldest-old patients has been rising. Advanced age is a risk factor for adverse outcomes after surgery. This study aimed to evaluate the short- and long-term outcomes of curative resection for colorectal cancer in nonagenarians. Methods Patients who had undergone curative resection for colorectal cancer (CRC) at Stage I to III from January 2010 to December 2019 were included. Cases of emergent surgery were excluded. The clinical characteristics were documented retrospectively, and factors affecting the long-term outcome were analyzed using multivariate analysis. Results Fifty patients met the selection criteria. Most of them were women (58.0%), and the median age was 92 years. Among these patients, 29 (58.0%) had a poor performance status (ASA-PS≥3). Laparoscopic surgery was performed in 42.0% of the patients, and 50% of the patients had postoperative complications classified as Clavien–Dindo grade 2 or severer, including 3 patients (6.0%) with grade 3 disease. No postoperative mortality occurred. The 30-day, 180-day, 1-year, 3-year and 5-year survival rates were 100%, 80.4%, 71.0%, 46.3%, and 33.8%, respectively. Multivariate analysis showed that a preoperative poor performance status (ASA-PS≥3) (HR: 3.067; 95% CI: 1.220–7.709; p = 0.017) was an independent prognostic factor for OS. Conclusion Curative elective resections for CRC in nonagenarians were performed safely without postoperative mortality. The preoperative performance status was significantly associated with OS after curative elective resection of colorectal cancer in nonagenarians. Our results suggest that excellent long-term outcomes can be achieved in a selected group with a good performance status.

Highlights • Surgical case of Granulocyte-Colony-Stimulating-Factor -Producing Cholangiocarcinoma is limited. • 18F-fluorodeoxyglucose positron emission tomography is reported to be useful in diagnosis. • 18F-fluorodeoxyglucose uptake in bone marrow is characteristic in this disease. • We used FDG uptake not only diagnosis but assessing tumor viability and determining the surgical indication after postoperative recurrence., Introduction and importance Granulocyte colony-stimulating factor (G-CSF)-producing intrahepatic cholangiocarcinoma is rare. Surgical cases with postoperative clinical course have rarely been reported. Case presentation A 63-year-old woman complained upper abdominal pain. Computed tomography (CT) showed intrahepatic mass measuring 9 × 9 × 9 cm in the left lateral segment. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed high uptake by the tumor, with diffuse uptake in the bone marrow. An extended left lobectomy was performed to achieve complete resection. Histopathological examination showed poorly differentiated adenocarcinoma with no lymph node metastasis. Immunohistochemical analysis revealed that tumor cells produced G-CSF. After chemotherapy with S-1 regimen at 10 months after the operation, CT and FDG-PET detected lymph node metastasis in the peri-duodenal area and left kidney metastasis, with no FDG uptake in the bone marrow. Serum G-CSF was normal. Combination chemotherapy with gemcitabine plus cisplatin was administered, and, 12 months after liver resection, metastases were enlarged and FDG uptake in the bone marrow was detected again. Serum G-CSF was elevated at 71.6 pg/mL. The patient was enrolled in a clinical trial of chemotherapy with another regimen and was alive at 19 months after liver resection. Clinical discussion Because of rapid progression, rapid diagnosis and resection are important. FDG uptake in the bone marrow is characteristic in G-CSF producing tumor. In this case, FDG uptake in the bone marrow reappeared after the enlargement of recurrent lesions, followed by tumor enlargement. Conclusion FDG-PET was useful for differential diagnosis and to assess tumor viability and determine the surgical indication.

The efficacy of laparoscopic multivisceral resection (Lap-MVR) has been reported by several experienced high-volume centers. The Endoscopic Surgical Skill Qualification System (ESSQS) was established in Japan to improve the skill of laparoscopic surgeons and further develop surgical teams. We examined the safety and feasibility of Lap-MVR in general hospitals, and evaluated the effects of the Japanese ESSQS for this approach.We retrospectively reviewed 131 patients who underwent MVR between April 2016 and December 2019. Patients were divided into the laparoscopic surgery group (LAC group, n = 98) and the open surgery group (OPEN group, n = 33). The clinicopathological and surgical features were compared between the groups.Compared with the OPEN group, BMI was significantly higher (21.9 vs 19.3 kg/mThe present multicenter study confirmed the feasibility and safety of Lap-MVR even in general hospitals, and revealed superior results for ESSQS-qualified surgeons.

INTRODUCTION The impact of obesity on short-term outcomes after laparoscopic colorectal surgery (LAC) in Asian patients is unclear. The purpose of the present multicenter study was to evaluate the safety and feasibility of LAC in obese Japanese patients. METHODS We retrospectively reviewed 1705 patients who underwent LAC between April 2016 and February 2019. Patients were classified according to body mass index (BMI): non-obese (BMI

The effectiveness of primary tumor resection (PTR) for asymptomatic stage IV colorectal cancer patients to continue prolonged and safe systemic chemotherapy has recently been re-evaluated. However, postoperative complications lead to a prolonged hospital stay and delay systemic treatment, which could result in a poor oncologic outcome. The objective of this study was to identify the risk factors for morbidity and delay of systemic chemotherapy in such patients. Between April 2016 and March 2018, 115 consecutive colorectal cancer patients with distant metastasis who had no clinical symptoms and underwent PTR in all participating hospitals were retrospectively reviewed. The patients were divided into two groups according to the presence (CD ≥ 2, n = 23) or absence (CD

Background/aim This study aimed to examine whether the semi-dry dot-blot (SDB) method can correctly identify metastasis to lymph nodes in colorectal cancer. Materials and methods A total of 200 dissected lymph nodes from 83 patients with colorectal cancer who underwent surgery between November 2013 and May 2016 were examined. Each lymph node was first examined by SDB using anti-pancytokeratin antibody (AE1/AE3). Pathological Stage I/II patients with a negative reaction were further analyzed by SDB using anti-cytokeratin 20 antibody (CK-20) to detect micrometastasis or isolated tumor cells. Results The sensitivity, specificity, and accuracy of SDB using AE1/AE3 were 91.3%, 100%, and 98.0%, respectively. Five of 99 lymph nodes of pathological Stage I/II patients had a negative reaction to AE1/AE3, but were positive to CK-20, while 3 showed isolated tumor cells. Conclusion The SDB is a useful diagnostic tool to detect lymph node metastases in colorectal cancer.