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Intestinal perfusion at the anastomotic site is thought to be one of the most influential risk factors for postoperative anastomotic leakage (AL). We evaluated the efficacy of indocyanine green (ICG) fluorescence imaging at the stump of the proximal colon in left-sided colectomy or rectal resection in terms of decreasing the incidence of AL. Prospectively collected data were retrospectively evaluated. Patients who underwent left-sided colectomy or rectal resection were enrolled (ICG group; n = 197), and patients who had undergone a similar procedure before the ICG group were enrolled from the charts as historical controls (HC group; n = 187). After ICG evaluation, anastomosis was performed where fluorescence was sufficient. The incidence of AL was compared between the ICG and HC groups. Propensity score (PS)-matched data were analyzed to clarify the risk of AL. AL occurred in 6 patients (3.3%) in the ICG group and 17 (10.7%) in the HC group. ICG evaluation revealed 179 patients with good fluorescence and 18 with poor/none perfusion (9.1%). The transection line was changed in all patients with poor/none fluorescence. Three of these 18 patients developed AL (16.7%), though transection line was changed at which is thought to be good. We hope AL in poor/none fluorescence can be prevented at the same rate of cases with good fluorescence. Actually, the rate of that was significantly higher compared with good fluorescence patients (P = 0.038). 93 patients in each group were compared by PS-matched data analysis, which showed the AL rate in the ICG group was significantly lower than that in the HC group (3.2% vs 10.8%, respectively; P = 0.046). Even though this study has limitations of comparison of data prospectively collected and retrospectively analyzed, intraoperative ICG fluorescence imaging evaluation could significantly decrease the incidence of AL.

Cancer‑associated fibroblasts (CAFs) are one of the major components of the cancer stroma in the tumor microenvironment. The interaction between cancer cells and CAFs (cancer‑stromal interaction; CSI) promotes tumor progression, including metastasis. Recently, the tissue inhibitor of metalloproteinase‑1 (TIMP‑1) was reported to promote cancer cell migration and metastasis, which is contrary to its anticancer role as an inhibitor of matrix metalloproteinase. Moreover, CAF‑derived TIMP‑1 is reported to regulate CAF activity. In the present study, we investigated the effect of TIMP‑1 on colon cancer cell migration

Platelet-derived growth factor receptor α (PDGFRα)-positive interstitial cells (PIC) are interposed between enteric nerve fibers and smooth muscle cells (SMCs) in the tunica muscularis of the gastrointestinal tract. PIC have robust expression of small conductance CaGene expression analysis, CaAdcyap1r1 (encoding PACPIC of mouse and human colon utilize PAC

The acquisition of resistance to apoptosis is one of the biggest problems in colorectal cancer (CRC) treatment. This study aimed to elucidate the mechanisms of resistance to apoptosis with a focus on interleukin (IL)-6 produced by the interaction between cancer cells and cancer-associated fibroblasts (CAFs).DLD-1 and HCT116 cell lines were treated with IL-6 and furthermore co-cultured with CAFs. The expression levels of Bcl-xL, Mcl-1 and phosphorylation of STAT3 were evaluated by western blotting. We also performed immunostaining for CRC specimens and evaluated the correlation between CAFs invasion and Bcl-xL/Mcl-1 expression.Both IL-6 and co-culturing enhanced Bcl-xL, Mcl-1 and the phosphorylation of STAT3. Immunohistochemistry showed a positive correlation between CAFs and Bcl-xL/Mcl-1. These results showed that the interaction between CAFs and cancer cells enhances Bcl-xL and Mcl-1 through the IL-6/STAT3 signaling pathway.Our findings provide new potential therapeutic targets and strategies for CRC treatment.

The cancer-stromal interaction has been demonstrated to promote tumor progression, and cancer-associated fibroblasts (CAFs), which are the main components of stromal cells, have attracted attention as novel treatment targets. Chitinase 3-like 1 (CHI3L1) is a chitinase-like protein, which affects cell proliferation and angiogenesis. However, the mechanisms through which cells secrete CHI3L1 and through which CHI3L1 mediates tumor progression in the cancer microenvironment are still unclear. Accordingly, the present study assessed the secretion of CHI3L1 in the microenvironment of colorectal cancer and evaluated how CHI3L1 affects tumor angiogenesis. CAFs and normal fibroblasts (NFs) established from colorectal cancer tissue, and human colon cancer cell lines were evaluated using immunostaining, cytokine antibody array, RNA interference, reverse transcription-quantitative PCR (RT-qPCR), ELISA, western blotting and angiogenesis assays. The expression and secretion of CHI3L1 in CAFs were stronger than those in NFs and colorectal cancer cell lines. In addition, interleukin-13 receptor α2 (IL-13Rα2), a receptor for CHI3L1, was not expressed in colorectal cancer cell lines, but was expressed in fibroblasts, particularly CAFs. Furthermore, the expression and secretion of IL-8 in CAFs was stronger than that in NFs and cancer cell lines, and recombinant CHI3L1 addition increased IL-8 expression in CAFs, whereas knockdown of CHI3L1 suppressed IL-8 expression. Furthermore, IL-13Rα2 knockdown suppressed the enhancement of IL-8 expression induced by CHI3L1 treatment in CAFs. For vascular endothelial growth factor-A (VEGFA), similar results to IL-8 were observed in an ELISA for comparison of secretion between CAFs and NFs and for changes in secretion after CHI3L1 treatment in CAFs; however, no significant differences were observed for changes in expression after CHI3L1 treatment or IL-13Rα2 knockdown in CAFs assessed using RT-qPCR assays. Angiogenesis assays revealed that tube formation in vascular endothelial cells was suppressed by conditioned medium from CAFs with the addition of human CHI3L1 neutralizing antibodies compared with control IgG, and also suppressed by conditioned medium from CAFs transfected with CHI3L1, IL-8 or VEGFA small interfering RNA compared with negative control small interfering RNA. Overall, the present findings indicated that CHI3L1 secreted from CAFs acted on CAFs to increase the secretion of IL-8, thereby affecting tumor angiogenesis in colorectal cancer.

Stoma creation through the extraperitoneal route reportedly reduces the risk of parastomal hernia and stomal prolapse after abdominoperineal resection (APR) for rectal cancer. We describe a new technique for laparoscopic extraperitoneal sigmoid colostomy following APR. After the rectus abdominis muscle is separated, Lap ProtectorTM and EZ AccessTM devices are placed. An extraperitoneal stoma tunnel is created laparoscopically as much as possible. Next, the peritoneum is separated from the inside of the abdominal cavity, and the extraperitoneal tunnel is opened. At the time of writing, we had performed laparoscopic extraperitoneal sigmoid colostomy in eight patients, without any complications or conversion to the conventional procedure. Thus, laparoscopic extraperitoneal sigmoid colostomy is a useful and safe technique for the laparoscopic creation of an extraperitoneal stoma tunnel after APR.

Introduction Robot-assisted laparoscopic surgery has been performed in various fields, especially in the pelvic cavity. However, little is known about the utility of robot-assisted laparoscopic rectal cancer surgery associated with robot-assisted radical prostatectomy (RARP). We herein report the clinical impact of robot-assisted laparoscopic rectal cancer surgery associated with RARP. Methods We experienced five cases of robot-assisted laparoscopic rectal cancer surgery associated with RARP. One involved robot-assisted laparoscopic abdominoperineal resection with en bloc prostatectomy for T4b rectal cancer, and one involved robot-assisted laparoscopic intersphincteric resection combined with RARP for synchronous rectal and prostate cancer. The remaining three involved robot-assisted laparoscopic low anterior resection (RaLAR) after RARP. For robot-assisted laparoscopic rectal cancer surgery, the da Vinci Xi surgical system was used. Results We could perform planned robotic rectal cancer surgery in all cases. The median operation time was 529 min (373-793 min), and the median blood loss was 307 ml (32-1191 ml). No patients required any transfusion in the intra-operative or immediate peri-operative period. The circumferential resection margin was negative in all cases. There were no complications of grade ≥III according to the Clavien-Dindo classification and no conversions to conventional laparoscopic or open surgery. Conclusion Robot-assisted laparoscopic surgery associated with RARP is feasible in patients with rectal cancer. The long-term surgical outcomes remain to be further evaluated.

Purpose The purpose of this study was to evaluate the usefulness of turbo spin-echo (TSE) DWI with fusion images in the T-staging compared with T2-weighted imaging (T2WI) alone and conventional echo-planner imaging (EPI) DWI. Methods In this prospective study, 4-mm-thick axial EPI-DWI, TSE-DWI, and T2WI were performed with the same slice locations for 20 patients with rectal cancer. Fusion images of DWI and T2WI were created for both EPI-DWI and TSE-DWI. Ten readers independently diagnosed the T-stages and scored the degree of confidence referring to T2WI alone and then to DWI, T2WI, and fusion images (DWI+T2WI) for each EPI-DWI and TSE-DWI. Visual score assessments of image quality were performed for each DWI. Results Inter-observer agreement of T-staging for 10 readers was slight on T2WI alone but fair on EPI-DWI+T2WI and excellent on TSE-DWI+T2WI images. No readers gave higher confidence scores for T2WI compared to EPI/TSE-DWI+T2WI and for EPI-DWI+T2WI compared to TSE-DWI+T2WI. In seven pathologically-proven cases, poor, poor to slight, and fair to perfect agreements with the pathological T-stage were observed with T2WI alone, EPI-DWI+T2WI, and TSE-DWI+T2WI, respectively. All readers gave higher scores regarding image distortion and lower scores regarding image noise for TSE-DWI compared to EPI-DWI. For DWI utility, higher scores were assigned for TSE-DWI compared to EPI-DWI in 7 readers and there were no significant differences in the other 3 readers. Conclusion TSE-DWI images might be more appropriate for image fusion with T2WI and rectal cancer T-staging compared with EPI-DWI and T2WI alone.

To determine whether or not migrating cancer cells are present on the surgical plane after lateral lymph node dissection (LLND) for lower rectal cancer and related to lateral recurrence (LR), we evaluated the lavage of LLND areas by reverse-transcription polymerase chain reaction (RT-PCR) to check the expression of CEA mRNA in the residual cancer cells. Thirty patients who underwent curative LLND were enrolled. Lavage was collected after LLND and subjected to RT-PCR to detect CEA mRNA. The median follow-up to check for recurrence was 31.4 months. CEA mRNA was detected in 9 of the 46 dissected areas. Based on the receiver operating characteristic curves, the cut-off value of PCR was set at 0.025. This cut-off point classified five patients into the high-expression group for CEA mRNA. During follow-up, LR developed in 1 of 40 low-expression areas of CEA mRNA and 3 of 6 high-expression areas. The LR rate was higher in the high-expression group than in the low-expression group (p = 0.015). A multivariate analysis showed that the high expression of CEA mRNA was likely an independent prognostic factor of LR. The expression of CEA mRNA in the lavage of LLND areas indicates the presence of residual cancer cells that cause LR.

Shoichi Watanabe,1 Motoki Nakamura,1 Hiroki Takahashi,2 Masayasu Hara,2 Kei Ijichi,3 Daisuke Kawakita,3 Akimichi Morita1 1Department of Geriatric and Environmental Dermatology, 2Department of Gastroenterological Surgery, 3Department of Neuro-otolaryngology, Nagoya City University Graduate School of Medical Science, Nagoya, Japan Aims: Limited data regarding the objective evaluation of skin exsiccation caused by epidermal growth factor receptor (EGFR) inhibitors exist. Objective indices were applied to evaluate the usefulness of a moisturizer against skin exsiccation associated with the use of EGFR inhibitors in cancer patients. Patients and methods: Patients with either colorectal or head and neck cancer treated with either cetuximab or panitumumab were randomly assigned 1:2 to the prophylactic-treatment arm, where participants received prophylactical moisturizer treatment (heparinoid preparation, Hirudoid®), or to the symptomatic-treatment arm, where moisturizer was applied after the onset of cutaneous symptoms. Patients were observed for 6 weeks after the start of the administration of EGFR inhibitor. Results: A total of 15 patients were included and assessed: 6 in the prophylactic treatment group and 9 in the symptomatic treatment group. We evaluated the effect of EGFR inhibitors on the physiologic function of the skin. Administration of EGFR inhibitors resulted in a continued reduction in the moisture content of the horny layer and a decrease in cutaneous sebum levels. Skin observation revealed frequent development of an acneiform rash and significantly higher exsiccation and exfoliation scores. Administration of EGFR inhibitor was associated with a decrease in the horny layer moisture content and lower cutaneous sebum levels in the symptomatic treatment group. In contrast, levels of both the indicators were increased in the prophylactic treatment group. Moreover, the EGFR inhibitor-associated increase in exsiccation and exfoliation scores were minimized in the prophylactic treatment group relative to the symptomatic treatment group. Conclusion: Application of a moisturizer is effective against dry skin induced by the administration of an EGFR inhibitor. Keywords: EGFR inhibitor, moisturizer, colorectal cancer, head and neck cancer, prophylactical moisturizer treatment, heparinoid preparation, skin exsiccation

T4 is one of the high-risk factors, but the efficacy of adjuvant chemotherapy for T4-Stage Ⅱ colon cancer are unclear.We retrospectively reviewed 211 patients with primary pStage Ⅱ colon cancer who underwent radical resection between 2004 and 2015.The 5-year overall survival rate(OS)of Stage ⅡA/ⅡB/ⅡC were 90.2/83.4/ 59.2%, and the 5-year recurrence-free survival rate(RFS)were 87.3/73.3/42.8%. Multivariate analysis of OS as a high-risk factor of T4 revealed male, ly2/3, no adjuvant chemotherapy, and in RFS, male, ly2/3. However, compared the cases with or without adjuvant chemotherapy, 5-year OS was no difference. There were no cases used oxaliplatin-based adjuvant chemotherapy.An adjuvant chemotherapy without oxaliplatin were not enough to improve the prognoses of T4-Stage Ⅱcolon cancer, so the oxaliplatin based regimen might be recommended.

Accurate localization of the tumor during robot-assisted laparoscopic surgery for rectal cancer is crucial. Several techniques have been described, but each has its shortcomings. We developed a new technique of near infrared ray-guided surgery (NIRGS) to localize the tumor accurately, using intra-operative colonoscopy and da Vinci Firefly technology. After clamping the oral side of the tumor, the colonoscope was inserted. In the normal visible light mode, we could not recognize the endoscopic light; however, after changing to the Firefly mode, the endoscopic light was seen clearly. Using this simple and new technique, we could locate the tumor easily and accurately. We performed this technique in 12 patients and detected the location of the tumor clearly in all, without any procedure-related complications. Based on these findings, NIRGS is a useful and safe technique for detecting tumor location during robot-assisted laparoscopic surgery for rectal cancer.

Gemcitabine (Gem) is widely used as chemotherapy for pancreatic cancer (PaCa), but its effect is not fully satisfactory. One of the reasons for this is the acquisition of Gem resistance (Gem‑R). To elucidate the mechanism of Gem‑R, two Gem‑R PaCa cell lines were established from AsPC‑1 and MIA PaCa‑2 cells. It was demonstrated that expression of interleukin‑8 (IL‑8) mRNA was significantly upregulated in Gem‑R PaCa cells by cDNA microarray and RT‑qPCR analyses. Increased IL‑8 secretion by Gem‑R cells was confirmed by cytokine array and enzyme‑linked immunosorbent assay. Moreover, we found that co‑culture with Gem‑R PaCa cells significantly enhanced tube formation of human umbilical vein endothelial cells, and treatment with an anti‑CXCR2 (main receptor for IL‑8) antibody significantly prevented this effect. We previously reported that a chemokine network centered on the IL‑8/CXCR2 axis plays an important role in PaCa angiogenesis, and suppression of this axis has an antitumor effect. Since acquisition of Gem‑R increased IL‑8 production and consequently increased tumor angiogenesis, the IL‑8/CXCR2 axis may be a potential novel therapeutic target for PaCa after acquiring Gem‑R.

Obturator nerve schwannomas are very rare. To date, only nine cases have been reported in the English-language literature; none of these were diagnosed preoperatively. A 68-year-old woman was admitted with left lower abdominal pain. CT and MRI revealed a mass 30 mm in diameter in the left obturator fossa, suggesting a retroperitoneal tumor. Because CT and MRI revealed clear continuity with the left obturator nerve, this case was diagnosed as an obturator nerve schwannoma. Tumor enucleation was performed by laparoscopy. On histopathological examination, this case was diagnosed as a benign obturator nerve schwannoma. Postoperatively, the patient developed weakness of the adductor muscle but recovered within 6 months with rehabilitation therapy. Preoperative diagnosis of obturator nerve schwannomas is quite difficult, but careful inspection of CT and MRI is important to identify the original nerve of schwannoma preoperatively. Accordingly, laparoscopic resection is a good treatment option.

Background & Aims Colonic musculature contain smooth muscle cells (SMC), interstitial cells of Cajal (ICC), and platelet-derived growth factor receptor α+ cells (PDGFRα+ cells), which are electrically coupled and operate together as the SIP syncytium. PDGFRα+ cells have enriched expression of small conductance Ca2+-activated K+ (SK) channels. Purinergic enteric neural input activates SK channels in PDGFRα+ cells, hyperpolarizes SMC, and inhibits colonic contractions. Recently we discovered that PDGFRα+ cells in mouse colon have enriched expression of α1A adrenoceptors (ARs), which coupled to activation of SK channels and inhibited colonic motility, and α1A ARs were principal targets for sympathetic regulation of colonic motility. Here we investigated whether PDGFRα+ cells in human colon express α1A ARs and share the roles as targets for sympathetic regulation of colonic motility. Methods Isometric tension recording, intracellular recording, and Ca2+ imaging were performed on muscles of the human colon. Responses to α1 ARs agonists or electric field stimulation with AR antagonists and neuroleptic reagents were studied. Results Exogenous or endogenous norepinephrine released from nerve fibers inhibited colonic contractions through binding to α1A ARs or enhanced colonic contractions by acting on α1D ARs. Inhibitory responses were blocked by apamin, an antagonist of SK channels. Phenylephrine, α1 AR agonists, or norepinephrine increased intracellular [Ca2+] in PDGFRα+ cells, but not in ICC, and hyperpolarized SMCs by binding to α1 ARs expressed by PDGFRα+ cells. Conclusions Human colonic contractions are inhibited by α1A ARs expressed in PDGFRα+ cells and activated by α1D ARs expressed in SMC., Graphical abstract

We evaluated the perioperative inflammatory mediators in a right hemicolectomy performed with single-incision laparoscopic surgery (SILS) and traditional multi-port laparoscopic surgery (MLS) to compare the postoperative inflammatory response and feasibility of SILS with that of MLS. In this retrospective study, we enrolled 56 consecutive colorectal cancer patients who underwent right hemicolectomy prospectively. Twenty patients underwent SILS, and 36 underwent MLS. The preoperative and postoperative levels of plasma vascular endothelial growth factor (VEGF), serum interleukin-6 (IL-6), and C-reactive protein (CRP) as well as the number of platelet cells were measured in all patients. The operation duration, number of harvested lymph nodes, length of the resected bowel, blood loss, and duration of hospital stay were also compared between the two groups. Neither SILS nor MLS had any conversion cases. The operation duration was longer for MLS than for SILS. Blood loss tended to be lower among patients who underwent SILS than among those who underwent MLS. However, the number of harvested LNs was significantly lower with SILS than with MLS. In both pre- and postoperative blood examinations, there was no marked difference in inflammatory mediators between MLS and SILS. There was no systemic inflammatory advantage associated with SILS compared with MLS.

Eicosapentaenoic acid (EPA) improves interleukin (IL)‑6 hypercytokinemia in patients with advanced cancer due to its anti‑inflammatory effects. This EPA mechanism has been revealed to lead to several anticancer effects. While the effects of EPA on cancer cells have been investigated, particularly in terms of angiogenesis, its effects on the tumor stroma remain unclear. In the present study, the authors clarified the role of EPA in cancer angiogenesis against colon cancer‑associated fibroblasts (CAFs) from the colon stroma. With established human CAFs and normal fibroblasts from colon stroma (NFs), the authors evaluated IL‑6 and vascular endothelial growth factor (VEGF) secretion with or without EPA treatment using ELISA. The signal inhibition of mitogen‑activated protein kinase (ERK) in CAFs by EPA was evaluated using western blotting. In vitro anti‑angiogenesis effects were evaluated by the angiogenesis assay on Matrigel using human umbilical vein endothelial cells (HUVECs) cultured with the supernatant obtained from CAF cultures with or without EPA. IL‑6 secretion was greater from CAFs compared with that from NFs and stimulation with lipopolysaccharide (LPS) resulted in greater IL‑6 secretion from the two fibroblast types compared with that from fibroblasts without LPS stimulation. While LPS stimulation increased VEGF secretion from the two fibroblast types, EPA decreased IL‑6 and VEGF secretion from CAFs. Western blotting revealed that the addition of 30 µM EPA inhibited the ERK phosphorylation signal in CAFs. Furthermore, the angiogenesis assay with Matrigel revealed that the CAF culture supernatants treated with EPA suppressed tubular formation in HUVECs. These reductions may have been caused by the inhibition of ERK phosphorylation by EPA. Thus, EPA reduces cancer angiogenesis associated with CAFs. Additional studies will be needed to clarify the continuous anti‑angiogenetic effect of chemotherapy using angiogenesis inhibitors (e.g. bevacizumab and aflibercept) in conjunction with or without EPA, and the clinical usage of EPA in conjunction with chemotherapy in vivo.

Cancer tissues are composed of cancer cells and the surrounding stromal cells (e.g., fibroblasts, vascular endothelial cells, and immune cells), in addition to the extracellular matrix. Most studies investigating carcinogenesis and the progression, invasion, metastasis, and angiogenesis of cancer have focused on alterations in cancer cells, including genetic and epigenetic changes. Recently, interactions between cancer cells and the stroma have attracted considerable attention, and increasing evidence has accumulated on this. Several researchers have gradually clarified the origins, features, and roles of cancer-associated fibroblasts (CAFs), a major component of the cancer stroma. CAFs function in a similar manner to myofibroblasts during wound healing. We previously reported the relationship between CAFs and angiogenesis. Interleukin-6 (IL-6), a multifunctional cytokine, plays a central role in regulating inflammatory and immune responses, and important roles in the progression, including proliferation, migration, and angiogenesis, of several cancers. We showed that CAFs are an important IL-6 source and that anti-IL-6 receptor antibody suppressed angiogenesis and inhibited tumor-stroma interactions. Furthermore, CAFs contribute to drug-resistance acquisition in cancer cells. The interaction between cancer cells and the stroma could be a potential target for anti-cancer therapy.

Apigenin is a natural flavonoid that exhibits anti-proliferative activity and induces apoptosis in various types of cancer, including colon cancer. The aim of the present study was to determine the mechanism underlying the apoptosis-inducing effect of apigenin in colon cancer. Apigenin reduced the proliferation of colon cancer cell lines, stimulated the cleavage of PARP and induced apoptosis in a dose-dependent manner. Apigenin treatment also suppressed the expression of the anti-apoptotic proteins Bcl-xL and Mcl-1. Small interfering RNA was used to knockdown Bcl-xL and Mcl-1 expression alone and in concert, and the proliferation and apoptosis of cancer cells were subsequently measured. The knockdown of Bcl-xL and Mcl-1 expression together markedly suppressed cell proliferation and induced apoptosis. Apigenin treatment also inhibited the phosphorylation of signal transducer and activator of transcription 3 (STAT3), which targets Bcl-xL and Mcl-1. The results of the current study therefore determined that apigenin induces the apoptosis of colon cancer cells by inhibiting the phosphorylation of STAT3 and consequently downregulates the anti-apoptotic proteins Bcl-xL and Mcl-1.

BACKGROUND Although robotic surgery is increasingly used in the management of rectal cancer, its oncologic safety remains uncertain. OBJECTIVE We aimed to evaluate the feasibility and safety of robotic-assisted rectal cancer resection in terms of short-term and midterm outcomes. DESIGN A prospectively collected set of samples was retrospectively evaluated. SETTINGS Data included in this study were collected at a single institution from 2007 to 2011. PATIENTS The study included 200 consecutive rectal cancer patients. INTERVENTION The patients underwent robotic-assisted resection surgery performed by a single surgeon. MAIN OUTCOME MEASURES The short-term (surgical outcome and pathologic data) and midterm outcomes (local pelvic control and overall and disease-free survival) were evaluated and compared with those in the published literature. RESULTS The median patient age was 60 years, and the male:female ratio was 2:1. The median distance of rectal tumors from the anal verge was 6 cm. Preoperative radiotherapy was performed in 55 patients. The median operation time was 270 minutes, and the median blood loss was 190 mL. Grade 3 to 5 complications, according to the Clavien-Dindo classification, were observed in 15 patients (7.5%). The circumferential resection margin was positive in 5 patients (2.5%). During the median follow-up period of 29.8 months, recurrence occurred in 27 patients (distant metastasis, 18 patients; local recurrence, 7 patients; and both local recurrence and distant metastases, 2 patients). The local pelvic control and overall and disease-free survival rates of stage III patients at 5 years were 93.0%, 88.6%, and 76.6%. LIMITATIONS This was a retrospective, uncontrolled study of selected patients by a single surgeon. CONCLUSIONS Our results demonstrated an acceptable morbidity and a low rate of positive circumferential resection margin with effective local control. We also achieved excellent survival data. The midterm oncologic safety justifies the practice of robotic rectal cancer resection to further investigate its role on long-term outcomes.

Robotic rectal surgery is gaining in popularity. We aimed to define the learning curve of an experienced laparoscopic colorectal surgeon in performing robot-assisted rectal surgery. We hypothesized that there are multiple phases in this learning process.We performed a retrospective analysis. Consecutive patients who underwent robot-assisted rectal surgery between July 2007 and August 2011 were identified. Operating times were analyzed using the CUSUM (cumulative sum) technique. CUSUMs were model fitted as a fourth-order polynomial. χ(2), Fisher's exact, two independent samples t test, one-way ANOVA, Kruskal-Wallis, and Mann-Whitney tests were used. A p value of0.05 was considered statistically significant.We identified 197 patients. The median (range) total operative, robot, console, and docking times (min) were 265 (145-515), 140 (59-367), 135 (50-360), and 5 (3-40), respectively. CUSUM analysis of docking time showed a learning curve of 35 cases. CUSUM analysis of total operative, robot, and console times demonstrated three phases. The first phase (35 patients) represented the initial learning curve. The second phase (93 patients) involved more challenging cases with increased operative time. The third phase (69 patients) represented the concluding phase in the learning curve. There was increased complexity of cases in the latter two phases. Of phase 1 patients, 45.7% had tumors ≤7 cm from the anal verge compared to 64.2% in phases 2 and 3 (p = 0.042). Of phase 1 patients, 2.9% had neoadjuvant chemoradiotherapy compared to 32.7% of patients in phases 2 and 3 (p0.001). Splenic flexure was mobilized in 8.6% of phase 1 patients compared to 56.8% of patients in phases 2 and 3 (p0.001). Median blood loss was50 ml in all three phases. The patients in phases 2 and 3 had a longer hospital stay compared to those in phase 1 (9 vs. 8 days, p = 0.002). There were no conversions.At least three phases in the learning curve for robot-assisted rectal surgery are defined in our study.

Background The potential severity of postoperative pancreatic fistula (POPF) after laparoscopy-assisted gastrectomy (LAG) necessitates efforts to identify predictive factors for POPF. The aim of the present study was to identify predictive factors for POPF and to establish a predictive scoring system for POPF after LAG. Patients and Methods Between June 2004 and March 2011, 277 gastric cancer patients who underwent curative resection with LAG were enrolled. POPF was defined according to the International Study Group for Pancreatic Fistula grading system. Risk factors for POPF were evaluated using logistic regression analysis, and a scoring system for POPF was established. Results In the derivation cohort, multivariate analysis revealed the risk factors for POPF as patient age ≤70 years (5 points), amylase level of postoperative day 1 drainage fluid >454 IU/L(5 points), total number of retrieved lymph nodes >21 (5 points), body mass index >21.45 kg/m2 (4 points), and operating time >337 min (2 points). In the validation cohort, at the cut-off point for high risk (score ≥15), the model had a negative predictive value of 94.5%, a positive predictive value of 57.4%, a sensitivity of 88.6%, and a specificity of 75.0% (C statistic = 0.857). Conclusion This study demonstrated that POPF after LAG is associated with specific preoperative and postoperative factors. With a simple predictive scoring system, patients at high risk for POPF can be accurately identified. This simple predictive scoring system will be useful for many clinicians to assess the risk of POPF after LAG and start treating at-risk patients earlier.

Since intersphincteric resection (ISR) for rectal cancer was established in the 1990 s, this technique has been applied to very low rectal cancer. This procedure requires advanced techniques for anorectal surgery. However, it is indicated only for early lesions and should be as minimally invasive as possible. We describe a minimally invasive ISR with a single-incision laparoscopic surgery (SILS) port. Our case involves a 59-year-old man with hemorrhage from the rectum. Pathologic examination of the transanally resected specimen revealed that the tumor had invaded into the deeper submucosa. To minimize surgical incisions, a SILS port was utilized in place of a 10- and a 5-mm trocar. The SILS port was inserted through a 2.5 cm transverse incision in the right lower abdomen, where a diverting stoma would be created. Two flexible or straight forceps introduced through this port afforded an easier dissection of the rectum to the levator ani muscle, and transanal dissection of the internal sphincter was performed in the standard manner to connect with the abdominal dissection. The only postoperative incision other than a stoma and surgical drain was one 10-mm incision above the umbilicus. Our technique of ISR with the SILS port is a useful clinical application of minimally invasive surgery.

In laparoscopic colon resection for rectosigmoid colon cancer, minilaparotomy is usually necessary for specimen retrieval and completion of primary anastomosis. This incision may increase postoperative pain, and cause wound infection or other complications. We describe a new technique of laparoscopic anterior colon resection without requiring a minilaparotomy incision.We attempted this procedure on 9 patients with sigmoid colon or rectal cancer. We ligated the inferior mesenteric artery and divided the bowel proximally, similar to conventional laparoscopic technique. We pulled out the specimen and the rectum transanally, and performed distal colon division extracorporeally. An anvil was inserted transanally into corporeal cavity and then, inserted into the proximal stump of the colon lumen laparoscopically. We placed a purse-string suture extracorporeally around the distal colon stump, and then completed a side-to-end anastomosis intracorporeally.The procedure was successfully completed in 8 of the 9 patients. Median operative time was 293 minutes and median blood loss was 47.2 mL. No major complications were observed.This novel technique of transanal specimen retrieval and intracorporeal anastomosis with extracorporeal purse-string placement can be performed safely and easily in patients with rectosigmoid colon cancer.

The aim of the present study was to determine the accuracy of yearly postoperative monitoring of serum tumor markers to either detect or rule out recurrence in colorectal cancer patients.A total of 127 colorectal cancer patients who underwent curative surgery were enrolled. The serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were assayed, and radiological examinations were performed routinely for 5 years after surgery or until recurrence was detected. Yearly recurrence rates (number of recurrences/number of patients assessed in a given year), sensitivities, specificities, and likelihood ratios were calculated. Post-test probabilities were calculated from these values.Recurrences tended to show almost the same frequencies in the first and second year after surgery (20 of 127 patients and 18 of 107 patients, respectively). However, the post-test probability of recurrence in patients with positive and negative serum CEA levels was significantly lower in the second year than in the first year (test positive: 40.0% and 76.0%; test negative: 9.3% and 0.5%, respectively).Measuring CEA can help to identify patients likely to demonstrate recurrence with high accuracy only within the first year after surgery. Another examination, such as imaging, is therefore necessary for monitoring patients at 2 or more years after surgery.

Foreign body retrieval surgery sometimes does not need excision and reconstruction of the gastrointestinal tract. To avoid unnecessarily large incisions is now feasible for such retrieval surgery. We report herein a case of a patient who underwent retrieval surgery with a single-incision laparoscopic surgery (SILS) to minimize surgical incision. Our case concerns a 72-year-old female with a 3 cm length needle incidentally discovered as a peritoneal foreign body without any apparent symptoms. Retrieval was performed safely with SILS port inserted through a 2.5 cm transverse incision below the umbilicus. Two flexible forceps introduced through the SILS port offer easy operation for retrieving foreign bodies even if dissection or other surgical maneuvers are required. Our technique of abdominal foreign body retrieval with the SILS port is a useful clinical application of minimally invasive surgery for such cases.

Background and Objectives The aim of this study was to determine the accuracy of postoperative monitoring of serum carcinoembryonic antigen (CEA) to detect or rule out recurrence in patients with stage II colorectal cancer (CRC) by comparing results with stage III. Methods A total of 303 patients with CRC who underwent curative surgery were enrolled. Serum CEA was assayed, and radiological examination was performed routinely for 5 years after surgery. Yearly recurrence rates, sensitivities, specificities, likelihood ratios, and posttest probabilities were calculated. Results Sensitivity and specificity of CEA monitoring in stage II patients are almost same as those in stage III. Whereas recurrences occurred early in stage III, they occurred almost as frequently in both early and late stage II. The obtained posttest probability of recurrence in stage II patients with CEA elevation was significantly lower (only 30% or less) than those in stage III (approximately 80%). Conclusion Elevation of CEA in patients with stage II CRC does not represent recurrence with high probability. One of the reasons for the unreliability of CEA monitoring was its high false-positive rate. Another tumor marker with a lower false-positive rate is necessary to follow-up stage II CRC patients. J. Surg. Oncol. 2010;102:154–157. © 2010 Wiley-Liss, Inc.

Background: The accuracy of 18F-2-deoxy-fluoro-D-glucose positron emission tomography (FDG-PET) for diagnosing nodal status in patients with lung cancer was initially reported as excellent, but, with increasing experience, the problem of false-positive and false-negative assessments has been observed. Purpose: To evaluate the accuracy of FDG-PET for diagnosing nodal status in lung cancer patients with pathologically proven N2 lymph nodes and compare it with that of computed tomography (CT). Material and Methods: Nineteen pN2 patients (13 males and six females) with primary lung cancer undergoing preoperative CT and FDG-PET were investigated. Lymph nodes were considered to be positive when uptake higher than the surrounding mediastinal level was visually observed. Slight symmetrical mediastinal uptake was considered to be negative, representing benign physiological accumulation. Radiological and pathological correlation was investigated, and the association between FDG accumulation and the size of metastatic lymph nodes and metastatic lesions was evaluated. Results: Of the 19 patients, nodal stage determined by using FDG-PET was cN0 in four (21%) cases, cN1 in three (16%), cN2 in nine (47%), and cN3 in three (16%). On CT, nodal stage was cN0 in three (16%) cases, cN1 in seven (37%), cN2 in eight (42%), and cN3 in one (5%). Thus, FDG-PET provided correct N-staging in 47%, under-staging in 37%, and overstaging in 16%. CT staging was correct in 42%, underestimated in 53%, and overestimated in 5%. The maximum area of metastatic foci was 15.8 ±21.3 mm2 (mean ± SD) in false-negative nodes and 75.0±56.3 mm2 in true-positive nodes ( P Conclusion: Diagnostic accuracy of FDG-PET (47%) was low and similar to that of CT (42%). The possibility of false-negative as well as false-positive findings should be recognized in interpreting PET images. Micrometastasis appeared to be the greatest cause of false-negative findings.

This study was designed to determine the efficacy of carcinoembryonic antigen (CEA) monitoring for screening patients with colorectal cancer by using posttest probability of recurrence.For this study, 348 (preoperative serum CEA level elevated: CEA+, n = 119; or normal: CEA-, n = 229) patients who had undergone potentially curative surgery for colorectal cancer were enrolled. After five-year follow-up with measurements of serum CEA levels and imaging workup, posttest probabilities of recurrence were calculated.Recurrence was observed in 39 percent of CEA+ patients and 30 percent in CEA- patients, and CEA levels were elevated in 33.3 percent of CEA+ patients and 17.5 percent of CEA- patients. With obtained sensitivity (68.4 percent, CEA+; 41 percent, CEA-), specificity (83 percent, CEA+; 91 percent, CEA-) and likelihood ratio (test positive: 4.0, CEA+; 4.4, CEA-; and test negative: 0.38, CEA+; 0.66, CEA-), posttest probability given the presence of CEA elevation in the CEA+ and CEA- was 72.2 and 65.5 percent, respectively, and that given the absence of CEA elevation was 20 and 22.2 percent, respectively.Whereas postoperative CEA elevation indicates recurrence with high probability, a normal postoperative CEA is not useful for excluding the probability of recurrence.

We evaluated the relationship of the pretreatment serum IL-6 levels with the outcome and treatment response in patients with advanced or metastatic colorectal cancer (CRC) who underwent bevacizumab-containing chemotherapy. In this retrospective study, the pretreatment serum IL-6 and plasma vascular endothelial growth factor (VEGF) levels were measured in 113 patients with metastatic CRC. The cut-off values for these measurements, as determined by a receiver operating characteristic curve analysis, were 4.3 and 66 pg/mL, respectively. The median follow-up period was 19 months (range 1–40 months). Sixty-three patients had primary cancer, and 38 had a metachronous recurrence. Thirty patients underwent curative resection, and 71 underwent chemotherapy, 53 of whom received bevacizumab-containing chemotherapy. Overall survival (OS) and progression-free survival (PFS) were estimated using Kaplan–Meier and multivariate Cox proportional hazards regression analyses. The plasma VEGF levels and positive KRAS mutation status were not associated with the outcomes. However, high serum IL-6 levels were significantly associated with poorer OS and PFS in comparison to low serum IL-6 levels. A Cox proportional hazards regression analysis showed that high serum IL-6 levels were an independent risk factor for a poor outcome. In patients with metastatic CRC, high pretreatment serum IL-6 levels were associated with a poor outcome and bevacizumab resistance.

We evaluated the ability of itraconazole to enhance the effects of bevacizumab in bevacizumab-resistant cancer cells, endothelial cells, and cancer-associated fibroblasts (CAFs).Human gastrointestinal cancer cell lines (HT-29, MKN-28 and MKN-45), human umbilical vein endothelial cells (HUVECs), and CAFs established from human colon cancer were used. In each of these cell lines, cell growth, apoptosis, and angiogenesis were evaluated with bevacizumab with and without itraconazole both in vitro and in vivo.Itraconazole suppressed HUVEC growth by apoptosis through inhibition of mitogen-activated protein kinase and ribosomal protein S6 kinase signaling. Itraconazole also suppressed monocyte chemoattractant protein-1 secretion and the growth of CAFs. In xenografts, compared to monotherapy with either agent alone, combined treatment with itraconazole and bevacizumab significantly reduced tumor volume, tumor weight, and microvessel density.Itraconazole-dependent suppression of endothelial cell and CAF growth resulted in synergistic effects with bevacizumab in bevacizumab-resistant cancer cells.

Peritoneal recurrence has a much lower incidence in colorectal cancer (CRC) patients than gastric cancer (GC) patients. The aim of this study is to clarify the reason for the rare peritoneal recurrence in CRC as compared with GC. The incidence and the abundance of free tumor cells in the peritoneal lavages from 102 CRC and 126 GC patients who underwent curative surgery were assessed by quantitative reverse transcription-polymerase chain reaction (qRT-PCR) with carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) as genetic markers. Prognostic significance of CEA and CK20 mRNA was also compared between CRC and GC after 2 years of follow-up by Kaplan-Meyer method with overall and peritoneal recurrence-free survival as endpoints. Positivity rate and average values of CEA and CK20 mRNA in peritoneal lavages of CRC patients, which are correlated to the depth of tumor invasion (pT category), were essentially the same as those of GC cases. Overall survival was significantly (marginally) worse in CEA mRNA (CK20 mRNA)-positive CRC patients than negatives like GC. However, peritoneal recurrence-free survival was not different between CEA (CK20) mRNA-positive and -negative CRC patients, in quite contrast to GC cases. Multivariate analysis showed that CEA mRNA was an independent prognostic factor for overall survival in GC patients, but not in CRC patients. These results suggest that the rare peritoneal recurrence in CRC patients is not due to the low incidence or the small number of intraperitoneal free cancer cells, but more likely reflects due to the low-peritoneal metastatic potential of CRC cells.

A new formula is proposed for evaluating discomfort glare from large glare sources with uniform luminance. The formula has four parameters: luminance of the glare source, size of the glare source, background luminance and position index. An experiment was conducted to investigate the effect of each parameter on the evaluation of discomfort glare. Twenty subjects evaluated discomfort glare from the model window. The new formula shows the relation between the degree of discomfort glare and the parameters. The formula is distinct from other formulas in that it has a simple form and the background luminance has little effect on the degree of discomfort glare. It is expected that discomfort glare from large glare sources with uniform luminance can be appraised using the formula.

Interleukin-6 (IL-6) is a well-known pro-inflammatory cytokine with pleiotropic bioactivity and is mainly produced by inflammatory cells. Several diseases are influenced by IL-6; thus, the anti-IL-6 receptor antibody has been used clinically e.g., in the treatment of rheumatoid disease and Castleman disease. Signal transduction through gp130 occurs primarily via the JAK/STAT pathway and secondarily via the PI3K and MAPK pathways. Activation of STAT3 is an important step for the expression of various genes associated with carcinogenesis and cancer progression. Experiments using STAT3 inhibitor and IL-6 shRNA have shown that the activation of STAT3 is necessary for cancer cell proliferation and survival. Several studies have also demonstrated that IL-6 exhibits characteristics associated with both inflammatory cytokines and proangiogenic factors. These studies have demonstrated that IL-6 contributes to angiogenesis as a potent inducer of VEGF, which is one of the most important angiogenic factors. Recently, it has also been reported that cancer–stromal interactions are necessary steps during cancer progression, such as during angiogenesis. These mechanisms of IL-6, which affect cancer cells directly and through cancer–stromal interactions are essential for cancer progression and are of various types. Therefore, increasing attention is being paid to IL-6 signaling as a novel cancer therapeutic approach. This review summarizes the role of IL-6 signaling from the viewpoint of cancer progression and the potency of the anti-IL-6 signaling antibody during cancer therapy.

Poorly-differentiated colorectal cancers (PD-CRC) show high metastatic potential and poor prognosis. However, molecular characteristics of PD-CRC remain unknown to date, particularly in molecular targeting therapy for patients with PD-CRC. In this study, we examined the expression of EGFR, HER2 and HER3 in PD-CRC by immunohisto- chemical analysis of archived clinical specimens of primary tumors and investigated the sensitivity of PD-CRC cell lines to gefitinib, a tyrosine kinase inhibitor for EGFR in vitro. We found that HER3 expression of PD-CRC among members of the HER family was significantly lower than that of well to moderately differentiated CRC (WMD-CRC) and 37% of the PD cases showed a EGFR + /HER2 + /HER3 - expression pattern. COLM-5 cells, a PD-CRC-derived cell line, which exhibits EGFR + /HER2 + /HER3 - expression pattern and recapitulates the typical histology of PD-CRC in xenografted tumors, showed high gefitinib sensitivity both in vitro and in vivo, compared with WMD-CRC cell line (COLM-2). Treatment with gefitinib resulted in the upregulation of p27 Kip1 expression and induction of G1 cell cycle arrest, concomitantly associated with inactivation of PI3K/Akt signaling in COLM-5 cells and marked inhibition of xenografted tumors in nude mice, but not evident in COLM-2 cells. Treatment with sodium butyrate, an HDAC inhibitor that induces differentiation, upregulated the expression of HER3 associated with enhancement of the PI3K/Akt signaling, attenuated gefitinib-mediated p27 Kip1 upregulation and reduced gefitinib sensitivity in COLM-5 cells in vitro. Furthermore, enforced expression of HER3 in COLM-5 cells resulted in significant resistance to gefitinib treatment both in vitro and in vivo. These findings suggest that deficient HER3 expression plays an important role in gefitinib sensitivity and that a malignant subset of PD with EGFR + / HER2 + /HER3 - phenotype is a potential candidate for a target of anti-EGFR molecular therapy such as gefitinib.

We aimed to retrospectively determine the accuracy of postoperative serum carcinoembryonic antigen (CEA) monitoring to detect or rule out recurrence in post-hepatectomy colorectal cancer patients by using a new statistical technique, likelihood ratio and post-test probability.A total of 110 colorectal cancer patients who underwent curative hepatectomy were enrolled. A serum CEA assay and radiological examination were performed routinely for 5 years after surgery or until recurrence was detected. Yearly recurrence rates, sensitivities, specificities, and likelihood ratios were calculated. Post-test probabilities were calculated using these values.All episodes of recurrence occurred within 3 years after hepatectomy. The most frequent recurrence site was the liver, with a recurrence rate of 61.4% of all recurrence. The post-test probabilities of recurrence in post-hepatectomy colorectal cancer patients with positive and negative serum CEA were approximately 70-90% and 10%, respectively.CEA elevation in colorectal cancer patients who underwent curative resection indicated recurrence with high accuracy because of the high recurrence rate in the liver, in which CEA elevation is more frequent than in other recurrent sites. The elevation of CEA in post-hepatectomy patients necessitates frequent examination using imaging techniques to reveal undetected metastasis as soon as possible.

A single-incision laparoscopic surgery (SILS) port may be used to reduce the number of surgical incisions. Here, we describe our technique, equivalent in technical difficulty to conventional laparoscopy, of using a SILS port at a planned diverting-stoma site in colorectal cancer patients. This technique is indicated for patients for whom the intent is to perform tumor resection with diverting ileostomy. Because ileostomy is usually created on the right, this technique is most useful for left-sided lesions. However, an additional port in the umbilicus enables dissection of the right colon. The SILS port is placed by the open method, with additional trocars added once pneumoperitoneum is established. One trocar port is eventually used for a drain. We use this technique not only for intersphincteric resection, wherein distal rectal stump stapling is not necessary, but also in total coloproctectomy and ultralow anterior resection, which require deep pelvis stapling or right-sided colonic dissection.

BACKGROUND Minimally invasive laparoscopic surgery was widely performed for colectomies. In recent years, as a new approach, the sigmoid colon or rectum is removed through the anus, minimizing the need for skin incisions. However, the resected ileocecal portion or the right side of the colon may be difficult to remove from the anus. Therefore, it usually needs to be removed using a skin incision, which typically restricts the size of the tissue. In these cases, we applied a less-invasive single-incision endoscopy-assisted colectomy to avoid forceps interference and reduce the port size required for the energy device. In this study, we introduce an ideal single-incision technique. METHODS We performed surgeries on 3 patients with cecal or proximal ascending colon cancer (1 early and 2 advanced cases). Under general anesthesia, we initially made a right pararectal incision (3 to 5 cm), which was dependent on the tumor size and fixed a GelPort (Applied Medical, Orange County, CA) and inserted 12- and 5-mm trocars. Through the 12-mm trocar, we inserted a gastrointestinal scope for dissecting the ileocecal area from the retroperitoneum using a hook knife, similar to the endoscopic submucosal dissection technique. After mobilization, all other maneuvers were performed by an open method. RESULTS The mean surgery time was 185 minutes. There were no major complications among the patients. DISCUSSION This single-incision endoscopy-assisted dissection needs no additional suction, irrigation, or electrocoagulator and is a realistic and idealistic technique at present. Transvaginal and transanal retrieval methods are still controversial. CONCLUSION We believe that this endoscopic technique may be essential for advancement to minimally invasive laparoscopic surgery toward natural orifice transluminal endoscopic surgery.

Background: Interleukin-6 (IL-6) has an important role in cancer progression, and high levels of plasma IL-6 are correlated with a poor prognosis in a variety of cancers. It has also been reported that tumour stromal fibroblasts are necessary for steps in cancer progression, such as angiogenesis. There have been few reports of a correlation between fibroblast actions and IL-6 levels. In this study, we examined the correlation between cancer stromal fibroblasts and IL-6 and the utility of IL-6 as a therapeutic target in human colon cancer. Methods: The expression levels of IL-6 and VEGF of fibroblasts and cancer cell lines were evaluated using real-time PCR and ELISA. The anti-angiogenic effect of inhibiting IL-6 signalling was measured in an angiogenesis model and animal experiment. Results: We demonstrate that stromal fibroblasts isolated from colon cancer produced significant amounts of IL-6 and that colon cancer cells enhanced IL-6 production by stromal fibroblasts. Moreover, IL-6 enhanced VEGF production by fibroblasts, thereby inducing angiogenesis. In vivo, anti-IL6 receptor antibody targeting stromal tissue showed greater anti-tumour activity than did anti-IL6 receptor antibody targeting xenografted cancer cells. Conclusion: Cancer stromal fibroblasts were an important source of IL-6 in colon cancer. IL-6 produced by activated fibroblasts induced tumour angiogenesis by stimulating adjacent stromal fibroblasts. The relationship between IL-6 and stromal fibroblasts offers new approaches to cancer therapy.

Diazonium salts efficiently serve as electrophilic aminating reagents of esters. The reaction of arenediazonium tetrafluoroborates with ketene silyl ketals yielded α-azo or α-hydrazono esters in good to excellent yields under very mild conditions. Hydrogenation of those esters gave α-amino esters quantitatively.

α-Arylation of ketones is accomplished by the use of arenediazonium salts as aryl-cation equivalents. The reaction of silyl enol ethers with arenediazonium tetrafluoroborates proceeds in the presence of palladium(0) catalysts and tetraphenylborate anion to give α-aryl ketones in moderate yields. Alternatively, silyl enol ethers smoothly react with arenediazonium tetrafluoroborates in pyridine even without palladium catalysts and tetraphenylborate anion, affording arylated ketones in good yields. A mechanism involving addition of an aryl radical to a silyl enol ether is proposed for the latter process.

Although laparoscopic colectomy is commonly performed around the world, an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery. Thus, a certain sized skin incision is required to remove the resected colon. Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction. We present a case characterized by a laterally spreading type of tumor of the cecum. We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy. Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction. The patient was discharged without complications on postoperative day 4. Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique. Although our method is restricted to flat or small lesions, we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.