Language：English   Publisher：Surgery Today  

Purpose: To clarify the influence of additional internal iliac artery (IIA) resection on the loss of the gluteus muscle volume after pelvic exenteration (PE). Methods: The subjects of this retrospective analysis were 78 patients who underwent PE with or without IIA resection (n = 44 and n = 34, respectively) between 2006 and 2018. The areas of gluteal muscles (GMs) and psoas muscles (PSMs) were calculated using CT images before and 6 months after PE, and the difference was compared. Results: The volumes of the GMs and PSMs were significantly reduced after PE (P < 0.001 and P = 0.005, respectively). In the IIA resection group, the GMs were significantly reduced after surgery, but the PSMs were not. The maximum GM (Gmax) was the most atrophied among the GMs. Multivariable analysis revealed that complete IIA resection was an independent promotor of the loss of volume of the Gmax (P = 0.044). In 18 patients with unilateral IIA resection, the downsizing rate of the Gmax was significantly greater on the resected side than on the non-resected side (P = 0.008). Conclusions: The GMs and PSMs were significantly smaller after PE. Complete IIA resection reduced the Gmax area remarkably. Preservation of the superior gluteus artery is likely to help maintain Gmax size, suggesting a potential preventative measure against secondary sarcopenia.

DOI： 10.1007/s00595-022-02635-z

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PubMed

Publisher：株式会社医学書院  

DOI： 10.11477/mf.1407214143

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Publisher：金原出版  

DOI： 10.18888/op.0000003383

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Publisher：南江堂  

DOI： 10.15106/j_geka85_536

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Language：Japanese   Publisher：The Japanese Society of Gastroenterological Surgery  

<p>Use of immune checkpoint inhibitors (ICIs) has recently been recommended for treatment of unresectable or recurrent colorectal cancer with a microsatellite instability-high (MSI-H) status. We report a case of recurrent sigmoid colon cancer that was treated with ICIs followed by radical resection. One year after primary resection, the patient was diagnosed with localized peritoneal metastasis invading the left lower abdominal wall. The tumor presented as RAS/BRAF wild-type and was treated with FOLFIRI+panitumumab as 1st line chemotherapy. After shrinkage was observed, the patient was referred to our department for possible resection. Treated with ipilimumab plus nivolumab was used for further disease control of the borderline resectable tumor. However, interim imaging showed a slight increase in tumor size, so radical surgery (abdominal wall tumor resection+lymph node dissection+fascia lata abdominal wall reconstruction) was performed after three courses of ICI treatment. The pathological results showed a complete response, and the patient is now under observation with neither adjuvant therapy nor recurrence.</p>

DOI： 10.5833/jjgs.2022.0056

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Language：English   Publisher：Digestive Endoscopy  

Transanal total mesorectal excision (taTME) has been rapidly accepted as a promising surgical approach to the distal rectum. The benefits include ease of access to the bottom of the deep pelvis linearly over a short distance in order to easily visualize the important anatomy. Furthermore, the distal resection margins can be secured under direct vision. Additionally, a two-team approach combining taTME with a transabdominal approach could decrease the operative time and conversion rate. Although taTME was expected to become more rapidly popularized worldwide, enthusiasm for it has stalled due to unfamiliar intraoperative complications, a lack of oncologic evidence from randomized trials, and the widespread use of robotic surgery. While international registries have reported favorable short- and medium-term outcomes from taTME, a Norwegian national study reported a high local recurrence rate of 9.5%. The characteristics of the recurrences included rapid, multifocal growth in the pelvis, which was quite different from recurrences following traditional transabdominal TME; thus, the Norwegian Colorectal Cancer Group reached a consensus for a temporary moratorium on the performance of taTME. To ensure acceptable baseline quality and patient safety, taTME should be performed by well-trained colorectal surgeons. Although the appropriate indications for taTME remain controversial, the transanal approach is extremely important as a means of goal setting in difficult TME cases and as an aid to the transabdominal approach in various types of extended pelvic surgeries. The benefits in transanal lateral lymph node dissection and pelvic exenteration are presented herein.

DOI： 10.1111/den.14464

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Language：Japanese   Publisher：The Japan Society of Coloproctology  

<p>A 75-year-old woman was referred to our hospital with a chief complaint of tiredness. She was diagnosed with cecum cancer, unresectable multiple liver metastases, and peritoneal dissemination. The companion gene test result showed that she was RAS mutant (KRAS G12V), BRAF V600E wild type, and microsatellite stable, and she was treated with FOLFOX + bevacizumab. Her cancer gene panel test revealed a BRCA1 pathological variant in the germline, and she was diagnosed with hereditary breast and ovarian cancer syndrome. With the increasing use of cancer gene panel testing, it is expected that the number of cases in which secondary findings in the germ line are unexpectedly detected, leading to the diagnosis of inherited diseases, will increase. Although this information is always included in the consent document, not only patients but also health care providers are often unaware of the importance of genetic counseling.</p>

DOI： 10.3862/jcoloproctology.76.443

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Language：English   Publisher：European Journal of Surgical Oncology  

Purpose: The aim of this study was to clarify the suitable radial margin (RM) for favourable outcomes after pelvic exenteration (PE), focusing on the discrepancy between the concepts of circumferential resection margin (CRM) and traditional R status. Methods: Seventy-three patients with locally advanced (LARC, n = 24) or locally recurrent rectal cancer (LRRC, n = 49) who underwent PE between 2006 and 2018 were retrospectively analysed. Patients were histologically classified into the following 3 groups; wide RM (≥1 mm, n = 45), narrow RM (0–1 mm, n = 10), and exposed RM (n = 18). The analysis was performed not only in the entire cohort but also in each disease group separately. Results: The rates of traditional R0 (RM > 0 mm) and wide RM were 75.3% and 61.6%, respectively, resulting in the discrepancy rate of 13.7% between the two concepts. Preoperative radiotherapy was given in 12.3%. In the entire cohort, the local recurrence and overall survival (OS) rates for narrow RMs were significantly worse than those for wide RMs (p < 0.001 and p = 0.002), but were similar to those for exposed RMs. In both LARC and LRRC, RM < 1 mm resulted in significantly worse local recurrence and OS rates compared to the wide RMs. Multivariate analysis showed that RM < 1 mm was an independent risk factor for local recurrence in both LARC (HR 15.850, p = 0.015) and LRRC (HR 4.874, p = 0.005). Conclusions: Narrow and exposed RMs had an almost equal impact on local recurrence and poor OS after PE. Preoperative radiotherapy might have a key role to ensure a wide RM.

DOI： 10.1016/j.ejso.2022.06.015

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Language：Japanese   Publisher：The Japanese Society of Gastroenterological Surgery  

<p><b>Purpose:</b> Patients with metastatic colorectal cancer (mCRC) with BRAF V600E mutation have a poor response to standard cytotoxic agents and extremely poor outcomes. Thus, the optimal indication for metastasectomy remains debatable, even when the metastatic region is resectable. The aims of this retrospective study were to examine the outcomes of BRAF V600E mCRC, identify risk factors for poor survival, and establish the optimal surgical indication for resection. <b>Materials and Methods:</b> The subjects were 14 patients with BRAF V600E mCRC who started treatment in our department between December 2016 and April 2020. No patients underwent surgery prior to introduction of systemic chemotherapy. Patients were divided into two groups based on the initial response to first-line chemotherapy: controlled disease (CD, <i>n</i>=8) for tumors that shrunk or stabilized from baseline, and uncontrolled disease (UD, <i>n</i>=6) for tumors that increased in size. <b>Results:</b> The median follow-up period was 39.7 months. The 2-year overall survival rate was 35.7% in all patients, and was higher in the CD group than in the UD group (50.0% vs. 16.7%, <i>P</i>=0.051). Six patients (42.9%) underwent curative metastasectomy, of whom 4 developed recurrence and one underwent re-resection. In the CD group, 2 of 3 patients who underwent metastasectomy were alive without cancer, while all 3 patients in the UD group developed recurrence after metastasectomy and 2 had early recurrence within 3 months. <b>Conclusion:</b> This study suggests that evaluation of the initial response to first-line chemotherapy may be a useful prognostic factor in BRAF V600E mCRC. Even if a tumor is resectable, the indication for metastasectomy should be carefully considered in cases with poor disease control in the initial response.</p>

DOI： 10.5833/jjgs.2021.0129

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Language：English  

DOI： 10.1093/jjco/hyac045

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Language：English   Publisher：Surgery Today  

Purpose: Parastomal hernia (PH) develops more frequently than incisional hernia (IH) after colorectal surgery with stoma. This study evaluated our hypothesis that inward traction of the fascia when closing a midline incision widens the stoma hole and increases the incidence of PH. Methods: A total of 795 patients who underwent colorectal resection between 2006 and 2016 were retrospectively analyzed. The risk classification was constructed from IH risk factors extracted from the non-stoma group. Then, the classification was extrapolated to the stoma group for predicting midline IH and PH. Results: The incidence of IH was 5.3% in the stoma group and 12.5% in the non-stoma group (p = 0.005). PH developed in 19.6% of 97 patients with permanent stoma. The risk classification was able to predict PH without a significant difference but was well balanced in patients with permanent stoma; however, it failed to predict IH in the stoma group. Conclusion: The risk classification constructed from the non-stoma group was useful for predicting not midline IH but PH, suggesting that the stoma site was the most vulnerable for herniation. The “fighting over the fascia” theory between the midline incision and stoma hole may explain the causal relationship between the midline IH and PH.

DOI： 10.1007/s00595-021-02434-y

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Publisher：株式会社医学書院  

DOI： 10.11477/mf.1407213704

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Publisher：南江堂  

DOI： 10.15106/j_geka84_484

CiNii Research

Language：Japanese   Publisher：The Japan Society of Coloproctology  

<p>A 69-year-old woman visited a previous hospital with chief complaints of abdominal pain and a femoral mass. CT revealed locally advanced cecal cancer which had retroperitoneal penetration and formed a widespread abscess extending to the right femur. Systemic chemotherapy brought remarkable tumor shrinkage, therefore, conversion ileocecal resection could be performed. She received capecitabine monotherapy as an adjuvant chemotherapy for a half year.</p><p>Two and a half years after surgery, a femoral tumor was found and she was referred to our hospital. Incisional biopsy revealed that the tumor was recurrent cecal cancer. The tumor was successfully removed with combined resection of the joint capsule and femoral nerve in cooperation with orthopedic surgeons. Intraoperative radiotherapy was given around the acetabulum to improve local control. Pathological examination demonstrated that it was R1 resection at that site.</p><p>Postoperative lymphatic leakage was prolonged, therefore, a rectus abdominis musculocutaneous flap was given by plastic surgeons.</p><p>One and a half years after surgery, although meningeal dissemination without neurological symptoms developed, she remains healthy without local relapse and is receiving systemic chemotherapy.</p>

DOI： 10.3862/jcoloproctology.75.44

CiNii Research

Language：Japanese   Publisher：The Japan Society of Coloproctology  

<p>A 75-year-old man underwent abdominoperineal resection （APR） and reconstruction using a right vertical rectus abdominis musculocutaneous （VRAM） flap for fistula-associated anal cancer 1 year ago. Pathological findings revealed mucinous adenocarcinoma （T4N0M0） with R1 resection. Six months after surgery, local recurrence developed and he was referred to our hospital. CT findings showed that the recurrent tumor, 30 mm in diameter, was adjacent to the right side of the prostate and the ventral side of the VRAM flap, however, there was no finding of invasion of the feeding vessels.</p><p>Total pelvic exenteration （TPE） with preservation of the VRAM flap was successfully performed. He was discharged on the 27th day after surgery and remains alive without recurrence 1 year after surgery.</p><p>The VRAM flap has been widely used in perineal reconstruction after extended pelvic surgery. In the case of local recurrence thereafter, redo surgery may be complicated, especially when the flap should be preserved. In this case, fortunately we could achieve R0 resection, however, preservation sometimes threatens curability, therefore, the indication should be carefully considered.</p>

DOI： 10.3862/jcoloproctology.75.15

CiNii Research

Publisher：株式会社医学書院  

DOI： 10.11477/mf.1407213500

CiNii Research

Language：English   Publisher：International Journal of Clinical Oncology  

Background: The carcinoembryonic antigen (CEA) “value” itself is often useless in patients with a normal CEA level at initial presentation and those with tumor-irrelevant elevated CEA. Although the unified marker using CEA has been desirable for recurrent tumor staging as well as for primary tumor staging, little is known concerning its relationship with the survival of patients with recurrent colorectal cancer in particular. Methods: This retrospective historical study included patients who experienced disease relapse after curative surgery for stage I–III colorectal cancer between 2006 and 2018. A total of 129 patients with recurrent disease after curative surgery for colorectal cancer were included. We focused on the CEA “ratio” (CEA-R: the ratio of the CEA level at the time of recurrence to that measured 3 months before recurrence) and aimed to evaluate the correlation between CEA-R and survival in recurrent colorectal cancer. Results: Patients with a high CEA-R (≥ 2) exhibited significantly worse 2 year survival than those with a low CEA-R (< 2) (88.1% vs. 44.9%, P < 0.001), irrespective of the CEA value before primary resection. Multivariate analyses demonstrated that the CEA-R (HR; 3.270, 95% CI 1.646–6.497, P = 0.001) was a significant prognostic factor. Conclusion: The CEA-R is a potential marker stratifying the survival of patients with disease relapse who exhibit aggressive biology at recurrent disease foci. As a novel marker, the CEA-R would serve as a clinical guide for tailoring treatment strategies at the time of disease relapse in patients with colorectal cancer.

DOI： 10.1007/s10147-021-01919-7

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DOI： 10.11477/mf.1407213349

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Language：English   Publisher：European Journal of Surgical Oncology  

Introduction: The oncological benefit of neoadjuvant chemotherapy (NAC) alone for locally advanced rectal cancer (LARC) remains controversial. The aim of this study was to clarify the clinical risk factors for poor prognosis before and after NAC for decision making regarding additional treatment in patients with LARC. Materials and methods: We examined a total of 96 patients with MRI-defined poor-risk locally advanced mid-low rectal cancer treated by NAC alone between 2006 and 2018. Survival outcomes and clinical risk factors for poor prognosis before and after NAC were analyzed. Results: In the median follow-up duration after surgery of 60 months (3–120), the rates of 5-year overall survival (OS), relapse-free survival (RFS), and local recurrence (LR) were 83.6%, 78.4%, and 8.2%, respectively. In the multivariate analyses, patients with cT4 disease had a significantly higher risk of poor OS (HR; 6.10, 95% CI; 1.32–28.15, P = 0.021) than those with cT3 disease. After NAC, ycN+ was significantly associated with a higher risk of poor OS (HR; 5.92, 95% CI; 1.27–27.62, P = 0.024) and RFS (HR; 2.55, 95% CI; 1.01–6.48, P = 0.048) than ycN-. In addition, patients with CEA after NAC (post-CEA) ≥ 5 ng/ml had a significantly higher risk LR (HR; 5.63, 95% CI; 1.06–29.93, P = 0.043). Conclusion: NAC alone had an insufficient survival effect on patients with cT4 disease, ycN+, or an elevated post-CEA level. In contrast, NAC alone is a potential treatment for other patients with LARC.

DOI： 10.1016/j.ejso.2020.10.038

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Publisher：南江堂  

DOI： 10.15106/j_geka83_506

CiNii Research

Language：Japanese   Publisher：The Japanese Society of Gastroenterological Surgery  

<p>Patients with colorectal cancer with the BRAF V600E mutation, which rarely coexists with a RAS mutation, have an extremely poor prognosis. In contrast, the outcomes of patients with a BRAF mutation and high microsatellite instability (MSI-high) have been found to be favorable. Thus, the significance of having multiple mutations remains unclear. We experienced a rare case with cervical lymph node metastasis from right-sided transverse colon cancer with RAS mutation, BRAF mutation and MSI-high, which developed 9 months after primary resection, just after completion of oxaliplatin-based 6-month adjuvant chemotherapy. As second-line chemotherapy, the patient received FOLFIRI plus aflibercept for 12 months. The tumor shrank markedly from 37 mm to 12 mm in maximum diameter and no new lesion was found; therefore, she underwent conversion surgery. Pathological findings confirmed no residual cancer cells (pathological complete response). Although the postoperative follow-up period is still <9 months, the patient has had no additional treatment after conversion surgery and is alive without recurrence. This case suggests that even in patients with metastatic colorectal cancer with the BRAF V600E mutation, aggressive surgical treatment might be an option in a situation of well-controlled systemic disease similar to that without a BRAF mutation. Further investigation of the significance of coexisting MSI-high with a BRAF mutation is required.</p>

DOI： 10.5833/jjgs.2020.0057

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