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There is no literature that mainly searched for rectal neuroendocrine tumor (rNET) using transanal minimal invasive surgery (TAMIS). We report our clinical experiences of TAMIS for rectal neuroendocrine tumors to evaluate the feasibility and safety. Between December 2010 and March 2020, the 25 consecutive patients with rectal neoplasma underwent the TAMIS procedure performed by single laparoscopic surgeon at the two hospitals. Of these, ten patients with rectal neuroendocrine tumors were reviewed retrospectively. The full-thickness excision down to the outer fatty tissues was completed using TAMIS technique. Clinicopathological findings, perioperative and postoperative complications were recorded. TAMIS for small rNET was successfully completed in all cases. There were seven cases with a tumor size of less than 10 mm, and three cases with a tumor size between 10 and 15 mm. Six patients underwent the primary tumor excision; the remaining four patients underwent resection for the scar after endoscopic procedure. The median surgical duration was 80.5 (53–124) minutes and the median blood loss was 1 (1–12) ml. All removed tumors in the 6 primary excisions were diagnosed as neuroendocrine tumor G1. The margins of specimens were completely free in all cases. Among the four patients after endoscopic procedure, all had no histological evidence of residual tumor. The median length of hospital stay was 7 days postoperatively. There was no post-operative mortality or severe complication. The median length of observation was 54 months. No recurrence, no local or distant metastasis and no mortality of all patients were observed. TAMIS is safety and feasible procedure for small rNET. Further experience and clinical trials are needed to fully define the advantages, disadvantages, and indications of TAMIS for rNET.

Hand-assisted laparoscopic surgery is considered to provide the benefits of laparoscopic surgery in various diseases. However, limited information is available regarding the feasibility of hand-assisted laparoscopic distal gastrectomy (HALDG)-a subset of hand-assisted laparoscopic surgery-as a gastric cancer treatment. This study aimed to evaluate the usefulness of HALDG compared with laparoscopy-assisted distal gastrectomy (LADG). Consecutive patients who underwent HALDG (n=58) or LADG (n=90) for stage I gastric cancer between 2005 and 2016 were eligible. Operative time was significantly shorter and blood loss was significantly higher in HALDG than in LADG (P

Background For colorectal cancer (CRC) patients, the standard histological lymph node (LN) evaluation has low sensitivity. Our previously developed one-step nucleic acid amplification (OSNA™) assay measures cytokeratin 19 gene expression in whole LNs. We recently showed that 17.6% of pN0 stage II CRC patients were OSNA positive, suggesting a correlation between OSNA results and disease recurrence. This multicenter, prospective study investigateed the prognostic value of the OSNA assay for pStage II CRC patients. Methods We examined 204 CRC patients who were preoperatively diagnosed as cN0 and cN1 and surgically treated at 11 medical institutions across Japan. Nine patients were excluded, and 195 patients (Stage I: n = 50, Stage II: n = 70, Stage III: n = 75) were examined. All LNs, harvested from patients, were examined histopathologically using one-slice hematoxylin–eosin staining. Furthermore, half of the LNs was examined by the OSNA assay. Patients were classified according to the UICC staging criteria and OSNA results, and the 3-year, disease-free survival (DFS) of each cohort was analyzed. Results Average 21.2 LNs/patient were subject to pathological examination. Approximately half of all harvested LNs (average, 9.4 LNs/patient) were suitable for the OSNA assay. Significantly lower 3-year DFS rates were observed in pStage (pathological Stage) II OSNA-positive patients than in OSNA-negative patients (p = 0.005). Among all assessed clinical and pathological parameters, only the OSNA result significantly affected 3-year DFS rates in pStage II CRC patients (p = 0.027). Conclusions This study shows that OSNA positivity is a risk factor for recurrence of the patients with pStage II CRC.

We previously reported that the one-step nucleic acid amplification (OSNA) assay provided a judgment performance for colorectal cancer equivalent to a 2-mm-interval histopathological examination of lymph nodes (concordance 97.1 %, n = 385 lymph nodes). In this prospective multicenter study, we uncovered an OSNA-assisted pathology to detect lymph node metastasis. A total of 204 (50 stage I, 74 stage II, and 80 stage III) colorectal cancer patients. All 4324 lymph nodes were examined by the standard histology (one-slice H&E staining) and 1925 lymph nodes (44.5 %) of them were also subject to the OSNA analysis. The concordance rate between 1 slice hematoxylin/eosin and OSNA assay was 95.7 % (1,842/1925 lymph nodes). The sensitivity and specificity of the OSNA assay were 86.2 % (125/145) and 96.5 % (1717/1780), respectively. Among 124 node-negative patients (pN0), the respective upstaging rates of pStages I, IIA, IIB, and IIC were 2.0 % (1/50), 17.7 % (11/62), 12.5 % (1/8), and 25 % (1/4). OSNA-positive patients had deeper invasion to the colonic wall and severe lymphatic invasion (P = 0.048 and P = 0.004, respectively). The sum of the quantitative results of OSNA and total tumor load increased as the number of metastasized lymph nodes increased: 1550 copies/μL in pN0, 24,050 copies/μL in pN1, and 90,600 copies/μL in pN2. The present study on colorectal cancer provided fundamental data regarding OSNA-assisted pathology of lymph node metastasis in Japan.

Postoperative adhesion is a frequent problem in patients undergoing surgery. In particular, gastrectomy is associated with a high risk of bowel obstruction. However, there are few reports of small bowel obstruction (SBO) after gastrectomy in the English-language literature. We reviewed the literature to assess the effectiveness of various techniques for preventing adhesion in patients treated with gastrectomy. We assumed that strategies used to prevent postoperative adhesion associated with colorectal surgery, cholecystectomy, appendectomy and gynecologic procedures are similar to those used in gastrectomy. We therefore reviewed reports on the prevention of postoperative SBO in any abdominal surgical procedure, focusing especially on gastrectomy. General intraoperative preventive techniques, such as the use of starch-free gloves, saline irrigation at a temperature below 37 °C and laparoscopic techniques whenever possible, may reduce the incidence of SBO in patients with gastric cancer who undergo gastrectomy. If preserving the omentum is unrelated to the survival rate of patients with gastric cancer, this technique should be recommended for preventing postoperative SBO. The use of hyaluronic acid/carboxymethylcellulose bioabsorbable membranes should also be considered in patients undergoing gastrectomy. However, demonstrating the advantages of bioabsorbable membranes would require larger randomized studies with a longer follow-up period.

要旨 【はじめに】 我々は 2005 年 1 月より胃病変に対して用手補助腹腔鏡下胃切除術 (HALG) を施行してきた．今回，当科の HALG の手術術式と成績を提示し，同法の有用性を検討する．【対象と術式】 2005 年 1 月から 2009 年 6 月までに胃病変に対して用手補助腹腔鏡下に施行した幽門側胃切除術/幽門保存胃切除術 (HALDG/HALPPG) 63 例， 胃全摘術 (HALTG) 19 例， 噴門側胃切除術 (HALPG) 13 例を対象とした．全ての術式でGelportTM を季肋下に装着し，12 mm ポート 2 本，5 mmポート 2 本を同一部位に挿入した．再建は小開腹創よりHALDG/HALPPG: Billroth-I または Roux-en-Y 法，HALTG: Roux-en-Y 法, HALPG: 空腸パウチ間置再建を施行した． 【結果】 手術時間は，HALDG: 209 分，HALTG: 251 分，HALPG: 229 分，出血量は 50 g, 134 g, 91 g， 術後入院日数は 13 日， 17 日， 14 日であった． 全ての症例で術中トラブルなく腹腔鏡下に手術を完遂した．【まとめ】 HALG は開腹手術に慣れた術者も受け入れ易く，胃病変に対して有用な手技の一つと考えられた．

Transanal endoscopic microsurgery using a platform for single-incision laparoscopic surgery (SILSTEM) is safe for excising rectal lesions. We tested three types of platforms.Nine patients underwent SILSTEM by one surgeon. Tumors located 5–15 cm from the anal verge were eligible. After measuring their dimensions, length, and trocar channels, the platforms tested were the SILSTM port (SP), EZTM access (EA), and GelPOINTTM Path (GP). Clinicopathology, intraoperative parameters, and postoperative outcomes were recorded.Six men and three women (median age 63 years) underwent SILSTEM using platform SP in three patients, EA in four, GP in two. Median operation time was 128 min (range 71–313). Median blood loss was 3 ml (range 1–71). Pathology confirmed adenocarcinoma in five patients, adenoma in three, and carcinoid in one. Patients were discharged within 2–13 days postoperatively. There was no postoperative fecal incontinence or soiling. Overall median follow-up was 13.3 months (range 1.3–27.2). There were no recurrences.SILSTEM can effectively resect rectal tumors using any of three platforms. Large prospective trials are needed to define the advantages, disadvantages, and indications for each platform and to draw conclusions regarding operation time, anorectal function, and costs.

We experienced a relatively rare case of pneumatosis cytoides coli in which multiple cysts due to gas occurred in the intestinal wall. A 45-year-old woman was admitted to the hospital because of anal bleeding and repeated abdominal pain. She was a painter and had been treated trichlorethelene for more than 20 years. There was no history of paticular disease nor family history. Abdominal X-ray film revealed a honey-comb shadow in the left abdomen. Barium-enema examination revealed many broad-based and smooth-surfaced polypoid lesions all over the sigmoid colon. Endoscopic examination of the colon showed multiple polypoid lesions, which decreased in size upon rupture with forceps. The patient was diagnosed as pneumatosis cystoides intestinalis (PCI) and successfully treated by 14 day oxygen inhalation in a dose of 5l catheter for 5 hours a day. The lesions completely disappeared, and no recurrence has been found for 7 months thereafter. Oxygenation therapy used in this case is excellent in that it can offer a reliable therapeutic effect with shorter period.

Transanal endoscopic surgery has slowly gained widespread acceptance among colorectal surgeons, despite the need for specific training and the high costs of specialized instrumentation. At the other extreme, some laparoscopic surgeons recommend single port access surgery using a single-incision laparoscopic surgery port. Single-incision laparoscopic surgery was applied to perform transanal endoscopic microsurgery in a patient with T1 rectal cancer under spinal anesthesia. The patient was a 74-year-old man who presented with a 2-cm elevated lesion in the right anterior portion of the rectum. Ordinary laparoscopic instruments were used to perform submucosal resection. The tumor was completely excised from the rectal wall with the use of an ultrasonic surgical scissors. The patient recovered uneventfully and was discharged 4 days after the operation. There was no fecal incontinence or soiling during the postoperative follow-up. Colonoscopy at 4 months after the operation showed no recurrence of either adenocarcinoma or adenoma.

腫瘤型進行大腸癌の特徴を明らかにするため,最近10年間で教室において切除された腫瘤型大腸癌50例の臨床病理学的事項について同時期の潰瘍型(530例)と比較検討し,さらに4亜型に分類し検討した.腫瘤型は潰瘍型に比較し,リンパ節転移率や肝転移率が低く,pm癌の割合が高かった.さらに脈管侵襲が潰瘍型に比べ少なく,組織学的進行度も進行していない症例が多かった.したがって,生存率は腫瘤型が有意に良好であった.4亜型の中では結節隆起型が最も一般的であり,小結節扁平隆起型はリンパ管侵襲やリンパ節転移ぷ多いがpmまでにとどまる例が多く,生存率は最も良好であった.結節亀裂型は結節隆起型が進行した型と推測され,予後は最も不良であった.以上より腫瘤型は潰瘍型より予後良好であるが,そのなかでも癌の進行度や臨床病理学的所見さらには予後に差があるので,肉眼形態より亜型に分類して検討することは意義のあることと考える.

大腸多発癌の病態を把握し大腸癌全体の予後向上に役立てるために,本研究を行った.1981年1月から1990年12,月までの10年間に経験した大腸多発癌は47例(同時性38例,異時性9例)であり,同時期の大腸癌手術例835例の5.6%に相当した.進行度や異時性多発癌の発現時期から判断すると,同時性に発生したものを見逃して異時性として扱った症例がいくつかある可能性が推察された.腺腫の併存は20例(42.6%)にみられ,単発大腸癌の14.0%(105/749)より有意に高率であった(p

最近10年間で教室で経験した大腸癌緊急手術例54例につき,臨床病理学的事項,術式,術後合併症,予後について検討を行った.緊急手術54例は同時期の大腸癌手術例896例の6.0%で,男31例,女23例で,平均年齢は63.3歳であった.その内訳はイレウス42例,穿孔9例,炎症2例,出血1例であった,癌占居部位において,予定手術例(842例)よりRの占める割合が少なかった(p

A recent 10 year-experience with 40 cases of multiple primary carcinoma of the large intestine and other organs was clinically studied. The 40 cases represented 4.8% of 835 cases operated on for colorectal carcinoma in the same period, including 11 synchronous, 27 heterochronous and 2 synchronous/heterochronous multiple carcinoma cases.Among carcinoma in other organs, gastric carcinoma was the most common (53.5%). Multiple carcinoma cases were more common in males and in elders, and appeared to have a family history of cancer in a higher frequency than the 835 operated cases. The clinicopathological findings of colorectal carcinomas in 32 multiple primary malignant cases with resection of colorectal carcinoma were not so characteristic compared to the 658 resectable cases without carcinoma of other organs. The cumulative 5-year survival rate of the 31 cases with resection of both colorectal carcinoma and carcinoma of other organs was significantly lower than that of 658 resectable cases described above. In order to improve the prognosis of multiple carcinomas, we have to make more effort at improving the prognosis of primary malignant tumors of other organs, especially gastric carcinoma, in synchronous cases, and at detecting early the associated colorectal carcinoma in heterochronous cases, if another carcinoma of other organ preceded.

Objective: This randomized controlled trial was designed to assess whether the use of a sodium hyluronate-based bioresorbable membrane reduces small bowel obstruction after gastrectomy for gastic cancer. Summary Background Data: Clinical studies have reported that a bioresorbable membrane significantly reduces the incidence and severity of adhesion after abdominopelvic surgery. Methods: Between 2003 and 2006, a total of 150 patients with gastric cancer who were scheduled to undergo gastrectomy were randomly assigned to a sodium hyaluronate-based bioresorbable membrane (Seprafilm) group or to a control group. Before closing the abdominal incision, 2 sheets of Seprafilm membrane were applied to the surface of the small intestine under the middle abdominal wound in the Seprafilm group. The primary end point was the incidence of bowel obstruction. Secondary end points were intraoperative and postoperative morbidity and mortality. We registered with Clinical Trials.gov using the Protocol Registration System (ID-NCT00529412). Results: We evaluated a total of 144 patients: 70 in the Seprafilm group and 74 in the control group. The overall incidence (Seprafilm group, 5.7% vs. control group, 9.5%; P = 0.534) and the cumulative incidence of small bowel obstruction (6.2% vs. 12.2% at 36 months; P = 0.3789) were slightly but not significantly lower in the Seprafilm group. The incidence of postoperative complications was similar in the groups (32.9% vs. 29.7%; P = 0.722). Seprafilm did not adversely affect bowel, liver, or renal functions. Conclusions: The use of Seprafilm does not significantly reduce the incidence of small bowel obstruction in patients undergoing gastrectomy for gastric cancer.

A 41-year-old man was found to have advanced gastric cancer with simultaneous multiple bone metastases when pyloric stenosis was being diagnosed in our hospital. We performed gastrojejunostomy from the lower third of the stomach to the upper third of the duodenum to relieve the obstruction. However, at 8 days after surgery, disseminated intra-vascular coagulation (DIC) occurred. Therefore, the patient was administered combined chemotherapy with TS-1 plus low-dose cisplatin in addition to anti-DIC therapy. TS-1 (150 mg/day) and cisplatin (10 mg/body intravenously over the course of 30 minutes) were administered on days 1 to 5, 8 to 12, and 15 to 19 (weekday-on/weekend-off schedule). There was remarkable response to this chemotherapy, and the patient was shifted from inpatient to outpatient treatment. The treatment course was repeated for 4 cycles until remission was observed. Because of hematologic relapse due to DIC at 6 months after the first treatment, he was readmitted for administration of combined chemotherapy. Fortunately, DIC once again responded to the same chemotherapy regimen. In this pathologic condition, combined chemotherapy is unavoidable when DIC occurs with cancer. Accordingly, it is necessary that an effective combined chemotherapy with mild bone marrow suppression be chosen. A companion drug should be chosen in consideration of delayed homo-toxicity and of the possibility of relapse into DIC in the drug withdrawal period. In addition, it is indispensable that careful consideration be given to the most favorable dose and regimen.

The patient was a 50-year-old female with peritoneal metastasis of Type 4 gastric cancer. She underwent a relative curative resection with total gastrectomy and peritonectomy. Postoperative chemotherapy with 5'-DFUR following 5-FU and CDDP was performed. Thirteen months after surgery, cancer recurrence was suspected due to elevated levels of the serum tumor markers carcinoembryonic antigen (8.9 ng/ml) and alpha fetoprotein (85.8 ng/ml). She was additionally treated with UFT 300 mg/day and Lentinan 2 mg/week. The serum tumor markers decreased gradually returned to normal levels. At 5 years and 8 months after surgery, she is alive without any sign of recurrence.

A 66-year-old man was found to have both advanced cancer of the middle thoracic esophagus and advanced cancer of the middle third of the stomach with paraaortic lymph node metastases. The prognosis was poor because of local advanced disease and distant metastasis. The patient was therefore given combined chemotherapy with TS-1 and cisplatin. TS-1 (80 mg/day) was administered on days 1 to 5, 8 to 12, 15 to 19, and 22 to 26 (weekday-on/weekend-off schedule), and cisplatin (70 mg/m2 intravenously over the course of 2 hours) was administered on days 1 and 15 of a 28-day cycle. After 2 courses of chemotherapy the esophageal lesion had a complete response, and the gastric lesion had a partial response (reduction ratio, 71.4%). However, stomatitis and anorexia of grade 2 (NCI-CTC) occurred. Two courses of TS-1 alone (80 mg/m2) were therefore given. The esophageal lesion continued to show a complete response and the gastric lesion a partial response (reduction ratio, 85.7%). There was no change in the para-aortic lymph node metastasis (No. 16a2 latero). No adverse reaction to chemotherapy was severer than grade 3, and a good response was obtained. These findings indicate that chemotherapy with a combination of TS-1 and cisplatin is effective against advanced esophageal cancer and advanced gastric cancer.