Search

Here, we report our experience with a 5-mm trocar site hernia (TSH) near a stoma. This is the first report describing the relationship between TSH and extraperitoneal colostomy. A 72-year-old man underwent laparoscopic abdominoperineal resection with extraperitoneal sigmoid colostomy and partial hepatectomy for rectal cancer accompanied by synchronous liver metastasis (pT3N1aM1a Stage IVA Union for International Cancer Control [UICC] 8th edition). The surgical procedures were completely performed without morbidity. After 1 year, he presented to our hospital with sudden nausea. Computed tomography (CT) revealed small bowel obstruction due to a 5-mm TSH, 1 cm from the stoma. The patient underwent laparoscopic hernia repair. The incidence of a 5-mm TSH is low. However, an abdominal wall vulnerability caused by the extensive exfoliation of the retroperitoneum due to the construction of the colostomy was observed, and the extraperitoneal colostomy influenced the onset of the 5-mm TSH. When the port and hernia sites are located in close proximity to each other, even a 5-mm trocar site may increase the incidence of TSH.

Several studies have reported the efficacy of near-infrared imaging using indocyanine green in laparoscopic low anterior resection (LAR), but a detailed examination of its fluorescence abnormalities is still insufficient. The purpose of this study was to clarify the incidence of fluorescence abnormalities and to create a new prediction score in laparoscopic LAR. This was a retrospective, multicenter study that included patients with rectal cancer who underwent laparoscopic LAR from September 2014 to November 2018. A total of 336 patients were included. The transection line was changed due to fluorescence abnormalities in 5.4% (18/336) of cases, and the median length of additional resection was 70 mm. Anastomotic leakage of Clavien-Dindo grade ≥ II occurred in 6.0% (20/336). The gender and the intraoperative pre-planned proximal margin (IpPM) were significant factors for fluorescence abnormalities. We devised the fluorescence abnormality prediction score (FAPS) derived from the gender, IpPM, and tumor height from the anal verge (TumorAV). The area under the curve of the FAPS was 0.784 (95% CI: 0.677–0.891). When the cutoff was 4, the sensitivity was 0.833, and the specificity was 0.626. The preoperative pre-planned proximal margin (PpPM) was calculated as follows: PpPM (mm) = 189 (mm) – TumorAV (mm) + 61 × Male (1/0). The proximal margin should be set to be larger than the PpPM to avoid fluorescence abnormalities. The incidence of fluorescence abnormalities in laparoscopic LAR was 5.4%. If the FAPS is used, the PpPM may be set from the viewpoint of the blood perfusion. Japanese Clinical Trials Registry: UMIN000032654 ( http://www.umin.ac.jp/ctr/index.htm ).

Lateral lymph node dissection (LLND) has been considered as the standard treatment strategy for locally advanced lower rectal cancer in Japan. Controversy remains around whether all patients require LLND. This study aims to examine the long-term outcomes of patients in which LLND was performed and clarify the value of LLND. Consecutive 458 patients with lower rectal cancer who underwent total mesorectal excision (TME) plus LLND from 1992 to 2012 were included. The long-term outcomes and risk factors for recurrent in patients performed TME + LLND were examined. We assessed the impact of LLND on survival using an estimated therapeutic index. The incidence of LLNM was 15.5%. The 5-year RFS and OS rates of patients with LLNM were 40.9% and 47.7%, while patients without LLNM had a good prognosis. The 5-year local recurrence (LR) rate was 9.2%, and independent risk factors for LR were T4 and LLNM. The LR rate of patients with LLNM was high (22.8%). The LLNM rate of the groups with 0, 1, 2, 3, or 4 risk factors (male, tumor location < 4 cm from anal verge, T4, and MLNM) was 3.8%, 9.2%, 18.1%, and 50.0%. The 5-year OS of the groups was 96.2%, 86.1%, 69.7%, and 48.5%. Although patients with locally advanced lower rectal cancer who received LLND had a good prognosis, LLND alone was insufficient to control local recurrence in patients with metastatic lateral nodes.

Although the effectiveness of antiemetic therapy for colorectal cancer chemotherapy has improved with further drug development, some patients still suffer from chemotherapy-induced nausea and vomiting (CINV) even with only 5-hydroxytryptamine-3 receptor antagonist and dexamethasone. The present study investigated the risk factors of CINV in patients who received chemotherapy for colorectal cancer and clarified which patients need additional neurokinin 1 receptor antagonist. Patients with colorectal cancer receiving moderate-emetic-risk chemotherapy (MEC) were enrolled in this prospective single-arm study with intravenous palonosetron 0.75 mg and dexamethasone 9.9 mg before chemotherapy and with paroral dexamethasone 8 mg on days 2 and 3. The primary endpoint was the complete response (CR) rate for delayed-phase CINV. A total of 179 patients were eligible for this study. The delayed CR rate was 84.9% (152/179). There were no significant differences in any risk factors, but women with a low body mass index (BMI) (a combination of “female sex” and “BMI < 20”) showed a significantly lower rate of CC (complete control) (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.17–1.13; p = 0.039), and young patients with a low BMI (combination of “age < 65” and “BMI < 20”) showed a significantly lower rate of CR (OR = 0.34, 95% CI = 0.13–0.88; p = 0.022) than the other patients. This study failed to identify any single risk factors associated with delayed CINV in patients who received chemotherapy for advanced colorectal cancer. However, combinations of “thin and women” or “young and thin patients” might be possible predictive conditions, thus, candidates for NK1 receptor antagonist administration in MEC. Further investigations are required to develop criteria for the supplementation of NK1 receptor antagonist.

The present study evaluated the safety and efficacy of neoadjuvant chemotherapy with modified 5-fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) plus panitumumab in clinical stage III rectal cancer with KRAS wild-type. We conducted a prospective multicenter phase II trial. KRAS wild-type clinical stage III rectal cancer patients were enrolled. Patients received 6 cycles of mFOLFOX6 with 6 mg/kg panitumumab as neoadjuvant chemotherapy. The primary outcome was the response rate (RR) defined by RECIST. Lateral lymph node dissection (LLDN) was performed when patients had a locally advanced tumor

BackgroundThe initial phases of robotic surgical skills acquisition are associated with poor technical performance, such as low knot-tensile strength (KTS). Transcranial direct-current stimulation (tDCS) can improve force and accuracy in motor tasks but research in surgery is limited to open and laparoscopic tasks in students. More recently, robotic surgery has gained traction and is now the most common approach for certain procedures (e.g. prostatectomy). Early-phase robotic suturing performance is dependent on prefrontal cortex (PFC) activation, and this study aimed to determine whether performance can be improved with prefrontal tDCS.MethodsFifteen surgical residents were randomized to either active then sham tDCS or sham then active tDCS, in two counterbalanced sessions in a double-blind crossover study. Within each session, participants performed a robotic suturing task repeated in three blocks: pre-, intra- and post-tDCS. During the intra-tDCS block, participants were randomized to either active tDCS (2 mA for 15 min) to the PFC or sham tDCS. Primary outcome measures of technical quality included KTS and error scores.ResultsSignificantly faster completion times were observed longitudinally, regardless of active (p p p p = 0.029) were only observed in the active group.ConclusiontDCS could reduce error and enhance KTS during robotic suturing and warrants further exploration as an adjunct to robotic surgical training.

Background We sought a diagnostic tool using perioperative variables that might predict post-hepatectomy liver failure (PHLF). Patients and methods In 68 patients undergoing major hepatectomy, data on inflammatory markers and coagulation factors were prospectively collected and were compared between patients with International Study Group of Liver Surgery definition grade B/C PHLF (LF group) and those without LF (non-LF group). Results Preoperatively, the LF group (n=9; 13.2%) had a lower platelet count and a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs 13 (ADAMTS13) activity and a higher prothrombin time-International Normalized Ratio (PT-INR) than the non-LF group. On postoperative day 1, the LF group had significantly higher serum interleukin 6 (IL6), C-C motif chemokine ligand 2 (CCL2), and IL10 levels than the non-LF group. The logistic regression model that included preoperative PT-INR and CCL2 on postoperative day 1 predicted grade B/C PHLF with 100% sensitivity and 89.8% specificity. Conclusion Our findings suggest that the combination of preoperative PT-INR and CCL2 on postoperative day 1 can predict PHLF earlier and precisely after major hepatectomy.

The aim of this retrospective study was to evaluate the frequency and risk factors of urinary dysfunction after autonomic nerve-preserving surgery for rectal cancer. This was a retrospective multiinstitution study of 1002 rectal cancer patients conducted between January 2008 and December 2012 in Yokohama Clinical Oncology Group. Patients who had preoperative urinary dysfunction or had not undergone autonomic nerve preservation surgery were excluded. Urinary dysfunction was defined as that with a Clavien-Dindo classification grade ≥ 2. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses. A total of 887 patients were analyzed. Postoperative urinary dysfunction was observed in 77 patients (8.8%). A multivariate logistic analysis showed that a tumor location in lower rectum (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.15–3.71; p = 0.02), tumor diameter ≥ 40 mm (OR 2.07; 95% CI 1.19–4.44; p

Para-aortic lymph node (PALN) metastasis of colorectal cancer is rare, and the treatment strategy for PALN metastasis (PALNM) is not established in contrast to liver or lung metastases. We sought to evaluate the survival outcomes and prognostic factors among patients undergoing surgery combined with extended lymphadenectomy for PALNM from left-sided colorectal cancer. From 1992 to 2012, 322 patients who underwent PALN dissection (PALND) synchronously with primary resection, among 1819 left-sided colorectal surgical cases, were retrospectively examined. We investigated the overall survival (OS) and prognostic factors for patients with PALNM. Of the 322 patients, 62 (19.3%) were histologically confirmed to have PALNM. The 5-year OS in patients with and without PALNM was 19.5% and 67.0% (p

There are few randomized controlled trials on the efficacy of spray-type anti-adhesion material during diverting ileostomy in laparoscopic rectal cancer surgery. This study will assess whether or not spraying an anti-adhesion material during diverting ileostomy could reduce the surgeon's multifaceted workload in ileostomy closure. Patients with laparoscopic or robotic surgery for rectal cancer scheduled for low anterior resection and diverting ileostomy will be enrolled in the ADOBARRIER study (multicenter, single-blind, randomized controlled trial). The target sample size is set at 120 cases, which will be randomly divided into an anti-adhesion material-using group and a non-using group at a ratio of 1:1. The primary endpoint is the multifaceted workload of the surgeon of ileostomy closure using SURG-TLX between groups with and without usage of the anti-adhesion material during diverting ileostomy construction; the secondly endpoint is the operative time, amount of intraoperative blood loss, degree of adhesions, and extent of intra-abdominal adhesions when the ileostomy is closed. This RCT will evaluate the efficacy and safety of spray-type anti-adhesion material for diverting ileostomy construction. The results of this study are expected to facilitate decision-making regarding the use of anti-adhesion material. This trial was registered with the Japan Registry of Clinical Trials (jRCT) in October 2020 as jRCTs032200155.

This study evaluated the results of laparoscopic surgery (LAP) compared to open surgery (OP) for locally advanced mid-to-lower rectal cancer. From February 2008 to December 2014, we collected patient data with clinical stage II/III mid-to-lower rectal cancer who underwent resection with LAP or OP at 13 institutions associated with the Yokohama Clinical Oncology Group (YCOG). The short-term outcomes and long-term prognoses associated with LAP and OP were analyzed after adjusting for the patients’ backgrounds using propensity score matching. Among 1091 eligible cases, a propensity score matching with six covariates—age, sex, body mass index, American Society of Anesthesiologists physical status category, tumor location, and clinical stage—extracted 237 cases each for the LAP and OP groups, respectively. After matching, there were no differences in background factors between the two groups except for the presence or absence of preoperative treatment. Operative time was significantly longer in the LAP group than that in the OP group (p < 0.001), while the amount of bleeding and the length of postoperative hospital stay were significantly lower in the LAP group than that in the OP group (p < 0.001 and p = 0.001, respectively). There were no significant differences between groups in the incidence of postoperative complications. The 3-year overall survival and relapse-free survival rates were 90.5% and 88.6% and 78.3% and 71.6% in the LAP and OP groups, respectively, which did not differ significantly. The short-term outcomes and long-term prognoses of LAP in this cohort study indicated that LAP could be a therapeutic option for locally advanced rectal cancer. Trial Registration: UMIN000040406

Randomized controlled trials (RCTs) comparing intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) could not prove a significant reduction in postoperative stay and therefore did not provide sufficient evidence of IA. Recently, we reported a new intracorporeal anastomosis method and intracorporeal end-to-end anastomosis (IEEA). However, there have been no studies comparing intracorporeal side-to-side anastomosis (ISSA) to IEEA. The main purpose of this study is to verify the superiority of IA over EA. The secondary purpose is to compare IEEA with ISSA. Patients scheduled to undergo laparoscopic colectomy for colon cancer are recruited to the CONNECT study (multicenter, single-blind, randomized controlled study), cases in which anastomosis by the double-stapling technique is planned will be excluded. The target sample size is set at 300 cases in total, which will be randomized into 3 groups (EA, IEEA, and ISSA) in a 2:1:1 ratio. The primary endpoint is the length of postoperative hospital stay in the IA and EA groups; the secondly endpoint is the anastomotic time in IEEA and ISSA groups. We will also evaluate SF-36 ver.2, EORTC QLQ-C30 ver.3, operator stress using SURG-TLX, and the long-term outcomes, such as 5-year disease-free survival and overall survival. This RCT will compare the postoperative length of stay between IA and EA in twice the number of cases of previous RCTs. Concurrently, although as a secondary purpose, this will be the first study to compare IEEA and ISSA. Trial registration: This trial was registered with the UMIN Clinical Trials Registry in September 2020 as UMIN000041565.

Recently, several studies have suggested that near-infrared (NIR) imaging using indocyanine green (ICG) may contribute to the reduction of anastomotic leakage (AL) after colorectal cancer (CRC) surgery. However, few reports have focused on the usefulness of NIR imaging for AL after stapled functional end-to-end anastomosis (stapled FEEA). The purpose of this study was to clarify the frequency of fluorescence abnormalities on NIR imaging, in cases reconstructed with stapled FEEA. This retrospective study included patients with colon or appendiceal cancer who underwent laparoscopic colectomy with stapled FEEA reconstruction between March 2016 and August 2019. A total of 400 patients who were managed at our three institutions were included in the present study. The rate of Clavien-Dindo (CD) grade > III AL was 1.0% (4/400). The median length of postoperative hospital stay was 7 days (IQR 25–75th percentile 6–8 days). In 11 patients (2.8%), the transection line was changed by NIR imaging, due to fluorescence abnormalities. The rate of transverse colon involvement in anastomosis was significantly higher in cases with fluorescence abnormalities than in cases with normal fluorescence (p = 0.035). The frequency of fluorescence abnormalities on NIR was 2.8% in cases of colon resection with reconstruction by using stapled FEEA. There was a probability of abnormal fluorescence on NIR in cases where the transverse colon was involved in the anastomosis. This means that NIR may have potential benefit in such cases. UMIN000039977

Aim The present study clarified the effect on the health‐related quality of life and patient satisfaction of single‐incision laparoscopic colectomy compared with multiport laparoscopic colectomy for colorectal cancer. Methods We conducted a multicenter, randomized, control trial comparing single‐incision and multiport laparoscopic colectomy for colon cancer. We performed a pre‐planned secondary analysis of health‐related quality of life and patient satisfaction data of 200 patients. Health‐related quality of life was evaluated using the Japanese 36‐item Short Form Health Survey (SF‐36) version 2.0 before surgery and at 1 month after surgery. Patient satisfaction was compared using seven questionnaires at 1 month after surgery. Results One hundred patients were assigned to each group. After excluding 18 patients (9.0%) who did not complete the SF‐36, 182 patients (91.0%) were included in the analysis (92 cases of single‐incision laparoscopic colectomy and 90 cases of multiport laparoscopic colectomy). The SF‐36 scores at 1 month after surgery were not significantly different between the two arms. The role physical, bodily pain, vitality and physical component summary were significantly lower at 1 month after surgery than before in both groups. However, the role emotional was significantly lower after surgery than before only in the single‐incision laparoscopic colectomy group. In terms of patient satisfaction at 1 month after surgery, there were no significant differences in any of the seven items on the questionnaire. Conclusions Single‐incision laparoscopic colectomy was similar to multiport laparoscopic colectomy in terms of health‐related quality of life and patient satisfaction. However, single‐incision laparoscopic colectomy may be inferior than multiport laparoscopic colectomy in terms of the role emotional., We demonstrated in this sub‐analysis of a multicenter, randomized controlled trial comparing single‐incision laparoscopic colectomy (SILC) and multiport laparoscopic colectomy (MPLC) for colon cancer patients that SILC was similar to MPLC in terms of health‐related quality of life and satisfaction. However, SILC may be inferior in terms of the role emotional.

Background Surgical site infection (SSI) is a common morbidity in patients undergoing colorectal surgery, and the focus of previous studies has primarily been on incisional SSI. Most reports thus far have focused on open surgery rather than on laparoscopic colorectal surgery (Lap CR). Therefore, the aim of the present study was to identify the risk factors for incisional SSI in patients undergoing elective Lap CR. Methods This retrospective study was conducted to evaluate the occurrence and risk factors of incisional SSI for elective Lap CR. From January 2008 to June 2018, 1825 consecutive patients with a preoperative diagnosis of colorectal cancer who underwent Lap CR were analyzed at a single institution. Results Incidence of incisional SSI was 3.3%. Postoperative hospital stay (days) was significantly longer in the incisional SSI group than in the non‐incisional SSI group (8 [6‐12] vs 10 [8‐19], P

Purpose To assess the predictive ability of the maximum chemiluminescence intensity (CImax) for severe neutropenia (SN) during neoadjuvant chemo(radio)therapy [NAC(RT)] in patients with advanced pancreatic or biliary tract cancer. Methods Clinicopathological variables and blood test data before NAC(RT) were evaluated in 64 patients with advanced pancreatic or biliary tract cancer who received gemcitabine plus tegafur/gimeracil/oteracil as NAC(RT). Results Thirty-nine patients (60.9%) developed Grade 3–4 SN. The median time between commencing NAC(RT) and the onset of SN was 15 (range 10–36) days. SN occurred during the NAC period, not the RT period. The CImax, neutrophil count, serum interleukin-6 level, C-reactive protein level, complement C3 titer, serum complement titer, and 50.0% hemolytic unit of complement before NAC(RT) were significantly lower in patients with SN than in those without SN (P

The safety and efficacy of laparoscopic surgery for transverse and descending colon cancer remain controversial. This study aimed to evaluate the short- and long-term outcomes of this procedure. We conducted a single-institutional randomized controlled trial. Patients with transverse or descending colon cancer were randomly allocated to receive laparoscopic surgery (LAC) or conventional open surgery (OC). The primary endpoint was the overall complication rate between the two groups. The secondary endpoints were the length of the postoperative hospital stay, the health-related quality of life (HRQOL) score (at 1, 6, and 12 months after surgery), the 5-year relapse-free survival (RFS), and the 5-year overall survival (OS). Between August 2008 and October 2012, a total of 66 patients were enrolled (33 in the LAC group and 33 in the OC group). The patient characteristics showed no significant differences between the two groups. The complication rates (≥ grade 3) were 6.1% in the LAC group and 12.1% in the OC group (p = 0.392). The length of postoperative stay was not significantly different between the two groups. Regarding the HRQOL, the physical functioning, role physical, bodily pain, social functioning, mental health, and role component summary at 1 month after surgery and the social functioning and mental health at 6 months after surgery were better in the LAC group than in the OC group. The 5-year RFS and OS rates were similar between the LAC and OC groups (RFS 90.5% and 87.3%, respectively, p = 0.752; OS 93.3% and 100.0%, respectively, p = 0.543). The short- and long-term outcomes of laparoscopic surgery for transverse and descending colon cancer are almost equal to those of open surgery. Laparoscopic resection is a better choice than open surgery for managing this cancer with regard to the short- and mid-term QOL. ClinicalTrials.gov Identifier: NCT01861691 .

Background The fecal occult blood test (FOBT) is widely accepted as the most economic and non‐invasive screening method for colorectal cancer (CRC). However, the FOBT is inconvenient because it requires a fecal sample and shows limited accuracy. Alternatively, we hypothesized that fecal gas compounds from bowel movements may be a non‐invasive biomarker for CRC. Methods Gas compounds were collected from the bowel movements of 30 patients with CRC and from 26 healthy controls. The patient group comprised 17 males and 13 females, and the average age was 68 years. Additionally, 22 patients had colon cancer, and eight patients had rectal cancer. Gas compounds were analyzed using gas chromatography and compared with those from healthy controls. Results In the gas analysis, methyl mercaptan was significantly higher in the CRC group than in the control group. Hydrogen was significantly lower in the CRC group than in the control group and was correlated with tumor depth and advanced disease stage. Sensitivity, specificity, and accuracy of detection by a discriminant formula were 90%, 57.7%, and 75%, respectively. Conclusion Gas compounds from defecation constitute a promising, novel non‐invasive approach for CRC screening. (UMIN000028256), This study analyzed the gas compounds of colorectal cancer (CRC) patients and healthy controls at defecation in toilet using an extremely non‐invasive technique. The volatile organic compounds from defecation are different compared with CRC patients and healthy controls. The sensitivity, specificity, and accuracy of the discriminant formula for colorectal cancer were 90%, 57.7%, and 75%, respectively. We concluded that gas compounds from defecation constitute a promising, novel non‐invasive approach for CRC screening.

Although obesity is considered as a risk factor for postoperative morbidity in abdominal surgery, its effect on the outcomes of laparoscopic-assisted colectomy (LAC) is still unclear. The technical difficulty and risk factor for postoperative complication in LAC are thought to be influenced by visceral obesity. The aim of this prospective study was to evaluate the impact of visceral fat on the surgical outcomes of LAC.Between April 2005 and December 2010, consecutive patients with preoperatively diagnosed colon cancer, excluding medium and low rectal cancer, who underwent LAC, were enrolled. Their visceral fat area (VFA) and body mass index (BMI) were prospectively collected. The VFA was assessed by Fat Scan software. The patients were classified into two groups as follows: VFA nonobese with VFA100 cm(2) (VNO) and VFA obese with VFA ≧100 cm(2) (VO). The predictive factors for surgical complications of LAC were evaluated by univariate and logistic regression analyses.A total of 338 consecutive patients were enrolled in this study. Of the 338 patients, 194 (57.4 %) and 138 (42.6 %) were classified into the VNO and VO groups, respectively. Logistic regression analysis showed that high BMI (≧25 kg/m(2)) and VO independently predicted the incidence of overall postoperative complications (p = 0.040 and 0.007, respectively). VO was more highly related to the incidence of overall postoperative complications, anastomotic leakage (p = 0.021), and surgical site infection (SSI) (p = 0.013) than high BMI.VFA is a more useful parameter than BMI in predicting surgical outcomes after LAC.

The effects of subcutaneous closed-suction Blake drain for preventing incisional surgical site infections (SSIs) after colorectal surgery have never been evaluated in a randomized controlled trial (RCT). Thus, we performed a RCT to evaluate the clinical benefits of using a subcutaneous closed-suction Blake drain in patients undergoing colorectal surgery. Consecutive patients who underwent colorectal surgery were enrolled in this study. Patients were randomly assigned to the subcutaneous closed-suction drainage arm or the control (no subcutaneous drainage) arm. The primary endpoint was incidence rate of incisional SSIs. And, we performed logistic regression analysis to detect predictive factors for incisional SSIs after colorectal surgery. From November 2012 to September 2014, a total of 240 patients were enrolled in this study. One-hundred-seventeen patients who were treated by the control arm and 112 patients by the subcutaneous drainage arm were judged to be eligible for analysis. The incidence of incisional SSIs rate was 8.7 % in the overall patients. The incidence of incisional SSIs rate was 12.8 % in the control arm and 4.5 % in the subcutaneous drainage arm. There was significantly reduction of the incidence in the subcutaneous drainage arm than in the control arm (p = 0.025). Logistic regression analysis demonstrated that thickness of subcutaneous fat >3.0 cm, forced expiratory volume in 1 s as percent of forced vital capacity (FEV1.0 %) >70 %, and subcutaneous drain were independent predictors of postoperative incisional SSIs (p = 0.008, p = 0.004, and p = 0.017, respectively). The results of our RCT suggest that a subcutaneous Blake drain is beneficial for preventing incisional SSIs in patients undergoing colorectal surgery.

The treatment of splenic flexural colon cancer is not standardized because the lymphatic drainage is variable. The aim of this study is to evaluate the lymph flow at the splenic flexure. From July 2013 to January 2016, consecutive patients of the splenic flexural colon cancer with a preoperative diagnosis of N0 who underwent laparoscopic surgery were enrolled. Primary outcome is frequency of the direction of lymph flow from splenic flexure. We injected indocyanine green (2.5 mg) into the submucosal layer around the tumor and observed lymph flow using the laparoscopic near-infrared camera system in 30 min after injection. Thirty-one patients were enrolled in this study. The lymph flow was visualized in 31 patients (100 %) without any complications. No case exhibited lymph flow in both the left colic artery (LCA) and left branch of the middle colic artery (lt-MCA) areas. There were 19 cases (61.3 %) with lymph flow directed to the area of the root of the inferior mesenteric vein (IMV), regardless of the presence of the left accessory aberrant colic artery. Lymph node metastases were observed in six cases (19.4 %), and all of the involved lymph nodes existed in lymph flow areas determined by real-time indocyanine green fluorescence imaging. The findings of the lymph flow pattern of splenic flexure suggest that lymph node dissection at the root of the IMV area is important, and it may be not necessary to ligate both the lt-MCA and LCA, at least in cases without widespread lymph node metastases.

It has been reported that some patients do not have an anastomosis of a marginal artery near the rectosigmoid junction, but the frequency of this condition and its clinical significance so far remain unclear. The aim of this study was to evaluate the blood flow at the marginal artery near the rectosigmoid junction. From January 2013 to January 2014, we enrolled consecutive patients with a preoperative diagnosis of left-sided colon cancer or rectal cancer who underwent surgery with lymph node dissection. During the operation, the blood flow through the point of origin of the last sigmoid arterial branch, originating from the inferior mesenteric artery, was interrupted, and the rectosigmoid junction was supplied by only the marginal artery. We injected indocyanine green intravenously and observed the blood flow using a near-infrared camera system. A total of 119 consecutive patients were enrolled in this study. Sixty-eight patients (57.1 %) had a good anastomosis of the marginal artery near the rectosigmoid junction (type A). In 27 patients (22.7 %), a fluorescence border was recognized, but the fluorescence border diminished within 60 s (Type B). In 18 patients (15.1 %), delayed fluorescence was recognized over 60 s (type C), and 6 patients (5.0 %) had no fluorescence at all (type D). A mean length of 14.8 cm was found from the peritoneal reflection to fluorescence border of blood flow. This study proves that cases without the anastomosis of the marginal artery of the rectosigmoid junction truly exist, using studies in living humans (UMIN000011186).