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Objectives We previously reported the feasibility of neoadjuvant capecitabine and oxaliplatin plus bevacizumab as a treatment for locally advanced rectal cancer (UMIN000003219). The aim of this study is to investigate the prognostic relevance of neoadjuvant chemotherapy followed by total mesorectal resection (TME). Methods Twenty-five patients of our prior multicenter prospective study of neoadjuvant chemotherapy followed by TME enrolled to this study. We analyzed the adjuvant chemotherapy regimen, and the duration between surgery and initial chemotherapy treatment. Five-year progression-free survival and overall survival were estimated using the Kaplan-Meier method. Results Among survivors, the median follow-up time was 66 months. Recurrence occurred in six patients, all of whom had suboptimal tumor regression after neoadjuvant chemotherapy. Five patients died from other causes. The rate of local recurrence and distant metastasis was 17.4% and 8.7%, respectively. Five-year progression-free survival was 70.0%, and 5 year overall survival was 84.0%. Conclusions We report the long-term survival of patients who received neoadjuvant chemotherapy without radiation followed by TME, revealing a generally favorable prognosis.

PURPOSE The International Union Against Cancer highlighted tumor budding as a tumor-related prognostic factor. International assessment criteria for tumor budding were recently defined by the 2016 International Tumor Budding Consensus Conference (ITBCC2016). This study aimed to clarify the prognostic and predictive values of tumor budding in a randomized controlled trial evaluating the superiority of adjuvant chemotherapy with oral tegafur-uracil over surgery alone for stage II colon cancer (SACURA trial; ClinicalTrials.gov identifier: NCT00392899 ). PATIENTS AND METHODS Between 2006 and 2010, we enrolled 991 patients from 123 institutions with stage II colon cancer. Tumor budding was diagnosed by central review on the basis of the criteria adopted in the ITBCC2016. We prospectively recorded all clinical and pathologic data, including the budding grade, and performed prognostic analyses after 5 years of completing the patients’ registration. RESULTS Of 991 tumors, 376, 331, and 284 were classified as BD1, BD2, and BD3, respectively; the 5-year relapse-free survival (RFS) rate was 90.9%, 85.1%, and 74.4%, respectively ( P < .001), and ranged widely in T4 tumors (86.6% to 53.3%). The budding grade significantly correlated with recurrence in the liver, lungs, lymph nodes, and peritoneum ( P < .001 to .01). Multivariable analysis revealed that budding and T stage exerted an independent impact on RFS, and on the basis of the Harrell concordance index, these two factors substantially contributed to the improvement of the Cox model for predicting RFS. Both the BD2 and BD3 groups demonstrated greater improvement in the 5-year recurrence rate in the adjuvant chemotherapy group than the surgery-alone group by approximately 5%, but the difference was statistically nonsignificant. CONCLUSION Tumor budding grade on the basis of the ITBCC2016 criteria should be routinely evaluated in pathologic practice and could improve the benefit of adjuvant chemotherapy for stage II colon cancer.

Despite the widespread use of surgical energy devices and the potential for rare but serious complications, pilot data from North America suggest that surgeons and surgical trainees have knowledge gaps in their safe use. The purpose of this study was to determine baseline knowledge of general surgeons and surgical trainees regarding the safe use of electrosurgery (ES) across varying levels of experience in Japan.Participants completed a 35-item multiple-choice question examination, testing critical knowledge of ES. The examination was developed according to the objectives and blueprints of SAGES' Fundamental Use of Surgical Energy™ curriculum. Sections of the examination included: "principles of ES," "ES-related adverse events," "monopolar and bipolar devices," and "pediatric considerations and interference with implantable devices." Scores were compared between PGY5 and PGY 1-5 participants.A total of 145 general surgeons and surgical trainees of all years after medical school (PGY 1-5: 57, PGY5: 88) from ten academic and five community hospitals completed the assessment (mean age 35; 91% male). The mean score in the entire cohort was 58 ± 12% (range 23-83%), with significantly higher scores in the PGY5 group compared to the PGY 1-5 group (60 ± 11 vs. 53 ± 12%, p0.01). Among all participants, 92% were not familiar with best practices when using ES on patients with a pacemaker; 44% believe that ES uses thermal energy from cautery; 19% did not know how to manage an operating room fire; 16% thought that a dispersive electrode should be cut to fit a child; and 27% believe that insulation failure in minimally invasive surgical instruments is mostly visible under careful inspection.General surgeons and trainees at all levels have knowledge gaps in the safe and effective use of energy devices, regardless of years of experience. There is a need for educational curricula to help address these gaps and contribute to safer surgery.

Introduction Widespread application of laparoscopic cholecystectomy (LC) has resulted in a high complication rate and leads to prolonged hospital stays. This study aimed to investigate the preoperative and intraoperative clinical factors that relate to prolongation of hospital stay. Methods We studied 370 patients who underwent LC for gallbladder disease between 2008 and 2012. Clinical risk factors were retrospectively collected. The clinical pathway for LC was indicated for all patients, and they were divided into two groups according to postoperative length of stay (LOS): the normal duration group (LOS ≤5 days) and the long duration (LD) group (LOS ≥6 days). Multiple regression analysis was used to predict risk factors that identified hospital prolongation to create a LOS prediction score. Results The normal duration group was 236 patients and the LD group was 134. Seventeen patients (4.6%) required conversion from laparoscopic to open surgery. LOS was 4.82 days in the normal duration group and 12.08 days in the LD group. In the LD group, 18.7% of the patients stayed more than 14 days, but no patients were readmitted. Thirteen clinical factors were statistically different between the two groups. ASA score and LC difficulty were the most predictive risk factors for LOS prolongation. LOS prediction score consisted of eight variables selected from 13 factors; it helped determine the likelihood of whether a patients’ hospital stay was prolonged (sensitivity, 82.1%; specificity, 75.0%). Conclusion Thirteen factors closely related to hospital stay duration and LOS prediction score could predict the prolongation of a patient's hospital stay.

Fournier壊疽は皮膚，尿道，直腸肛門周囲から起因菌が陰嚢皮下に達し，陰部動脈の閉塞性動脈炎を起こし，急速な壊疽をもたらす予後不良の感染症である．今回，低位前方切除術々後縫合不全から鼠径管を介しFournier壊疽を発症したが，救命しえた1例を経験した．症例:60歳，男性，手術歴:左陰嚢水腫．進行直腸癌に対して2008年6月に低位前方切除術施行．術後ドレーン排液の汚染は認めず，術後7日目に陰嚢の腫脹，疼痛を認めた．翌日には陰嚢皮膚の壊疽を認め，CTにて陰嚢内および左鼠径部から側腹部に気腫像を伴いFournier壊疽と診断した．緊急広範デブリドレナージ，両側精巣摘除，横行結腸人工肛門造設術を施行した．術後6日目に人工呼吸器離脱．術後52日目に植皮術を行い，治癒し退院した．本症例はドレーンが有効でなく，縫合不全の膿汁が完全には癒合していない腹膜鞘状突起から左鼠径管に入り，Fournier壊疽に至ったと考えられた．

The objective of this study was to investigate the clinicopathological features and postoperative survival of primary colorectal signet-ring cell carcinoma.Nineteen patients with primary colorectal signet-ring cell carcinoma were identified from a database of 5884 surgical patients with colorectal cancers treated surgically at Osaka University Hospital and affiliated hospitals between 1993 and 2007. The clinicopathological data of those patients were compared with those of 5792 patients with non-signet-ring cell colorectal carcinoma (5417 with well or moderately differentiated adenocarcinoma and 375 with poorly differentiated adenocarcinoma or mucinous carcinoma).All patients showed a tumor depth of over T3. Lymph node involvement occurred in 14 patients. Seven of 19 patients presented with distant metastasis at the time of diagnosis. The overall 5-year survival rate in primary signet-ring cell carcinoma was significantly lower at 24.1%, in comparison to 77.5% in well or moderately differentiated adenocarcinoma and 57.7% in poorly differentiated adenocarcinoma or mucinous carcinoma. Likewise, the postoperative survival in Stage III was also significantly worse. On the other hand, no significant difference was observed in Stage II or IV.The most important feature of primary colorectal signet-ring cell carcinoma is the advanced stage at the time of diagnosis. In addition, the postoperative survival is worse than for other types of colorectal cancer.

正中切開法は通常は臍をよけて切開されている．一方，欧米では臍に切開を加えても合併症に差はなく，むしろ美容上よいと報告されている．最近，臍を利用した腹腔鏡手術，豊胸術などの報告を認める．2007年2月より当科では腹腔鏡手術のみならず正中切開は臍に切開を加えてきた（臍切開法）．手技の要点は，臍の最深部の直上および直下の白線に吸収糸をかけて臍がずれないように縫合閉腹する．臍の上，下の皮膚にはステープラーをかけるが，臍の皮膚は縫合しない．特有の合併症もなく，切開創が直線的であり，皮膚切開線が短縮でき，美容上よい．白線が狭い下腹部でも臍部から正中を容易に同定できる．結語:臍をよけて切るという慣習的な考えを捨て，臍切開法は一般的に行われるべき標準手技であると考える．

筆者はラテックスおよび手袋，薬品アレルギー患者となった．手袋のパウダーフリー化およびアレルギープロテクトグローブとしてのポリウレタン手袋内履きの試みを報告する．症例（筆者）:1985年外科医として勤務．手の皮膚炎から，ラテックスフルーツ症候群，喘息，全身の小痒疹出現．I型およびIV型アレルギーが重症化し，2004年に離職．パウダーがラテックス抗原暴露の原因となるため院内のラテックス手袋はパウダーフリーとし，合成ゴム手袋で2005年に復職．しかし，IV型アレルギーが再燃したため2008年より添加化学物質のない未滅菌ポリウレタン手袋（デュラクリーン®ライクラ®）を内覆きし，速乾式アルコールを塗り合成ゴム手袋をはめる方法で手術を施行し，アレルギー反応は改善した．結語:1，ラテックス手袋はすべてパウダーフリーにすべきである．2，ポリウレタン手袋を内履きすることはアレルギー対策に有効である．

難治性小腸皮膚瘻に対して皮弁形成瘻孔閉鎖術を施行し治癒した2例を経験した．術式の概要:全身麻酔下に瘻孔周囲に全周性の皮膚切開をおいて周囲の瘢痕組織を切除．一部残した周囲皮膚組織を含めて吸収糸で瘻孔を縫合閉鎖．その上を血行の良い皮弁で覆う．症例1は10年前に精巣腫瘍にて精巣摘除術，後腹膜リンパ節郭清術，化学療法および放射線療法40Gyの既往．今回，腹部正中創に瘻孔出現．放射線治療に起因する小腸皮膚瘻と診断し，本術式を施行した．術後3週にて食事開始，治癒した．症例2は激症型アメーバ大腸炎にて大腸亜全摘術，回腸瘻造設術々後に小腸穿孔，腹膜炎を合併し，難治性小腸皮膚瘻を形成した．術後11カ月の保存療法にて改善せず，本術式を施行した．術後，腸液漏の再燃を一旦認めたが術後約3カ月で治癒した．難治性小腸皮膚瘻に対して本術式は試みられるべき術式と考えられた．

A fibrin-coated collagen fleece (TachoComb, Nycomed, Denmark) is a powerful topical hemostatic agent, which has been aggressively used in conventional open surgery with a favorable clinical outcome. However, the use of TachoComb in laparoscopic surgery has not yet gained wide clinical acceptance, because a simple and well-functioning application system is not available. The authors have newly developed a quick, simple, and effective laparoscopic TachoComb application technique: housing a small strip of TachoComb in a rubber tube, then conveying it into the peritoneal cavity, and applying it using standard laparoscopic forceps. The repeated application of TachoComb strips is feasible and of practical value especially in laparoscopic surgery, since a small TachoComb never compromises either the application procedure or laparoscopic visualization.

Jejunal pouch reconstruction is used to provide reservoir function after total gastrectomy, but controversy remains regarding pouch functions and quality of life (QOL). In this study, pouch motility was studied in conjunction with postoperative QOL.Pouch motility of 23 patients with jejunal pouch interposition after total gastrectomy was examined by manometry under fasting conditions and by an emptying test using dual-scintigraphy under postprandial conditions. Residual food was graded by endoscopic examinations. QOL was evaluated using the Gastrointestinal Quality of Life Index, and a stasis- or dumping-related symptom score.The pouch showed interdigestive contractile activity. Bursts of contractile activity occurred frequently and were long-lasting compared with the migrating motor complex phase III of the control jejunum. The percentage of time of contractile bursts correlated with postprandial pouch emptying (liquid: R(2) = 0.229, P.03; solid: R(2) = 0.243, P.02). Patients with little or no residual food had more percentage of time of contractile bursts than those with moderate residual food (P.01). The percentage of time of contractile bursts was correlated with the Gastrointestinal Quality of Life Index score (R(2) = 0.262, P.02), stasis-related symptoms (R(2) = 0.279, P.01), and dumping-related symptoms (R(2) = 0.218, P.03).An interposed jejunum pouch showed bursts of contractile activity that affected postoperative gastrointestinal function and patient QOL.

Objective: Combined chemotherapy with S-1 and irinotecan (IRIS) for metastatic colorectal cancer has been reported to be effective and safe. However, there are only a few studies on the effects of adding bevacizumab to IRIS. We conducted a clinical study to evaluate the efficacy and safety of IRIS plus bevacizumab as first-line therapy for metastatic colorectal cancer. Methods: Forty metastatic colorectal cancer patients were enrolled in this phase II study. All patients received irinotecan (80 mg/m2) and bevacizumab (7 mg/kg) on days 1 and 15 and S-1 (40-60 mg twice daily) on days 1-21 of a 5-week repeated cycle. Results: The response rate was 47.4% [95% confidence interval (CI) 31.5-63.2], progression-free survival was 11.9 months (95% CI 9.4-16.8), and overall survival was 23.4 months (95% CI 19.0-inf). The only grade 3 hematological toxicity was neutropenia (16%) and the incidences of grade 3 nonhematological toxicity were low at Conclusion: In this clinical study, we revealed IRIS plus bevacizumab to be a promising first-line regimen for metastatic colorectal cancer with a low incidence of serious toxicities, in which favorable response rates and extension of survival time can be expected.

A case of postlaparoscopic subcutaneous emphysema developed along cutaneous striae was reported. A 35-year-old male patient with marked cutaneous striae underwent hand-assisted laparoscopic proctocolectomy for steroid-dependent ulcerative colitis. After an uneventful surgery, he developed subcutaneous emphysema, which was noted along the cutaneous striae in the bilateral thigh. The localization of emphysema suggested that Pfannensteil mini-laparotomy for hand access was most responsible for the development of subcutaneous emphysema.

Carbon dioxide (CO2), with its rapid absorptive nature, has been proven superior to atmospheric air as an insufflating agent in various clinical settings. However, CO2 insufflation has not gained wide clinical acceptance, mainly because there has been no suitable feeding system. The authors therefore have developed a versatile “dual-channel” CO2 insufflator that facilitates wider use of CO2. The objectives of this study were to introduce the authors’ prototype insufflator, to evaluate its safety and performance, and to validate CO2 application using the prototype. The prototype insufflator provides one CO2 inlet connected to a regular CO2 gas cylinder and two CO2 outlets positioned on the front and back of the device, respectively. The CO2 gas fed from the cylinder is pressure-regulated and divided into two independent conduits inside the device. The front outlet feeds CO2 gas for pneumoperitoneum at an electronically controlled pressure and flow rate. The back channel supplies CO2 gas at a fixed flow rate, allowing manual control of insufflation for various purposes. The device was evaluated with canine models. The prototype was safe and performed well. The CO2 application (colonoscopy in this series) using the back channel was feasible while intact CO2 pneumoperitoneum was simultaneously maintained via the front channel. There were no device malfunctions. The serial abdominal x-rays indicated that intraluminal CO2 insufflation such as that used for CO2 colonoscopy caused less residual intestinal gas than conventional air insufflation. The dual-channel CO2 insufflator enabled two different modes of CO2 insufflation at the same time from a single CO2 cylinder. The authors are now improving the prototype to allow safer and wider usage of CO2 in the operating room.

Bowel distention after colonoscopy has been considered as a cause of blood flow disturbance. Carbon dioxide (CO2), with its higher absorbability and vasodilating effect, may reduce parietal blood flow disturbance of distended colon when used for intraluminal insufflation instead of air. The purpose of this study was to assess parietal blood flow of the colon distended with intraluminal air/CO2 insufflation.A 5-cm segment of rat colon was insufflated with either air (air group) or CO2 (CO2 group). Two insufflation methods were employed: temporary insufflation up to an intraluminal pressure of 60 mmHg and continuous insufflation at a pressure of 5, 15, and 30 mmHg. Bowel distention and parietal blood flow measured by laser Doppler imaging were evaluated.For temporary insufflation, bowel distention was prolonged in the air group, whereas it rapidly resolved in the CO2 group. Parietal blood flow decreased in both groups; however, it recovered within 5 min in the CO2 group. For continuous insufflation, under 5 mmHg insufflation, blood flow decreased in the air group, whereas it increased in the CO2 group. Blood flow decreased in both groups under 15 mmHg insufflation; however, it decreased less in the CO2 group. There was a reverse relationship between insufflation pressure and blood flow difference. Inhibition of nitric oxide synthase, ATP-sensitive K+ channel, or heme oxygenase was ineffective against a CO2-induced increase in blood flow.CO2 insufflation preserved parietal blood flow not only by rapid resolution of bowel distention but also by its potential vasodilative effect.

Miriplatin, a cisplatin derivative with a high affinity for iodized oil, is a novel chemotherapeutic agent designed for use in the transarterial treatment of hepatocellular carcinoma. This case report describes our experience with transarterial chemoembolization (TACE) using miriplatin in 2 patients with neuroendocrine liver metastases. A 38-year-old man with multiple neuroendocrine liver metastases was treated by whole liver chemoembolization, and a 35-year-old woman with a single hepatic lesion was treated by superselective chemoembolization. No serious adverse events were noted during the interventional procedures, or during the observation period of 3 mo in either patient. Sufficient iodized oil uptake was observed in the hypervascular lesions on the unenhanced computed tomography (CT) at 7 d after the procedure. Contrast-enhanced CT obtained at 3 mo after chemoembolization revealed that all hepatic lesions were substantially reduced in size irrespective of tumor vascularity or degree of cystic degeneration, although iodized oil accumulation was only marginal for lesions with cystic degeneration. Thus, TACE with miriplatin can be a safe and effective therapeutic option for the treatment of neuroendocrine metastases of the liver.

Highlights • Retroperitoneal liposarcoma related pregnancy is rare. • Liposarcoma is sometimes positive for hormone receptor. • Additional therapy for liposarcoma is important to improve prognosis., Introduction Liposarcoma is one of the most common soft tissue sarcomas; however, early diagnosis is rare as the tumor remains difficult and unpalpable for a prolonged period of time. Presentation of case Here we report the first case of retroperitoneal liposarcoma associated with pregnancy and expression of estrogen receptor. A 34-year-old woman experienced persistent abdominal distension after her first delivery. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a large (40 cm ×35 cm), solid, palpable abdominal mass with fat attenuation displacing the ascending colon and the right kidney to the left. Laparotomy and an en-bloc resection of the tumor were performed; further, right nephrectomy and adrenalectomy were required. Histopathology showed a well-differentiated liposarcoma; approximately 10–20% of the tumor cells were ER-positive. Discussion Retroperitoneal liposarcoma associated with pregnancy is an extremely rare occurrence. Surgical resection is unquestionably the first choice of treatment, but complete resection is sometimes impossible due to the volume and depth of invasion of the tumor. In such cases, additional therapy for liposarcoma is important to improve prognosis. Thus, this report highlights the need for further research into hormone therapy. Conclusion Retroperitoneal liposarcoma has a high local recurrence rate due to the difficulty in complete surgical resection; therefore, additional hormone therapy is important for improving the prognosis.