Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer

Total pelvic exenteration (TPE) may be the only procedure that can cure T4 rectal cancer that directly invades the urinary bladder or prostate. Here, we describe our experience of laparoscopic TPE with en bloc lateral lymph node dissection for advanced primary rectal cancer. A 62‐year‐old man diagnosed with advanced lower rectal cancer (T4bN0M0) underwent laparoscopic TPE with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy. Ligation of the dorsal vein complex was performed under direct visualization through the perineal approach, and the large perineal defect was reconstructed using bilateral V‐Y advancement of the gluteus maximus musculocutaneous flaps. The ileal conduit was constructed extracorporeally through an extended umbilical port that was extended to 4 cm. The total operative time was 831 min and estimated blood loss was 600 mL. Laparoscopic TPE appears to be safe and feasible in selected patients.     

Intra‐abdominal desmoid tumor after laparoscopic low anterior resection for rectal cancer: A case report

Desmoid tumors are monoclonal fibroblastic proliferations arising from soft tissue classified as intra‐abdominal, extra‐abdominal and abdominal wall types. We present a patient with an intra‐abdominal desmoid tumor diagnosed 20 months after laparoscopic resection of rectal cancer. A 70‐year‐old woman with hematochezia was diagnosed with advanced rectal cancer. Preoperative chemoradiotherapy followed by laparoscopic low anterior resection was performed. During follow‐up, a nodular soft‐tissue density measuring 28 mm was detected in the presacral region. Metastasis from rectal cancer was diagnosed and four courses of chemotherapy were given, including capecitabine, oxaliplatin and bevacizumab. Computed tomography scan showed that the mass slightly decreased in size and surgical resection was performed. Histopathological examination revealed a proliferation of spindle‐shaped cells and collagenous stroma diagnosed as a desmoid tumor. This report highlights the possibility of a desmoid tumor in the differential diagnosis of an intra‐abdominal mass found during follow‐up after resection of colorectal cancer including following laparoscopic resection.     

Laparoscopic right hemicolectomy for metachronous ascending colon cancer with preservation of an ileal conduit constructed after previous radical cystectomy for bladder cancer

A 79‐year‐old woman who had undergone laparoscopic radical cystectomy and ileal conduit construction for bladder cancer 4 years earlier presented to our hospital with anemia. We diagnosed advanced ascending colon cancer (cT4bN2M1) and documented tumor regression after six courses of folinic acid, 5‐fluorouracil, and oxaliplatin therapy. We then performed laparoscopic right hemicolectomy. Intraoperatively, we found that the right colic artery was the feeding artery of the tumor, whereas the ileocolic artery, which was the main feeder of the conduit, was not. We performed lymph node dissection along the surgical trunk with central vascular ligation of the right colic artery and the right branch of the middle colic artery while preserving the ileal conduit and its blood supply (ileocolic artery and ileal branches). The postoperative course was uneventful, and the patient remains well and cancer‐free 2 years after colonic surgery. We believe that this is the first report of laparoscopic right colectomy in a patient with an ileal conduit.     

Laparoscopic abdominoperineal resection with lateral lymph node dissection for advanced rectal and prostate cancer with synchronous lateral lymph node metastases

Here we report a case of advanced rectal and prostate cancer with synchronous lateral lymph node (LLN) metastases that was treated with laparoscopic surgery. A 71‐year‐old man presented with fecal occult blood and was diagnosed with rectal cancer. A metastatic right LLN was suspected after CT examination of a 19‐mm lymph node (proximal internal iliac artery region) and a 13‐mm lymph node (distal internal iliac artery region) in the right lateral region. We planned neoadjuvant chemotherapy to suppress local and distant recurrence. This treatment decreased the size of the primary rectal tumor. We performed laparoscopic abdominoperineal resection and right LLN dissection. The histopathological diagnosis was LLN metastases from the rectal and prostate cancers. It is rare for synchronous metastases from rectal and prostate cancers to be observed in the LLN. It may be difficult to determine an appropriate treatment strategy in cases like this.     

Combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy for synchronous double cancer of the rectum and the prostate

Here we report a combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy. A 74‐year‐old man was diagnosed with T4b low rectal and prostate cancer. The operation was performed after neoadjuvant chemotherapy for the rectal cancer. The procedure used eight ports in total, five for laparoscopic abdominoperineal resection and six for robotic‐assisted prostatectomy. First, laparoscopic total mesorectal excision including division of the inferior mesenteric artery was performed, and then, robotic dissection of the prostate was performed. The en bloc specimen was removed through the perineal wound. Then, robotic urethrovesical anastomosis was performed. An extraperitoneal end colostomy was created to finish the operation. The operating time was 545 min, and blood loss was 170 mL. The postoperative course was uneventful, and the patient discharged on postoperative day 17. The combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy were performed safely without any additional technical difficulty, as both procedures shared port settings and patient positions.     

Reduced‐port laparoscopic surgery for rectal cancer: Feasibility based on our early experience

We report our experience of a reduced‐port laparoscopic surgery as an advanced laparoscopic surgery for rectal cancer. Twelve selected patients with clinical T1–2 and N0 rectal cancer (clinical stage I) underwent low anterior resection of the rectum. The procedures were performed with one port plus a multiple‐instrument access port with three channels. The multiple‐instrument access port was placed at the umbilicus or the site of diverting stoma, and another port was placed in the right abdomen or in the opposite abdomen of ostomy. The median operative time and intraoperative bleeding were 280 min and 15 mL, respectively. The median number of harvested lymph nodes was 20. No major perioperative morbidities occurred in this series. The median postoperative hospital stay was 10 days. Low anterior resection performed by reduced‐port laparoscopic surgery is feasible as multiport laparoscopic surgery, and it is a reliable surgical option in selected patients with rectal cancer.     

Neoadjuvant chemoradiotherapy followed by laparoscopic distal gastrectomy in advanced gastric cancer: A case report and review of literature

BACKGROUNDThe laparoscopic technique has been widely applied for early gastric cancer, with the advantages of minimal invasion and quick recovery. However, there is no report about the safety and oncological outcome of laparoscopic gastrectomy with D2 lymph node dissection for patients after neoadjuvant chemoradiotherapy. CASE SUMMARYA 60-year-old man was diagnosed with advanced distal gastric cancer, cT4aN1M0 stage III. The neoadjuvant chemoradiotherapy was performed based on the regimen of gross tumor volume 50G y/25 f and clinical target volume 45 Gy/25 f, as well as concurrent S-1 60 mg Bid. Then laparoscopic distal gastrectomy with D2 lymph node dissection was undertaken successfully for him after achieving partial response evaluated by radiological examination. The patient recovered smoothly without moderate or severe postoperative complications. The postoperative pathological stage was ypT3N0M0 with American Joint Committee on Cancer tumor regression grade 1. He was still in good condition after 5 years of follow-up.CONCLUSIONNeoadjuvant chemoradiotherapy followed by laparoscopic technique could be applicable and may achieve satisfactory oncological outcomes. Our finding requires further validation by cohort studies.     

Mediastinoscopic salvage esophagectomy for recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy in a previously pneumonectomized patient

We herein report a case of mediastinoscopic salvage esophagectomy for recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy in a previously pneumonectomized patient. A 66‐year‐old man with a medical history of left‐sided pneumonectomy for lung cancer was diagnosed with local recurrence of lower esophageal squamous cell carcinoma (cT3N0M0 cStage II) 9 years after definitive chemoradiotherapy. The mediastinoscopic cervical approach and laparoscopic transhiatal approach were combined, and the thoracic esophagus was safely mobilized to separate the esophagus from the stump of the left bronchus and to divide dense adhesions between the esophagus and fibrotic tissue at the site of the previous left mediastinal pleural resection. The esophagectomy was uneventful and followed by reconstruction with a gastric conduit via the retrosternal route. The pathological diagnosis was esophageal squamous cell carcinoma (pT3‐AD, pN1, M0, pStage III), indicating R0 resection. Even as salvage surgery, mediastinoscopic esophagectomy is a safe and curative treatment strategy for esophageal cancer patients who have previously undergone pneumonectomy.     

术前放化疗联合手术治疗低位局部晚期直肠癌19例疗效观察

目的探讨术前放化疗联合手术治疗低位局部晚期直肠癌的临床价值。方法2001年2月~2004年12月本院肿瘤科共对19例低位局部晚期直肠癌患者采用术前放化疗联合手术治疗方案。术前放疗总剂量45 Gy,每周5次,每次1.8Gy,同时联合奥沙利铂、甲酰四氢叶酸钙2、5-氟尿嘧啶同步化疗。放化疗结束6周后行手术治疗。结果经过术前放化疗治疗,原发病灶平均直径由4.6 cm缩小为2.5 cm(P<0.05);57.9%的病例T降期,58.3%的病例N降期。全组74%(14/19)的病例采用保留肛门手术,26%(5/19)的患者采用腹会阴联合切除术。术后病理手术标本呈轻度反应2例、中度反应5例、重度反应11例,肿瘤消失2例。结论对低位局部晚期直肠癌患者采用新辅助治疗,可使肿瘤分期降低,提高手术切除率和保肛率。     

Laparoscopic anterior resection for rectal cancer in a patient with a ventriculoperitoneal shunt

Laparoscopic surgery has been relatively contraindicated in patients with ventriculoperitoneal shunts (VPS) because of concerns about the effect of the pneumoperitoneum on shunt function. However, there have been recent reports of laparoscopic surgery on the gallbladder and cecum. This is the first report of laparoscopic high anterior resection for rectal cancer without manipulation of the VPS catheter in a patient with VPS. We made a diagnosis of advanced rectal cancer in a 77‐year‐old man who had a VPS to treat hydrocephalus after a subarachnoid hemorrhage. We performed the procedure with the patient in a 15° head‐down tilt and with 10‐mmHg pneumoperitoneum pressure. There were no postoperative complications. We concluded that laparoscopic surgery for rectal cancer can be safely performed in patients with VPS.     

Lateral lymph node recurrence of rectal cancer with a pathological complete response to chemotherapy confirmed by laparoscopic lateral lymph node dissection: A case report

Lateral lymph node (LLN) metastasis is one of the forms of local recurrence after surgery for lower rectal cancer. We here present a case of LLN recurrence of rectal cancer that was shown by laparoscopic lateral lymph node dissection (LLND) to have a complete pathological response to chemotherapy. A 58-year-old man underwent open low anterior resection for lower rectal cancer. After detection of right LLN recurrence 43 months after the operation, 11 cycles of capecitabine, oxaliplatin, and bevacizumab chemotherapy were administered. Laparoscopic right LLND was performed 55 months after the first operation. Pathological examination revealed no viable tumor cells in the dissected lymph nodes. The patient remains alive without recurrence 61 months after the first surgery and 6 months after laparoscopic LLND. Laparoscopic LLND for LLN recurrence of rectal cancer is feasible and should be considered a valid treatment option.     

Transanal total pelvic exenteration in the prone jackknife position for rectal cancer invading the bladder,seminal vesicles,and small intestine

A 58-year-old man had rectal cancer directly invading the urinary bladder and small intestine, without distant metastasis. We successfully performed complete resection using a hybrid approach, including laparoscopic surgery and transanal total pelvic exenteration (TaTPE) with the patient in the prone jackknife (PJK) position. In the PJK position, gravity and pelvic morphology lead to a clear and wide surgical field. This case demonstrates that total pelvic exenteration using laparoscopic surgery and TaTPE in the PJK position provides a better surgical field than either TaTPE or laparoscopic surgery in the supine position. TaTPE in the PJK position may also be useful for curative surgery in locally advanced rectal cancer.     

Laparoscopic sigmoidectomy with splenic flexure mobilization for colon cancer in situs inversus totalis: Preoperative assessment and preparation

Situs inversus totalis (SIT) is a rare condition in which the internal organ's position is a mirror image of normal anatomy. Although several investigators reported laparoscopic surgery for colorectal cancer in patients with SIT, it is considered difficult even for an experienced surgeon because of the mirror position. We show a case report of laparoscopic sigmoidectomy with the splenic flexure mobilization (SFM) procedure in SIT. A 79-year-old woman with SIT was referred to our hospital for a locally advanced sigmoid cancer (cT3N1M0, cStageIIIB). We safely performed the laparoscopic sigmoidectomy with SFM, as shown in detail below. No postoperative complication occurred, and the patient is in good health with no recurrences 30 months after surgery, as of the writing this report. We propose three critical points; checking the CT angiography to understand the anatomy; using flip-horizontal video of “normal” laparoscopic sigmoidectomy to confirm an unfamiliar situation; adding the epigastric trocar to make SFM procedures safe and comfortable.     

新辅助放化疗对直肠癌患者三年生存率和生存质量的影响分析

目的 探讨新辅助放化疗对局部进展期且可切除的直肠癌患者生存质量及肛门功能的影响.方法 四川省人民医院2015～2018年收治的中低位直肠癌患者,将术前分期为T3～4或N1～2且可切除的103例患者纳入研究,按是否行新辅助放化疗分为新辅助组53例和手术组50例.新辅助组化疗方案为FOLFOX、XELOX或单药口服,放疗方...     

Simultaneous laparoscopic left hemicolectomy and spleen‐preserving distal pancreatectomy for descending colon cancer with pancreatic invasion

Here, we describe laparoscopic colectomy with spleen‐preserving distal pancreatectomy for descending colon cancer with pancreatic tail invasion. A 69‐year‐old man with descending colon cancer staged as clinical state IIIC (cT4b [pancreas] N1M0) underwent definitive laparoscopic surgery that was performed in collaboration with surgeons who specialize in laparoscopic colorectal and hepatobiliary‐pancreatic laparoscopy. After the left colon was mobilized, tumor infiltration of the pancreas, but not the splenic vessels, was confirmed, and the spleen was preserved. The procedures were safely completed laparoscopically, without intraoperative and postoperative complications. Laparoscopic multivisceral resection could be a treatment option for similar patients but only when performed by multidisciplinary specialists.     

Laparoscopic subtotal proctocolectomy for synchronous triple colorectal cancers: a case report

A 42‐year‐old woman presented with abdominal pain. On the basis of CT results, we diagnosed her condition as bowel obstruction caused by advanced transverse colon cancer. Colonoscopy findings showed three lesions: (i) an advanced tumor in the transverse colon; (ii) a laterally spreading descending colon tumor; and (iii) a rectal polyp. The tumors and the polyp were all pathologically diagnosed as adenocarcinoma. After inserting a self‐expanding metallic stent into the main tumor of the transverse colon to decompress the bowel, we performed endoscopic submucosal dissection of the laterally spreading descending colon tumor. Pathological examination results showed submucosal invasion and a positive margin. Because we endoscopically identified that the rectal polyp was invading the submucosa, we performed laparoscopic subtotal proctocolectomy and ileorectal anastomosis with lymph node dissection along the surgical trunk; we also performed central vascular ligation of the ileocolic artery, right and left branches of the middle colic artery, and inferior mesenteric artery. The patient's postoperative course was uneventful. We present this case because there have been few reports on laparoscopic subtotal or total proctocolectomy for synchronous multiple colorectal cancers.     

局部晚期直肠癌同步放化疗前后血浆D-二聚体和高密度脂蛋白对疗效评价的意义

目的分析同步放化疗前后局部晚期直肠癌患者血浆D-二聚体和高密度脂蛋白胆固醇(HDL-C)水平的变化在疗效评价中的意义。方法采用胶乳增强免疫比浊法和直接法测定106例局部晚期直肠癌患者同步放化疗前后血浆D-二聚体和HDL-C水平的变化,并与96例健康体检者做对照。结果与健康体检者相比,局部晚期直肠癌患者的血浆D-二聚体水平明显升高(P0.01),HDL-C水平明显降低(P0.01)。同步放化疗后有效组D-二聚体水平明显降低(P0.01),HDL-C水平明显升高(P0.01),差异有统计学意义。同步放化疗后无效组血浆D-二聚体水平明显升高(P0.05),HDL-C水平明显降低(P0.01)。结论局部晚期直肠癌患者同步放化疗前后血浆D-二聚体和高密度脂蛋白的水平变化可为疗效评价提供依据。     

进展期中低位直肠癌术前同期放化疗的临床研究

目的：探讨术前同期放化疗在进展期（T3、T4）中低位直肠癌治疗中的疗效。方法：将2006年10月—2008年10月60例中低位直肠癌患者随机分为两组：单纯放疗组在给单纯放疗后进行常规手术治疗;同期放化疗组在予希罗达（Xeloda）口服和同期放疗后再手术。对术前单纯放疗组与同期放化疗组的降期效果、手术切除率、保肛率、局部复发率及术后生活质量等进行比较。结果：同期放化疗组于放化疗结束后检查发现肿块均有不同程度缩小、活动度增加,降期、降级作用较单纯放疗组明显（P〈0.05）。同期放化疗组和单纯放疗组的手术切除率分别为90%和66.7%,保肛率分别为63%和30%,两组比较均有显著性差异（P〈0.05）。局部复发率分别为3.7%和10%,两组比较无统计学差异（P〉0.05）。同期放化疗组术后生活质量明显优于单纯放疗组（P〈0.01）。结论：术前Xeloda联合放疗对进展期中低位直肠癌是较好的新辅助治疗方案。     

术前同期放化疗在直肠癌综合治疗中的地位．

外科手术是直肠癌的主要治疗方式,而全系膜切除则被广泛的作为标准治疗。术前同期放化疗在肿瘤降期和病理缓解率方面有明显的优势,提高了局部控制率和保肛率,尽管术后并发症发生率增加,但并没有增加肿瘤相关死亡率,术前同期放化疗已经被广泛的研究和运用到临床治疗中。这篇综述用来阐述术前同期放化疗在局部进展期直肠癌治疗中的地位。     

直肠腔内弹性成像对直肠癌新辅助治疗后肿瘤浸润深度降期的评估

目的评估直肠腔内弹性成像应变比值（SR）判断直肠癌新辅助治疗后肿瘤浸润深度（T分期）降期的临床应用价值。 方法收集北京协和医院收治的进展期直肠癌（T₃期）患者62例,在新辅助放化疗前后,分别行常规直肠腔内超声（ERUS）和直肠腔内弹性成像检查。计算放化疗前后病灶SR差值及SR降幅,以SR降幅判断T分期降期。比较常规ERUS与弹性成像判断T分期降期的准确性。 结果放化疗后,58例（58/62,94%）直肠癌病灶的SR值呈明显下降（t=2.823,P<0.01）,另有4例（7%）SR值升高。pT_0~2期的SR平均值为2.20±0.85,pT₃期的SR平均值为3.19±0.90,两者差异具有统计学意义（t=3.684,P<0.01）。以SR降幅≥33.80%判断放化疗后T分期降期的准确性为69%（40/58）,高于常规ERUS的准确性45%（28/62）,但两者差异无统计学意义（P>0.05）。结合SR降幅,常规ERUS准确诊断降期由14例升高至28例,较好地提高了常规ERUS对T分期降期的诊断准确性。 结论应用SR降幅可较好地辅助常规ERUS,提高直肠癌放化疗后T分期降期诊断准确性,为直肠癌新辅助放化疗疗效及预后评估提供一种新型的较为可靠、无创而又简便的影像学方法。