Synchronous Colorectal Malignancy and Abdominal Aortic Aneurysm Treated With Endovascular Aneurysm Repair Followed by Laparoscopic Colectomy

Although the incidence of synchronous abdominal aortic aneurysm (AAA) and malignancies is increasing, there has been no clear consensus in the surgical treatment of such patients. The focus on surgical treatments with minimal invasiveness, such as endovascular aneurysm repair (EVAR) for AAA and laparoscopic colectomy for colorectal cancer, has increased; however, the clinical applicability of combination treatment with EVAR and laparoscopic colectomy has not been established. A 61-year-old man was diagnosed with AAA, advanced sigmoid colon cancer, and coronary artery stenosis. Because the patient also had chronic renal failure with nephrotic syndrome, among several other comorbidities, surgery was considered to be associated with high risks in this patent. Sequential treatments with percutaneous coronary intervention, EVAR, and laparoscopic colectomy were successfully performed. Staged treatment of EVAR followed by laparoscopic colectomy may be a promising strategy for high-risk patients with AAA associated with malignancy.Key words: Abdominal aortic aneurysm, Endovascular aneurysm repair, Colorectal cancer, Laparoscopic surgeryWith the aging of the general population, the prevalence of diseases associated with arterial sclerosis, such as abdominal aortic aneurysm (AAA), and that of neoplasms such as colorectal cancer (CRC), has also been increasing.¹ Therefore, the number of cases with concurrent AAA and CRC is expected to increase. However, there has been no clear consensus in the surgical treatment of such patients. The resection of CRC followed by aneurysm repair with a synthetic graft is associated with the potential risk of aneurysmal rupture during the perioperative period of the cancer operation.² Conversely, aneurysm repair prior to CRC resection may result in the delay of cancer therapy and consequent cancer progression²; there is also a possibility of aortic graft infection in the case of anastomotic leakage.¹In recent years, there has been increased focus on surgical treatments with minimal invasiveness for various diseases. In the treatment of AAA, endovascular aneurysm repair (EVAR) is a promising alternative to the conventional open graft replacement. In a large randomized study,³ EVAR was reported to achieve low operative morbidity and mortality, short hospital stay and operation time, and minimal blood loss. However, as a minimally invasive surgical procedure, the use of laparoscopic surgery for CRC is becoming more widespread. Patients who undergo laparoscopic CRC resection have significantly less blood loss and shorter hospital stays than those who undergo more invasive procedures,⁴ even though the reported oncologic outcome is equivalent to that of open surgery.⁵ Although several studies on therapy for concomitant AAA and CRC have been reported,⁶ there have only been a few reports on combination treatment with EVAR and laparoscopic colectomy.⁷ In the present report, we describe a case of synchronous AAA and sigmoid colon cancer with several other comorbidities, in which successful treatment with EVAR and laparoscopic surgery was achieved.     

Conversion Therapy Using mFOLFOX6 With Panitumumab for Unresectable Liver Metastases From Multiple Colorectal Cancers With Familial Adenomatous Polyposis

A 39-year-old man received a diagnosis of unresectable multiple liver metastases from multiple colorectal cancers with familial adenomatous polyposis. After construction of an ileostomy, modified FOLFOX6 (mFOLFOX6) with panitumumab was administrated because rectal cancer and sigmoid colon cancer are KRAS wild type. The 13 courses of chemotherapy resulted in a marked reduction in the size of liver metastases and sigmoid colon cancer. Consequently, curative resection with total colectomy, ileal pouch anal anastomosis, and liver metastasis resection with radiofrequency ablation was performed. Progression of KRAS wild-type rectal cancer after chemotherapy suggested that each clone from rectal and sigmoid colon cancer might have a different sensitivity to epidermal growth factor receptor antibody. Immunohistochemical analysis revealed loss of PTEN expression in rectal cancer compared with liver metastases from sigmoid colon cancer, showing that the difference of mFOLFOX6 with panitumumab might be related to activation of the PI3K-AKT pathway.Key words: Panitumumab, mFOLFOX6, Colorectal cancer, Liver metastases, Familial adenomatous polyposisThe only available treatment associated with long-term survival in patients with liver metastases from colorectal cancer is complete liver tumor resection, with 5-year survival rates ranging from 25% to 57%.¹ However, only 40% to 50% of patients with colorectal metastasis to the liver are eligible for surgical resection.² Therefore, other liver metastasis patients undergo palliative chemotherapy to stabilize the disease and prolong their overall survival.During the past decade, the biggest advance made regarding unresectable liver metastases from colorectal cancer has been the ability of oncologists to convert inoperable liver disease to resectable disease using various molecular targeting drugs.^3,4 Several clinical studies have shown that the association of chemotherapy with bevacizumab (vascular endothelial growth factor monoclonal antibody), or cetuximab [epidermal growth factor receptor (EGFR) monoclonal antibody] is particularly promising in improving the resectability rate and, ultimately, survival.⁵Panitumumab is a fully human monoclonal antibody that binds specifically to the EGFR, and consequently, severe panitumumab-related infusion reactions are rare. Panitumumab, when added to FOLFOX4 (folinic acid, 5-fluorouracil, and oxaliplatin), increased response rate and improved progression-free survival in previously untreated metastatic colorectal cancer.⁶ Retrospective analyses of phase 3 trials of anti-EGFR antibodies, including cetuximab and panitumumab, found KRAS status to be an important predictive marker of efficacy, with only wild-type patients benefiting from treatment.⁷Here, we report a successful conversion therapy using modified FOLFOX6 (mFOLFOX6) plus panitumumab in a patient with familial adenomatous polyposis (FAP) who had unresectable multiple liver metastases from multiple colorectal cancers. To the best of our knowledge, we are the first researchers to demonstrate treatment of multiple target tumors derived from different clones with mFOLFOX6 and panitumumab, and to show differential panitumumab sensitivity for multiple primary tumors and liver metastases.     

Laparoscopic Repair of a Diaphragmatic Hernia Associated with Radiofrequency Ablation for Hepatocellular Carcinoma: Lessons from a Case and the Review of the Literature

We describe the case of a patient with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was successfully treated by laparoscopic surgery. A 62-year-old man with a long history of hepatitis C-induced liver cirrhosis was admitted to our institution because of recurrent postprandial periumbilical pain. Eight years earlier, he had undergone radiofrequency ablation for hepatocellular carcinoma at hepatic segment VIII. Computed tomography, gastrografin enema examination revealed transverse colon obstruction because of a diaphragmatic hernia. We diagnosed diaphragmatic hernia associated with the prior radiofrequency ablation treatment. The patient underwent laparoscopic repair of the diaphragmatic hernia. Though the patient experienced the recurrence once, relaparoscopic treatment has improved the patient''s conditions. Thus, diaphragmatic hernia can develop as a complication of radiofrequency ablation treatment. A laparoscopic approach is safe, feasible, and minimally invasive, even in patients with cirrhosis who develop iatrogenic diaphragmatic hernia as a complication of radiofrequency ablation treatment.Key words: Diaphragmatic hernia, Radiofrequency ablation, Complication, Laparoscopic surgeryAlthough surgery is accepted as the first-line treatment for hepatocellular carcinoma (HCC) and colorectal metastases that are limited in number, radiofrequency ablation (RFA) is an effective treatment option for patients with primary and metastatic liver tumor, who are not surgical candidates because of tumor location, poor hepatic reserve, or advanced age.^1,2,3 Chen et al conducted a prospective randomized trial comparing RFA with hepatectomy; however, they were not able to determine whether on treatment alternative was superior to the other.⁴ RFA treatment is the best option among the locoregional treatments for HCC.^5,6 According to the HCC treatment algorithm in the National Comprehensive Cancer Network guideline, RFA treatment should be chosen as a locoregional therapy depending on the degree of liver damage. Tumors ≤ 3 cm are optimally treated with ablation.⁷ RFA for hepatic tumors is a relatively safe modality with a reported overall complication rate of 7.1% and a very low mortality rate (0.3%);⁸ however, the guideline reinforces awareness of the major vessels, major bile ducts, diaphragm, and other intra-abdominal organs.⁷Diaphragmatic hernia is defined as out-pocketing of abdominal contents into the thoracic cavity, through a defect in the diaphragm. However, most of the acquired diaphragmatic hernias are caused by penetrating or blunt traumatic injury and are rarely caused by surgical procedures such as gastric banding or abdominal surgeries (e.g., nephrectomy).^4,9 Especially, the appearance of a diaphragmatic hernia after RFA treatment is quite rare and clinically unrecognized as a complication of RFA.¹⁰ Surgical intervention is the best single treatment for the permanent cure of a diaphragmatic hernia. Among the surgical procedures, open laparotomy for diaphragmatic hernia has been widely accepted; however, only 1 case of liver cirrhosis and HCC has been reported, in which a laparoscopic approach was used to treat the diaphragmatic hernia associated with RFA treatment.¹⁰ We report the case of a patient with a diaphragmatic hernia caused by RFA treatment for HCC with cirrhosis, who was successfully treated with laparoscopic surgery.     

Intravenous Lidocaine for Effective Pain Relief After a Laparoscopic Colectomy: A Prospective,Randomized, Double-Blind,Placebo-Controlled Study

A perioperative intravenous lidocaine infusion has been reported to decrease postoperative pain. The goal of this study was to evaluate the effectiveness of intravenous lidocaine in reducing postoperative pain for laparoscopic colectomy patients. Fifty-five patients scheduled for an elective laparoscopic colectomy were randomly assigned to 2 groups. Group L received an intravenous bolus injection of lidocaine 1.5 mg/kg before intubation, followed by 2 mg/kg/h continuous infusion during the operation. Group C received the same dosage of saline at the same time. Postoperative pain was assessed at 2, 4, 8, 12, 24, and 48 hours after surgery by using the visual analog scale (VAS). Fentanyl consumption by patient-controlled plus investigator-controlled rescue administration and the total number of button pushes were measured at 2, 4, 8, 12, 24, and 48 hours after surgery. In addition, C-reactive protein (CRP) levels were checked on the operation day and postoperative days 1, 2, 3, and 5. VAS scores were significantly lower in group L than group C until 24 hours after surgery. Fentanyl consumption was lower in group L than group C until 12 hours after surgery. Moreover, additional fentanyl injections and the total number of button pushes appeared to be lower in group L than group C (P < 0.05). The CRP level tended to be lower in group L than group C, especially on postoperative day1 and 2 and appeared to be statistically significant. The satisfaction score was higher in group L than group C (P = 0.024). Intravenous lidocaine infusion during an operation reduces pain after a laparoscopic colectomy.Key words: Analgesics, Colectomy, Pain, LidocaineBecause of a substantial increase in the incidence of benign and malignant tumors of the colon, the number of laparoscopic colorectal surgeries has increased.¹ Laparoscopic colectomy appears to be less painful, involves less bleeding, and has a faster recovery than an open colectomy.² Further, laparoscopic colorectal surgery has been proven to be beneficial in comparison with robot-assisted laparoscopic colorectal surgery in many aspects.³ However, postoperative pain because of surgical incision is still an issue that requires resolution. Therefore, various clinical applications such as intrathecal morphine, epidural analgesia, patient-controlled analgesia (PCA), and nonsteroidal anti-inflammatory drugs (NSAIDs) are used to control pain after a laparoscopic colectomy.^4,5 However, optimal management has not yet been established. A regional block can have technical difficulties and complications. The epidural failure rate has been reported up to 40%, and other drugs, such as opioids or NSAIDs, have side effects or drug allergies.^5,6Intravenous lidocaine is inexpensive, easy to inject, and a relatively safe drug.⁷ A number of studies showed that intravenous lidocaine has analgesic, anti-hyperalgesic, and anti-inflammatory properties, as well as a fast recovery, reducing the hospital stay and the time for bowel function recovery.^8–10 In addition, lidocaine in a nontoxic concentration has been reported to decrease the variant volatile anesthesia requirement in an animal study.¹⁰ Therefore, the authors aimed to determine whether a continuous infusion of intravenous lidocaine would have an adequate postoperative analgesic effect for a laparoscopic colectomy. The hypothesis of this study was that an intravenous lidocaine infusion during an operation could decrease postoperative pain.     

Substernal Goiter: When is a Sternotomy Required?

The presence of substernal goiter is, per se, an indication for surgical management. Surgical approach of substernal goiter can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The aim of this study was to identify the preoperative predictors of a sternotomy in the management of substernal goiter in order to provide better preoperative planning and patient consent. Between 2005 and 2012, 665 patients were referred to our clinic for thyroidectomy, 42 patients (6.3%) had substernal goiter and were included in this study. All substernal goiters were treated surgically, 38 (90.5%) by a cervical approach and 4 (9.5%) by full median sternotomy. All surgeries were successful, with no major postoperative complications. Minor postoperative complications of transient hypocalcemia and transient paralysis of the recurrent laryngeal nerve occurred in 5 (11.9%) and 2 (4.7%) cases, respectively. Indication of median sternotomy was as follows: extension of goiter below the aortic arch, large thyroid tissue extending towards tracheal bifurcation, and ectopic thyroid tissue in the mediastinum. Substernal goiter can be removed through a cervical incision, but on rare occasions, a median sternotomy may be required.Key words: Sternotomy, Substernal goiter, Surgery, TreatmentSubsternal goiter (SG) was first described by Haller in 1749 and first surgically removed by Klein in 1820.¹⁻⁴ There is no uniform definition of substernal goiter.¹⁻³ However, various different criteria have been suggested by authors. These include a thyroid gland extending 3 cm below the sternal notch or extension of the gland below the fourth thoracic vertebra.^5,6 An extension of the thyroid gland below the thoracic inlet has been defined as substernal, retrosternal, intrathoracic, or mediastinal goiter. Drawing upon the relationship of the intrathoracic extension of SG to the arcus aorta and the right atrium and findings from imaging methods, diagnostic classifications have been established that take into account the percentage of goitrous thyroid in the mediastinum.^7,8 Substernal goiters are common, with a reported incidence of 1−20% of all patients undergoing thyroidectomy.^3,5,9−14 Diagnosis of substernal goiter is most frequently made in the fifth or sixth decade of life, with a female/male rate of 4:1.^11,14,15 The vast majority of SGs (85−90%) are located in the anterior mediastinum with the remainder (10−15%) located in the posterior mediastinum.^1,10,16,17Substernal goiters show, in most cases, a slow-growing enlargement, which usually remain asymptomatic for many years; about 20−40% of substernal goiters are discovered as an incidental finding on a radiographic examination.^2,11,18 Patients with mediastinal goiter are rarely asymptomatic. The most common symptoms are related to compression of the airways and the esophagus, and represented by dyspnea, choking, inability to sleep comfortably, dysphagia, and hoarseness.^2,12,14,18 In the diagnostic management of mediastinal goiter, chest computed tomography (CT) was of the highest value. CT scanning is, at present, the most exhaustive examination for assessment of the extent of the goiter and compression effects on adjacent anatomic structures. A preoperative CT scan should be routinely performed in every suspicion of a substernal goiter.^12,19−21 Magnetic resonance imaging (MRI) adds little additional information to that obtained with CT and is not routinely used.¹¹Substernal goiter must be removed surgically due to relation to compressive symptoms, potential airway compromise, and the possibility of an association with thyroid malignancy.¹⁷ There is a general consensus that most can be successfully removed via a cervical approach and that thoracic access is rarely necessary.^9,11,12 Various factors have been reported to increase the likelihood of a median sternotomy being required. These factors include involvement of the posterior mediastinum, extension of the goiter to the aortic arch, recurrent goiter, superior vena cava obstruction, malignancy with local involvement, and emergent airway obstruction.^{6,10,12,16,17,19} In addition, inability to palpate the lowermost extent of the gland also is considered to be an indication for median sternotomy. The incidence of sternotomy in substernal goiter is variable, ranging between 0−11 %.^2,9,11,12 This wide range in incidence might be related to variation in the definition of substernal goiter.In order to improve preoperative planning and patient consent, we aimed to identify the preoperative predictors of a sternotomy in the management of substernal goiter.     

Tissue Management With Tri-Staple Technology in Major and Minor Laparoscopic Liver Resections

One of the most relevant technologic advancements in laparoscopic liver resection (LLR) is owing to the improved ability to safely secure and divide vascular and biliary structures and the liver parenchyma by the use of endostaplers. We compared, retrospectively, 35 LLRs with the Tri-Staple technology versus 57 LLRs without, during a 14-month period. Colorectal liver metastases were overall the main indication for LLR. Neither major hepatectomy nor left lateral sectionectomy was done in the nonstapled group. Mean surgical time and blood loss were similar, whereas the tumor number and size were significantly larger in the stapled group (P ≤ 0.01). The conversion rate was 0% and 3.5% (n = 2); and the morbidity rate was 9% (n = 3) and 12% (n = 7), respectively, in the stapled and nonstapled group (P = 0.8). No overall 3-month mortality was recorded. Endo GIA Reloads with Tri-Staple technology allow a proper division of the intrahepatic vessels and biliary structure. These devices in LLRs are safe and feasible, allowing major hepatectomy and complex cases as 2-staged procedures and laparoscopic living donor liver resections.Key words: Laparoscopic liver resection, Minimally invasive liver surgery, Endo-staplers, Tri-Staple technology, Laparoscopic living donor liver resectionThere has been exponential growth of reported experiences of laparoscopic liver resection (LLR) since the first procedure was performed in 1992, with more than 3000 published procedures available worldwide today.^1–7 Meticulous knowledge of surgical anatomy of the liver, improvements in perioperative care, development of newer instruments, enhanced diagnostic imaging, and advancement in laparoscopic skills are considered the major advances that have been achieved in this field.The indications for laparoscopic hepatic resection are usually the same as the standard approach, as previously advised by the Louisville Statement Consensus Conference.⁸ Although LLR was initially indicated for benign lesions, the recurrence pattern has been shown to be similar to that described for open resection of colorectal liver metastases (CRLM) and/or hepatocellular carcinoma, reporting outcomes at least as good as those reported for open surgery.^9–14In addition, laparoscopic living liver donor hepatectomy has demonstrated its potential role especially in left lateral sectionectomy procurement, where it looks to be more appropriate compared with laparoscopic-assisted techniques in right-lobe living liver donation.^15,16One of the most relevant technologic advancements in minimally invasive liver surgery is owing to the improved ability to safely secure and divide vascular and biliary structures and eventually the liver parenchyma. For this, endostaplers are playing a very important role.The Endo GIA Reloads with Tri-Staple technology (Covidien Europa, Dublin, Ireland) were introduced in 2010 and have been utilized for LLR at Ghent University Hospital since April 2011 as part of standard of care.The Department of General, Hepatobiliary, and Pancreatic Surgery at the Ghent University Hospital started a systematic program of laparoscopic liver surgery in 2004. Today, more than 60% of all resectional procedures are done by laparoscopy.The purpose of this study is to analyze the personal experience and overall results in major and minor LLR comparing stapled versus nonstapled groups.     

Hand-Assisted Laparoscopic (HAL) Multiple Segmental Colorectal Resections: Are They Feasible and Safe?

The objective of this study was to evaluate the short-term outcomes of synchronous hand-assisted laparoscopic (HAL) segmental colorectal resections. The surgical options for synchronous colonic pathology include extensive colonic resection with single anastomosis, multiple synchronous segmental resections with multiple anastomoses, or staged resections. Traditionally, multiple open, synchronous, segmental resections have been performed. There is a lack of data on HAL multiple segmental colorectal resections. A retrospective chart review was compiled on all patients who underwent HAL synchronous segmental colorectal resections by all the colorectal surgeons from our Group during the period of 1999 to 2014. Demographics, operative details, and short-term outcomes are reported. During the period, 9 patients underwent HAL synchronous multiple segmental colorectal resections. There were 5 women and 4 men, with median age of 54 (24–83) years and median BMI of 24 (19.8–38.7) kg/m². Two patients were on long-term corticosteroid therapy. The median operative time was 210 (120–330) minutes and median operative blood loss was 200 (75–300) mLs. The median duration for return of bowel function was 2 days and the median length of stay was 3.5 days. We had 2 minor wound infections. There were no deaths. Synchronous segmental colorectal resections with anastomoses using the hand-assisted laparoscopic technique are safe. Early conversion to open and use of stomas are advisable in challenging cases.Key words: Hand assisted laparoscopic surgery, Synchronous, Colorectal anastomosesSynchronous colonic pathology affecting distant colonic segments, although uncommon, poses a management dilemma. The surgical options include extensive resections with single anastomosis or multiple segmental resections with synchronous multiple anastomoses. Extended colonic resections may alter bowel function and affect quality of life.¹ On the other hand, the risk of anastomotic leak maybe increased with multiple colonic anastomoses. Studies have shown that open synchronous multiple colonic anastomoses are safe.^2,3Traditionally, multiple segmental resections have been performed with open surgery. Hand-assisted laparoscopic (HAL) colectomy has an edge over open surgery with decreased postoperative pain, length of stay and wound, and pulmonary complications.⁴ The aim of this study is to evaluate the short-term outcomes in a cohort of patients who underwent synchronous HAL multiple segmental colorectal resections.     

Recurrent Cholangitis by Biliary Stasis Due to Non-Obstructive Afferent Loop Syndrome After Pylorus-Preserving Pancreatoduodenectomy: Report of a Case

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.Key words: Nonobstructive afferent loop syndrome, Biliary stasis, Hepaticojejunostomy, Hepatobiliary scintigraphy, Double-balloon enteroscopyIt has been reported that cholangitis occurs in between 6.7% and 14.3% of postoperative pancreatoduodenectomy (PD).¹ Most cases of cholangitis originate due to biliary stasis, which is broadly caused by either anastomotic or nonanastomotic stenosis. In many cases, anastomotic stenosis is accompanied by intrahepatic biliary duct dilatation and obstructive jaundice, making early diagnosis and treatment possible.^2–3 On the other hand, nonanastomotic stenosis, including those of afferent loop syndrome, is performed as a conservative treatment for unexplained fever and cholangitis. However, in many cases, the cause remains unidentified, thereby causing this condition to repeat itself. Since cholangitis can at times be fatal, it is therefore important to identify the cause.It has been reported that afferent loop syndrome occurs in around 13% of postoperative PD patients.⁴ Afferent loop syndrome is generally caused by mechanical occlusion due to the recurrence or metastasis of cancer,^4–6 adhesion,^7–8 torsion,⁹ internal hernia,¹⁰ enterolithiasis,^11–12 etc., and thereafter, leads to a syndrome associated with acute abdominal symptom or acute cholangitis. On the other hand, nonobstructive afferent loop syndrome may also be caused by biliary stasis due to jejunal motility failure or the length of the blind end or jejunum, and thereafter, leads to acute cholangitis, liver abscess, and the formation of enterolithiasis and intrahepatic stones. Nonobstructive afferent loop syndrome occurs in around 37% of all of the afferent loop syndrome,^12–13 but few cases have actually been reported.We herein report a rare case in which the patient experienced recurrent cholangitis and liver abscess by biliary stasis due to nonobstructive afferent loop syndrome after pylorus-preserving pancreatoduodenectomy (PPPD) for cholangiocarcinoma.     

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Prospective,Randomized Study

We aimed to compare the clinical outcome and cost of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Sixty patients with acute cholecystitis were randomized into early (within 24 hours of admission) or delayed (after 6–8 weeks of conservative treatment) laparoscopic cholecystectomy groups. There was no significant difference between study groups in terms of operation time and rates for conversion to open cholecystectomy. On the other hand, total hospital stay was longer (5.2 ± 1.40 versus 7.8 ± 1.65 days; P = 0.04) and total costs were higher (2500.97 ± 755.265 versus 3713.47 ± 517.331 Turkish Lira; P = 0.03) in the delayed laparoscopic cholecystectomy group. Intraoperative and postoperative complications were recorded in 8 patients in the early laparoscopic cholecystectomy group, whereas no complications occurred in the delayed laparoscopic cholecystectomy group (P = 0.002). Despite intraoperative and postoperative complications being associated more with early laparoscopic cholecystectomy compared with delayed intervention, early laparoscopic cholecystectomy should be preferred for treatment of acute cholecystitis because of its advantages of shorter hospital stay and lower cost.Key words: Acute cholecystitis, Laparoscopic cholecystectomy, Outcome assessment, Cost and cost analysisElective laparoscopic cholecystectomy has become the gold standard for treatment of symptomatic gallstones.¹ However, in the early days, acute cholecystitis was a contraindication of laparoscopic cholecystectomy, and patients with acute cholecystitis were managed conservatively and discharged for re-admission in order to have elective surgery performed for the definitive treatment.^2,3 Then, randomized controlled trials and meta-analyses had shown the benefits of early surgery (within the acute admission period, which is 24 to 72 hours) compared with delayed cholecystectomy with respect to hospital stay and costs, with no significant difference in morbidity and mortality.^2,4,5 Thus, in the late 1980s early surgery for acute cholecystitis had gained popularity. The updated Tokyo Guidelines announced in 2013 by the Japanese Society of Hepato-Biliary-Pancreatic Surgery suggested that early laparoscopic cholecystectomy is the first-line treatment in patients with mild acute cholecystitis, whereas in patients with moderate acute cholecystitis, delayed/elective laparoscopic cholecystectomy after initial medical treatment with antimicrobial agent is the first-line treatment.⁶With the increased experience in laparoscopy, surgeons started to attempt early laparoscopic cholecystectomy for acute cholecystitis.² However, early laparoscopic cholecystectomy is still performed by only a minority of surgeons.^7–9 Furthermore, the exact timing, potential benefits, and cost-effectiveness of laparoscopic cholecystectomy in the treatment of acutely inflamed gallbladder have not been clearly established and continue to be controversial.^1,10The aim of this study was to compare the intra-operative and postoperative outcomes, and cost of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.     

Effect of Preoperative Colonic Drainage for Obstructing Colorectal Cancer

Obstructing colorectal cancer (OCRC) is believed to indicate poorer long-term survival. The purpose of this study was to compare retrospectively perioperative safety and long-term results in patients undergoing surgery for OCRC following preoperative colonic decompression with that in those undergoing elective surgery alone for nonobstructing colorectal cancer (CRC). A total of 656 consecutive CRC patients undergoing colectomy between 2001 and 2011 at our institute were eligible for inclusion in the study. The patients were divided into an OCRC group, which included 104 patients undergoing colectomy with preoperative colonic decompression, and a CRC group, which included 552 patients undergoing colectomy alone. Morbidity, mortality, and prognosis were assessed. In the OCRC group, decompression was performed by nasointestinal tube in 42 patients (40.4%), transanal tube in 15 (14.4%), and colostomy in 47 (45.2%). The mortality rate was 0% in the OCRC group and 0.4% in the CRC group (2 of 552 patients). The morbidity rate was 44.8% in the OCRC group (48 of 104 patients) and 36.6% in the CRC group (202 of 552 patients). The 5-year overall survival rate was 69.5% in the OCRC group and 72.9% in the CRC group [hazard ratio 0.76; 95% confidence interval, 0.35 to 1.16; P = 0.48)]. No statistically significant difference in survival was observed between the 2 groups in stage II, III, or IV, or overall. No difference was observed in safety or survival between advanced OCRC patients undergoing preoperative colonic decompression and advanced non-obstructing CRC patients undergoing surgery alone.Key words: Intestinal obstruction, Colorectal cancer, Colonic decompression, Survival, SafetyObstructing colorectal carcinoma (OCRC) is frequently at an advanced stage by the time of surgical intervention and is associated with a high rate of morbidity and hospital death.^1–3While some studies have reported that OCRC has a poorer prognosis than nonobstructing CRC,^4,5 others have found no difference.^6,7 This poses a problem in the surgical management of OCRC.In many institutions, 1-stage primary resection is recommended for OCRC, as this allows colostomy and further nonsurgical drainage for the obstruction to be avoided.^8–10On the other hand, disruption of anastomosis was observed in more than 50% of cases in which resection was performed as initial surgery without surgical or nonsurgical decompression for the obstruction, threatening overall deterioration in the patient''s condition.Therefore, some have recommended decompression as a means of avoiding this problem.¹¹ However, the effectiveness of surgical or nonsurgical decompression for OCRC remains controversial.Since January 2001, we have performed preoperative decompression in all OCRC patients to reduce the rate of surgical complications and hospital death.The purpose of this study was to compare retrospectively perioperative safety and long-term results in patients undergoing elective surgery for advanced OCRC after preoperative colonic decompression with that in patients undergoing elective surgery alone for advanced nonobstructing CRC.     

Rectal Cancer With Disseminated Carcinomatosis of the Bone Marrow: Report of a Case

We report a rare case of disseminated carcinomatosis of the bone marrow from rectal cancer with disseminated intravascular coagulation (DIC). A 65-year-old man was admitted with melena and low back pain at rest. X-ray examination showed rectal cancer with multiple bone metastases. Laboratory examination showed severe anemia and DIC. Histologic examination showed disseminated carcinomatosis of the bone marrow. The DIC was considered to be caused by disseminated carcinomatosis of the bone marrow from rectal cancer, and we immediately started treatment with anti-DIC therapy and anticancer chemotherapy with the modified FOLFOX6 regimen (mFOLFOX6). After some response to therapy, the patient''s general condition deteriorated, and he died 128 days after admission. This is the first English report showing disseminated carcinomatosis of the bone marrow from colorectal cancer treated with mFOLFOX6.Key words: Bone marrow neoplasms, Rectal neoplasms, Disseminated intravascular coagulationBone metastases diffusely invading the bone marrow with disseminated intravascular coagulation (DIC) and microangiopathic hemolytic anemia (MHA) tend to accompany solid tumors; this condition is called disseminated carcinomatosis of the bone marrow,¹ and it is associated with an extremely poor prognosis. Among solid tumors, DIC is most commonly associated with breast cancer, prostate cancer, and lung cancer^2,3; carcinomatosis arising from colorectal cancer is rare.Herein we report on a patient with disseminated carcinomatosis of the bone marrow with rectal cancer who developed acute DIC and was treated with a modified FOLFOX6 regimen (mFOLFOX6). We also review 11 similar previously reported cases.^4–10     

Changes in the Frequencies of Abdominal Wall Hernias and the Preferences for Their Repair: A Multicenter National Study From Turkey

Abdominal wall hernias are a common problem in the general population. A Western estimate reveals that the lifetime risk of developing a hernia is about 2%.^1–3 As a result, hernia repairs likely comprise the most frequent general surgery operations. More than 20 million hernias are estimated to be repaired every year around the world.⁴ Numerous repair techniques have been described to date however tension-free mesh repairs are widely used today because of their low hernia recurrence rates. Nevertheless, there are some ongoing debates regarding the ideal approach (open or laparoscopic),^5,6 the ideal anesthesia (general, local, or regional),^7,8 and the ideal mesh (standard polypropylene or newer meshes).^9,10Although laparoscopic procedures have gained popularity worldwide, laparoscopic repairs still constitute only a small fraction of hernia surgeries,¹¹⁻¹³ mainly due to costs and the need for expertise. Today, general anesthesia is still the most frequently-used anesthesia technique. The usage of local anesthesia has been increasing, however, although its routine use is limited to specific hernia centers.^14–16 On the other hand, standard heavyweight propylene meshes lead the market mostly because of their low cost. Newer lightweight meshes should be considered as a first alternative to heavyweight conventional polypropylene meshes, provided that adequate fixation is guaranteed.The most frequent hernia type is inguinal. According to some classical reference books, the frequency of abdominal wall hernias is as follows: inguinal (70%–75%), femoral (6%–17%), and umbilical (3%–8.5%), followed by rare forms (1%–2%).^1,2 No changes in the frequencies of different types of abdominal wall hernias have been published in 3 consecutive editions of a well-known surgical textbook between 2004 and 2012.^17–19 However, a recent UK study found that the frequencies of different types of abdominal wall hernias change with time and that the figures given in the classical books should be subject to scrutiny.³In our observations over recent years, there have been some changes not only in the frequencies but also in the repair preferences and anesthetic techniques in daily surgical practice. Therefore, we aim to carry out a multicenter study to reflect the actual frequencies of abdominal wall hernias and the technical preferences for repairing these hernias in Turkey, a country with a population of over 70 million.     

Safe Transanal Tumor Resection Using a Harmonic Scalpel

We performed a safe and simple transanal tumor resection involving total layer resection using a harmonic scalpel as a resecting device. Here we report the results of our experience with this technique between 2005 and 2011. This study involved 32 patients who underwent transanal tumor resection using a harmonic scalpel. The subjects comprised 18 men and 14 women ranging in age from 34 to 87 years (mean: 64.5 years). The tumors measured 8 to 70 mm (mean: 31 mm) in diameter. The operation took 7 to 86 minutes (mean: 29 minutes), and the amount of bleeding was 0 to 165 mL (mean: 16.2 mL). There was no intraoperative blood loss that necessitated hemostatic procedures. Histopathologically, the lesions included hyperplastic polyp in 1 case, adenoma in 9, carcinoma in situ in 7, submucosal invasive cancer in 6, muscularis propria cancer in 4, carcinoid in 1, malignant lymphoma in 1, gastrointestinal stromal tumor in 1, mucosal prolapsed syndrome in 1, and mucosa-associated lymphoid tissue lymphoma in 1. With our technique, en bloc resection was achieved in all patients, and the use of a harmonic scalpel enabled us to complete the operation within 30 minutes, on average, without intraoperative bleeding.Key words: Rectal tumor, Transanal tumor resection, Harmonic scalpelWith technical developments and advances in colonoscopic diagnosis, such as magnifying endoscopy^1–3 and the narrow band imaging system,^4,5 and ablative surgery, such as endoscopic mucosal resection (EMR)^1,6 and endoscopic submucosal dissection (ESD),⁷ cures have become achievable with endoscopic resection (ER) alone in many cases of early colorectal carcinoma. ER is the treatment of choice for early colorectal carcinoma. However, with large lesions, conventional EMR cannot be performed as an en bloc resection; and even with lesions smaller than 20 mm in diameter, incomplete resection or piecemeal resection often occurs. After endoscopic piecemeal mucosal resection, histopathological assessment of complete resection is difficult and the risk of local recurrence is high.⁸ ESD has also been used to treat large colorectal adenomas, with recurrence rates of 0 to 9% and complication rates of only 0 to 9%.^9–11 However, compared with conventional EMR, the ESD technique is technically challenging and time consuming and requires a steep learning curve.^9,12 In addition, there are some issues involved in ER of lower rectal neoplastic lesions. Specifically, ER of these lesions is associated with higher risk of postoperative bleeding than that of lesions at other sites, because the rectum has abundant blood flow, and resection of some lower rectal lesions causes pain because of the sensory nerve distribution in this area.On the other hand, spread of laparoscopic surgery for colorectal cancer has led to a marked improvement of the quality of life (QOL) of these patients after resection,^13,14 and the incidence of lymph node metastasis in cases of submucosal invasive (SM) cancer is as low as about 10%.^15–18 Taking these into account, radical surgical resection, including abdominoperitoneal resection that requires a permanent stoma, seems to be excessively invasive in cases of early colorectal cancer. Recent years have seen great benefits of surgical treatment for lower rectal cancer, because intersphincteric resection (ISR)¹⁹ has become more common, allowing sphincter-preserving surgery even in patients in whom creation of a permanent stoma would have otherwise been required. The feasibility of ISR under laparoscopy has also improved the postoperative QOL.²⁰ However, even at present, the QOL is not necessarily satisfactory in terms of bowel function. In this regard, transanal tumor resection is a useful procedure for tumor removal in some cases, yielding a postoperative QOL comparable with that after EMR.We perform safe transanal tumor resection involving total layer resection using a harmonic scalpel as a resecting device. Here we report the results of our experience with this technique.     

Production of Intraperitoneal Interleukin-6 Following Open or Laparoscopic Assisted Distal Gastrectomy

The interleukin (IL)-6 concentration in plasma or serum has been considered to represent the degree of stress resulting from surgery. However, IL-6 in peritoneal fluid has rarely been considered. The aim of this study was to assess the concentration and amount of IL-6 in peritoneal fluid as indicators of surgical stress. To obtain basic data on peritoneal release of IL-6 during gastric cancer surgery, we measured IL-6 in peritoneal drainage samples, stored for up to 72 hours postoperatively, from patients who had undergone conventional open (ODG group, n = 20) and laparoscopic-assisted (LADG group, n = 19) distal gastrectomy. Within 24 hours, 61 and 77% of the IL-6 was released into the peritoneal cavity in the LADG and ODG groups, respectively. In both groups, the concentration and amount of peritoneal fluid IL-6 were significantly correlated with each other (LADG group: Spearman''s rank correlation test [rS] = 0.48, P = 0.04; ODG group: rS = 0.58, P = 0.01). The concentration and amount of IL-6 in peritoneal fluid was 2.8- and 3.6-fold higher in the ODG than in the LADG group, respectively (P < 0.01). With regard to the relationship between the serum C-reactive protein (CRP) peak and the concentration or amount of peritoneal fluid IL-6 released within 24 hours, only the concentration of peritoneal fluid IL-6 in the LADG group was significantly correlated (rS = 0.60, P = 0.01) with the serum CRP peak. Our findings suggest that the amount and concentration of IL-6 released into the peritoneal cavity for up to 24 hours after surgery can each be a reliable parameter for assessment of surgical stress.Key words: Interleukin (IL)-6, Cytokine, Peritoneal fluid, Surgical stress, Gastric cancer, Laparoscopic surgery, GastrectomyRecent advances in laparoscopy techniques have heralded a new era in the field of abdominal surgery, and laparoscopic approaches are now being employed for the treatment of malignant neoplasms of the stomach, colon and other organs.^1–5It has been reported that levels of circulating proinflammatory cytokines such as interleukin (IL)-1 beta, IL-6, IL-8, and tumor necrosis factor (TNF)-alpha are related to the extent and severity of surgical procedures.^6–8 Interleukin 6 is a sensitive and early marker of tissue damage, and in general the greater the surgical trauma, the greater the response of IL-6.⁹ Many studies have shown that the level of IL-6, as an indicator of surgical stress, is significantly lower after laparoscopic surgery than after open surgery.^9–15 Most of the studies reported so far have measured and analyzed the concentration of IL-6 in plasma or serum,^{9,10,12–16,18} and only rarely in peritoneal fluid,^{11,12,15,17,19,20} and the results have indicated significant correlations between the level of IL-6 and several clinical parameters. However, there is some concern as to whether the concentration of IL-6 in peritoneal fluid adequately reflects the degree of surgical stress. Interleukin 6 is released into the abdominal cavity in response to surgical injury.^16,20,21 Therefore, the total amount of IL-6 contained in peritoneal fluid might be regarded as a gold standard for assessing the severity of local surgical stress. However, this possibility has never been fully addressed.In the present study, we analyzed both the concentration and total amount of IL-6 in peritoneal fluid sequentially in the early postoperative period after distal gastrectomy, and compared laparoscopic and open surgical procedures in terms of intraperitoneal IL-6 production in order to observe the basic pattern of IL-6 release.     

Use of Stapling Devices for Safe Cholecystectomy in Acute Cholecystitis

Many techniques are described for the ligation of a difficult cystic duct (CD). The aim of this study is to assess the effectiveness and safety of stapling of a difficult CD in acute cholecystitis using Endo-GIA. From January 2008 to June 2012, 1441 patients with cholelithiasis underwent laparoscopic cholecystectomy (LC) at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. Of these, 19 (0.62%) were identified as having a difficult CD and were ligated using an Endo-GIA stapler. All patients were successfully treated with a laparoscopic approach. The length of hospital stay was 3.4 days. There were umbilical wound infections in 4 patients (21%). The length of follow-up ranged from 1.0 to 50.4 months. In conclusion, Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and stapling are not possible, fibrin sealant can be applied to avoid bleeding. The vascular Endo-GIA can be applied in a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.Key words: Cholecystectomy, Endo-GIA, Acute cholecystitis, StaplerAfter the introduction of laparoscopic cholecystectomy (LC) in 1987,¹ LC replaced open cholecystectomy as the gold standard for the treatment of cholelithiasis in international guidelines.² LC was initially considered to be contraindicated for acute gallbladder inflammation, but it is currently a common procedure for acute cholecystitis.Some of the difficult situations a surgeon is likely to face during the performance of a laparoscopic cholecystectomy include anatomic anomalies such as a sessile gallbladder or short cystic duct and pathologic entities such as an empyema, Mirizzi syndrome, or a frozen Calot''s triangle secondary to infection and fibrosis.³It is suggested that laparoscopic surgery should be carried out within 72 hours from the onset of the symptoms because after that time there are higher rates of conversion to open procedures, increased risks of complications, and longer operative times.^4–6 The generally accepted procedure in patients whose symptoms started 72 hours before admission is to “cool down” the patient with appropriate medical therapy and to perform LC after a period of 6 to 12 weeks.^7,8 This approach aims to avoid a potentially more difficult cholecystectomy during an emergency admission and to avoid the difficulties of access to an emergency room.^9,10 However, more than 20% of patients may fail to respond to conservative treatment and require an urgent and rather more difficult cholecystectomy, and a further 25% of patients will require readmission with a severe acute complication of cholelithiasis while awaiting a cholecystectomy.^11,12 The scar formation, distortion, and organized adhesions around the gallbladder occurring secondary to the chronic inflammation in Calot''s triangle make the dissection difficult. The cystic duct (CD) is sometimes edematous, fibrous, or enlarged owing to inflammation and adhesions in acute cholecystitis and may be difficult to manage. Several methods were proposed for ligating the CD, including titanium or absorbable endoclip, endoloop, tie, ultrasonic or bipolar sealer, and the Endo-GIA stapler (Covidien, Mansfield, Massachusetts).^13–19This study proposes an effective, safe, and easy procedure for the stapling of dilated or difficult CD using the Endo-GIA.     

Sacral Nerve Function in Child Patients After Ileal J-Pouch-Anal Anastomosis for Ulcerative Colitis

To clarify the neurological function of the puborectalis muscle (PM) in child patients with soiling after ileal J-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), we examined the terminal motor latency in the sacral nerves that regulate the PM. Eight patients after IPAA for UC were studied (6 males and 2 females aged 11 to 13 years with a mean age of 12.8 years). All patients 6 months after IPAA showed soiling (group A) and these patients showed continence at 2 years after IPAA (group B). Group C serving as controls consisted of 16 subjects (10 males and 6 females aged 12 to 17 years with a mean age of 14.4 years). Left- and right-sided sacral nerve terminal motor latency (SNTML) tests were performed at 6 months and 2 years after IPAA in order to measure the latency of the response in the bilateral PM following magnetic stimulation of sacral nerve root segments 2 to 4 (S2–S4) of the spinal column overlying the cauda equina. The following results were obtained. (1) Right-sided SNTML: group A exhibited significant prolongation compared with groups B and C (P < 0.0001 and P < 0.0001, respectively). There was no significant difference between groups B and C (P = 0.2329). (2) Left-sided SNTML: group A exhibited significant prolongation compared with groups B and C (P = 0.0002 and P < 0.0001, respectively). There was no significant difference between groups B and C (P = 0.2315). Note that significant differences were not established between SNTML values measured on the right and left sides. Soiling in child patients 6 months after IPAA may be caused by damage to the bilateral sacral nerves during the operation. However, the damage to the sacral motor nerve improves within 2 years after IPAA.Key words: Soiling, Sacral nerve terminal motor latency, Puborectalis muscle, Ulcerative colitis, ChildThe functional results of total colectomy, mucosal proctectomy, and ileal J-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) have been acceptable and patient satisfaction has been very high because patients are free from stoma.^1–3 In general, the functional outcomes after IPAA in children are better than those in adults.^4–12 However, some child patients experience defecation function impairments after IPAA, including minor fecal incontinence (soiling), incontinence, increased bowel movement, urgency of defecation, evacuation difficulty, irregular bowel habitus, difficulty in distinguishing gas from feces, and diarrhea.^8–10,12 The most common abnormality is soiling.^8–10 Soiling in both children and adults is usually more severe in the early postoperative period of about 3 to 6 months after operation and improves with time, but may become permanent more than 1 year after IPAA.^3–6,9 Generally, the frequency of soiling in child patients more than 1 year after IPAA is 0 to 12%,^4–6,8,9,12 and in adults 30 to 40%.^2,13,14 Over the past 20 years or so, the function of the anorectum in patients with soiling after IPAA has been studied in depth using anorectal manometry.^15–17 According to the data of anorectal manometry in child patients after IPAA, the anal sphincter complex comprising the internal anal sphincter and external anal sphincter is important to prevent soiling.¹⁷ In contrast, the puborectalis muscle (PM) was considered the most important factor preventing soiling in other studies not using anorectal manometry, which cannot detect the function of the PM, although less is known about the neurological functions in patients with soiling after IPAA in regard to the sacral nerve (SN) that regulates the PM.^18–20 To the best of our knowledge, there are no reports of electrophysiological studies of SN in child patients with soiling after IPAA for UC. We therefore studied bilateral SN function using sacral nerve terminal motor latency (SNTML) in child patients with soiling 6 months after IPAA and the same patients without soiling 2 years after IPAA for UC.     

High Expression of DARPP-32 in Colorectal Cancer Is Associated With Liver Metastases and Predicts Survival for Dukes A and B Patients: Results of a Pilot Study

The purpose of this study was to investigate prognostic significance of Dopamine and cAMP-Regulated neuronal Phosphoprotein 32 (DARPP-32) expression in primary colorectal cancer. The study material consisted of clinical and histopathological data of 100 patients operated for colorectal cancer between 1994 and 1997. For immunohistochemical analysis, specific rabbit antibodies for DARPP-32 were used and the percentage of stained tumor cells was calculated under gross magnification (400 times) on a sample of 500 tumor cells. DARPP-32 expression in the primary tumor was significantly greater in patients with distant metastases compared to patients with no distant metastases (p=0.002). In multivariate regression analysis, DARPP-32 expression in the primary tumor was a significant predictor of distant metastases. With a cut-off point of 76.5%, DARPP-32 expression in the primary tumor significantly influenced both overall and disease free survival, especially for Dukes A and B patients (p=0.037). The results of this study indicate that DARPP-32 may be a potential marker of worse prognosis and a valuable tool for managing further adjuvant treatment in patients with stages Dukes A and B colorectal cancer.Key words: Colorectal neoplasms, Dopamine and cAMP-regulated phosphoprotein 32, Humans, Nerve tissue proteins, Liver metastasesColorectal cancer is the second most common cause of cancer related death in Western Europe and the United States, with the incidence of 50/100,000 population.¹ In spite of significant developments in surgery and new chemotherapy drugs and protocols as well as radiotherapy regimens, this malignancy still has high mortality.²The 5-year survival rate of colorectal cancer patients with Dukes A cancer ranges from 74 to 93%. Patients with Dukes B cancer have a 5-year survival of 40 to 82%, and those with positive lymph nodes (Dukes C) have a 5-year survival rate of 30 to 59%.^3,4 Recurrences are observed in as much as 34% of patients with Dukes A and B stage, compared with 59% in patients with lymph node metastases.⁵Liver metastases are a well proven major determinant of survival in patients with colorectal cancer.^2,6 Therefore, better selection of patients with potential to develop liver metastases or those having occult metastases may increase the survival of those patients in whom adjuvant therapies would not otherwise be indicated.^2,5,7Recently, overexpression of dopamine and 3′5′-cyclic adenosine monophosphate regulated neuronal phosphoprotein 32 (DARPP-32) has been found in several gastrointestinal adenocarcinomas.⁸ Although most of the research on this protein focused on its role in the central nervous system,^9–11 the finding of overexpression of this protein in cancer tissues brought up the hypothesis of its role in carcinogenesis.^8,12 Genetic studies led to the discovery of frequent 17q DNA amplifications in gastric cancer.⁸ Subsequently, the gene located at this site, called PPP1R1B, has been sequenced and found to encode DARPP-32 molecule, that was brought into connection with several malignancies.^8,13–18 The DARPP-32 molecule is a protein with molecular mass of 32 kDa, consisting of 204 amino acids and 4 phosphorylation sites: Thr34, Thr75, Ser102, and Ser137. Depending on the phosphorylation of 1 of these 4 amino acids, the DARPP-32 molecule is acting as the signal integrator and as the regulator of the phosphorylase and kinase activities in eukaryotic cells.¹⁹Basic research indicates that DARPP-32 may be associated with worse prognosis in some carcinomas.²⁰ However, it is remains unknown if evaluation of DARPP-32 expression in colorectal cancer patients may aid to evaluate prognosis.The purpose of this study was to investigate possible associations of DARPP-32 expression in primary colorectal cancer with known prognostic determinants of colorectal cancer and therefore set the basis for further clinical research.     

Salvage Lymphadenectomy for Recurrent Esophageal Cancer After Chemoradiotherapy

Although salvage esophagectomies are widely performed, reports on salvage lymphadenectomy (SL) are few. We review our SL cases to clarify the indications. Fifty-five patients with esophageal cancer underwent chemoradiotherapy or radiotherapy, including 3 patients with single lymph node (LN) recurrences and one with allochronic double cervical node recurrence. Our department removed 5 recurrent LNs from these 4 patients. In Case 1, right supraclavicular LN was judged to be metastatic and R0 resection was carried out; he is alive without recurrence. In Case 2, we found, allochronically, metastases in his left cervical paraesophageal LN and left supraclavicular LN; residual tumors were R1 in both lesions. He is alive despite esophageal recurrence. In Case 3, a lymphadenectomy was performed on his thoracic para-aortic LN; however, tumor was removed incompletely, and he died 4 months after SL from disease progression. In Case 4, a subcarinal LN was thought to be metastatic, and was removed but no malignant tissues detected. He died 17 months after SL from pneumonia. Our experiences suggest that some patients survive relatively long with SL. Moreover, molecular examination of resected lesions could guide subsequent therapies. SL might be more widely used for these patients if not otherwise contraindicated.Key words: Esophageal cancer, salvage lymphadenectomy, Salvage surgery, Esophagectomy, ChemoradiotherapyEsophageal cancer is the eighth most common form of cancer worldwide, and is one of the most difficult malignancies to cure.¹ Excluding cases with severe concomitant diseases, surgery is the best modality to cure esophageal cancer.² However, many patients with esophageal cancer have concomitant diseases that are associated with alcohol and tobacco consumption, such as chronic obstructive pulmonary disease, liver cirrhosis, and synchronous cancers of the lung or head and neck region.³ For patients with such concomitant diseases, chemoradiotherapy (CRT) is usually performed to cure esophageal cancer. For unresectable advanced-stage tumors, CRT is also used, and sometimes has favorable results. The Radiation Therapy Oncology Group trial (RTOG 85-01) has established CRT without surgery as one standard for definitive treatment.⁴ Many patients and oncologists have accepted the nonsurgical approach with CRT as definitive therapy for esophageal carcinoma. Although complete response (CR) rates are high and short-term survival is favorable after definitive CRT, locoregional disease persists or recurs in 40–60% of patients.⁵ From Japan, a phase II study of CRT for Stage II–III esophageal squamous cell carcinoma (JCOG9906)⁶ found a CR rate of 62.2%, with 34.2% patients having residual or locoregional recurrence without distant metastasis after CRT.For resectable residual or recurrent lesions after definitive CRT, surgical excision is the only curative modality. Therefore, such operations are called salvage surgery. In Japan, salvage surgery is defined as a procedure for recurrent or residual cancer after definitive CRT (RT > 50 Gy)⁷ and thought to be the only curative method. Conversely, salvage surgery is widely considered elsewhere to be a type of palliative surgery—the excision of tissue to reduce the risk of death due to physiologic derangement. Although salvage esophagectomy is performed in many institutions in Japan,^8–13 reports on salvage lymphadenectomy (SL) are still few.^14,15 In this article, we review our SL cases, and examine indications for this kind of surgery.     

Outcomes of Surgical Treatment of Primary Signet Ring Cell Carcinoma of the Colon and Rectum: 22 Cases Reviewed With Literature

Colorectal primary signet ring cell carcinoma (PSRCCR) is a rare entity with a dismal prognosis, mainly because of delayed diagnosis. The objective of this study was to investigate the clinicopathologic features and prognostic factors for PSRCCR. This is a retrospective study including the data of 22 patients with PSRCCR who underwent surgery. Patients were categorized by age, sex, tumor site, and stage. Fifteen patients were male. Median age was 40 years. Sites for metastases were lymph nodes (86.4%), peritoneum (40.9%), and liver (9.1%). Most of the patients (91%) had stage III or IV tumors. The rates of curative and palliative resections performed were equal. Mean overall survival and mean progression-free survival times were found to be 33.3 ± 7.1 months (95% confidence interval, 19.4–47.2 months) and 11.8 ± 3.5 months (95% confidence interval, 4.9–18.7 months), respectively. It was concluded that site of the tumor, presence of bowel obstruction, peritoneum and lung metastases, adjacent organ infiltration, TNM stage, and efficiency of surgery have significant effects on survival. All in all, these aggressive tumors are generally diagnosed at advanced stages. Depending on the situation, survival is shorter. A high degree of vigilance is required for these patients to avoid the negative impact of late diagnosis on survival.Key words: Signet ring cell, Colorectal cancer, Histopathology, SurvivalPrimary signet ring cell carcinoma is a tumor most commonly located in the stomach, and less frequently in the breast, gallbladder, bladder, and pancreas.¹ Primary signet ring cell carcinoma of the colon and rectum (PSRCCR) is a rare entity, with a reported incidence of less than 1%.² It has a markedly poor prognosis.³ Because symptoms often develop late, it is usually diagnosed at an advanced stage.⁴ Furthermore, it typically appears in young adults.⁵Macroscopically, PSRCCR shows the characteristic appearance of linitis plastica, as a shrunken, rigid structure.^1–5 Histologically, the neoplastic cells resemble signet rings because they contain abundant intracytoplasmic mucin, which pushes the nuclei to the periphery.^1–5 The presence of mucus secretion in microscopic examinations of the tumor is one of the most important parameters determining the biologic behavior of colorectal carcinomas; other factors are age, sex, tumor location, tumor diameter, grade, stage, lymphatic and vascular invasion, periserosal overgrowth, and distant metastasis.^6,7So far, only a limited number of case reports have been published on this subject. Most publications have reported on a small number of patients and have presented controversial results. The objective of this study was to investigate the characteristic clinicopathologic features of colorectal signet ring cell carcinomas and the parameters affecting prognosis within our patient group.     

The Effectiveness of a Rapid-Access Flexible Sigmoidoscopy Clinic in a District Hospital

Historically rapid-access colorectal clinics have had high proportions of nonconforming referrals from primary care physicians, which calls into question the clinics'' efficacy. We aim to determine the effectiveness of our rapid-access flexible sigmoidoscopy clinic, and the adherence to the referral guidelines for suspected bowel cancer by general practitioners. We performed a 3-month retrospective audit to evaluate (1) the proportion of patients seen within 2 weeks, (2) the appropriateness of referrals, (3) the proportion of patients with findings, and (4) the proportion of patients who had further tests. A total of 59 patients (19 male, 40 female; age 35–86 years) were included in the study. All were offered an appointment within 2 weeks. Forty-one cases (82%) were appropriate referrals. Twenty-eight patients (47%) had pathology at sigmoidoscopy. Cancer pick-up rate was 6%. Thirty-seven patients (74%) had further investigations. We determined that our rapid-access clinic for symptomatic patients has high diagnostic accuracy and that access to early investigation is being used appropriately by general practitioners. In the current climate of spending cuts and streamlining services, our study confirms we are meeting targets for delivery of our colorectal service. The majority of referrals under the 2-week rule are appropriate. Rapid access to early investigation is being used appropriately by general practitioners contrasting previous studies with high proportions of nonconforming referrals.Key words: Rapid access, Department of health, Colorectal cancer, Screening, Flexible sigmoidoscopyEfforts to improve diagnostic and treatment services for colorectal cancer (CRC) have been implemented in the National Health Service (NHS) since the early 1990s. The NHS Bowel Cancer Screening Programme focusing on occult fecal tests has been piloted, assessed, and rolled out on a national level.^1,2Recommendations from the Department of Health of a maximum 2-week wait for initial specialist assessment of all urgent general practitioner (GP) referrals with suspected cancer led to the restructuring of colorectal services and the widespread establishment of dedicated rapid-access flexible sigmoidoscopy clinics in hospitals across the United Kingdom.^3,4 Evidence-based reviews for stratifying CRC risk have further contributed to the outline of current referral protocols for patients with high-risk symptoms.⁵Over the past decade, the service has significantly evolved, as a result of considerable work examining its effectiveness and efficiency. Various authors have commented positively on the suitability and safety of the use of flexible sigmoidoscopy in establishing a diagnosis of distal colonic pathologies and excluding carcinoma,^6,7 while others have highlighted the need for flexible sigmoidoscopy in order for a one-stop service to be effective and safe.^8,9Queen Mary''s Hospital (QMH) is a District General Hospital (DGH) situated in Kent and serving a population of approximately 300,000. Since its establishment, the rapid-access flexible sigmoidoscopy clinic averages 250 patients per year. There is a consultant-led dedicated endoscopy session each week. The majority of referrals come through primary care physicians, with some cases directly referred from the Trust''s Emergency Department.This study aimed to determine the efficacy of the rapid-access flexible sigmoidoscopy clinic in meeting the 2-week target from referral to preliminary assessment, including an assessment of the pathologies found, and the adherence to the Department of Health''s referral guidelines for bowel cancer by GPs.