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BackgroundWhether laparoscopic surgery after prior abdominal surgery (PAS) is safe and feasible for colorectal cancer (CRC) remains controversial. The present study aimed to evaluate the impact of PAS on short-term outcomes following laparoscopic CRC surgery.MethodsWe performed retrospective analysis used propensity score-matched analysis to reduce the possibility of selection bias. Participants comprised 1284 consecutive patients who underwent elective laparoscopic CRC surgery between 2010 and 2020. Patients were divided into two groups according to PAS. Patients with PAS were then matched to patients without these conditions. Short-term outcomes were evaluated between groups in the overall cohort and matched cohort, and risk factors for conversion to laparotomy and severe postoperative complications were analyzed.ResultsAfter propensity score matching, we enrolled 762 patients (n = 381 in each group). Before matching, significant group-dependent differences were observed in sex, age, primary tumor site, pathological (p) T stage, and type of procedure. No significant difference was found between groups in terms of rate of conversion to laparotomy, estimated blood loss, rate of extended resection, length of postoperative stay, and postoperative complications. After matching, estimated operative time was significantly longer in the PAS group (p = 0.01). Significant differences were found between groups in terms of reason for conversion to laparotomy. Multivariate analyses identified significant risk factors for conversion to laparotomy as pT stage ≥ 3 (odds ratio [OR] 2.36; 95% confidence interval [CI] 1.05–5.26) and body mass index ≥ 25 kg/m2 (OR 3.56; 95% CI 1.07–11.7). Multivariate analyses identified rectum in the primary tumor site as the only significant risk factor for severe postoperative complications (OR 2.37; 95% CI 1.08–5.20).ConclusionsLaparoscopic CRC surgery after PAS showed acceptable short-term outcomes compared to Non-PAS. The laparoscopic approach appears safe and feasible for CRC regardless of whether the patient has a history of PAS.

BackgroundLong-term outcomes of single-incision laparoscopic colectomy (SILC) for colon cancer (CC), as practiced in real-world settings, especially in relation to disease stage, have not been established. We examined, retrospectively, both short- and long-term outcomes of SILC versus those of multiport laparoscopic colectomy (MPLC) performed for CC in a propensity-score-matched cohort.MethodsThe study involved 263 patient pairs matched 1:1 from among 691 patients who, between January 2008 and May 2014, underwent either SILC or MPLC for a primary solitary CC at our hospital. Short-term and long-term operative outcomes were compared between the two groups.ResultsOperation time was the only surgical outcome that varied significantly between the two groups (p = 0.0004). Overall 5-year cancer-specific survival (CSS) in the SILC group was 93.7 (95% CI 89.6–96.2)%, and CSS per pathological stage (I, II and III) was 98.5 (90.0–99.8)%, 96.0 (88.2–98.7)%, and 88.3 (79.6–93.6)%, respectively, whereas overall 5-year CSS in the MPLC group was 93.3 (89.4–95.9)%, and CSS per pathological stage was 100%, 95.4 (88.3–98.3)%, and 84.1 (74.1–90.8)% (p = 0.5278, 0.2679, 0.7666, and 0.9073), respectively. Overall 3-year disease-free survival (DFS) in the SILC group was 94.0 (90.2–96.4)%, and 3-year DFS per pathological stage was 98.6 (90.4–99.8)%, 90.1 (81.4–95.0)%, and 79.0 (69.4–86.2)%, respectively, whereas overall 3-year DFS in the MPLC group was 93.2 (89.4–95.7)%, and 3-year DFS per pathological disease stage was 100%, 94.5 (87.4–97.7)% and 75.5 (64.7–83.8)% (p = 0.2829, 0.7401, 0.4335 and 0.8518), respectively. Thus, oncological outcomes did not differ significantly between groups. Incisional hernia occurred in 21 (8.0%) SILC group patients and 17 (6.5%) MPLC group patients, without a significant between-group difference (p = 0.6139).ConclusionOur data indicate that perioperative and oncological outcomes of SILC performed for CC are comparable to those of MPLC performed for CC.

Background The reported incidence of postoperative delirium (POD) in elderly patients ranges from 6 to 53 %. Several preoperative and operative factors have been reported as risk factors of POD. Aim The aim of this study was to determine the incidence of and risk factors for POD in patients with colorectal cancer who had undergone laparoscopic colorectal resection. Methods A total of 311 consecutive patients aged 75 years and older who underwent laparoscopic surgery for colorectal cancer at our department from January 2008 to December 2013 were classified as delirious group ( n  = 44) and nondelirious group ( n  = 267). Short-term outcomes and risk factors for POD were analyzed. Results POD was diagnosed in 14.1 % of elderly patients with colorectal cancer. Univariate analysis showed that older age, high American Society of Anesthesiology (ASA) score, performance status >2, low prognostic nutrition index (PNI), past history of delirium or dementia, operative approach, Organ/Space SSI, and cardiac or pulmonary disease were significantly associated with POD. Multivariate logistic regression analysis identified older age, past history of delirium or dementia, operative approach, and Organ/Space SSI as four independent risk factors for POD. Conclusions Our results suggest that the risk of POD is associated with older age, past history of delirium or dementia, operative approach, Organ/Space SSI.

We aimed to clarify usefulness of the modified Frailty Index 11 (mFI-11) for assessing risk of postoperative complications (POCs) and effectiveness of perioperative management team (POMT) intervention for improving postoperative status of frail aged patients requiring colorectal cancer (CRC) surgery. We compared, retrospectively, surgical outcomes among 151 consecutive CRC surgery patients aged ≥80 years. Patients were grouped by mFI-11 scores and by POMT intervention (vs. no POMT intervention). POCs were more prevalent, postoperative stays were longer, and discharge status was poorer among high-risk (mFI-11 ≥ 3/11) patients without POMT intervention than among low-risk (mFI-11 ≤ 2/11) patients (p = 0.04, p = 0.02, p < 0.01). Multiple POCs occurred less frequently and performance of activities of daily living was better for high-risk patients with (vs. those without) POMT intervention (p = 0.04, p = 0.03). POMT intervention appears beneficial for frail aged patients scheduled for CRC surgery. •mFI-11 is useful to identify high-risk frail aged patients requiring CRC surgery.•POMT intervention improves postoperative status of frail aged patients.•POMT intervention appears beneficial for frail aged patients for CRC surgery.

Purpose Due to its rarity and biological heterogeneity, guidelines for primary appendiceal tumor (PAT) are based on scarce evidence, resulting in no strong recommendations. The present study explored prognosis-related factors, including the timing of lymph node dissection (LND), in PAT patients after curative resection (CR) to determine the optimal surgical therapies. Methods We retrospectively collected and analyzed data from 404 patients with PATs who underwent CR at 43 tertiary hospitals from 2000 to 2017. This manuscript is based on revised manuscript during review process. Please, change the bold characters to normal characters in the manuscript. Results After propensity score matching, there were no marked differences in the recurrence-free survival (RFS) or overall survival (OS) between the primary and secondary LND groups (P = 0.993 and 0.728 ). A multivariate analysis showed that lymph node metastasis (LNM) was an independent factor for the RFS (hazard ratio [HR] 2.59 ; 95% confidence interval [CI] 1.09–6.13 ; P = 0.031 ) and OS (HR 4.70 ; 95% CI 1.40–15.76 ; P = 0.012 ). There were significant associations between the LNM rates and tumor depth (P < 0.0001 ) and the histological type (P = 0.006 ). There was no LNM in patients with low-grade appendiceal mucinous neoplasm (LAMN) or well-differentiated mucinous adenocarcinoma (G1) or patients with any Tis or T1 PATs. Conclusions LNM was an independent prognostic predictor in PATs after CR with LND. Tumor depth and histological type were not prognostic predictors but were LNM predictors. Secondary LND based on the pathological findings of resected specimens is considered an acceptable surgical management without a worse prognosis than primary LND, and it may be omitted in LAMN+G1 or in any Tis and T1 PATs.

Single-port surgery is a recent advancement in minimally invasive techniques for colon disease. However, single-port laparoscopic rectal resection (SPLR) is rare. The aim of this study was to compare the short-term results of SPLR with those of multi-port laparoscopic rectal resection (MPLR) for rectal cancer. Patients who underwent SPLR (n = 50) or MPLR (n = 50) for rectal cancer from July 2010 to March 2014 were analyzed. Patients with tumor diameter less than 40 mm and body mass index less than 30 kg/m2 were matched for age, sex, tumor location, and preoperative evaluation. Operative parameters and outcomes were compared between groups. Patients with lower rectal cancer were excluded. SPLR was successful in 98.0% of cases. Operative procedure, operative time, blood loss, field of lymph node dissection, and rate of postoperative complications did not differ significantly. Length of hospital stay was shorter with SPLR than with MPLR (8 vs 10 days, respectively; P = .018). Oncological outcomes did not differ significantly between the 2 groups. SPLR is safe and feasible in selected patients with rectal cancer.

The clinical significance of FOLFOXIRI (5-FU, leucovorin, oxaliplatin, and irinotecan) plus anti-EGFR monoclonal antibody using cetuximab for metastatic colorectal cancer (mCRC) remains controversial. We report results from a randomized phase 2 DEEPER trial (UMIN000018217, jRCTs061180022) to test the superiority of modified (m)-FOLFOXIRI plus weekly cetuximab over bevacizumab in patients with RAS wild-type (wt) mCRC. Primary endpoint was depth of response (DpR). Secondary endpoints included objective response rate (ORR), early tumor shrinkage (ETS) at week 8, progression-free survival (PFS), overall survival (OS), time to tumor growth (TTG), time to treatment failure (TTF), association between tumor shrinkage and prognosis, association between TTG and prognosis, R0 resection rate, and safety. In 359 enrolled patients with RAS wt mCRC, median DpR was significantly better in cetuximab (57.3% vs 46.0%, p  = 0.0029); however, ORR, ETS, R0 resection rate, TTG, TTF, PFS and OS were similar between 2 treatments. There was a weak association between DpR and survival time in both treatments. The correlation between TTG and OS was slightly stronger in cetuximab. The post-hoc exploratory analysis showed that cetuximab produced greater PFS (15.3 vs 11.7 months; HR 0.68) and OS (53.6 vs 40.2 months; HR 0.54) in patients with left-sided and RAS / BRAF wt tumors. m-FOLFOXIRI plus cetuximab has clinical benefit for tumor shrinkage in RAS wt mCRC. The survival benefit for RAS / BRAF wt and left-sided mCRC needs further investigation. Anti-EGFR therapy plus doublet chemotherapy is standard of care for patients with RAS wild-type metastatic colorectal cancer (mCRC) but the role of triplet chemotherapy is unclear. Here, the authors report a randomised phase 2 trial testing the superiority of adding cetuximab (anti-EGFR) over bevacizumab (anti-VEGF) to modified FOLFOXIRI (5-FU, leucovorin, oxaliplatin and irinotecan) in patients with RAS wild-type mCRC.

BackgroundSmall bowel obstruction (SBO) arises on various backgrounds, and the surgical procedure is often modified intraoperatively as needed. Single-incision laparoscopic surgery (SILS) is less invasive than conventional multiport laparoscopic surgery (MPS) and reported to be equally safe and efficient. We have been applying SILS to SBO requiring surgical treatment, and we conducted a retrospective study to clarify the role of SILS in the management of SBO.MethodsThirty-four consecutive patients were identified for inclusion in the study through a review of hospital records of patients having undergone surgery for SBO between May 2013 and June 2018. Patients with tumor- or hernia-related SBO were excluded. We also identified, for comparison, a group of patients who had undergone open surgery for SBO during the preceeding 5-year period. The primary study endpoint was the SILS completion rate, and analyses were performed to identify risk factors for conversion to open surgery and perioperative complications.ResultsThe SILS completion rate was 70.6% (24/34 patients), with conversion open surgery required for the remaining 10 (29.4%) patients. Conversion was necessitated by limited working space in 5 (50%) patients, discovery of massive necrosis in 3 (30%), and non-detection of the responsible lesion in 2 (20%). Univariable analysis showed an American Society of Anesthesiologists Physical Status score (p = 0.020) and severe intra-abdominal adhesions (p = 0.007) to be risk factors for conversion. Conversion to open surgery (vs complete SILS) was significantly associated with increased operation time (p = 0.018), blood loss (p = 0.021), postoperative stay (p = 0.010), and postoperative complications (p = 0.004). Open surgery was significantly associated with increased postoperative stay (p = 0.026) and postoperative complications (p = 0.011).ConclusionSILS appears to be a reasonable surgical treatment option for selected patients with SBO.

Locally recurrent rectal cancer (LRRC) involving the upper sacrum is generally considered a contraindication for curative surgery. In the surgical management of LRRC, sacrectomy is frequently performed to secure clear resection margins. Nonetheless, the indications for high sacrectomy remain controversial due to potential postoperative complications, questions about radicality, and the increased complexity of the operation. Furthermore, comprehensive studies addressing this issue are notably absent. This study aimed to assess the feasibility, safety, and surgical prognosis in high sacrectomy for LRRC.BACKGROUND/AIMLocally recurrent rectal cancer (LRRC) involving the upper sacrum is generally considered a contraindication for curative surgery. In the surgical management of LRRC, sacrectomy is frequently performed to secure clear resection margins. Nonetheless, the indications for high sacrectomy remain controversial due to potential postoperative complications, questions about radicality, and the increased complexity of the operation. Furthermore, comprehensive studies addressing this issue are notably absent. This study aimed to assess the feasibility, safety, and surgical prognosis in high sacrectomy for LRRC.All patients with LRRC who required concomitant sacrectomy, but did not include the inferior margin of the second sacral vertebra, between 2003 and 2014, were reviewed retrospectively.PATIENTS AND METHODSAll patients with LRRC who required concomitant sacrectomy, but did not include the inferior margin of the second sacral vertebra, between 2003 and 2014, were reviewed retrospectively.Eight patients with a median age of 59 years were included in this study. The proximal resection line for sacral bone resection was the central part of the S1 vertebra in one patient, lower edge of the S1 vertebra in six patients, and central part of the S2 vertebra in one patient. Negative margin resection was achieved in five out of the eight patients. The median operative time was 922 min, and the median operative blood loss volume was 6,370 ml. Major complications included pelvic abscess (n=5), ileus (n=1), and pulmonary vein embolism (n=1), none of which proved fatal during the postoperative period. Both the 5-year local re-recurrence-free survival rate and the 5-year distant metastasis-free survival rate were 50% (4/8).RESULTSEight patients with a median age of 59 years were included in this study. The proximal resection line for sacral bone resection was the central part of the S1 vertebra in one patient, lower edge of the S1 vertebra in six patients, and central part of the S2 vertebra in one patient. Negative margin resection was achieved in five out of the eight patients. The median operative time was 922 min, and the median operative blood loss volume was 6,370 ml. Major complications included pelvic abscess (n=5), ileus (n=1), and pulmonary vein embolism (n=1), none of which proved fatal during the postoperative period. Both the 5-year local re-recurrence-free survival rate and the 5-year distant metastasis-free survival rate were 50% (4/8).High sacrectomy is safe and feasible to achieve negative margins in patients with LRRC.CONCLUSIONHigh sacrectomy is safe and feasible to achieve negative margins in patients with LRRC.

Single-port surgery for rectal cancer is challenging and controversial. The aim of this study was to compare the short-term outcomes of single-port laparoscopic low anterior resection (S-LAR) to multi-port laparoscopic low anterior resection (M-LAR) for upper rectal cancer. From January 2011 to December 2015, a total of 93 patients who underwent S-LAR (n = 44) or M-LAR (n = 49) without protective diverting ileostomy for upper rectal cancer were identified. Tumors were located between the inferior margin of the second sacral vertebra and the peritoneal reflection. Short-term outcomes were compared between groups. S-LAR was successful in 75% of cases: 25% of cases required one additional port. Operative factors, perioperative outcomes, oncological outcomes did not differ significantly between groups. In patients with stage I-III disease, the 3-year relapse-free survival rate was significantly higher in the S-LAR group than in the M-LAR group (p = 0.032). The 3-year overall survival rate was similar between groups. S-LAR is safe, feasible and can provide satisfactory oncological outcomes in selected patients with upper rectal cancer. •We assess the safety and feasibility of S-LAR for upper rectal cancer.•Short-term and long-term oncological outcomes did not differ significantly between S-LAR and M-LAR group.•S-LAR is safe, feasible and can provide satisfactory oncological outcomes in selected patients with upper rectal cancer.