Application of indocyanine green-enhanced near-infrared fluorescence-guided imaging in laparoscopic lateral pelvic lymph node dissection for middle-low rectal cancer

BACKGROUND As one effective treatment for lateral pelvic lymph node(LPLN)metastasis(LPNM),laparoscopic LPLN dissection(LPND)is limited due to the complicated anatomy of the pelvic sidewall and various complications after surgery.With regard to improving the accuracy and completeness of LPND as well as safety,we tried an innovative method using indocyanine green(ICG)visualized with a near-infrared(NIR)camera system to guide the detection of LPLNs in patients with middle-low rectal cancer.AIM To investigate whether ICG-enhanced NIR fluorescence-guided imaging is a better technique for LPND in patients with rectal cancer.METHODS A total of 42 middle-low rectal cancer patients with clinical LPNM who underwent total mesorectal excision(TME)and LPND between October 2017 and March 2019 at our institution were assessed and divided into an ICG group and a non-ICG group.Clinical characteristics,operative outcomes,pathological outcomes,and postoperative complication information were compared and analysed between the two groups.RESULTS Compared to the non-ICG group,the ICG group had significantly lower intraoperative blood loss(55.8±37.5 mL vs 108.0±52.7 mL,P=0.003)and a significantly larger number of LPLNs harvested(11.5±5.9 vs 7.1±4.8,P=0.017).The LPLNs of two patients in the non-IVG group were residual during LPND.In addition,no significant difference was found in terms of LPND,LPNM,operative time,conversion to laparotomy,preoperative complication,or hospital stay(P>0.05).CONCLUSION ICG-enhanced NIR fluorescence-guided imaging could be a feasible and convenient technique to guide LPND because it could bring specific advantages regarding the accuracy and completeness of surgery as well as safety.

Feasibility and limitations of combined treatment for lateral pelvic lymph node metastases in rectal cancer

Colorectal cancer ranks among the most commonly diagnosed cancers globally,and is associated with a high rate of pelvic recurrence after surgery.In efforts to mitigate recurrence,pelvic lymph node dissection(PLND)is commonly advocated as an adjunct to radical surgery.Neoadjuvant chemoradiotherapy(NACRT)is a therapeutic approach employed in managing locally advanced rectal cancer,and has been found to increase the survival rates.Chua et al have proposed a combination of NACRT with selective PLND for addressing lateral pelvic lymph node metastases in rectal cancer patients,with the aim of reducing recurrence and improving survival outcomes.Nevertheless,certain studies have indicated that the addition of PLND to NACRT and total mesorectal excision did not yield a significant reduction in local recurrence rates or improvement in survival.Consequently,meticulous patient selection and perioperative chemotherapy may prove indispensable in ensuring the efficacy of PLND.

Management of lateral pelvic lymph nodes in rectal cancer:Is it time to reach an Agreement?

In this editorial,we proceed to comment on the article by Chua et al,addressing the management of metastatic lateral pelvic lymph nodes(mLLN)in stage II/III rectal cancer patients below the peritoneal reflection.The treatment of this nodal area sparks significant controversy due to the strategic differences followed by Eastern and Western physicians,albeit with a higher degree of convergence in recent years.The dissection of lateral pelvic lymph nodes without neoadjuvant therapy is a standard practice in Eastern countries.In contrast,in the West,preference leans towards opting for neoadjuvant therapy with chemoradiotherapy or radiotherapy,that would cover the treatment of this area without the need to add the dissection of these nodes to the total mesorectal excision.In the presence of high-risk nodal characteristics for mLLN related to radiological imaging and lack of response to neoadjuvant therapy,the risk of lateral local recurrence increases,suggesting the appropriate selection of strategies to reduce the risk of recurrence in each patient profile.Despite the heterogeneous and retrospective nature of studies addressing this area,an international consensus is necessary to approach this clinical scenario uniformly.

Prophylactic lateral pelvic lymph node dissection in stage Ⅳ low rectal cancer

AIM To assess the clinical significance of prophylactic lateral pelvic lymph node dissection (LPLND) in stage Ⅳ low rectal cancer.METHODS We selected 71 consecutive stage Ⅳ low rectal cancer patients who underwent primary tumor resection,and enrolled 50 of these 71 patients without clinical LPLN metastasis.The patients had distant metastasis such as liver,lung,peritoneum,and paraaortic LN.Clinical LPLN metastasis was defined as LN with a maximum diameter of 10 mm or more on preoperative pelvic computed tomography scan.All patients underwent primary tumor resection,27 patients underwent total mesorectal excision(TME) with LPLND(LPLND group),and 23 patients underwent only TME(TME group).Bilateral LPLND was performed simultaneously with primary tumor resection in LPLND group.R0 resection of both primary and metastatic sites was achieved in 20 of 50 patients.We evaluated possible prognostic factors for 5-year overall survival (OS),and compared 5-year cumulative local recurrence between the LPLND and TME groups.RESULTS For OS,univariate analyses revealed no significant benefit in the LPLND compared with the TME group (28.7% vs 17.0%,P = 0.523); multivariate analysis revealed that R0 resection was an independent prognostic factor.Regarding cumulative local recurrence,the LPLND group showed no significant benefit compared with TME group (21.4% vs 14.8%,P = 0.833).CONCLUSION Prophylactic LPLND shows no oncological benefits in patients with Stage Ⅳ low rectal cancer without clinical LPLN metastasis.

Laparoscopic lateral lymph node dissection in two fascial spaces for locally advanced lower rectal cancer

BACKGROUND The procedure for lateral lymph node(LLN)dissection(LLND)is complicated and can result in complications.We developed a technique for laparoscopic LLND based on two fascial spaces to simplify the procedure.AIM To clarify the anatomical basis of laparoscopic LLND in two fascial spaces and to evaluate its efficacy and safety in treating locally advanced low rectal cancer(LALRC).METHODS Cadaveric dissection was performed on 24 pelvises,and the fascial composition related to LLND was observed and described.Three dimensional-laparoscopic total mesorectal excision with LLND was performed in 20 patients with LALRC,and their clinical data were analyzed.RESULTS The cadaver study showed that the fascia propria of the rectum,urogenital fascia,vesicohypogastric fascia and parietal fascia lie side by side in a medial-lateral direction constituting the dissection plane for curative rectal cancer surgery,and the last three fasciae formed two spaces(Latzko's pararectal space and paravesical space)which were the surgical area for LLND.Laparoscopic LLND in two fascial spaces was performed successfully in all 20 patients.The median operating time,blood loss and postoperative hospitalization were 178(152-243)min,55(25-150)mL and 10(7-20)d,respectively.The median number of harvested LLNs was 8.6(6-12),and pathologically positive LLN metastasis was confirmed in 7(35.0%)cases.Postoperative complications included lower limb pain in 1 case and lymph leakage in 1 case.CONCLUSION Our preliminary surgical experience suggests that laparoscopic LLND based on fascial spaces is a feasible,effective and safe procedure for treating LALRC.

Short term outcomes of minimally invasive selective lateral pelvic lymph node dissection for low rectal cancer

BACKGROUND Pelvic recurrence after rectal cancer surgery is still a significant problem despite the introduction of total mesorectal excision and chemoradiation treatment(CRT),and one of the most common areas of recurrence is in the lateral pelvic lymph nodes.Hence,there is a possible role for lateral pelvic lymph node dissection(LPND)in rectal cancer.AIM To evaluate the short-term outcomes of patients who underwent minimally invasive LPND during rectal cancer surgery.Secondary outcomes were to evaluate for any predictive factors to determine lymph node metastases based on pre-operative scans.METHODS From October 2016 to November 2019,22 patients with stage II or III rectal cancer underwent minimally invasive rectal cancer surgery and LPND.These patients were all discussed at a multidisciplinary tumor board meeting and most of them received neoadjuvant chemoradiation prior to surgery.All patients had radiologically positive lateral pelvic lymph nodes on the initial staging scans,defined as lymph nodes larger than 7 mm in long axis measurement,or abnormal radiological morphology.LPND was only performed on the involved side.RESULTS Majority of the patients were male(18/22,81.8%),with a median age of 65 years(44-81).Eighteen patients completed neoadjuvant CRT pre-operatively.18 patients(81.8%)had unilateral LPND,with the others receiving bilateral surgery.The median number of lateral pelvic lymph nodes harvested was 10(3-22)per pelvic side wall.8 patients(36.4%)had positive metastases identified in the lymph nodes harvested.The median pre-CRT size of these positive lymph nodes was 10 mm.Median length of stay was 7.5 d(3-76),and only 2 patients failed initial removal of their urinary catheter.Complication rates were low,with only 1 lymphocele and 1 anastomotic leak.There was only 1 mortality(4.5%).There have been no recurrences so far.CONCLUSION Chemoradiation is inadequate in completely eradicating lateral wall metastasis and there are still technical limitations in accurately diagnosing metastases in these areas.A pre-CRT lymph node size of≥10 mm is suggestive of metastases.LPND may be performed safely with minimally invasive surgery.

Selective lateral lymph node dissection after neoadjuvant chemoradiotherapy in rectal cancer

BACKGROUND Lateral lymph node metastasis is one of the leading causes of local recurrence in patients with advanced mid or low rectal cancer.Neoadjuvant chemoradiotherapy(NCRT)can effectively reduce the postoperative recurrence rate;thus,NCRT with total mesorectal excision(TME)is the most widely accepted standard of care for rectal cancer.The addition of lateral lymph node dissection(LLND)after NCRT remains a controversial topic.AIM To investigate the surgical outcomes of TME plus LLND,and the possible risk factors for lateral lymph node metastasis after NCRT.METHODS This retrospective study reviewed 89 consecutive patients with clinical stage II-III mid or low rectal cancer who underwent TME and LLND from June 2016 to October 2018.In the NCRT group,TME plus LLND was performed in patients with short axis(SA)of the lateral lymph node greater than 5 mm.In the non-NCRT group,TME plus LLND was performed in patients with SA of the lateral lymph node greater than 10 mm.Data regarding patient demographics,clinical workup,surgical procedure,complications,and outcomes were collected.Multivariate logistic regression analysis was performed to evaluate the possible risk factors for lateral lymph node metastasis in NCRT patients.RESULTS LLN metastasis was pathologically confirmed in 35 patients(39.3%):26(41.3%)in the NCRT group and 9(34.6%)in the non-NCRT group.The most common site of metastasis was around the obturator nerve(21/35)followed by the internal iliac artery region(12/35).In the NCRT patients,46%of patients with SA of LLN greater than 7 mm were positive.The postoperative 30-d mortality rate was 0%.Two(2.2%)patients suffered from lateral local recurrence in the 2-year follow up.Multivariate analysis showed that cT4 stage(odds ratio[OR]=5.124,95%confidence interval[CI]:1.419-18.508;P=0.013),poor differentiation type(OR=4.014,95%CI:1.038-15.520;P=0.044),and SA≥7 mm(OR=7.539,95%CI:1.487-38.214;P=0.015)were statistically significant risk factors associated with LLN metastasis.CONCLUSION NCRT is not sufficient as a stand-alone therapy to eradicate LLN metastasis in lower rectal cancer patients and surgeons should consider performing selective LLND in patients with greater LLN SA diameter,poorer histological differentiation,or advanced T stage.Selective LLND for NCRT patients can have a favorable oncological outcome.

Predictive factors for lymph node metastasis and defining a subgroup treatable for laparoscopic lymph node dissection after endoscopic submucosal dissection in poorly differentiated early gastric cancer

AIM To investigate the predictive factors of lymph node metastasis(LNM)in poorly differentiated early gastric cancer(EGC);to guide the individual application of a combination of endoscopic submucosal dissection(ESD)and laparoscopic lymph node dissection(LLND)in a suitable subgroup of patients with poorly differentiated EGC.METHODS We retrospectively analyzed 138 patients with poorly differentiated EGC who underwent gastrectomy with lymphadenectomy between January 1990 and December 2015.The association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses.Odds ratios(OR)with 95%confidence interval(95%CI)were calculated.We further examined the relationship between the positive number of the significant predictive factors and the LNM rate.RESULTS The tumor diameter(OR=13.438,95%CI:1.773-25.673,P=0.029),lymphatic vessel involvement(LVI)(OR=38.521,95%CI:1.975-68.212,P=0.015)and depth of invasion(OR=14.981,95%CI:1.617-52.844,P=0.024)were found to be independent risk factors for LNM by multivariate analysis.For the 138 patients diagnosed with poorly differentiated EGC,21(15.2%)had LNM.For patients with one,two and three of the risk factors,the LNM rates were 7.7%,47.6%and 64.3%,respectively.LNM was not found in 77 patients that did not have one or more of the three risk factors.CONCLUSION ESD might be sufficient treatment for intramucosal poorly differentiated EGC if the tumor is less than or equal to2 cm in size and when LVI is absent upon postoperative histological examination.ESD with LLND may lead to the elimination of unnecessary gastrectomy in poorly differentiated EGC.

Combination of endoscopic submucosal dissection and laparoscopic sentinel lymph node dissection in early mucinous gastric cancer:Role of lymph node metastasis

BACKGROUND Recent evidence showed that combining endoscopic submucosal dissection(ESD)and laparoscopic sentinel lymph node dissection may avoid unnecessary gastrectomy in treating early mucinous gastric cancer(EMGC)patients with risks of positive lymph node metastasis(pLNM).AIM To explore the predictive factors for pLNM in EMGC,and to optimize the clinical application of combing ESD and sentinel lymph node dissection in a proper subgroup of patients with EMGC.METHODS Thirty-one patients with EMGC who had undergone gastrectomy with lymph node dissection were consecutively enrolled from January 1988 to December 2016.Univariate and multivariate logistic regression analyses were used to estimate the association between the rates of pLNM and clinicopathological factors,providing odds ratio(OR)with 95%confidence interval.And the association between the number of predictors and the pLNM rate was also investigated.RESULTS Depth of invasion(OR=7.342,1.127-33.256,P=0.039),tumor diameter(OR=9.158,1.348-29.133,P=0.044),and lymphatic vessel involvement(OR=27.749,1.821-33.143,P=0.019)turned out to be significant and might be the independent risk factors for predicating pLNM in the multivariate analysis.For patients with 1,2,and 3 risk factors,the pLNM rates were 9.1%,33.3%,and 75.0%,respectively.pLNM was not detected in seven patients without any of these risk factors.CONCLUSION ESD might serve as a safe and sufficient treatment for intramucosal EMGC if tumor size≤2 cm,and when lymphatic vessel involvement is absent by postoperative histological examination.Combining ESD and sentinel lymph node dissection could be recommended as a safe and effective treatment for EMGC patients with a potential risk of pLNM.

Current perspectives on the management of lateral pelvic lymph nodes in rectal cancer

Significant controversies exist with regards to the optimal management of lateral pelvic lymph nodes metastases(mLLN)in patients with low rectal cancer.The differing views held by Japanese and Western clinicians on the management of mLLN have been well documented.However,the adequacy of pelvic lymph node dissection(PLND)or neoadjuvant chemoradiation(NACRT)alone in addition to total mesorectal excision(TME)have recently come into question,due to the relatively high incidence of lateral local recurrences following PLND and TME,or NACRT and TME alone.Recently,a more selective approach to PLND has been suggested,involving a combination of neoadjuvant therapy,followed by PLND only to patients in whom the oncological benefit is likely to outweigh the risk of potential adverse events.A number of studies have attempted to retrospectively identify certain nodal characteristics on preoperative imaging,such as nodal size,appearance,and size reduction following neoadjuvant therapy.However,no consensus has been reached regarding the optimal criteria for a selective approach to PLND,partly due to the heterogeneity and retrospective nature of most of these studies.This review aims to provide an overview of recent evidence with regards to the diagnostic challenges,considerations for,and outcomes of the current management strategies for mLLN in rectal cancer patients.

Lateral pelvic lymph nodes for rectal cancer:A review of diagnosis and management

The current status and future prospects for diagnosis and treatment of lateral pelvic lymph node(LPLN)metastasis of rectal cancer are described in this review.Magnetic resonance imaging(MRI)is recommended for the diagnosis of LPLN metastasis.A LPLN-positive status on MRI is a strong risk factor for metastasis,and evaluation by MRI is important for deciding treatment strategy.LPLN dissection(LPLD)has an advantage of reducing recurrence in the lateral pelvis but also has a disadvantage of complications;therefore,LPLD may not be appropriate for cases that are less likely to have LPLN metastasis.Radiation therapy(RT)and chemoradiation therapy(CRT)have limited effects in cases with suspected LPLN metastasis,but a combination of preoperative CRT and LPLD may improve the treatment outcome.Thus,RT and CRT plus selective LPLD may be a rational strategy to omit unnecessary LPLD and produce a favorable treatment outcome.

Exploration and optimization of surgical techniques for laparoscopic transhiatal lower mediastinal lymph node dissection for adenocarcinoma of esophagogastric junction: A prospective IDEAL 2a study with qualitative design

Objective: To explore the change and feasibility of surgical techniques of laparoscopic transhiatal(TH)-lower mediastinal lymph node dissection(LMLND) for adenocarcinoma of the esophagogastric junction(AEG)according to Idea, Development, Exploration, Assessment, and Long-term follow-up(IDEAL) 2a standards.Methods: Patients diagnosed with AEG who underwent laparoscopic TH-LMLND were prospectively included from April 14, 2020, to March 26, 2021. Clinical and pathological information as well as surgical outcomes were quantitatively analyzed. Semistructured interviews with the surgeon after each operation were qualitatively analyzed.Results: Thirty-five patients were included. There were no cases of transition to open surgery, but three cases involved combination with transthoracic surgery. In qualitative analysis, 108 items under three main themes were detected: explosion, dissection, and reconstruction. Revised instruction was subsequently designed according to the change in surgical technique and the cognitive process behind it. Three patients had anastomotic leaks postoperatively, with one classified as Clavien-Dindo Ⅲa.Conclusions: The surgical technique of laparoscopic TH-LMLND is stable and feasible;further IDEAL 2b research is warranted.

Laparoscopic retroperitoneal lymph node dissection versus open retroperitoneal lymph node dissection for testicular cancer:A comparison of clinical and perioperative outcomes

Objective:This study was performed to evaluate the clinical and perioperative outcomes of laparoscopic retroperitoneal lymph node dissection(L-RPLND)and open retroperitoneal lymph node dissection(O-RPLND)performed by one surgeon at a single center.Methods:We evaluated 30 patients with stage IIA germ cell tumors who underwent retroperitoneal lymph node dissection(15 underwent L-RPLND and 15 underwent O-RPLND)at our institution between April 1,2010 and March 31,2018.The clinical parameters were compared between patients who underwent L-RPLND using the retroperitoneal approach and those who underwent O-RPLND using the transperitoneal approach.There were no significant differences in the background characteristics of the two groups except for the median follow-up duration(46 months for L-RPLND and 71 months for O-RPLND,p=0.02).Results:L-RPLND was associated with a shorter mean operative time(mean 222 min for L-RPLND vs.453 min for O-RPLND,p<0.001).There was significantly less blood loss during surgery in the L-RPLND group compared to the O-RPLND group(mean 165 mL for L-RPLND vs.403 mL for O-RPLND,p<0.001).Parameters related to postoperative recovery were significantly better for the L-RPLND group than for the O-RPLND group.There were no differences in the histopathological characteristics between the two groups.No patients in either group exhibited disease recurrence.Conclusion:Patients who underwent L-RPLND had more rapid recovery,and shorter hospital stay compared to those who underwent O-RPLND;complications were comparable between the two groups.L-RPLND is an efficient procedure with the benefits of minimally invasive surgery.

Sentinel Lymph Node Biopsy as Guidance for Lateral Neck Dissection in Patients with Papillary Thyroid Carcinoma

Introduction: The surgical management of lateral lymph nodes in differentiated thyroid carcinoma is controversies. Therefore, we analyzed whether sentinel lymph nodes (SLN) biopsy of the first draining nodes in the jugulo-carotid chain is an accurate technique to select patients with true-positive but nonpalpable lymph nodes for selective lateral node dissection. Materials and Methods: From January 2009 to December 2009, 12 patients with solitary papillary carcinoma measuring 2 cm by ultrasonography were included in this study. After the thyroid gland was exposed to avoid injuring the lateral thyroid lymphatic connection, approximately 0.2 ml of 5mg/ml indocyanine green was injected into the parenchyma of upper and lower thyroid gland. Some stained lymph nodes in the jugulo-carotid chain could be identified following the stained lymphatic duct and dissected as the SLN. After that, thyroidectomy with modified neck dissection was performed. Results: The mean tumor size was 22.1 ± 4.6 mm. Identification and biopsy of stained SLN in the ipsilateral jugulo-carotid chain was successful in all 12 cases. In 6 cases, histopathological analysis of SLNs revealed metastases of the papillary thyroid carcinoma. Among them, 2 cases had additional metastatic lymph nodes in the ipsilateral compartment. Of the 6 patients who had negative lymph node metastasis (LNM) in SLNs, all patients had negative LNM in the ipsilateral compartment. Conclusions: The method may be helpful in the detection of true-positive but nonpalpable lymph nodes and may support a decision to perform a selective lateral node dissection in patients with papillary thyroid carcinoma.

Gastric cancer: Current status of lymph node dissection

D2 procedure has been accepted in Far East as the standard treatment for both early(EGC) and advanced gastric cancer(AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials(RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council(MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recur-rence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Effect of visceral obesity on outcomes of fluorescence-guided lymphadenectomy during laparoscopic gastrectomy for gastric cancer:Post hoc analysis of a randomized phase 3 trial

Objective:To explore the impact of visceral fat area(VFA)on the short-and long-term efficacy of indocyanine green(ICG)-guided D2 lymphadenectomy for gastric cancer(GC).Methods:A post hoc analysis was performed in patients who participated in a phase 3 randomized clinical trial of ICG-guided laparoscopic radical gastrectomy vs.conventional laparoscopic radical gastrectomy from November 2018 to July 2019.The VFA was calculated based on preoperative computed tomography images.Short-term efficacy included the quality of lymph node(LN)dissection and surgical outcomes,while long-term efficacy included overall survival(OS)and recurrence-free survival(RFS).Results:This study included 126 patients each in the ICG(high-VFA,n=43)and non-ICG groups(high-VFA,n=38).Compared with the non-ICG group,the ICG group had significantly more retrieved LNs(low-VFA:50.1 vs.43.9,P=0.001;high-VFA:49.6 vs.37.5,P<0.001)and a significantly lower LN noncompliance rate(low-VFA:32.5%vs.50.0%,P=0.020;high-VFA:32.6%vs.73.7%,P<0.001),regardless of the VFA.The ICG group had a shorter postoperative hospital stay and fewer intra-abdominal infections than the ICG group in the high-VFA patients(P=0.025 and P=0.020,respectively)but not in the low-VFA patients.Regardless of the VFA,the 3-year OS(RFS)was better in the ICG group than in the non-ICG group[low-VFA:83.1%(76.9%)vs.73.9%(67.0%);high-VFA:90.7%(90.7%)vs.73.7%(73.5%);P for interaction=0.474(0.547)].Conclusions:The short-and long-term efficacies of ICG tracing were not influenced by visceral obesity.

T1 rectal mucinous adenocarcinoma with bilateral enlarged lateral lymph nodes and unilateral metastasis:A case report

BACKGROUND There are a few cases of lateral lymph node(LLN)metastasis(LLNM)of T1 rectal cancer.Moreover,LLNM is easily missed,especially in patients with early-stage rectal cancer.To our knowledge,the possibility of bilateral LLNM before surgery has not been reported in previous studies.CASE SUMMARY A 36-year-old woman underwent endoscopic submucosal dissection at a local hospital owing to a clinical diagnosis of a rectal polyp.The pathology report showed a diagnosis of T1 rectal mucinous adenocarcinoma.She was considered to have bilateral LLNM after the examination at our hospital.Laparoscopic total mesorectal excision plus bilateral LLN dissection was performed and the pathological outcomes indicated unilateral LLNM.The patient received longcourse adjuvant chemoradiotherapy with no recurrence or metastasis observed during the 1-year follow-up period.CONCLUSION T1 rectal cancer could lead to LLNM and possibly,bilateral LLNM.Therefore,adequate clinical evaluation is essential for these patients.

Additional laparoscopic gastrectomy after noncurative endoscopic submucosal dissection for early gastric cancer: A single-center experience

BACKGROUND The necessity of additional gastrectomy for early gastric cancer (EGC) patients who do not meet curative criteria after endoscopic submucosal dissection (ESD) is controversial. AIM To examine the clinicopathologic characteristics of patients who underwent additional laparoscopic gastrectomy after ESD and to determine the appropriate strategy for treating those after noncurative ESD. METHODS We retrospectively studied 45 patients with EGC who underwent additional laparoscopic gastrectomy after noncurative ESD from January 2013 to January 2019 at the Cancer Hospital of the Chinese Academy of Medical Sciences. We analyzed the patients’ clinicopathological data and identified the predictors of residual cancer (RC) and lymph node metastasis (LNM). RESULTS Surgical specimens showed RC in ten (22.2%) patients and LNM in five (11.1%).Multivariate analysis revealed that positive horizontal margin [odds ratio (OR)=13.393, 95% confidence interval (CI): 1.435-125, P=0.023] and neural invasion (OR=14.714, 95%CI: 1.087-199, P=0.043) were independent risk factors for RC. Undifferentiated type was an independent risk factor for LNM (OR=12.000, 95%CI: 1.197-120, P=0.035). Tumors in all patients with LNM showed submucosal invasion more than 500 μm. Postoperative complications after additional laparoscopic gastrectomy occurred in five (11.1%) patients, and no deaths occurred among patients with complications. CONCLUSION Gastrectomy is necessary not only for patients who have a positive margin after ESD, but also for cases with neural invasion, undifferentiated type, and submucosal invasion more than 500 μm. Laparoscopic gastrectomy is a safe, minimally invasive, and feasible procedure for additional surgery after noncurative ESD. However, further studies are needed to apply these results to clinical practice.

Single port laparoscopic right hemicolectomy with D3 dissection for advanced colon cancer

We report the first case of single port laparoscopic right hemicolectomy for advanced colon cancer.An abdominal 3 cm length incision was made via the umbilicus.A small wound retractor and a surgical glove were used as a single port.All soft tissue anterior to the superior mesenteric vein was completely removed and D3 lymph node dissection was achieved.The total operative time was 180 min with minimal blood loss (<50 mL).The size of the tumor was 5 cm×3 cm and its tumor stage was T3N0.Sixty-nine lymph nodes were harvested and none were positive.We believe that single port surgery for colon cancer is a feasible and safe procedure with surgical results comparable to conventional laparoscopic procedures.

Preoperative chemoradiation and extended pelvic lymphadenectomy for rectal cancer:Two distinct principles

Extended pelvic lymphadenectomy(EPL) with total mesorectal excision(TME) has been reported to provide oncological benefit in lower rectal cancer in Japan.In Western countries EPL is not widely accepted because of frequent morbidity but instead preoperative chemoradiation(CRT) followed by TME has been established as a standard treatment for decreasing local recurrence.Recently,several studies have focused on the comparison between these two distinct therapeutic approaches in Western countries and Japan.A study comparing Dutch trial data and Japanese data revealed that EPL and RT are almost equivalent in decreasing local recurrence in lower rectal cancer as compared with TME alone.Considering that almost 45 survival can be achieved by EPL even in the presence of metastatic lateral lymph nodes(LLNs),EPL performed by experienced surgeons definitely contributes to decrease local recurrence.On the other hand,a randomized controlled trial in Japan that compared EPL with conventional TME following preoperative RT revealed that EPL is associated with a higher frequency of sexual and urinary dysfunction without oncological benefits in the presence of preoperative RT.On this point,preoperative CRT followed by conventional TME without EPL would be a better therapeutic approach in patients without evident metastatic LLNs.For future treatment,it would be desirable to have a narrower indication for EPL using full advantage of recent improvement in image diagnosis.Although objective comparison of these two principles between Japan and the West is difficult due to differences in patient groups,further studies would lead to the next great step towards future improvement in treating lower rectal cancer.