Objectives: This study aimed to determine the optimal cutoff values for predicting mesorectal lymph node metastasis in rectal cancer using preoperative magnetic resonance imaging (MRI) parameters.

Methods: We retrospectively analyzed 67 patients with rectal cancer who underwent resection and preoperative pelvic MRI at our institution between April 2015 and December 2023. The MRI-based long- and short-axis diameters of mesorectal lymph nodes were compared with pathological findings to assess their correlation with lymph node metastasis. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff values for metastasis prediction.

Results: The median age was 70.5 years, and 48 were male. Among the 67 patients, 30 had mesorectal lymph node metastasis. At our institution, lymph nodes with a long-axis diameter of ≥ 8 mm on MRI were considered positive for metastasis. Using this threshold, the sensitivity and specificity for predicting mesorectal lymph node metastasis were 0.63 and 0.54, respectively. ROC curve analysis identified cutoff values of 6.9 mm for the long-axis diameter, 4.8 mm for the short-axis diameter, and 0.83 for the short-to-long axis ratio. The areas under the ROC curve for the long-axis, short-axis, and short-to-long axis ratio were 0.81, 0.86, and 0.60, respectively.

Conclusions: A preoperative long-axis diameter of ≥ 7 mm and a short-axis diameter of ≥ 5 mm were found to be reliable predictors of mesorectal lymph node metastasis in rectal cancer. Using a 5-mm short-axis cutoff improved diagnostic specificity. These findings require further validation in clinical settings to optimize treatment strategies.

Objectives: Although hybrid endoscopic submucosal dissection (ESD) has gained popularity over the years, its usefulness in ensuring an adequate submucosal [SM] layer for T1b (SM invasion depth ≥1,000 μm) colorectal carcinoma (CRC) remains unknown. We retrospectively compared conventional ESD (C-ESD) with planned hybrid ESD (PH-ESD) for cT1b CRCs measuring 20-30 mm.

Methods: We analyzed 71 consecutive cases of cT1b CRC (20-30 mm). The patients were classified into C-ESD (n=38), PH-ESD (n=21), or salvage hybrid ESD (n=12) groups. We compared the clinicopathological characteristics, including resected SM and vertical margin (VM) distance, and outcomes between the C-ESD and PH-ESD groups. We also investigated the factors leading to VM positivity (VM1).

Results: The PH-ESD group exhibited a significantly shorter procedure time (40.5 vs. 60.5 min) and a significantly higher rate of VM ≥500 μm (81.0% vs. 47.4%) compared to the C-ESD group. Regarding superficial tumors, the PH-ESD group exhibited significantly longer resected SM (1,243 vs. 837 μm) and VM (545 vs. 302 μm) distances and a significantly higher rate of VM ≥500 μm (72.7% vs. 14.3%) than the C-ESD group. All VM1 lesions were resected using C-ESD or salvage hybrid ESD. VM1 lesions exhibited significantly higher rates of poorly differentiated histology at the deepest invasive front (71.9% vs. 14.3%) and perioperative perforation (28.6% vs. 0%) than VM-negative lesions.

Conclusions: PH-ESD for 20-30-mm T1b CRCs may be more useful than C-ESD in terms of procedure time, especially for superficial lesions, ensuring a longer resected SM distance and VM ≥500 μm.

Objectives: Pure well-differentiated adenocarcinoma (PWDA) could be a safe factor against lymph node metastasis (LNM) and recurrence in patients with T1 colorectal cancer. We investigated the utility and endoscopic features of PWDA to determine its predictive ability.

Methods: We analyzed the LNM and recurrence rates, along with various clinicopathological factors, including PWDA, in 315 patients with T1 colorectal cancer who underwent surgical resection at our center. PWDA was defined as a lesion consisting of well-differentiated adenocarcinoma only. Three pathologists evaluated the consistency of the PWDA diagnosis and performed inter- and intraobserver assessments of PWDA and lymphatic invasion. Endoscopic features of PWDA was also examined.

Results: The LNM, recurrence, and PWDA rates in patients with T1 colorectal cancer were 9.5%, 2.9%, and 31.1%, respectively. Significant differences were observed in T1b (100% vs. 82.8%; p = 0.014) and non-PWDA (100% vs. 65.6%; p < 0.001) between patients with and without LNM. Multivariate analyses showed that non-PWDA was an independent risk factor for LNM (odds ratio [OR], 12.09; 95% confidence interval [CI], 1.59-92.0; p = 0.016). Furthermore, significant differences in venous invasion (44.4% vs. 19.6%; p < 0.001), and non-PWDA (100% vs. 68.0%; p < 0.001) were observed between patients with and without recurrence. The agreement among three pathologists on the diagnosis of PWDA was acceptable (kappa value > 0.5). Surface redness (p < 0.001), a rugged surface (p < 0.01), fold convergence (p < 0.001), and an impression of fullness (p = 0.031) were significantly related with PWDA.

Conclusions: PWDA can predict safety against LNM and recurrence in patients with T1 colorectal cancer.

Objectives: There is no consensus on the significance of peritoneal lavage cytology for the prognosis of patients with colorectal cancer. In this prospective multicenter study, we aimed to determine whether positive peritoneal lavage cytology results predict poor patient outcomes and to clarify if the appropriate timing of cytology is before or after tumor resection.

Methods: Patients diagnosed with pathological stage II or III colorectal cancer between 2013 and 2017 were enrolled in this study. Peritoneal lavage cytology was performed twice, before and after the tumor resection, and the results were analyzed to determine their effect on prognosis and peritoneal recurrence.

Results: We analyzed 1378 patients, and 54 (3.9%) had positive cytology results. Furthermore, 30 patients were positive before tumor resection, 13 after tumor resection, and 11 for both markers. The 5-year relapse-free survival rates (5yRFS) with positive and negative cytology before tumor resection in patients with pStage II were 44.4 and 81.7%, respectively (p=0.0014). The 5-year overall survival rates (5yOS) were 57.1 and 91.6%, respectively (p=0.0046). In Stage III, the 5yRFS and 5yOS between patients with positive and negative cytology did not differ. Patients with positive and negative cytology before tumor resection in pStage II had peritoneal recurrence rates of 11.1 and 1.66%, respectively (p=0.034). These rates were 12.5 and 2.51%, respectively, in patients with pStage III (p=0.011).

Conclusions: A positive cytology result before tumor resection is a prognostic factor in Stage II colorectal cancer and is instrumental in predicting peritoneal recurrence in Stages II and III colorectal cancer.

Objectives: Colorectal cancer remains a major global health concern. Identifying high-risk patients is crucial for optimizing treatment strategies. The prognostic value of biomarkers, especially considering competing risks, remains unclear. We used a competing risks model to exclude the influence of non-cancer-related mortality and examined FAR as a predictor of recurrence in colorectal cancer.

Methods: This retrospective study analyzed 359 patients with stage II or III colorectal cancer from the cecum to the oral side of the peritoneal inversion, all of whom underwent curative resection at Fukui University Hospital. The primary outcome was cancer recurrence. The fibrinogen-albumin ratio (FAR) was assessed using univariate and multivariate analyses, including competing risk models, with a cutoff value of >0.131.

Results: Univariate analysis identified factors significantly associated with poorer outcomes, including T4 stage, gross appearance type 3/4/5 tumors, stage III disease, elevated neutrophil-to-lymphocyte ratio, prognostic nutritional index, carcinoembryonic antigen, and FAR. Multivariate analysis confirmed FAR as an independent prognostic factor. A predictive model combining FAR, stage III disease, and T4 stage demonstrated the best performance based on Akaike information criterion and Bayesian information criterion values.

Conclusions: FAR is a robust prognostic biomarker for colorectal cancer. Incorporating FAR into clinical practice may enable healthcare providers to more accurately stratify high-risk patients, facilitating personalized treatment strategies.

Objectives: Sarcopenia is generally defined based on the age-related muscle mass and weakness. However, it has been reported that patients with Crohn's disease, who develop severe inflammation of the gastrointestinal tract, are more likely to develop sarcopenia. We retrospectively investigated the effect of the iliopsoas muscle area, which is an indicator of sarcopenia, on postoperative complications in patients with Crohn's disease.

Methods: We included 98 patients with Crohn's disease who underwent surgery in our department between January 2016 and December 2021, and performed retrospectively analyzed. The psoas muscle index (PMI) was calculated as the average of the left and right iliopsoas muscles (L3, cm²) / height². We divided patients into the low PMI (men <2.33 cm²/m², women <1.85 cm²/m²) and normal PMI groups and compared their preoperative and intraoperative factors and postoperative outcomes.

Results: The median age of the 98 patients was 37.0 (17-77) years. Complications were noted in 40 patients (40.8%), including 10 (10.2%) with anastomotic leakage. There were 26 (26.5%) patients with a low PMI. The incidence of all postoperative complications, grade ≥2 complications, anastomotic leakage and surgical site infection (SSI) were significantly higher in the low-PMI group than in the normal-PMI group. According to a multivariate analysis, low PMI (p=0.04) was only independent predictor for grade 2 or above postoperative complications.

Conclusions: A low PMI is associated with postoperative complications, especially anastomotic leakage, in patients with Crohn's disease.

Objectives: The aim of this study was to evaluate the effectiveness of injectable sclerotherapy using Polidocanol foam in patients with hemorrhoids and severe anemia during a 1-year follow-up period, while utilizing the Hemorrhoidal Disease Severity Score (HDSS) in conjunction with Short Health Scale (SHS) for assessment.

Methods: A retrospective analysis was conducted on patients with severe anemia and hemorrhoids who underwent injectable sclerotherapy using Polidocanol foam between February 2022 and May 2023.

Results: The bleeding symptoms in all patients resolved immediately after treatment. Hemoglobin levels increased rapidly within one month after treatment, and statistically significant improvements were observed in HDSS score, and SHS score (P<0.001) during the one-year follow-up. Two patients experienced recurrence of prolapse symptoms during the one-year follow-up period and subsequently underwent hemorrhoidectomy.

Conclusions: The use of Polidocanol foam in injectable sclerotherapy demonstrates highly promising effects in patients suffering from severe anemia caused by hemorrhoids.

The number of reports of robotic surgery for colorectal cancer, including reports of simultaneous surgery involving multiple organs, has increased in recent years. We report a case of simultaneous robotic surgery for a giant uterine fibroid and rectal cancer. The patient 45-year-old woman was diagnosed with rectal cancer and a giant uterine fibroid measuring 18 cm in maximum diameter. The uterine fibroid was oriented toward the cervix and was approached from both sides, and the broad ligament of the uterus was cut off using a vessel sealer. The cervix was dissected from the side of the abdominal cavity using monopolar curved scissors. The GelPOINT Access Platform™ was attached to the vagina, and the laparoscopic camera was inserted into the vagina to confirm the resection site. The border between the uterus and rectum was confirmed from both the abdominal cavity and vaginal sides, and simple total hysterectomy was safely performed. The rectum was dissected below the peritoneal reflection. The excised uterine specimen measured 18×13×5 cm long. The patient underwent robotic surgery for a giant uterine fibroid and rectal cancer. It is important to plan and simulate the surgery beforehand as well as select the site for trocar placement.

A 78-year-old woman was diagnosed with lower rectal cancer extending to the dentate line. She underwent preoperative chemoradiotherapy, which resulted in tumor shrinkage and clinical complete response (cCR), leading to the implementation of the "Watch and Wait" strategy. At the 21-month surveillance mark, pruritus and erythematous lesions appeared around her anus, which were histologically diagnosed as secondary Paget disease with invasion based on biopsy specimens. Because the primary lesion maintained cCR, local excision of the skin lesion was performed, and negative resection margins were confirmed by pathological examination. At the 4-year postoperative follow-up, neither local recurrence nor distant metastases were observed. This case suggests that although the primary focus disappeared entirely with the use of chemoradiotherapy, microscopic perianal secondary Paget disease hidden outside the radiation field became apparent during surveillance. As total neoadjuvant therapy (TNT) becomes more widespread, the frequency of cCR is expected to increase. During the "Watch and Wait" period, vigilant observation of the perianal skin as well as the rectal region should be performed.

Primary colorectal choriocarcinoma is extremely rare with only 35 cases described in the literature during over 40 years. The neoplasm is characterized by biphasic tumor growth composed of adenocarcinomatous and choriocarcinomatous differentiation. Diagnostic elusiveness, aggressive nature and lack of established treatment make the prognosis extremely poor, and most patients die during the first year after diagnosis. We present a 66-year-old man with a primary choriocarcinoma of the transverse colon presenting with peritoneal metastasis and acute colonic obstruction. The patient was treated with systemic three-drug chemotherapy (mFOLFOXIRI: 5-fluorouracil/leucovorin + oxaliplatin + irinotecan) in combination with bevacizumab, a highly active regimen for metastatic colorectal adenocarcinoma. Tumor shrinkage was accompanied by a decrease of mononucleated trophoblast-like carcinoma cells in an endoscopic biopsy during the treatment, and the symptoms of disease were relieved within a quite short period of therapy, though rapid regrowth associated with serum beta human chorionic gonadotropin escalation occurred following discontinuation of therapy. The patient died 8 months after the initial diagnosis. Although our patient survived longer than the median survival period documented in the literature, further cases will need to be examined in the future to establish whether this antitumor treatment is effective to prolong survival.

Solitary fibrous tumors (SFT) are rare mesenchymal neoplasms, and surgical resection with a negative margin is considered to have a good prognosis. It is commonly located in the thoracic cavity but rarely develops in the pelvis. One of the features of the Hugo RAS system is the independent robotic arm carts that enable high flexibility of settings and safe operations with reduced interference, even in a narrow pelvis, which may be particularly useful in surgery for pelvic masses. A 34-year-old woman presented to our hospital with a pelvic mass detected by transvaginal ultrasound during a prenatal check-up. Colonoscopy, computed tomography, and magnetic resonance imaging suggested a gastrointestinal stromal tumor, smooth muscle tumor, schwannoma, and SFT. However, since a definitive diagnosis could not be obtained and continuity with the rectum could not be ruled out, intersphincteric resection (ISR) was performed for diagnostic and therapeutic purposes. The pathological results showed complete resection of the SFT with negative margins, and the patient had a good postoperative course. Herein, we report the first case of safe and complete resection of a massive pelvic SFT using the Hugo RAS system.