Objective: This study aimed to analyze the risk factors for leakage in laparoscopic rectal cancer surgery.
Methods: We retrospectively examined 112 patients who underwent anastomosis with the double stapling technique in laparoscopic rectal cancer surgery at our hospital. To identify the risk factors, we analyzed age, sex, body mass index, diabetes, preoperative albumin level, preoperative bowel obstruction, tumor location, invasion depth of tumor, and Prognostic Nutritional Index as the patient factors. As the surgery factors, we analyzed operation time, amount of bleeding, number of firings for rectal transection, reduced port surgery, ligation of the inferior mesenteric artery root, size of the circular stapler, and covering stoma.
Results: The median age of the 112 patients was 67 years. Twelve patients had anastomotic leakage. A significant difference was confirmed for circular staple size (31 mm or more) and operation time (400 minutes or longer). Multivariate analysis revealed that a circular staple size of 31 mm or more was an independent risk factor for anastomotic leakage.
Conclusion: The findings of this study suggested that circular staple size is a risk factor for anastomotic leakage.
We report two cases of two-stage surgery preceded by endovascular aneurysm repair for colorectal cancer with abdominal aortic aneurysm.
Patient 1: The patient was an 83-year-old man. He had refused to undergo surgery for abdominal aortic aneurysm despite recommendations by his physician. He presented with blood discharge and dizziness, and detailed examinations revealed the presence of cancer in the ascending colon with severe anemia, as well as abdominal aortic aneurysm measuring 100 mm along the short axis.
Patient 2: The patient was an 82-year-old man who presented with a chief complaint of abdominal distension. He had rectosigmoid cancer with colonic ileus, as well as abdominal aortic aneurysm measuring 54 mm along the short axis.
Considering the risk of infection with vascular grafts, we performed endovascular aneurysm repair followed by a secondary procedure. The secondary procedure for colorectal cancer was performed 7 days and 11 days after endovascular aneurysm repair for patient 1 and 2, respectively. A colonic stent was used prior to endovascular aneurysm repair in patient 2 in order to perform the subsequent procedures safely.
Given that both cases were treated safely within a short period of time, this strategy may be useful in colorectal cancer patients with abdominal aortic aneurysm.
A 70-year-old man who had undergone mesh plug repair for right inguinal hernia 17 years earlier visited our hospital because of a right inguinal sense of incongruity. Three years later, right inguinal severe swelling and redness were observed, and a left inguinal abscess was found on abdominal enhanced computed tomography (CT), so we diagnosed late-onset mesh infection. Based on the suspicion of a fistula between the plug and cecum we performed an operation. The infected plug and onlay patch were entirely removed. Pulmonary embolism, ileus, and SSI developed postoperatively, but the course improved, and there was no recurrence of the hernia. To the best of our knowledge, there have been only case in which an endoscopic mesh plug was observed 17 years after surgery. Furthermore, there has been no reported case of mesh infection 20 years after surgery. We present our case with a review of the literature.
We report a case of emergency laparoscopic surgery for intestinal intussusception and obstruction due to jejunal metastasis of malignant melanoma.
A 49-year-old man was referred by a home doctor to our department because of vomiting. Contrast-enhanced CT showed penetration of an advanced tumor into the anal side of the jejunum in the frontal section and a target sign was found in the axial section.
The patient was diagnosed with intestinal intussusception and obstruction and an emergency laparoscopic surgery was planned. We identified the lesion and lifted it out of the body through an extraction site and the intussusception was repaired by the Hutchinson procedure. Since many enlarged black lymph nodes were found in the mesentery, partial small intestinal resection and regional lymph node dissection were performed for small intestinal cancer. As a result of histopathological examination, jejunal metastasis of malignant melanoma was diagnosed.
The patient was discharged on the 9th postoperative day without any complications. He received postoperative adjuvant chemotherapy with nivolumab. Finally, the left subclavian lymph node metastasis disappeared, and he was diagnosed as complete response. He remains alive at 2 years and 9 months without recurrence.
Case 1: A 67-year-old man had undergone a sigmoid colon resection and colostomy for sigmoid colon cancer in 1998 when he was 53 years old. In 2013, he noticed a tumor in the colostomy and revisited our hospital. At first, only the tumor of the colostomy was removed, but the pathological findings showed the depth was SM, and there was carcinoma of the stump of the resected specimen. Therefore, we resected the old colostomy and reconstructed a new colostomy. The resected specimen showed the remaining tumor, n0 Stage I.
Case 2: A 70-year-old male had undergone abdominal perineal rectal amputation for rectal cancer and colostomy construction in 2014 when he was 66 years old. A tumor was noted in the colostomy during the follow-up colonoscopy. Considering metachronous colostomy cancer, we resected the old colostomy and reconstructed a new colostomy. The pathological findings showed the resected colostomy was MP, n0 Stage I.
Discussion: Only 41 cases have been reported in Japan. The long-term diagnosis and treatment of this disease appear to be a problem.
The patient, a 29-year-old man, had a palpable anal fistula, which was displayed by ultrasonography. Furthermore, a small lesion of the intersphincteric space near the dentate line was displayed as well, therefore a fistulectomy was performed. On the fortieth day after the surgery, the lesion had healed. However, the patient felt an induration on the other side of the anus. When we palpated it, it appeared to be another anal fistula and the finding was confirmed by ultrasonography, which revealed that the small lesion of the intersphincteric space near the dentate line had shifted to the anal fistula.
Endoscopic resection is recommended for a rectal NET of diameter less than 10 mm. We conducted laparoscopic low anterior resection of a 4-mm rectum NET, which was positive for vascular invasion at its pathological diagnosis after endoscopic resection, and metastasis of lymph node was observed. Even if a primary lesion is minimal, if there is a possibility of lymph node metastasis, additional resection should be considered. We report this case with a review of the literature.