Objective: To evaluate the mid-term efficacy of laparoscopic-assisted natural orifice specimen extraction surgery (NOSES) colectomy using the Cai tube in the treatment of left colorectal cancer. Methods: A prospective randomized control trial (China Clinical Trials Registration Number: ChiCTR-OOR-15007060) was performed. Sixty patients with left colorectal cancer at Department of Gastrointestinal Surgery of Zhongshan Hospital from September 2015 to August 2017 were prospectively enrolled. Case inclusion criteria: (1) left colorectal adenocarcinoma (rectal cancer with distance ≥ 8 cm from tumor low margin to anal edge, sigmoid colon cancer, descending colon cancer and left transverse colon cancer) confirmed by preoperative pathology; (2) satisfactory conditions of conventional laparoscopic surgery; (3) maximum diameter of the tumor < 4.5 cm confirmed by preoperative abdominal and pelvic CT or MRI; (4) BMI < 30 kg/m². Case exclusion criteria: (1) benign lesions, mucinous adenocarcinoma, signet-ring cell carcinoma and other special pathological types of tumors confirmed by preoperative pathological examination; (2) multiple or recurrent cancers; (3) with a history of neoadjuvant chemoradiotherapy; (4) obvious regional infiltration or distant metastasis indicated by preoperative imaging examination; (5) intestinal obstruction, intestinal perforation, etc. Participants were randomly assigned to NOSES group (using the Cai tube) and conventional laparoscopy (CL) group by random number table method. Clinical data between two groups were compared and analyzed, including perioperative conditions, tumor exfoliation cell detection and bacterial culture results of intraperitoneal lavage fluid, postoperative complications (Clavien-Dindo grading), postoperative pain [visual simulation scoring (VAS) assessment], anal function (Kirwan anal function grading assessment), and postoperative 3-year disease-free survival (DFS), overall survival (OS), overall recurrence rate, and local recurrence rate. Results: A total of 60 patients were enrolled, with 30 in the NOSES group and 30 in the CL group. All the patients in the NOSES group successfully completed operation with Cai tube. Baseline data between the two groups were not significantly different (all P>0.05). There were no statistically significant differences between two groups in conversion rate to open surgery, number of lymph node harivested, proximal and distal resection margin of tumor, negative rate of circumferential margin, operation time, blood loss, inflammatory indexes, postoperative anal function, postoperative hospital stay, hospitalization cost, morbidity of postoperative complications (Clavien-Dindo grade II or above) (all P>0.05). Compared to the CL group, the NOSES group had lower maximum postoperative VAS score (2.5±0.3 vs. 5.1±0.4, t=3.187, P<0.01), and fewer use of additional postoperative analgesia [6.7% (2/30) vs. 33.3% (10/30),χ²=6.670, P=0.02]. The postoperative time to gas passage was shorter in the NOSES group [(2.2±1.4) days vs. (3.1±1.2) days,P=0.026]. No tumor cells and bacterial contamination were found in abdominal lavage fluid before and after operation in either group. The anal function at postoperative 3-month of all the patients in the NOSES group was Kirwan grade I to II, while in the CL group, anal function of 2 cases (6.7%) was Kirwan grade III, and of 28 cases was also Kirwan grade I to II, whose difference was not statistically significant (P>0.05). In the NOSES group and the CL group, 3-year DFS was 96.7% and 83.3% (P=0.090), OS was 100% and 90% (P=0.096), overall recurrence rate was 3.3% and 10.0% (P=0.166), and local recurrence rate was 3.3% and 3.3% (P=0.999), respectively, whose differences were not statistically significant (all P>0.05). Conclusions: In the treatment of left colorectal cancer, compared with conventional laparoscopic colectomy, NOSES colectomy using Cai tube exhibits less scar, less postoperative pain, shorter recovery of gastrointestinal function, and similar mid-term outcomes. Given proper surgical indications, the surgical procedure is safe and feasible.
Follow-Up Studies ; Humans ; Laparoscopy ; Pain, Postoperative ; Postoperative Complications/surgery* ; Prospective Studies ; Rectal Neoplasms/surgery* ; Retrospective Studies ; Sigmoid Neoplasms/surgery* ; Treatment Outcome

Anastomosis, Surgical ; Colon, Sigmoid/surgery* ; Colorectal Neoplasms/surgery* ; Humans ; Robotics

Tumor spreading through the lymphatic drainage is an important metastatic pathway for rectum and sigmoid colon carcinoma. Regional lymph node dissection, as an important part of radical resection of colorectal cancer, is the main way for patients with colorectal cancer to achieve radical resection and acquire tumor-free survival. The regional lymph nodes of sigmoid cancer include paracolic lymph nodes, intermediate lymph nodes, and central lymph nodes locating at the root of blood vessel, and radical surgery should include lymph node dissection at the above three stations. The lymphatic pathways of metastasis for rectal cancer include longitudinal metastasis within the mesorectum and lateral metastasis beyond the mesorectum. The standard surgical method of rectal cancer is total mesorectal excision (TME) at present, and the resection range includes the metastatic lymph nodes within the mesorectum through the longitudinal pathway. However, there are many different opinions about lateral lymph node dissection(LLND) aiming at the metastatic lymph nodes locating at the lateral space of rectum. The range of lymph node dissection for rectum and sigmoid cancer is a vital factor that determines the prognosis of patients. Insufficient range of dissection can lead to residual metastatic lymph nodes and have serious impacts on the prognosis of patients. Excessive range of dissection can result in greater surgical trauma, prolonged operation time, more blood loss, and higher rate of complication without oncological benefits. Individualizating the appropriate resection range of rectum and sigmoid colon cancer on the basis of standardization and according to the clinical stage and invasion range of tumor demonstrates great significance of ensuring the radical operation, reducing trauma, promoting rehabilitation, protecting the function and improving the prognosis.
Humans ; Lymph Node Excision/methods* ; Lymph Nodes/pathology* ; Rectal Neoplasms/pathology* ; Rectum/pathology* ; Reference Standards ; Sigmoid Neoplasms/surgery*

We reported a case of irreducible indirect inguinal hernia caused by sigmoid colon cancer entering the right groin.The patient complained about a right groin mass for more than 60 years with progressive enlargement for 3 years and pain for half a month.Abdominal CT examination at admission showed rectum and sigmoid colon hernia in the right inguinal area and thickening of sigmoid colon wall.Electronic colonoscopy and pathological diagnosis showed sigmoid colon cancer.Therefore,the result of preliminary diagnosis was irreducible indirect inguinal hernia caused by sigmoid colon cancer entering the right groin.We converted laparoscopic exploration to laparotomy followed by radical sigmoidectomy and employed end-to-end anastomosis of descending colon and rectum in combination with repair of right inguinal hernia.The patient recovered well after operation and was discharged.
Colon, Sigmoid/surgery* ; Groin ; Hernia, Inguinal/surgery* ; Humans ; Laparoscopy ; Sigmoid Neoplasms/surgery*

PURPOSE: We assessed the oncologic and anastomotic benefits of low ligation of the inferior mesenteric artery (IMA) with additional lymph node (LN) retrieval. METHODS: We performed a retrospective case-control study between January 2011 and July 2015. All patients underwent curative resection of a primary sigmoid or rectal tumor. We excluded patients with distant metastases at the time of diagnosis. The case group included patients who underwent high ligation of the IMA (high group, HG). The control group included patients who underwent low ligation of the IMA with low group with additional LN retrieval (LGAL). Controls were identified by matching patients based on age (±5 years), sex, tumor location, and final histopathological stage. Finally, each group included 97 patients. RESULTS: Clinical characteristics did not significantly differ between groups. The mean number of additional harvested LN was 2.19 (range, 0–11), and one patient in the LGAL had a metastatic LN among the additional harvested LN. The overall morbidity was 22.7% in the HG and 30% in the LGAL (P = 0.257). Anastomotic leakage occurred in 14 patients (14.4%) in the HG and 5 patients (5.2%) in the LGAL (P = 0.030). The mean disease-free survival time in the HG was longer than that in the LGAL (P = 0.008). The mean overall survival (OS) time was 70.4 ± 1.3 months. The mean OS was 63.7 ± 1.6 months in the HG and 69.1 ± 2.6 months in the LGAL (P = 0.386). CONCLUSION: Low ligation of the IMA with additional LN retrieval is technically safe. However, the oncologic effect was better after high ligation of IMA.
Anastomotic Leak ; Case-Control Studies ; Colon, Sigmoid ; Colorectal Neoplasms ; Diagnosis ; Disease-Free Survival ; Humans ; Ligation ; Lymph Nodes ; Mesenteric Artery, Inferior ; Neoplasm Metastasis ; Rectal Neoplasms ; Retrospective Studies

PURPOSE: Bevacizumab has been used as a promising drug for metastatic colorectal cancer in combination with chemotherapeutic agents. However, it has a few serious adverse effects, such as intestinal bleeding or perforation. The purpose of this study is to identify the clinical characteristics of intestinal perforation induced by bevacizumab in colorectal cancer patients.METHODS: From January 2007 to June 2018, a total of 488 patients underwent chemotherapy with bevacizumab for metastatic colorectal cancer. Medical records were reviewed retrospectively.RESULTS: Nine patients (1.8%) were identified with intestinal perforation induced with bevacizumab. The median age was 59 years (range, 36–68 years). The primary tumor site was the sigmoid colon in six patients, the rectum in three patients. The liver was the most common metastatic organ (7 patients). Perforation sites were primary tumor site of the colorectum in four patients and the small bowel in five patients. Intestinal perforation was developed after a median of 3 chemotherapy cycles (range, 1–15 cycles), and a median of 7 days (range, 3–32 days) after chemotherapy. One patient expired due to sepsis.CONCLUSION: Bevacizumab induced intestinal perforation is a lethal adverse effect in patients with colorectal cancers. The characteristics of intestinal perforation varied according to perforation site, previous chemotherapy cycles, and clinical course. Careful monitoring is necessary with the use of bevacizumab in conjunction with chemotherapeutic agents.
Bevacizumab ; Colon, Sigmoid ; Colorectal Neoplasms ; Drug Therapy ; Hemorrhage ; Humans ; Intestinal Perforation ; Liver ; Medical Records ; Rectum ; Retrospective Studies ; Sepsis

Colorectal carcinoma invading the submucosa but not the muscularis propria (pT1) represents the earliest form of clinically relevant colorectal cancer in most patients. T1 colorectal cancer with synchronous liver metastasis is considered to be rare. We report a rare case of T1 colon cancer with synchronous liver metastasis not detected by preoperative imaging study. A 54-year-old male patient presented to our department for treatment of sigmoid colon cancer following an endoscopic submucosal dissection. Histopathological examination revealed the pedunculated mass was moderately differentiated adenocarcinoma without lymphovascular invasion and the depth of submucosal invasion was 2,000 µm, the resection margin was not involved. We performed a laparoscopic anterior resection with lymph node dissection. After the 3 months, the patient's carcinoembryonic antigen level elevated from 1.4 to 7.26 ng/mL (normal level: <1.5 ng/mL) and the abdominal computed tomography and FDG-PET/CT (positron emission tomography-computed tomography) showed multiple hepatic metastases in both hepatic lobes (SUVmax: 5.6) without evidence of local recurrence or lymphadenopathy. We strongly suspected a synchronous liver metastasis not detected by imaging study as opposed to a systemic recurrence. Therefore, evaluation and follow-up protocol of T1 colorectal cancer should be changed for discovery and prediction of synchronous liver metastasis; because we cannot exclude the possibility of synchronous liver metastasis.
Adenocarcinoma ; Carcinoembryonic Antigen ; Colon ; Colonic Neoplasms ; Colorectal Neoplasms ; Follow-Up Studies ; Humans ; Liver ; Lymph Node Excision ; Lymphatic Diseases ; Male ; Middle Aged ; Neoplasm Metastasis ; Recurrence ; Sigmoid Neoplasms

PURPOSE: Although laparoscopic surgery is widely accepted in the treatment of colorectal cancer, conversion to open surgery is associated with the rate of unfavorable outcomes. The aim of this study was to determine the factors associated with open conversion from laparoscopic surgery for colorectal cancer.METHODS: A total of 3,002 patients who underwent laparoscopic colectomy as an initial plan for the treatment of colorectal cancer located from the sigmoid colon to the rectum were retrospectively evaluated between January 2009 and December 2018 at Samsung Medical Center in Korea. Risk factors significantly associated with open conversion were determined using univariate and multivariate regression models.RESULTS: Among the 3,002 patients, open conversion was performed in 120 patients (4%). Age >60 years (adjusted odds ratio [AOR], 2.370), preoperative bowel obstruction (AOR, 2.348), clinical T4 stage (AOR, 2.201), and serum carcinoembryonic antigen level >5 ng/mL (AOR, 2.289) were significantly associated with open conversion. Moreover, mucinous carcinoma was a significantly more frequent histopathologic type than adenocarcinoma (10.0% vs. 3.2%, P<0.001) in the open conversion group with an AOR of 2.549 (confidence interval, 1.259–5.159; P=0.009).CONCLUSION: The present study presented a novel finding, i.e. mucinous carcinoma as the histopathologic type could be an independent predictive factor for conversion from laparoscopic colectomy to open surgery. Identifying patients with mucinous carcinoma will help stratify the risk of open conversion preoperatively.
Adenocarcinoma ; Adenocarcinoma, Mucinous ; Carcinoembryonic Antigen ; Colectomy ; Colon, Sigmoid ; Colorectal Neoplasms ; Conversion to Open Surgery ; Humans ; Korea ; Laparoscopy ; Mucins ; Odds Ratio ; Rectum ; Retrospective Studies ; Risk Factors

PURPOSE: Most patients with rectal cancer undergo a total mesorectal excision and a partial resection of the sigmoid colon to improve oncologic outcomes. The aim of this study was to assess the distribution of lymph nodes (LNs) in rectal cancer. METHODS: The records of 54 patients with mid and low rectal cancer between April 2015 and March 2017 were reviewed, and 49 patients were enrolled in this study. All harvested LNs were analyzed according to the harvested area: the mesorectum area (MA), the vascular pedicle area (VA), and the sigmoid area (SA). RESULTS: Finally, 865 LNs were harvested from all patients, and of these, 71 (8.2%) showed metastases. In stage III patients, 343 LNs were harvested, and of these, 52 (15.2%) showed metastases. Significant differences were found in the total numbers of harvested LNs by area (P < 0.001) and in the numbers of harvested positive LNs by area (P < 0.001). In stage III patients, LNs from the MA were more frequently to be positive than were those from the VA (P < 0.001) or the SA (P < 0.001). CONCLUSION: LN metastasis in the SA was rare. Therefore, resecting the mesorectum and the vascular pedicle may be more important than resecting the sigmoid mesentery due to concerns about LN metastases.
Colon, Sigmoid ; Humans ; Lymph Nodes ; Mesentery ; Neoplasm Metastasis ; Rectal Neoplasms

PURPOSE: The management of a colonoscopic perforation (CP) varies from conservative to surgical. The objective of this study was to evaluate the outcomes between surgical and conservative treatment of patients with a CP. METHODS: From 2003 to 2016, the medical records of patients with CP were retrospectively reviewed. Patients were divided into 2 groups depending on whether they initially received conservative or surgical treatment. RESULTS: During the study period, a total of 48 patients with a CP were treated. Among them, 5 patients had underlying colorectal cancer and underwent emergency radical cancer surgery; these patients were excluded. The mean age of the remaining 43 patients was 64.5 years old, and the most common perforation site was the sigmoid colon (15 patients). The initial conservative care group included 16 patients, and the surgery group included 27 patients. In the conservative group, 5 patients required conversion to surgery (failure rate: 5 of 16 [31.3%]). Of the surgery group, laparoscopic surgery was performed on 19 patients and open surgery on 8 patients, including 2 conversion cases. Major postoperative complications developed in 11 patients (34.4%), and postoperative mortality developed in 4 patients (12.5%). The only predictor for poor prognosis after surgery was a high American Society of Anesthesiologists physical status classification. CONCLUSION: In this study, conservative treatment for patients with a CP had a relatively high failure rate. Furthermore, surgical treatment showed significant rates of complications and mortality, which depended on the general status of the patients.
Classification ; Colon, Sigmoid ; Colonoscopy ; Colorectal Neoplasms ; Emergencies ; Humans ; Laparoscopy ; Medical Records ; Mortality ; Postoperative Complications ; Prognosis ; Retrospective Studies