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Nitta T, Kataoka J, Ishii M, Ueda Y, Ohta M, Horiguchi K, Taki M, Senpuku S, Matsutani A, Ishibashi T. Bilateral laparosocopic lateral lymph node dissection by the totally extraperitoneal approach after intersphincteric resection of the lower rectum: report of a case. Ann Med Surg (Lond) 2023; 85:4589-4592. [PMID: 37663743 PMCID: PMC10473375 DOI: 10.1097/ms9.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/15/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction and Importance Lateral lymph node dissection (LLND) for recurrent lateral pelvic lymph node metastasis could be the only surgical treatment to improve its prognosis, but is difficult and challenging technically. Case Presentation A 75-year-old Japanese man who underwent a radical laparoscopic intersphincteric resection to treat double lower rectal cancer. Computed tomography and MRI showed lower rectal wall thickening and bilateral lateral lymph node swelling. The authors scheduled and performed the LLND for recurrent lateral pelvic lymph nodes after ISR by the totally extraperitoneal (TEP) approach. The bottom of the obturators lymph node (#263D) were positive for metastasis histologically. Clinical Discussion The TEP approach is an especially effective option for the treatment of bilateral LLND. Conclusion Herein, the authors introduce our surgical technique: successful challenging treatment of the LLND by the TEP approach after intersphincteric resection of the lower rectum.
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Affiliation(s)
- Toshikatsu Nitta
- Division of Surgery Gastroenterological Center, Medico Shunju Shiroyama Hospital, Osaka, Japan
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Su H, Xu Z, Bao M, Luo S, Liang J, Pei W, Guan X, Liu Z, Jiang Z, Zhang M, Zhao Z, Jin W, Zhou H. Lateral pelvic sentinel lymph node biopsy using indocyanine green fluorescence navigation: can it be a powerful supplement tool for predicting the status of lateral pelvic lymph nodes in advanced lower rectal cancer. Surg Endosc 2023; 37:4088-4096. [PMID: 36997652 DOI: 10.1007/s00464-023-10033-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 03/12/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND An innovative instrument for laparoscopy using indocyanine green (ICG) allows easy detection of sentinel lymph nodes (SLNs) in lateral pelvic lymph nodes (LPLNs). Here, we investigated the safety and efficacy of lateral pelvic SLN biopsy (SLNB) using ICG fluorescence navigation in advanced lower rectal cancer and evaluated the sensitivity and specificity of this technique to predict the status of LPLN. METHODS From April 1, 2017 to December 1, 2020, we conducted lateral pelvic SLNB using ICG fluorescence navigation during laparoscopic total mesorectal excision and lateral pelvic lymph node dissection (LLND) in 23 patients with advanced low rectal cancer who presented with LPLN but without LPLN enlargement. Data regarding clinical characteristics, surgical and pathological outcomes, lymph node findings, and postoperative complications were collected and analyzed. RESULTS We successfully performed the surgery using fluorescence navigation. One patient underwent bilateral LLND and 22 patients underwent unilateral LLND. The lateral pelvic SLN were clearly fluorescent before dissection in 21 patients. Lateral pelvic SLN metastasis was diagnosed in 3 patients and negative in 18 patients by frozen pathological examination. Among the 21 patients in whom lateral pelvic SLN was detected, the dissected lateral pelvic non-SLNs were all negative. All dissected LPLNs were negative in two patients without fluorescent lateral pelvic SLN. CONCLUSION This study indicated that lateral pelvic SLNB using ICG fluorescence navigation shows promise as a safe and feasible procedure for advanced lower rectal cancer with good accuracy, and no false-negative cases were found. No metastasis in SLNB seemed to reflect all negative LPLN metastases, and this technique can replace preventive LLND for advanced lower rectal cancer.
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Affiliation(s)
- Hao Su
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Zheng Xu
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Mandula Bao
- Department of Pancreatic and Gastric Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Shou Luo
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Jianwei Liang
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Wei Pei
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Xu Guan
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Zheng Jiang
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Mingguang Zhang
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Zhixun Zhao
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China
| | - Weisen Jin
- Department of Anorectal Diseases, Third Medical Center of Chinese PLA General Hospital, Haidian District, Beijing, 100039, People's Republic of China.
| | - Haitao Zhou
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, China.
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Kim JS, Kim J, Baek SJ, Park H, Kwak JM, Kim SH. Laparoscopic Extraperitoneal Approach for Lateral Pelvic Node Dissection in Rectal Cancer: Techniques and Short-Term Outcomes. Surg Innov 2023; 30:13-19. [PMID: 35232305 DOI: 10.1177/15533506221076193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Lateral pelvic lymph node dissection has been performed selectively in rectal cancer cases; however, it involves highly skilled techniques because of the complex adjacent anatomical structures. MATERIALS AND METHODS Laparoscopic EP-LPND was performed in Korea University Anam Hospital from June 2018, and short-term surgical outcomes were analyzed from June to December 2018. Among the patients with histologically diagnosed rectal adenocarcinoma, patients who were suspected Lateral pelvic lymph node metastasis at magnetic resonance imaging were selected for this procedure. RESULTS Seven patients underwent laparoscopic extraperitoneal approach for lateral pelvic lymph node dissection in the study period. The mean number of retrieved lymph node was 4.57, and metastatic lymph nodes were identified in 3 patients (42.8%). All of the lymph nodes with suspected metastasis preoperatively were removed in postoperative images. There was no immediate postoperative complication beyond the moderate grade associated with lateral pelvic lymph node dissection. The median follow-up was 9 months, and there were no local recurrence nor complications related to sexual and voiding functions. CONCLUSIONS The laparoscopic extraperitoneal approach might be an efficient way to perform lateral pelvic lymph node dissection using the same principles as the conventional method without violation of the peritoneum.
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Affiliation(s)
- Ji-Seon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Jin Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Se-Jin Baek
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Hyunmi Park
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Jung-Myun Kwak
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
| | - Seon-Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, 37997Korea University Anam Hospital, Seoul, Korea
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Chen Z, Sasaki K, Murono K, Kawai K, Nozawa H, Kobayashi H, Ishihara S, Sugihara K. Oncologic Status of Obturator Lymph Node Metastases in Locally Advanced Low Rectal Cancer: A Japanese Multi-Institutional Study of 3487 Patients. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11372-z. [PMID: 35243595 DOI: 10.1245/s10434-022-11372-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND The American Joint Committee on Cancer tumor-node-metastasis staging system for rectal cancer defines lateral pelvic lymph nodes (LPLNs) only in the internal iliac region as regional. However, the Japanese Society for Cancer of the Colon and Rectum (JSCCR) staging system, also considers obturator lymph nodes (LNs) as regional. This retrospective cohort study evaluated the oncologic status of obturator LNs in low rectal cancer. METHODS The study identified 3487 patients with pT3-T4 low rectal cancer who had undergone curative resections without preoperative radiotherapy or chemotherapy between 2003 and 2011 in the JSCCR database and divided them into six groups. Overall survival (OS) and recurrence-free survival (RFS) were analyzed by groups. RESULTS Histologic LPLN metastases were identified in 8% (279/3487) of all the patients and in 18.2% (279/1530) of the patients who underwent lateral pelvic node dissection. The 5-year OS and RFS rates of the obturator-LPLN group (P = 0.095) were worse than those of the internal-LPLN group (P = 0.075), but the difference was not significant. The OS of the obturator-LPLN group was similar to that of the resectable liver metastasis group (P = 0.731), and the RFS of the obturator-LPLN group was significantly better than that of the other-LPLN group (P = 0.016). CONCLUSION The prognosis for obturator LN metastases in low rectal cancer was not significantly worse than for internal iliac LN metastases, defined as regional by the current American Joint Committee on Cancer staging system, and the oncologic status of obturator LNs warrants more studies.
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Affiliation(s)
- Zhifen Chen
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazuhito Sasaki
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Koji Murono
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Kazushige Kawai
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Hioaki Nozawa
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University, Mizonokuchi Hospital, Kawasaki-city, Kanagawa, Japan
| | - Soichiro Ishihara
- Department of Colorectal Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan.
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Wakizaka K, Homma S, Ichikawa N, Yoshida T, Matsui H, Khor LW, Annen K, Fukushima T, Taketomi A. Lateral lymph node recurrence of rectal cancer with a pathological complete response to chemotherapy confirmed by laparoscopic lateral lymph node dissection: A case report. Asian J Endosc Surg 2022; 15:216-219. [PMID: 34374205 DOI: 10.1111/ases.12975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/17/2021] [Accepted: 07/25/2021] [Indexed: 11/26/2022]
Abstract
Lateral lymph node (LLN) metastasis is one of the forms of local recurrence after surgery for lower rectal cancer. We here present a case of LLN recurrence of rectal cancer that was shown by laparoscopic lateral lymph node dissection (LLND) to have a complete pathological response to chemotherapy. A 58-year-old man underwent open low anterior resection for lower rectal cancer. After detection of right LLN recurrence 43 months after the operation, 11 cycles of capecitabine, oxaliplatin, and bevacizumab chemotherapy were administered. Laparoscopic right LLND was performed 55 months after the first operation. Pathological examination revealed no viable tumor cells in the dissected lymph nodes. The patient remains alive without recurrence 61 months after the first surgery and 6 months after laparoscopic LLND. Laparoscopic LLND for LLN recurrence of rectal cancer is feasible and should be considered a valid treatment option.
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Affiliation(s)
- Kazuki Wakizaka
- Department of Surgery, Chitose City Hospital, Chitose, Japan
| | - Shigenori Homma
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tadashi Yoshida
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroki Matsui
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Lee Wee Khor
- Department of Surgery, Chitose City Hospital, Chitose, Japan
| | - Kazuya Annen
- Department of Surgery, Chitose City Hospital, Chitose, Japan
| | | | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Elhusseini M, Aly EH. Lateral pelvic lymph node dissection in the management of locally advanced low rectal cancer: Summary of the current evidence. Surg Oncol 2020; 35:418-425. [PMID: 33038847 DOI: 10.1016/j.suronc.2020.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/23/2020] [Accepted: 09/27/2020] [Indexed: 02/07/2023]
Abstract
Lateral pelvic lymph nodes (LPLN) are a major site for local recurrence following curative resection for low locally advanced rectal cancer. Ongoing advances in imaging techniques have improved predicting LPLN metastasis (LPLNM) during pre-operative staging. However, there is ongoing debate on optimal management of this subgroup of patients with variation between guidance of different societies. In Japan, LPLNM is considered as local disease and addressed by lateral pelvic node dissection (LPLND) in addition to total mesorectal excision (TME). However, in the west, LPLNM is considered as metastatic disease and those patients are offered neoadjuvant chemoradiotherapy (nCRT) followed by TME surgery. The potential surgical risks and morbidity associated with LPLND as well as the uncertainty of the oncological outcome have raised the concern that patients with locally advanced low rectal cancer with LPLNM could be over or under-treated. A comprehensive review of literature was performed, summarizing the current evidence on available modalities for predicting LPLNM, the role of LPLND in the management of advanced low rectal cancer and the available surgical approaches with their impact on surgical and oncological outcomes. LPLND is associated with increased operative time, blood loss and post-operative morbidity. The potential benefits for local disease control and survival still awaits high quality studies. There has been increasing number of reports of the use minimally invasive approaches in LPLND in an attempt to reduce post-operative complications. There is need for high quality evidence to define the role of LPLND in management of patients with advanced low rectal cancer.
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Affiliation(s)
- Mootaz Elhusseini
- University of Aberdeen, UK; Aberdeen Royal Infirmary, Department of Surgery, Surgical Admin Block, Yellow Zone, Level Foresterhill, Aberdeen, Scotland, AB25 2ZN, UK
| | - Emad H Aly
- University of Aberdeen, UK; Aberdeen Royal Infirmary, Department of Surgery, Surgical Admin Block, Yellow Zone, Level Foresterhill, Aberdeen, Scotland, AB25 2ZN, UK.
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Zhang J, Zhong P, Tong H, Jiang J, Tong D. Novel technical modifications of hand-assisted laparoscopic dissection of a large obturator mass: A case report and literature review. Oncol Lett 2020; 20:269. [PMID: 32989403 DOI: 10.3892/ol.2020.12132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/05/2020] [Indexed: 11/05/2022] Open
Abstract
Laparoscopic lateral pelvic tumor dissection (LLPTD) for transobturator tumors may be technically challenging due to the requirement for sufficient operative space. The present study discusses a technique modification with combination of the laparoscopic approach and hand-assisted (HA) open surgery for patients with large obturator masses. LLPTD was performed using the combined approach, defined as HA-LLPTD, with one case treated. According to this technique, a combined working space is constructed based on the outreached laparoscopic space and open extraperitoneal approach, followed by HA-LLPTD. Finally, a literature review was performed to retrospectively evaluate 17 cases of obturator tumors, in terms of tumor type and operative approach. The tumor in the present case was successfully and completely resected, without any obvious intra- and post-operative complications. Based on the literature review, the majority of the cases were benign (~75%) and originated from neurological tissue (~50%). The selection of the operative approach was either open or minimally invasive (50% each). HA-LLPTD allows experienced urological laparoscopic surgeons to safely and completely perform obturator surgery without obstruction of the obturator foramen or formation of intraperitoneal adhesions and associated complications. Therefore, HA-LLPTD may be more useful for transobturator tumor resection compared with the conventional intraperitoneal approach.
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Affiliation(s)
- Jun Zhang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing 400042, P.R. China
| | - Peng Zhong
- Department of Pathology, Daping Hospital, Army Medical University, Chongqing 400042, P.R. China
| | - Haipeng Tong
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, P.R. China
| | - Jun Jiang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing 400042, P.R. China
| | - Dali Tong
- Department of Urology, Daping Hospital, Army Medical University, Chongqing 400042, P.R. China
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Law BZY, Yusuf Z, Ng YE, Aly EH. Does adding lateral pelvic lymph node dissection to neoadjuvant chemotherapy improve outcomes in low rectal cancer? Int J Colorectal Dis 2020; 35:1387-1395. [PMID: 32504333 DOI: 10.1007/s00384-020-03656-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Lateral pelvic lymph node metastasis occurs in 15 to 20% of patients with locally advanced low rectal cancer which increases risk of local recurrence and reduced survival following neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME). Adding lateral pelvic lymph node dissection (LPLND) could improve outcomes in those patients. This review aims to determine if the addition of LPLND to the conventional management of advanced rectal cancer would yield improved outcomes. METHODS OVID Medline, Cochrane, Clinicaltrials.gov , EMBASE, Clinicaltrialsregister.eu, Web of Knowledge and CABAbstracts were searched using the following keywords: 'lateral pelvic lymph node dissection', 'pelvis lymphadenectomy', 'chemoradi*', 'rectal cancer', 'rectal neoplasm', 'rectal carcinoma' and 'rectal tumour'. Studies were included if they were in English and included rectal cancer patients that had nCRT, rectal resection ± LPLND. Primary outcome was 3-year and 5-year local recurrence. Secondary outcome was 3-year and 5-year overall survival. RESULTS Six studies were identified with 1210 patients who had nCRT and TME, and 268 patients who had nCRT and rectal resection plus LPLND. Patients who had LPLND had non-significant lower 3-year and 5-year local recurrence rate compared with those who did not (p = 0.10 and p = 0.12, respectively). They demonstrated a lower 3-year overall survival but higher 5-year overall survival and both were not significant (p = 0.81 and p = 0.57, respectively). CONCLUSION Available evidence suggests that there is no significant reduction in local recurrence rates or improved survival from LPLND to the current treatment modalities. Further studies are required to define the role of lateral pelvic lymph node dissection in low rectal cancer.
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Affiliation(s)
| | | | - Yu En Ng
- University of Aberdeen, Aberdeen, Scotland, UK
| | - Emad H Aly
- University of Aberdeen, Aberdeen, Scotland, UK. .,Aberdeen Royal Infirmary, Aberdeen, Scotland, UK.
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