Transanal total pelvic exenteration in the prone jackknife position for rectal cancer invading the bladder, seminal vesicles, and small intestine

A 58-year-old man had rectal cancer directly invading the urinary bladder and small intestine, without distant metastasis. We successfully performed complete resection using a hybrid approach, including laparoscopic surgery and transanal total pelvic exenteration (TaTPE) with the patient in the prone jackknife (PJK) position. In the PJK position, gravity and pelvic morphology lead to a clear and wide surgical field. This case demonstrates that total pelvic exenteration using laparoscopic surgery and TaTPE in the PJK position provides a better surgical field than either TaTPE or laparoscopic surgery in the supine position. TaTPE in the PJK position may also be useful for curative surgery in locally advanced rectal cancer.

Antimicrobial stewardship without infectious disease physician for patients with candidemia: A before and after study

Background

Little is known about the effects of antimicrobial stewardship team (AST) without infectious disease physician (IDP) on clinical outcome in patients with candidemia.

Methods

We conducted a before and after study involving patients with hospital‐acquired candidemia at a tertiary hospital without IDPs. The AST consisted of physicians, pharmacists, nurse, microbiologist, and administrative staff. A candidemia care bundle was developed based on the Infectious Disease Society of America (IDSA) guideline. The non‐IDP AST provided recommendations to the attending physicians whose patients developed candidemia during hospitalization. The primary outcome was 30‐day all‐cause mortality, while the secondary outcomes were adherence to the IDSA guidelines regarding the management of candidemia. Data of up to 3 years of preintervention and 3 years of intervention period were analyzed.

Results

By 30 days, 11 of 46 patients (23.9%) in the intervention group and 7 of 30 patients (23.3%) in the preintervention group died (adjusted hazard ratio for the intervention group: 0.68 [95% CI 0.24‐1.91]). The non‐IDP AST was associated with appropriate empirical antifungal therapy (100% vs 60.0%; proportion ratio 1.67 [95% CI 1.24‐2.23]), appropriate duration of treatment (84.7% vs 43.3%; 1.96 [1.28‐3.00]), removal of central venous catheters (94.4% vs 70.8%; 1.33 [1.02‐1.74]), and ophthalmological examination (93.5% vs 63.3%; 1.48 [1.12‐1.96]).

Conclusions

Although we found no significant difference in 30‐day mortality, the non‐IDP AST was associated with improved adherence to guidelines for management of candidemia.

Laparoscopic radical lymph node dissection for advanced colon cancer close to the hepatic flexure

INTRODUCTION

Complete mesocolic excision is currently recognized as a standard procedure for colon cancer. Gastroepiploic, infrapyloric, and superficial pancreatic head lymph node metastases in the gastrocolic ligament have been reported for colon cancer close to the hepatic flexure. We sought to investigate metastases in the gastrocolic ligament in colon cancer close to the hepatic flexure.

METHODS

This was a single-center retrospective study. All patients with T2 or deeper invasive colon cancer in the relevant tumor location who underwent laparoscopic right hemicolectomy or extended right hemicolectomy at our institution between 1 April 2011 and 31 March 2015 were included.

RESULTS

Lymph node dissection in the gastrocolic ligament was performed in 35 cases. Complications occurred in 11 patients (31%) and were grades I and II according to the Clavien-Dindo classification. Lymph node metastases in the gastrocolic ligament were found in only three patients (9%). Each metastasis was larger than 9 mm.

CONCLUSIONS

Metastases in the gastrocolic ligament occurred in 9% of patients with T2 or deeper invasive colon cancer close to the hepatic flexure. Laparoscopy was feasible and useful during gastrocolic ligament resection. This study included a small sample and lacked an extended follow-up. Further studies are needed to determine the clinical relevance of this finding, particularly in terms of recurrence and long-term survival.

Laparoscopic Hartmann's procedure for fecal peritonitis resulting from perforation of the left-sided colon in elderly and severely ill patients

BACKGROUND

Traditional treatment for fecal peritonitis resulting from perforation of the left-sided colon has been performed using Hartmann's procedure to reduce the high mortality caused by anastomotic leakage. However, the morbidity rates associated with abdominal incision (due in great part to wound infection, and dehiscence of abdominal fascia) are high. Therefore, we propose using laparoscopic Hartmann's procedure with abdominal incisions only for the port site to reduce the high morbidity associated with the laparoscopic procedure as compared to open surgery.

METHODS

Between April 2008 and July 2011, we treated 16 consecutive patients (median age, 83 years) with fecal peritonitis resulting from perforations in the left-sided colon due to various causes. The American Society of Anesthesiologists score of each patient was either IV or V. Patients underwent a four-port laparoscopic Hartmann's procedure. Specimens were extracted through the stoma site. Irrigation of the abdominal cavity with more than 10 L of saline was performed in every case, as was insertion of three 10-mm silicon drains via the port site into the left- and right subphrenic spaces or the pouch of Douglas.

RESULTS

The median total surgical time was 166 min (range, 123-250 min). There were no intraoperative complications, and there was no need to convert to open surgery. Fourteen patients survived. There was no wound infection or dehiscence of abdominal fascia. Successful laparoscopic reversals of the laparoscopic Hartmann's procedure were performed in all 14 survivors.

CONCLUSIONS

This laparoscopic Hartmann's procedure is a promising surgical strategy for treating fecal peritonitis arising from perforation of the left-sided colon.

Molecular mechanisms of liver metastasis

Colorectal cancer is the second most common cancer, and is the third leading cause of cancer-related death in Japan. The majority of these deaths is attributable to liver metastasis. Recent studies have provided increasing evidence that the chemokine-chemokine receptor system is a potential mechanism of tumor metastasis via multiple complementary actions: (a) by promoting cancer cell migration, invasion, survival and angiogenesis; and (b) by recruiting distal stromal cells (i.e., myeloid bone marrow-derived cells) to indirectly facilitate tumor invasion and metastasis. Here, we discuss recent preclinical and clinical data supporting the view that chemokine pathways are potential therapeutic targets for liver metastasis of colorectal cancer.

Single-access laparoscopic colectomy with a novel multiport device in sigmoid colectomy for colon cancer

PURPOSE

Laparoscopic-assisted colectomy is a common procedure for colorectal disease, and laparoscopic colectomy from a single access point is rapidly evolving. This report describes the use of single-access laparoscopic colectomy (SALC) with a novel multiport device in sigmoidectomy for colon cancer.

METHODS

Data were collected retrospectively on 5 patients who underwent the procedure for colon cancers in the period from November 2008 through January 2009. The abdomen was approached through a 3- to 4-cm incision via the umbilicus in every case. To ensure maintenance of the pneumoperitoneum, the procedure was performed with a specially developed multiport device enveloped by a glove containing 3 5-mm ports. In all 5 patients, the root of the inferior mesenteric artery was isolated and divided at the distal side where the left colic artery branched off.

RESULTS

The median total surgical time was 185 (range, 176-210) minutes. In all patients, surgical blood loss was slight (range, 0-20 mL). Only one patient required conversion into laparoscopic-assisted colectomy by the addition of 2 ports, because the location adjacent to the descending colon made it necessary to mobilize the splenic flexure. The median number of harvested lymph nodes was 17 (range, 12-24). No postoperative complications occurred. The postoperative hospital stay was 7 days for every patient.

CONCLUSIONS

Single-access laparoscopic sigmoidectomy seems to be feasible and safe when performed by experienced laparoscopic surgeons who are familiar with the unique principles of this procedure. Additional experience and continued investigations are warranted.

Acetylcholine receptor effects on accumbal shell dopamine-mediated turning behaviour in rats

The nature of acetylcholine receptor effects on dopaminergic functions within the nucleus accumbens shell was studied in rats, using turning behaviour as read-out parameter. Unilateral injections of the acetylcholine receptor agonist, carbachol (1.0-5.0 microg), into the nucleus accumbens shell dose-dependently elicited contraversive circling. Unilateral injections of the combination of a fixed dose of the dopamine D(2) receptor agonist, quinpirole (10.0 microg), with increasing doses of the dopamine D(1) receptor agonist, SKF 38393 (1.0-5.0 microg), into the nucleus accumbens shell dose-dependently elicited contraversive pivoting. The same held for the combination of a fixed dose of SKF 38393 (5.0 microg) with increasing doses of quinpirole (5.0 and 10.0 microg), which was injected into the nucleus accumbens shell. The nicotinic acetylcholine receptor antagonist, mecamylamine (5.0 and 10.0 microg), injected into the nucleus accumbens shell, which alone did not elicit any turning behaviour, significantly suppressed both the contraversive circling induced by carbachol (5.0 microg) and the contraversive pivoting induced by the mixture of SKF 38393 (5.0 microg) and quinpirole (10.0 microg). The muscarinic acetylcholine receptor antagonist, methylscopolamine (1.0 and 2.5 microg), injected into the nucleus accumbens shell, which alone did not elicit any turning behaviour, significantly suppressed the contraversive circling induced by carbachol (5.0 microg), whereas it significantly increased the contraversive pivoting induced by both the mixture of SKF 38393 (1.0 microg) and quinpirole (10.0 microg) and the mixture of SKF 38393 (5.0 microg) and quinpirole (5.0 microg). Neither SKF 38393 (5.0 microg) nor quinpirole (10.0 microg) injected into the nucleus accumbens shell affected the contraversive circling induced by carbachol (5.0 microg). Carbachol (1.0 microg) injected into the nucleus accumbens shell caused a slight initial potentiation followed by an inhibition of the contraversive pivoting induced by the mixture of SKF 38393 (5.0 microg) and quinpirole (10.0 microg). These results confirm that stimulation of both nicotinic and muscarinic acetylcholine receptors in the nucleus accumbens shell is required for the accumbens-dependent, acetylcholine-mediated circling. The study provides the original evidence that stimulation of nicotinic acetylcholine receptors in the nucleus accumbens shell is required for the accumbens-dependent, dopamine-mediated pivoting. Finally, the present study shows that muscarinic acetylcholine receptors in the nucleus accumbens shell play an inhibitory role in the production of the accumbens-dependent, dopamine-mediated pivoting.

GABAA and GABAB receptors in the nucleus accumbens shell differentially modulate dopamine and acetylcholine receptor-mediated turning behaviour

The ability of GABAA and GABAB receptors in the shell of the nucleus accumbens to modulate distinct types of turning behaviour was investigated in freely moving rats, using the unilateral injection technique. The GABAA receptor agonist muscimol and the GABAA receptor antagonist bicuculline did not produce turning behaviour; the same holds for the GABAB agonist baclofen and the GABAB antagonist 2-hydroxysaclofen. A mixture of the dopamine D1 receptor agonist SKF 38393 and the dopamine D(2/3) receptor agonist quinpirole has been found to elicit contraversive pivoting, when injected into the shell. This pivoting was dose-dependently inhibited by muscimol, and the inhibitory effect of muscimol was antagonised by bicuculline. Pivoting was also dose-dependently inhibited by baclofen; however, 2-hydroxysaclofen did not antagonise the inhibitory effect. The acetylcholine receptor agonist carbachol has been found to elicit contraversive circling, when injected into the shell. This carbachol-induced circling was inhibited by baclofen, and 2-hydroxysaclofen antagonised the inhibitory effect. Carbachol-induced circling was also partially inhibited by muscimol; however, the inhibitory effect of muscimol was not antagonised by bicuculline. It is concluded that mesolimbic GABAA receptors exert an inhibitory control on dopamine-dependent pivoting that can be elicited from the shell of the nucleus accumbens, and that GABAB receptors exert an inhibitory control on acetylcholine-dependent circling that can be elicited from the shell of the nucleus accumbens. This data extends the earlier reported findings that the neurochemical substrate in the shell of the nucleus accumbens that mediates dopamine-dependent pivoting is fundamentally different from the shell substrate that mediates acetylcholine-dependent circling.

Role of mu- and delta-opioid receptors in the nucleus accumbens in turning behaviour of rats

The role of mu-, delta1- and delta2-opioid receptors in the nucleus accumbens in pivoting was investigated in freely moving rats. Unilateral injections of the mu-opioid receptor agonist, [D-Ala2,N-Me-Phe4,Gly5-ol]-enkephalin (DAMGO, 1 and 2 microg) and the delta2-opioid receptor agonist, deltorphin II (1 and 2 microg), but not the delta1-opioid receptor agonist, [D-Pen(2,5)]-enkephalin (DPDPE, 1-4 microg), into the shell or the core of the nucleus accumbens significantly induced contraversive pivoting. The pivoting induced by DAMGO (2 microg) and deltorphin II (2 microg) was inhibited significantly by the mu-opioid receptor antagonist, D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Phe-Thr-NH2 (CTOP, 0.1 and 1 microg), and the delta2-opioid receptor antagonist, naltriben (NTB, 0.1 and 1 mg/kg, i.p.), respectively. The DAMGO (2 microg)- or deltorphin II (2 microg)-induced pivoting was also inhibited significantly by co-administration of the dopamine D1/D2 receptor antagonist, cis(Z)-flupentixol (1 and 10 microg). The pivoting induced by unilateral injections of a mixture of dopamine D1 (SKF 38393, 5 microg) and D2 (quinpirole, 10 microg) receptor agonists into the shell was significantly inhibited by cis(Z)-flupentixol (1 and 10 microg) or NTB (1 and 3 mg/kg, i.p.), but not CTOP (1 microg) or delta1-opioid receptor antagonist, (E)-7-benzylidenenaltrexone (1 mg/kg, i.p.). The contraversive pivoting elicited by the cholinergic agonist, carbachol (5 microg), into the core was inhibited by co-administration of the muscarinic M1 antagonist, pirenzepine (1 microg), but not cis(Z)-flupentixol (1 microg). The results suggest that unilateral activation of mu- or delta2-opioid, but not delta1-opioid, receptors in the core and/or shell of the nucleus accumbens elicits contraversive pivoting that requires intact dopamine D1/D2 receptors in the shell, but not intact muscarinic M1 mechanism in the core. The study also shows that delta2-opioid, but not mu- and delta1-opioid, receptors in the core and/or shell modulate the shell-specific, dopamine D1/D2 receptor mechanisms involved in the production of pivoting.

GABA(A) receptors in the nucleus accumbens core modulate turning behavior induced by dopamine receptor stimulation

The role of GABA(A) and GABA(B) receptors in the core of the nucleus accumbens in turning behavior of rats was investigated. Unilateral injections into the core of the nucleus accumbens of the GABA(A) receptor agonist (muscimol, 50 ng) and antagonist (bicuculline, 200 ng), and the GABA(B) receptor agonist (baclofen, 100 ng) and antagonist (2-hydroxysaclofen, 2 microg) did not produce turning behavior. In rats pretreated with unilateral injections of the dopamine D1-like/D2-like receptor antagonist, cis(Z)-flupentixol (10 microg), into the ventrolateral striatum and saline into the nucleus accumbens core of contralateral side, systemic injection of a mixture of dopamine D1-like (SKF 38393, 3 mg/kg) and D2-like (quinpirole, 1 mg/kg) receptor agonists has been found to elicit contraversive pivoting, namely pivoting away from the side of the core injection. This dopamine D1-like/D2-like receptor-mediated pivoting was significantly inhibited by injections into the core of the nucleus accumbens of muscimol (50 ng), but not bicuculline (200 ng). In contrast, the dopamine D1-like/D2-like receptor-mediated pivoting was suppressed by either baclofen (100 ng) or 2-hydroxysaclofen (2 microg) injected into the nucleus accumbens core. It is therefore concluded that neither GABA(A) nor GABA(B) receptor stimulation in the core of the nucleus accumbens produces turning behavior, and that GABA(A), but not GABA(B), receptors in the nucleus accumbens core may modulate dopamine D1-like/D2-like receptor-mediated pivoting.

Gabaa receptors in the pedunculopontine tegmental nucleus play a crucial role in rat shell-specific dopamine-mediated, but not shell-specific acetylcholine-mediated, turning behaviour

The role of GABA(A) receptors in the pedunculopontine tegmental nucleus in turning behaviour of rats was studied. Unilateral injection of the GABA(A) receptor agonist, muscimol (25-100 ng), into the pedunculopontine tegmental nucleus dose-dependently produced contraversive pivoting, namely tight head-to-tail turning marked by abnormal hindlimb backward stepping. This effect was GABA(A) receptor specific, since it was prevented by the GABA(A) receptor antagonist, bicuculline (50 ng), which alone did not elicit turning behaviour. Unilateral injection of a mixture of dopamine D(1) ((+/-)-1-phenyl-2,3,4,5-tetrahydro-1H-3-benzazepine-7,8-diol [SKF 38393], 5 microg) and D(2) (quinpirole, 10 microg) receptor agonists into the nucleus accumbens shell has been found to elicit contraversive pivoting, whilst unilateral injection of the acetylcholine receptor agonist (carbachol, 5 microg) into the same site is known to elicit contraversive circling, namely turning marked by normal stepping. The pivoting induced by a mixture of SKF 38393 (5 microg) and quinpirole (10 microg) injected into the nucleus accumbens shell was significantly inhibited by bicuculline (50 ng) injected into the pedunculopontine tegmental nucleus, whereas muscimol (25 ng) had no effect. Neither muscimol (25 ng) nor bicuculline (50 ng) modulated the contraversive circling induced by carbachol (5 microg) injected into the nucleus accumbens shell. It is therefore concluded that unilateral stimulation of GABA(A) receptors in the pedunculopontine tegmental nucleus can elicit contraversive pivoting and that the pedunculopontine tegmental nucleus is one of the output stations of the accumbens region that mediates shell-specific, dopaminergic pivoting, but not of the accumbens region that mediates shell-specific, cholinergic circling.

Role of AMPA and NMDA receptors in the nucleus accumbens shell in turning behaviour of rats: interaction with dopamine receptors

The role of AMPA and NMDA receptors in the shell of the nucleus accumbens in turning behaviour of rats was investigated. Unilateral injection of the AMPA receptor agonist, AMPA (0.25, 0.4, 0.5 and 1 microg), into the shell of the nucleus accumbens dose-dependently produced contraversive pivoting, namely tight head-to-tail turning marked by abnormal hindlimb backward stepping, while injection of AMPA (0.5 microg) into the core produced only a marginal effect. This shell-specific AMPA effect was dose-dependently inhibited by the AMPA receptor antagonist, NBQX (1 and 10 ng), which alone did not produce turning behaviour. The AMPA-induced pivoting was also dose-dependently inhibited by the non-competitive NMDA receptor antagonist, MK-801 (0.1 and 0.5 microg). Neither MK-801 (0.1, 0.5 and 5 microg) nor the NMDA receptor agonist, NMDA (0.5 and 1 microg), injected unilaterally into the shell, produced turning behaviour. Unilateral injection of a mixture of dopamine D(1) (SKF 38393, 5 microg) and D(2) (quinpirole, 10 microg) receptor agonists into the shell has been found to elicit contraversive pivoting. The dopamine D(1)/D(2) receptor antagonist, cis-(Z)-flupentixol (1 and 10 microg), injected into the shell, in doses known to block dopamine D(1)/D(2) receptor-mediated pivoting, also significantly inhibited AMPA (0.5 microg)-induced pivoting. Moreover, both NBQX (1 and 10 ng) and MK-801 (0.1 and 0.5 microg), injected into the shell, significantly inhibited dopamine D(1)/D(2) receptor-mediated pivoting. It is therefore concluded that unilateral stimulation of AMPA receptors in the shell of the nucleus accumbens can elicit contraversive pivoting, and that both AMPA and dopamine D(1)/D(2) receptors play a critical role in shell-specific pivoting in contrast to NMDA receptors that at best play only a modulatory role.