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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

The ideal level of ligation of the inferior mesenteric artery (IMA) during curative resection of sigmoid colon and rectal cancer is still controversial. The aim of this meta-analysis was to examine the impact of high ligation and low ligation of the IMA on anastomotic leakage, overall morbidity, postoperative mortality, and oncological outcomes in patients undergoing surgery for sigmoid colon and rectal cancer. PubMed, EMBASE, Web of Science, and BioMed Central databases were searched to identify relevant articles published from May 1953 to March 2018. A total of 18 articles (14 non-randomized studies and 4 randomized clinical trials) were identified. Review Manager 5.3 software was used for analysis of data. The pooled odds ratio (OR) and weighted mean difference (WMD), with 95% CI, were calculated using either the fixed effects model or random effects model. Of the 5917 patients included in this meta-analysis, 3652 patients underwent low ligation of the IMA and 2265 patients underwent high ligation of the IMA. Anastomotic leakage rate was 9.8% in high ligation patients vs. 7.0% in low ligation patients; the risk of anastomotic leakage was significantly higher in high ligation patients (OR = 1.33; 95% CI 1.10–1.62; P = 0.004). What is more, overall morbidity was also significantly higher in high ligation patients (OR = 1.39; 95% CI, 1.05–1.68; P = 0.05). Postoperative mortality, number of harvested lymph nodes, overall recurrence rate, and 5-year survival rate did not differ significantly between the two groups. Low ligation of the IMA during curative resection of sigmoid colon and rectal cancer appears to be associated with lower risk of anastomotic leakage and overall morbidity. However, there was no significant advantage of low ligation over high ligation of IMA in terms of postoperative mortality, the number of harvested lymph nodes, overall recurrence rate, or 5-year survival rate.

/pdf/high-ligation-of-the-inferior-mesenteric-artery-during-iaux4d0i95.pdf

High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: a meta-analysis

Preservation versus non-preservation of left colic artery in sigmoid and rectal cancer surgery: A meta-analysis

In rectal anterior resection, a clear consensus regarding the optimal level of inferior mesenteric artery (IMA) ligation does not exist because of a lack of randomized trials. We conducted a randomized trial to determine if the IMA should be tied at the origin (high tie, HT) or distal to the left colic artery (low tie, LT) (HTLT study). This study is a subanalysis of HTLT study for laparoscopic surgery. All candidates were randomly divided into the HT or LT groups. The lymph node dissection around the origin of the IMA was performed in the LT group. The stratified factor was the approach (open or laparoscopy). Evaluation parameters were operative factors, short-term and long-term results. In the present study, laparoscopic surgeries were examined as subgroup analysis. From June 2006 to September 2012, 331 patients were registered. Two hundred and fifteen patients (107 for HT: 108 for LT) underwent laparoscopic surgeries. There was no difference between the groups in background. The incidence of anastomotic leakage (HT: LT %) showed no significant differences for grade 2 or higher (11.2:9.3), and grade 3 or higher (2.8:4.6). There were no differences in operative time (200:205 min), blood loss (15:15 ml), number of dissected lymph nodes (22:20), and postoperative hospital stay (10:10 days). The incidence of bowel obstruction in HT was significant (3.7 vs. 0%, p = 0.043). There were no significant differences in overall survival (5-year: 91.3 vs. 90.2%, p = 0.850) and disease-free survival (5-year: 83.2 vs. 78.0%, p = 0.525). There were no differences in the first recurrent site and death reason between both groups. The risk factors for leakage were being male and an anastomotic level in a multivariate analysis by logistic regression. The IMA ligation level was unrelated to anastomotic leakage. No significant difference was detected in long-term results between HT and LT.

Short-term and long-term results of a randomized study comparing high tie and low tie inferior mesenteric artery ligation in laparoscopic rectal anterior resection: subanalysis of the HTLT (High tie vs. low tie) study

In an effort to optimize further the surgical management of colon cancer, many groups have advocated extended lymphadenectomy as a strategy to improve completeness of resection and lymph node harvest. This review evaluates lymphadenectomy according to the definitions for extent of lymph node dissection based on the guidelines provided by the Japanese Society of Cancer of the Colon and Rectum and the contemporary concepts of complete mesocolic excision and central vascular ligation. The proposed benefits of a D3 or central nodal dissection along root vessels in colon cancer is improving accuracy of lymph node evaluation and ensuring complete removal of lymph nodes that may harbor undetected tumor cells or other undefined immunologic processes important for metastases. Metastasis to central lymph nodes occurs in 1 to 8% of patients with colon cancer and is most commonly seen in T3 and T4 tumors. Although central lymph node metastasis is associated with decreased survival after resection, resection of the nodes, when present, may confer a survival benefit analogous to resection of metastasis at distant sites. Current data support a standardized anatomic approach to colonic resection with complete resection of the mesocolic envelope and ligation at least to the D2 level.

Impact of Proximal Vascular Ligation on Survival of Patients with Colon Cancer

Larger insulinomas are reportedly more likely to be malignant; however, their biological behavior has not been clearly elucidated. We here report the characteristics and treatment of a giant insulinoma with local invasion and lymph node metastasis. We also review published reports concerning the clinical features of giant insulinomas and comparing their grading with that of pancreatic neuroendocrine tumors. A 71-year-old man was referred to our hospital for investigation of persistent hypoglycemia. On the current presentation, laboratory tests showed serum glucose, immunoreactive insulin, and C peptide concentrations of 45 mg/dL, 17.2 μIU/mL and 4.1 ng/mL, respectively. Dynamic magnetic resonance imaging showed a hypervascular tumor measuring 13.5 cm in the head of the pancreas. Computed tomography scanning demonstrated local invasion and lymph node involvement. He thus had Whipple’s triad, which is associated with malignant insulinoma. No distant metastases having been identified, pancreaticoduodenectomy was performed. Intraoperatively, three separate tumors were identified in the pancreatic head. Pathological examination showed all three tumors were pancreatic neuroendocrine tumors; the tumor cells in the largest mass were strongly immunoreactive for insulin. The Ki-67 index was 2–5% in most parts of the largest tumor and over 20% in the poorly differentiated areas. This tumor was classified as neuroendocrine carcinoma in accordance with the 2010 World Health Organization classification of pancreatic endocrine neoplasms. He remains free of evidence of recurrence 2 years postsurgery. A review of published reports indicated that giant insulinomas are more malignant than smaller ones, and metastatic disease is found on presentation in 56% of patients with giant insulinomas; however, we were unable to identify any correlation between grade of pancreatic neuroendocrine tumor and biological behavior of giant insulinomas. Giant insulinomas more frequently exhibit malignant behavior, such as local invasion, lymph node involvement, and liver metastasis, than smaller ones. However, there was no relationship between grade and rate of metastases or survival in this small case series. Identification of useful biological markers is necessary.

https://link.springer.com/content/pdf/10.1186%2Fs40792-016-0265-z.pdf

Giant insulinoma: report of a case and review of published reports.

Recently, gastrointestinal stromal tumors that have developed outside of the digestive tract have been reported. These tumors are collectively termed extra-gastrointestinal stromal tumors. Extra-gastrointestinal stromal tumors can also develop in the liver. Only eight case reports involving primary GIST of the liver have been published. We report a case and review the literature regarding this disease. A 70-year-old woman with a past history of gastric cancer visited our hospital for regular inspection. With extensive radiological imaging, a computed tomography scan revealed a mass with a size of 6.8 cm in the lateral segment of the liver. 18F-Fluoro-2-deoxyglucose positron emission tomography revealed no other malignancies except for the liver tumor. Because the lesion was suspected of being a primary malignant hepatic tumor, lateral segmentectomy was performed. The immunohistochemical analysis supported the diagnosis of gastrointestinal stromal tumors in the liver. The patient has had no evidence of recurrence during the 10-month follow-up period; imatinib chemotherapy was not administered. Primary hepatic gastrointestinal stromal tumors had no characteristics that distinguished them from ordinary tumors in imaging examinations. Primary gastrointestinal stromal tumors might have developed from interstitial Cajal-like cells.

/pdf/primary-gastrointestinal-stromal-tumor-of-the-liver-a-case-11xq9hyfg4.pdf

Primary gastrointestinal stromal tumor of the liver: a case report and review of the literature

A ferromagnetic material comprising an iron alloy which contains 2 to 12% by weight of silicon and 5 to 25% by weight of at least one of ruthenium, rhodium, palladium, iridium, platinum, gold and silver, exhibits a high saturation flux density and good corrosion resistance. Excellent magnetic characteristics are obtained in a multilayered film which is obtained by alternatingly laminating the above ferromagnetic material and a spacer layer composed of other material. Further, a markedly increased recording density is exhibited by a magnetic head for perpendicular magnetic recording, when the end of the main pole is composed of the ferromagnetic material.

Ferromagnetic material, ferromagnetic laminate and magnetic head

A ferromagnetic material is composed of an iron alloy which contains 2 to 12% by weight of silicon and 5 to 25% by weight of at least one element selected from the group consisting of ruthenium, rhodium, palladium, iridium, platinum, gold and silver. This ferromagnetic material exhibits a high saturation flux density and good corrosion resistance. Excellent magnetic characteristics are obtained by a multilayered film which is obtained by alternatingly laminating the above ferromagnetic material and a spacer layer composed of other material. Further, a markedly increased recording density is exhibited by a magnetic head for perpendicular magnetic recording, when the end of the main pole is composed of the ferromagnetic material.

Ferromagnetic material and a magnetic head using the same material

The authors studied Fe-Si magnetic thin films with Ru added formed on glass substrates by RF sputtering. Addition of Ru tended to lower the saturation magnetic flux density, but the rate of decrease was smaller than for transition metals such as Cr. The permeability and coercive force remained unaffected. Polarization curve measurements and tests using salt sprays indicated that films with Ru added were more resistant to corrosion. Fe-Si-Ru alloys were obtained with a saturation flux density of about 1.7 T, a permeability of about 500 and a corrosive resistance comparable to that of Ni-Fe alloys.

Magnetic Properties of Fe-Si-Ru Sputtered Films

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