Yusuke Sakimura

Background: Local recurrence (LR) after laparoscopic rectal cancer surgery remains a major clinical concern. While surgical expertise is important, the impact of combined operator and assistant certification on local recurrence remains unclear. Methods: This retrospective multicenter study analyzed 2825 patients with stage II–III rectal cancer who underwent laparoscopic resection in the EnSSURE cohort. The primary endpoint was the 3‐year cumulative incidence of LR, treating death and distant metastasis as competing events. The primary analysis used a Fine–Gray model including an interaction term between operator and assistant certification based on the Endoscopic Surgical Skill Qualification System. Secondary analyses included a four‐group Fine–Gray analysis (qualified operator and assistant [QQ], qualified operator only [QN], qualified assistant only [NQ], and neither qualified [NN]). A cause‐specific Cox model was used for sensitivity analysis. Results: During a median follow‐up of 55 months, LR occurred in 125 patients (4.4%). A significant interaction between operator and assistant certification was observed (subdistribution hazard ratio [sHR] 0.43, 95% confidence interval [CI] 0.20–0.95; p = 0.038), whereas neither was independently associated with LR. In the four‐group analysis, the risk of LR was significantly higher in the QN, NQ, and NN groups compared with the QQ group (QN: sHR 2.37; NQ: sHR 2.12; NN: sHR 2.18). Results were consistent in sensitivity analyses. Conclusions: A significant interaction between operator and assistant certification was associated with a lower risk of LR, suggesting that surgical outcomes may depend on team composition rather than individual qualifications alone. Trial Registration: UMIN Clinical Trials Registry System: UMIN000040645 (June 3, 2020)

Background: Endoscopic submucosal dissection (ESD) is increasingly applied for early gastric cancer. ESD is a less invasive procedure and could be a radical treatment. However, in some cases, ESD cannot be completed owing to patient or technical factors. In such cases, which could have the potential for curative resection with ESD, standard gastrectomy is excessively invasive. Through closed laparoscopic and endoscopic cooperative surgery (LECS), gastric tumor can be precisely resected without exposing tumor cells to the abdominal cavity. Compared with standard gastrectomy, closed LECS is less invasive for the treatment of early gastric cancer. Case presentation: We performed closed LECS for three cases of early gastric cancer after failed ESD. In all three cases, ESD was interrupted owing to technical and patient factors, including perforation, respiratory failure, and carbon dioxide narcosis. All three cases successfully underwent closed LECS with complete tumor resection and showed an uneventful postoperative course. All three patients remain alive and have experienced no complications or recurrence, with a median follow up of 30 (14–30) months. Conclusions: Closed LECS is less invasive and useful procedure for the treatment of early gastric cancer, particularly in cases with difficulty in ESD.

Background: Intestinal nonrotation is a rare congenital condition that causes fatal colonic volvulus at any age. Once volvulus attack occurs, radical surgical therapy is required for treatment and the prevention of recurrence. This report describes the case of an adult female patient with a recurrence of cecum volvulus due to intestinal nonrotation after transverse colon resection for colonic volvulus.Case presentation: A 27-year-old female visited our emergency room (ER) with intermittent abdominal pain and nausea. Enhanced computed tomography (CT) showed enlargement of the level of the ascending and transverse colon and an obstruction with a whirlpool sign at the transverse colon. The small intestine was distributed on the right side of the abdominal cavity, and the large intestine occupied the left side. She was diagnosed with volvulus with intestinal nonrotation, and emergency surgery was performed. Surgical examination indicated that the ascending colon to the transverse colon was not fixed to the retroperitoneum, and the transverse colon was rotated 180° clockwise. The axis of the volvulus was a mesenteric adhesion of the transverse colon. The involved transverse colon was resected, and the intestine was reconstructed by functional end-to-end anastomosis (FEEA). Six years after the initial surgery, the patient presented to the ER with abdominal fullness and lower abdominal pain. Enhanced CT revealed that the cecum, ascending colon, and remaining transverse colon were dilated with an obstruction. The appendix was located in the left upper abdominal cavity. The clinical diagnosis was cecal volvulus with intestinal nonrotation. An emergency laparotomy revealed that the cecum was rotated 180° clockwise. The terminal ileum to the remaining transverse colon was resected, and FEEA was performed. Seven months later, she suffered obstruction of the intestine caused by an operative adhesion, and conservative treatment was successful. The patient has had no abdominal symptoms for one and a half years so far.Conclusions: Surgeons should realize that nonrotation of the intestines induces volvulus in adulthood and should familiarize themselves with its clinical findings, appropriate treatment, and prognosis. Even after surgical treatment, awareness of the recurrence of volvulus should be maintained to avoid a late diagnosis.