The Endoscopic Surgical Skill Qualification System (ESSQS) was established in Japan to provide an objective measure of the skills of laparoscopic surgeons. This study aimed to assess the effects of the ESSQS on short- and long-term outcomes of laparoscopic right colectomy. We retrospectively reviewed the data of 671 patients with right colon cancer who underwent laparoscopic surgery between 2016 and 2023. Patients were divided into an expert group (n = 194) and a non-expert group (n = 477) based on whether surgery was performed by an ESSQS-qualified surgeon. After propensity score matching, 167 patients in each group were matched. The short- and long-term outcomes were compared between the groups. Before matching, the expert group showed significantly greater frequencies of preoperative treatment (3.1

Postoperative complications may affect the long-term outcomes after colorectal cancer (CRC) surgery. This multicenter study compared prognostic factors for overall survival (OS) in younger (≤ 74 years) and older (≥ 75 years) patients after curative resection for CRC, focusing on the 1-year and post-1-year outcomes. We analyzed data from 1582 patients who underwent curative surgery for CRC at six hospitals between April 2016 and December 2019. Kaplan–Meier and Cox models were used to identify the risk factors for complications and survival. Older patients had a significantly worse overall survival (OS) and survival beyond the 1-year landmark. Postoperative complications were associated with increased 1-year mortality in both age groups. In younger patients, survival beyond 1 year was associated with a positive N status and a low BMI. In contrast, in older patients, postoperative complications remained associated with survival beyond the 1-year landmark, along with a male sex, positive N status, and poor ASA-PS. The prolonged impact of complications on survival in older patients with CRC underscores the need for age-specific surgical strategies and proactive complication management.

Robotic-assisted surgery has become an established technique for rectal cancer, providing enhanced visualization and precision. However, the learning curve for robotic-assisted low anterior resection remains steep due to complex pelvic anatomy and technical challenges. Proctoring—supervised instruction by an experienced surgeon—has been introduced to facilitate early skill acquisition, yet its quantitative impact on robotic-assisted surgery remains unclear. This multicenter retrospective study included 131 patients who underwent robotic-assisted low anterior resection or ultra-low anterior resection for lower rectal cancer between July 2018 and June 2024. Patients were divided into two groups: those who underwent surgery at facilities with and without a certified proctor (Proctor group, n = 58; Non-proctor group, n = 73). Operative outcomes, console time to rectal transection, and learning curves were analyzed using linear regression and cumulative sum analysis. The Proctor group demonstrated significantly shorter operative and console times compared to the Non-proctor group (257 vs. 323 min, p < 0.001; 154 vs. 184 min, p < 0.001). In the first 10 cases, console times were markedly shorter in the Proctor group, indicating greater operative efficiency in the early phase. Cumulative sum analysis showed that the curve reached its peak at 13 cases in the Proctor group and 16 cases in the Non-proctor group, indicating earlier stabilization of console time in the Proctor group. No significant differences were observed in complication rates or oncologic parameters between the groups. Structured proctoring was associated with shorter console times and earlier stabilization of console time during the initial phase of robotic-assisted low anterior resection. Although the overall rate of improvement and long-term outcomes were comparable between groups, structured proctoring may help improve operative efficiency during the early stages of program implementation.

Background: Critically ill patients often have long-lasting limitations in activities of daily living, particularly in walking ability. Although early mobilization increases the likelihood of independent ambulation at hospital discharge, the timing at which different mobilization levels become associated with ambulatory recovery is unclear. This study describes the timing for achieving several mobilization levels and its associations with ambulatory recovery at hospital discharge.Methods: In this single-center retrospective cohort study, patients were divided into a regained group, composed of patients whose ambulation recovered to pre–intensive care unit (ICU) admission levels by hospital discharge, and a non-regained group. Multivariable logistic regression analyses and receiver operating characteristic curve analyses were performed to examine the association between the timing of mobilization (standing, marching in place, and assisted walking) and regained ambulation at hospital discharge.Results: In total, 295 patients were included, and 223 (76%) of them had regained ambulation at hospital discharge. The adjusted odds ratio for standing peaked on day 10 after ICU admission (odds ratio, 5.61; 95% CI, 2.21–17.76) and declined thereafter. The optimal cutoff time linking marching in place and walking with assistance to regained ambulation was also day 10 after ICU admission (marching in place: area under the curve [AUC], 0.78; sensitivity, 0.83; specificity, 0.64; and walking with assistance: AUC, 0.79; sensitivity, 0.77; specificity, 0.68).Conclusions: The findings suggest that mobility status on day 10 after ICU admission can serve as a pragmatic marker for identifying patients at risk of poor ambulatory recovery.

BACKGROUND:The number of elderly people undergoing surgery for colorectal cancer has been increasing. We examine prognosis, including risks of surgery by age and cancer- and noncancer-related deaths. METHODS:This study retrospectively reviewed 1830 patients who underwent curative resection colorectal surgery. Patients were divided into oldest-old (>85 years old, n = 49), elderly (75-84 years old, n = 637), and young (<75 years old, n = 1144) patient groups. RESULTS:Physical status was poorer (P < .001), postoperative complications were more frequent (49.0% vs. 20.9% vs. 18.4%; P < .001), and adjuvant chemotherapy was less frequent (0% vs. 44.3% vs. 83.5%; P < .001) as patients got older. Multivariate analysis revealed oldest-old [odds ratio (OR) 4.373, 95% confidence interval (CI) 2.362-8.110; P < .001] as independent predictors of postoperative complications. Elderly patients [hazard ratio (HR) 2.494, 95%CI 1.707-3.642; P < .001], oldest-old patients (HR 5.969, 95%CI 3.229-11.035; P < .001), poor physical status (HR 2.546, 95%CI 1.694-3.827; P < .001), and postoperative complications (HR 1.805, 95%CI 1.252-2.602; P = .001) were predictive factors for noncancer-specific survival. CONCLUSIONS:Elderly patients had many complications and a higher risk of dying from other causes. Surgical risk and general condition must be considered when deciding the appropriateness of surgery and adjuvant therapy.

High-risk Stage II may have a worse prognosis than low-risk Stage III colorectal cancer and there are limited reports examining the efficacy of adjuvant chemotherapy in Stage II and III subgroups. Using a multicenter database, 598 colorectal cancer patients who underwent laparoscopic colorectal resection and were pathologically diagnosed with high-risk Stage II (T4N0) or low-risk Stage III (T1-2N1, T1-2N2, T3N1) between April 2016 and December 2022 were retrospectively reviewed. Fewer patients received adjuvant chemotherapy in the T4N0 group (54.7/45.0/44.7/27.7

INTRODUCTION:Although robot-assisted surgery has been rapidly gaining popularity in recent years, few reports have examined the impact of individual robotic arm movements on surgical outcomes. This study investigated the relationship between extra arm (EA) usage and experience of surgeons in robot-assisted surgery. METHODS:A total of 176 robot-assisted rectal resections were performed by three surgeons from 2018 to 2022. Each surgeon's first 20 cases categorized in the Early group and the 21st-40th cases in the Late group. Sixty cases in the Early group and 60 cases in the Late group were included to compare patient background, EA motion, and surgical outcomes. RESULTS:More anastomoses were performed closer to the anus in the Late group (p = 0.001). Console time was significantly shorter in the Late group (196 min vs. 153 min, p = 0.020). EA injuries, improper grasping, and intraoperative problems (intraoperative bleeding, misidentification of layers) were significantly less frequent in the Late group (p = 0.001). CONCLUSIONS:As experience with robot-assisted surgery increases, appropriate and safe use of an EA was achieved, and operative time and intraoperative problems were reduced.

This study aimed to compare the perioperative outcomes of robotic versus laparoscopic complete mesocolic excision (CME) and to assess the safety and feasibility of robotic CME (R-CME) for right-sided colon cancer. As part of this analysis, the feasibility and safety of the robotic approach were also evaluated. Patients who underwent right hemicolectomy with either robotic CME (R-CME, 48 patients) or laparoscopic CME (L-CME, 123 patients) between April 2016 and December 2023 were retrospectively analyzed using propensity score matching (PSM). After matching, the R-CME and L-CME groups each of the 40 included patients. The R-CME group had less intraoperative blood loss (P = 0.007), a shorter median time to first flatus (P < 0.001), and a shorter median postoperative hospital stay (P = 0.012) than the L-CME group. The other surgical outcomes were not significantly different between the two groups. R-CME was associated with less blood loss, faster recovery of bowel function, and shorter hospital stay than L-CME, suggesting that robotic CME using a cranial approach may be a feasible and safe option for right-sided colon cancer. These favorable outcomes may reflect not only the general advantages of the robotic platform but also the procedural benefits of the cranial approach, which enables early vascular control and reduced bowel interference.

PURPOSE:Pelvic exenteration (PE) for rectal cancer is highly invasive. The trans-anal approach (Ta-PE) offers a minimally invasive alternative. This study evaluates the perioperative and long-term outcomes of laparoscopic-assisted Ta-PE. METHODS:A retrospective analysis was conducted on 17 patients who underwent laparoscopic-assisted Ta-PE with preserving anal sphincter between April 2018 and September 2024. Perioperative and oncological outcomes, including operative time, complications, hospital stay, and survival rates, were assessed. RESULTS:The median age was 64 years (nine men, eight women). Total-PE was performed in 11 patients (64.7%), and posterior-PE in 6 (35.3%). Urinary diversion was required in 13 (76.5%). Mean operative time was 464 min, with no conversions. Clavien-Dindo Grade III-IV complications occurred in four cases (23.5%), including pelvic abscess (n = 3) and postoperative bleeding (n = 1). No reoperations or 90-day mortality were observed. The median hospital stay was 21 days. Three-year overall survival, disease-free survival, and local control rates were 69.9%, 45.4%, and 93.8%, respectively. CONCLUSION:Laparoscopic-assisted Ta-PE is a promising minimally invasive option for locally advanced rectal cancer, with favorable perioperative outcomes and effective local disease control. Larger studies are needed to confirm these findings and refine patient selection.

PURPOSE:As the population ages, more surgeries are being performed on patients in poor general condition. Such patients are at greater risk of life-threatening postoperative complications and perioperative mortality. METHODS:This multicenter study investigated 4164 consecutive patients who underwent colorectal surgery between 2016 and 2023. Patients were divided into those who experienced life-threatening complications (LT group, n = 31) and those who did not (no-LT group, n = 4133). Clinical features were compared between groups. RESULTS:Thirty-one patients (0.7%) experienced life-threatening complications. Age was higher (80 years vs. 71 years, p = 0.011), body mass index was lower (19.7 kg/m2 vs. 22.0 kg/m2, p < 0.001), poor performance status (performance status ≥ 3) was more frequent (54.8% vs. 10.4%, p < 0.001), and open surgery was more frequent (25.8% vs. 9.0%, p < 0.001) in the LT group. Multivariate analysis revealed high age (odds ratio 2.268, 95% confidence interval 1.079-4.763; p = 0.030), poor performance status (odds ratio 7.714, 95% confidence interval 3.622-11.251; p < 0.001) and open surgery (odds ratio 1.792, 95% confidence interval 1.205-6.799; p = 0.016) as independent predictors of life-threatening complications. CONCLUSION:Patients with a risk of life-threatening complications should be given a detailed preoperative description of the risks, and indications and approaches to surgery should be thoroughly examined.

Efficient operating room management is essential and requires precise surgery scheduling. We hypothesized that an estimation formula for the preparation time for anesthesia induction and surgery could be developed by incorporating anesthesia and surgical factors, as well as the 'clinical department,' into the formula. This retrospective observational study analyzed 12,528 scheduled surgical cases. A regression analysis that included the clinical department, six anesthesia factors, and five surgical factors was conducted. This analysis aimed to develop both an analytical framework and an equation for estimating the time required for both anesthesia induction and surgical preparation. Our estimation formula wielded high accuracy (R2 = 0.801). Particularly, there was only a difference of less than 3 min for surgeries under general anesthesia. In addition, modeling preparation time using "medical interventions performed in the operating room" as a factor instead of patient characteristics was found to be beneficial. It was possible to develop a highly accurate formula for estimating preparation time of anesthesia induction and surgery by analyzing the anesthesia factors and the surgical factors and incorporating the clinical department as an estimation factor. However, this study represents the development phase of the estimation formula. A multicenter study is essential to validate its generalizability and robustness across different settings before broader application.

Anastomotic leakage is a major postoperative complication of colorectal surgery. LigaSure™ is used commonly for vessel-sealing, but its use for intestinal anastomosis or closure, particularly the healing process, is underreported. We conducted this study to evaluate the feasibility of using LigaSure™ for intestinal wall closure, compared with hand-sewn methods. We performed intestinal wall closure of the cecum in rat laparotomy procedures, dividing subjects into a LigaSure™ group (LS) and a hand-sewn group (HS). We compared operation times, tissue structure changes, and pressure resistance from immediately post-operatively to postoperative day (POD) 14. No postoperative dehiscence or mortality occurred in either group. The LS group required significantly less closure time (113 s) than the HS group (321 s, p < 0.001). The adhesion rates for a midline incision were not significantly different between the groups (LS: 26.7

Purpose The Endoscopic Surgical Skill Qualification System was established in Japan to evaluate safe endoscopic surgical techniques and teaching skills. Trainee surgeons obtaining this certification in rural hospitals are disadvantaged by the limited number of surgical opportunities. To address this problem, we established a surgical training system to educate trainee surgeons. Methods Eighteen certified expert surgeons affiliated with our department were classified into an experienced training system group (E group, n = 9) and a non-experienced group (NE group, n = 9). Results of the training system were then compared between the groups. Results The number of years required to become board certified was shorter in the E group (14 years) than that in the NE group (18 years). Likewise, the number of surgical procedures performed before certification was lower in the E group ( n = 30) than that in the NE group ( n = 50). An expert surgeon was involved in the creation of the certification video of all the E group participants. A questionnaire to board-certified surgeons revealed that guidance by a board-certified surgeon and trainee education (surgical training system) was useful for obtaining certification. Conclusions Continuous surgical training, starting with trainee surgeons, appears useful for expediting their acquisition of technical certification in rural areas.

Laparoscopic rectal surgery is often technically difficult. The Endoscopic Surgical Skill Qualification System (ESSQS) was established in Japan as an objective measure of skill for laparoscopic surgeons. However, the advantages of the ESSQS qualification for laparoscopic rectal surgery have been limited. The aim of this multicenter study was to assess the effects of the ESSQS on short- and long-term outcomes for laparoscopic rectal cancer surgery. We retrospectively reviewed 933 rectal cancer patients who underwent laparoscopic surgery between 2016 and 2023. Patients were divided into two groups: those for whom surgery was performed by an ESSQS-qualified surgeon (Expert group, n = 568); and those for whom surgery was performed by an ESSQS-unqualified surgeon (Non-expert group, n = 365). After propensity score matching, 299 patients from each group were matched. Short- and long-term outcomes were compared between groups. Before matching, the Expert group showed greater frequencies of poor performance status (PS) (PS ≥ 3, 10.6

Background Intestinal Behçet's disease (BD) is often associated with ulceration that requires surgery, including perforation and abscess formation. However, no consensus has been reached on the optimal extent of resection or treatment strategy. This study reviewed four cases of intestinal or suspected intestinal BD. Case presentations In Case 1, a 74-year-old woman diagnosed with BD 2 years earlier was treated with anti-tumor necrosis factor α antibody (Infliximab) and steroids. She had oral and pubic ulcers. After close investigation of abdominal pain, perforation of the gastrointestinal tract was suspected and surgery was performed. Multiple perforating ulcers and abscesses were found in the distal ileum, and the small intestine was resected. Postoperatively, the patient was treated with an increased steroid dose and symptoms have remained stable. Case 2 involved a 69-year-old woman with oral and pubic ulcers, ocular ulcer, and skin lesions. She experienced sudden onset of abdominal pain during treatment for lymphoma. She showed multiple perforating ulcers throughout the ileum and underwent resection of the small intestine and ileostomy. Upper abdominal pain appeared during postoperative treatment for high-output syndrome. The patient underwent omentoplasty after perforation of the upper gastrointestinal tract was diagnosed. Postoperatively, anti-interleukin-1 beta antibodies (canakinumab) was administered to control the disease. Case 3 involved an 81-year-old, previously healthy woman. She presented to her previous physician with complaints of pubic ulcer, hemorrhage and abdominal pain. Colonoscopy showed multiple ulcers throughout the entire colon. Steroid therapy was started, but bleeding proved difficult to control and total proctocolectomy was performed. Histopathology revealed multiple perforating ulcers and BD was diagnosed. Postoperatively, the patient remains under steroid control. Case 4 involved a 43-year-old man with abdominal pain who showed abscess formation in the ileocecal region. After excision of the ileocecal area, multiple ulcers were diagnosed. Two years later, abdominal pain recurred and free air was found in the abdomen on close imaging. Emergency anastomotic resection was performed due to ulceration and perforation of the anastomosis. Conclusions Intestinal BD may flare up after surgical treatment and require multiple surgeries. Introducing pharmacotherapy as soon as possible after surgical treatment is important to control the disease.

Lateral pelvic lymph node dissection (LPND) is a challenging surgical technique with complex anatomy and narrow pelvic manipulation. The outcomes of robotic and laparoscopic surgery for LPND are still unclear. We retrospectively reviewed 169 consecutive patients who underwent rectal cancer surgery with LPND between 2016 and 2023. Patients were divided into two groups according to whether LPND was performed by robotic surgery (R group, n = 40) or laparoscopic surgery (L group, n = 129). Clinicopathological feature and outcomes were compared between groups. Frequency of surgery with combined resection of adjacent structures (5.0

Background The effect of laparoscopic surgery on short-term outcomes in colorectal cancer patients over 90 years old has remained unclear. Methods We reviewed 87 colorectal cancer patients aged over 90 years who underwent surgery between 2016 and 2022. Patients were divided into an open surgery group (n = 22) and a laparoscopic surgery group (n = 65). The aim of this study was to investigate the effect of laparoscopic surgery on postoperative outcome in elderly colorectal cancer patients, as compared to open surgery. Results Seventy-eight patients (89.7%) had comorbidities. Frequency of advanced T stage was lower with laparoscopic surgery ( p = 0.021). Operation time was longer (open surgery 146 min vs. laparoscopic surgery 203 min; p = 0.002) and blood loss was less (105 mL vs. 20 mL, respectively; p < 0.001) with laparoscopic surgery. Length of hospitalization was longer with open surgery (22 days vs. 18 days, respectively; p = 0.007). Frequency of infectious complications was lower with laparoscopic surgery (18.5%) than with open surgery (45.5%; p = 0.021). Multivariate analysis revealed open surgery ( p = 0.026; odds ratio, 3.535; 95% confidence interval, 1.159–10.781) as an independent predictor of postoperative infectious complications. Conclusions Laparoscopic colorectal resection for patients over 90 years old is a useful procedure that reduces postoperative infectious complications.

BACKGROUND/AIM:Colonic stents have been inserted as a bridge to surgery in patients with resectable colorectal cancer, allowing bowel decompression for systemic assessment and better preparation to avoid stoma construction. However, reports of short- and long-term prognoses for elderly patients remain limited.PATIENTS AND METHODS:This retrospective study reviewed 175 consecutive patients who underwent colonic stent insertion for bowel obstruction followed by curative colectomy. Patients were divided into those >80 years old (Old, n=49) and those <80 years old (Young, n=126). After propensity score matching, 41 patients in each group matched.RESULTS:Before matching, performance status was poorer (p<0.001), postoperative complication rate was higher (p=0.009), adjuvant chemotherapy rate was lower (p<0.001), and hospital stay was longer (p<0.001) in the Old group. After matching, adjuvant chemotherapy rate was lower (9.8% vs. 39.0%; p=0.003) and hospital stay was longer (14 vs. 12 days; p=0.029) in the Old group. Five-year relapse-free survival (42.9% vs. 68.8%; p=0.200), overall survival (66.3% vs. 87.7%; p=0.081), and cancer-specific survival (68.2% vs. 87.7%; p=0.129) rates were comparable between groups.CONCLUSION:Colorectal resection after colonic stent insertion is useful for elderly patients, with potential to reduce postoperative complication rates and achieve good long-term results with appropriate case selection.

Background Pancreatic and duodenal-related complications after right colectomy carry a higher risk of mortality. Case presentation A 64-year-old woman underwent laparoscopic right colectomy for a laterally spreading tumor in the cecum. On postoperative day 10, she experienced sudden hematemesis. Contrast-enhanced computed tomography (CT) of the abdomen showed a large amount of hemorrhage in the stomach, but no obvious extravasation. In addition, free air was observed near the duodenal bulb. Despite blood transfusion, vital signs remained unstable and emergency surgery was performed. The abdomen was opened through midline incisions in the upper and lower abdomen. A fragile wall and perforation were observed at the border of the left side of the duodenal bulb and pancreas, with active bleeding observed from inside. As visualization of the bleeding point proved difficult, the duodenum was divided circumferentially to confirm the bleeding point and hemostasis was performed using 4-0 PDS. The left posterior wall of the duodenum was missing, exposing the pancreatic head. For reconstruction, the jejunum was elevated via the posterior colonic route and the duodenal segment and elevated jejunum were anastomosed in an end-to-side manner. Subsequently, gastrojejunal and Brown anastomoses were added. Drains were placed before and after the duodenojejunal anastomosis. Postoperative vital signs were stable and the patient was extubated on postoperative day 1. Follow-up contrast-enhanced CT of the abdomen showed no active bleeding, and the patient was discharged home on postoperative day 21. As of 6 months postoperatively, the course of recovery has been uneventful. Conclusions We encountered a case of pancreaticoduodenal artery hemorrhage after laparoscopic right colectomy. Bleeding at this site can prove fatal, so treatment plans should be formulated according to the urgency of the situation.