ISSN 1948-9366 (online)

World Journal of
Gastrointestinal Surgery
World J Gastrointest Surg 2016 August 27; 8(8): 541-597

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Contents

Monthly Volume 8 Number 8 August 27, 2016

EDITORIAL
541

Unexpected gallbladder cancer: Surgical strategies and prognostic factors

Clemente G

MINIREVIEWS
545

Surgical palliation of gastric outlet obstruction in advanced malignancy

Potz BA, Miner TJ

556

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a narrative review
Sofo L, Caprino P, Sacchetti F, Bossola M

564

Surgical approach to right colon cancer: From open technique to robot. State of art
Fabozzi M, Cirillo P, Corcione F

574

Can the prognosis of colorectal cancer be improved by surgery?

Takii Y, Maruyama S, Nogami H

ORIGINAL ARTICLE
Retrospective Study
578

Hand-assisted laparoscopic restorative proctocolectomy for ulcerative colitis

Shimada N, Ohge H, Yano R, Murao N, Shigemoto N, Uegami S, Watadani Y, Uemura K, Murakami Y, Sueda T

Observational Study
583

Pancreaticoduodenectomy: A study from India on the impact of evolution from a low to a high volume unit
Shah OJ, Singh M, Lattoo MR, Bangri SA

SYSTEMATIC REVIEWS
590

Open abdomen in gastrointestinal surgery: Which technique is the best for temporary closure during
damage control?
Ribeiro Junior MAF, Barros EA, de Carvalho SM, Nascimento VP, Cruvinel Neto J, Fonseca AZ

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August 27, 2016|Volume 8|Issue 8|

World Journal of Gastrointestinal Surgery

Contents

Volume 8 Number 8 August 27, 2016

ABOUT COVER

Editorial Board Member of World Journal of Gastrointestinal Surgery , Hyo K Lim,

MD, PhD, Professor, Department of Radiology, School of Medicine, Samsung
Medical Center, Sungkyunkwan University, Seoul 135710, South Korea

AIM AND SCOPE

World Journal of Gastrointestinal Surgery (World J Gastrointest Surg, WJGS, online ISSN 1948-9366,
DOI: 10.4240) is a peer-reviewed open access academic journal that aims to guide clinical
practice and improve diagnostic and therapeutic skills of clinicians.
WJGS covers topics concerning micro-invasive surgery; laparoscopy; hepatic, biliary,
pancreatic and splenic surgery; surgical nutrition; portal hypertension, as well as associated
subjects. The current columns of WJGS include editorial, frontier, diagnostic advances,
therapeutics advances, field of vision, mini-reviews, review, topic highlight, medical ethics,
original articles, case report, clinical case conference (Clinicopathological conference),
and autobiography. Priority publication will be given to articles concerning diagnosis and
treatment of gastrointestinal surgery diseases. The following aspects are covered: Clinical
diagnosis, laboratory diagnosis, differential diagnosis, imaging tests, pathological diagnosis,
molecular biological diagnosis, immunological diagnosis, genetic diagnosis, functional
diagnostics, and physical diagnosis; and comprehensive therapy, drug therapy, surgical
therapy, interventional treatment, minimally invasive therapy, and robot-assisted therapy.
We encourage authors to submit their manuscripts to WJGS. We will give priority to
manuscripts that are supported by major national and international foundations and those
that are of great basic and clinical significance.

INDEXING/
ABSTRACTING

World Journal of Gastrointestinal Surgery is now indexed in Emerging Sources Citation Index
(Web of Science), PubMed, and PubMed Central.

FLYLEAF

I-III

EDITORS FOR
THIS ISSUE
NAME OF JOURNAL
World Journal of Gastrointestinal Surgery
ISSN
ISSN 1948-9366 (online)
LAUNCH DATE
November 30, 2009
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Monthly

Editorial Board

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EDITOR-IN-CHIEF
Timothy M Pawlik, MD, MPH, FACS, Associate
Professor of Surgery and Oncology, Hepatobiliary
Surgery Program Director, Director, Johns Hopkins
Medicine Liver Tumor Center Multi-Disciplinary
Clinic, Co-Director of Center for Surgical Trials and
Outcomes Research, Johns Hopkins Hospital, 600
N. Wolfe Street, Harvey 611, Baltimore, MD 21287,
United States

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World J Gastrointest Surg 2016 August 27; 8(8): 574-577

ISSN 1948-9366 (online)

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DOI: 10.4240/wjgs.v8.i8.574

2016 Baishideng Publishing Group Inc. All rights reserved.

MINIREVIEWS

Can the prognosis of colorectal cancer be improved by

surgery?
Yasumasa Takii, Satoshi Maruyama, Hitoshi Nogami
for colorectal cancer limited locally. Evidence for the kind
of resection procedure that is effective for improving
prognosis is insufficient. Prognosis improvement is
expected with the no-touch isolation technique (NTIT),
making it the most important resection procedure. We
are conducting a multicenter randomized controlled trial
(RCT) to confirm the efficacy of NTIT in patients with
colorectal cancer. The present review serves as a preface
to our trial, as it focuses on basic and clinical studies
that support the efficacy of NTIT. The detection ratios
of circulating tumor cells (CTCs) of peripheral blood
indicate the progress and prognosis of colorectal cancer.
In a rabbit liver tumor model, metastases increased
after surgical manipulation. Also, CTCs increased during
the radical excision of colorectal cancer. However, NTIT
decreased the detection of CTCs of intraoperative portal
vein blood in patients with colorectal cancer. Although
these aforementioned results support the use of NTIT,
a previous controlled prospective trial was not able
to confirm the clinical benefit of NTIT, as it had an
insufficient sample size and many patients were lost to
follow-up. Therefore, we initiated a large-scale highquality RCT to confirm the efficacy of NTIT for colorectal
cancer.

Yasumasa Takii, Satoshi Maruyama, Hitoshi Nogami, Niigata

Cancer Center Hospital, Niigata 951-8566, Japan
Author contributions: All authors equally contributed to this
paper with conception and design of the study, literature review
and analysis, drafting and critical revision and editing, and final
approval of the final version.
Supported by National Cancer Research and Development
Fund, No. 26-A-4.
Conflict-of-interest statement: No potential conflicts of
interest.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative Commons
Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms,
provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Manuscript source: Invited manuscript
Correspondence to: Yasumasa Takii, MD, Chief of Gas
troenterological Surgery, Niigata Cancer Center Hospital, 15-3
Kawagishi-cho 2-chome, Chuo-ku, Niigata 951-8566,
Japan. takii@niigata-cc.jp
Telephone: +81-25-2665111
Fax: +81-25-2333849

Key words: Colorectal cancer; General surgery; Notouch isolation technique; Circulating tumor cells;
Randomized controlled trial
The Author(s) 2016. Published by Baishideng Publishing
Group Inc. All rights reserved.

Received: March 27, 2016

Peer-review started: March 29, 2016
First decision: May 17, 2016
Revised: June 1, 2016
Accepted: June 27, 2016
Article in press: June 29, 2016
Published online: August 27, 2016

Core tip: Currently, we are conducting a multicenter

randomized controlled trial to confirm the efficacy of
the no-touch isolation technique (NTIT) in patients with
colorectal cancer. A previous controlled prospective trial
was not able to confirm the clinical benefit of NTIT, as it
had an insufficient sample size and many patients were
lost to follow-up. However, basic and clinical studies
have supported the use of NTIT for treating colorectal
cancer. The present review serves as a preface to our

Abstract
Surgical resection is the only curative treatment modality

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August 27, 2016|Volume 8|Issue 8|

Takii Y et al . Review of the no-touch isolation technique

trial, as it provides background information on whether

the prognosis of colorectal cancer is improved by
surgery.

RCT, and we described the quality control of the followup and the surgery in the protocol. The present review
serves as a preface to our trial, as it focuses on basic
and clinical studies that support the benefit of NTIT for
colorectal cancer.

Takii Y, Maruyama S, Nogami H. Can the prognosis of

colorectal cancer be improved by surgery? World J Gastrointest
Surg 2016; 8(8): 574-577 Available from: URL: http://www.
wjgnet.com/1948-9366/full/v8/i8/574.htm DOI: http://dx.doi.
org/10.4240/wjgs.v8.i8.574

DISCUSSION
Does the detection ratio of circulating tumor cells of
peripheral blood indicate the progress and prognosis of
cancer?

Numerous articles have been published about the

relationship between cancer-bearing patients and circula
ting tumor cells (CTCs), but two meta-analyses have
generalized this point well.
[12]
In the first meta-analysis , five studies reported
on the incidence of CTCs in lymph node involvement
positive and negative groups, and three of those studies
showed a statistically significant increase in the lymph
node involvement positive groups compared with that in
the lymph node involvement negative groups. A metaanalysis of all the studies showed a significantly higher
incidence of CTCs in the lymph node involvement positive
groups (50%) than in the lymph node involvement
negative groups (21%). Five studies reported the rate
of hepatic metastases at maximal follow-up in patients
who were CTC positive and negative, and two of those
studies demonstrated a statistically significant hepatic
metastases rate in patients who were CTC positive
compared with that in those who were CTC negative. A
meta-analysis of all the studies indicated a significantly
increased hepatic metastases rate of 21% in patients
who were CTC positive compared with 8% in those
who were CTC negative. Three studies reported the
incidence of CTCs in different stages, and no study
showed a significant difference between CTC positive
and negative groups. A meta-analysis of all the studies
showed a significantly lower incidence of CTCs in stage
I and II groups (17%) than in stage III groups (32%).
When stage I and stage II tumors were compared, the
incidence of CTCs was higher in stage II (19%) than in
stage I (12%), but this was not statistically significant.
Three studies reported disease-free survival with data
extracted at 1-3 years. Disease-free survival was
significantly higher in the CTC negative groups than in
the CTC positive groups at 1 year, 2 years, and 3 years
after resection.
[13]
In the second meta-analysis , 36 studies (3094
patients) were eligible for the final analyses. Pooled
analyses showed that the detection of CTCs in the peri
pheral blood compartment was a statistically significant
prognostic factor of recurrence-free survival [HR = 3.06
(95%CI: 1.74-5.38) and overall survival (OS) = 2.70
(1.74-5.38)].

INTRODUCTION
Surgical resection is the only curative treatment for
colorectal cancer limited locally. The purpose of surgical
resection of primary colon cancer is complete removal
of the tumor, major vascular pedicles, and lymphatic
[1]
system of the affected colonic segment . Total mesore
[2-5]
[6]
ctal excision
and complete mesocolic excision (CME)
for colon and rectal cancers, respectively, reduce tumor
recurrence after curative resection. Furthermore,
[7]
Japanese D3 dissection is similar to CME . However,
evidence for the kind of resection procedure that is
effective for improving prognosis is insufficient. The notouch isolation technique (NTIT) is the most important
resection procedure, because prognosis improvement is
[8]
expected. NTIT was first proposed in the 1950s . In this
technique, central vascular ligation is the first priority,
and it is followed by mobilization of the tumor-bearing
segment of the colon. This technique aims to reduce
cancer cells flowing from the primary tumor site into the
liver and other organs by ligating the blood vessels first.
A retrospective study showed improvement in prognosis
[9]
with this technique , but a randomized controlled
trial (RCT) failed to prove its efficacy with statistical
[10]
significance . Therefore, NTIT is not regarded as a
[1]
standard technique in current guidelines . Currently, we
are conducting a multicenter RCT to confirm the efficacy
of NTIT in patients with colorectal cancer undergoing
[11]
open surgery . In this trial, the conventional technique
gives first priority to mobilization of the tumor-bearing
segment of the colon, which is followed by central
vascular ligation and ligation of other vasculature.
Conversely, NTIT gives first priority to central vascular
ligation, which is followed by mobilization of the tumorbearing segment of the colon. This trial is designed to
confirm the superiority of NTIT over the conventional
technique in terms of disease-free survival. We hypo
thesize that the 3-year disease-free survival of the
NTIT arm will be greater than that of the conventional
technique arm (75%) by 6%. According to the method
of Schoenfeld and Richter, the sample size will be 840
patients (420 patients per arm) with a one-sided alpha
level of 5% and power of 80%, and 259 events are
expected to occur within 3 years of accrual and 3 years
of follow-up. Considering that some patients will be lost
to follow-up, the total target sample size is set at 850
patients. We secured statistically sufficient cases in this

WJGS|www.wjgnet.com

Do metastases increase after surgical manipulation of

the tumor?
[14]

Nishizaki et al
perform and experiment on liver
tumors in a rabbit model and reported the results. In

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Takii Y et al . Review of the no-touch isolation technique

Was the clinical use of NTIT proven in the controlled

prospective trial that compared NTIT and the
conventional technique?

this experiment, they inoculated carcinoma in a rabbit

liver, and they separated the rabbits into two groups
according to the presence or absence of manipulation
before hepatectomy. Then they compared the number
of tumors in the hepatic vein, number of metastases
in the lung, and prognosis between the two groups.
The incidence of vascular permeation of liver tumor
cells into the hepatic vein was significantly higher in
the manipulation group than in the non-manipulation
group (P < 0.01). On the fourteenth day after tumor
resection, the number of metastatic nodules in the lung
was significantly increased in the manipulation group
compared to that in the non-manipulation group (P <
0.01). The survival of rabbits after tumor resection was
significantly shorter in the manipulation group than in
the non-manipulation group (P < 0.01).

[10]

Wiggers et al
conducted a controlled prospective
trial to assess the effect of NTIT on the treatment of
colon cancers. This trial is the only RCT that has been
published on this topic. Two hundred and thirty-six
patients were prospectively and randomly assigned to
undergo NTIT or the conventional technique. OS did
not differ significantly between the two groups. This
RCT failed to prove the efficacy of NTIT with statistical
significance. After the results of this trial were published,
NTIT was not regarded as a standard technique in
current guidelines. However, there was a trend of good
survival and disease-free survival in the NTIT group
in the RCT. After a detailed review of the RCT, we
concluded that the RCT could not show the superiority
of NTIT because it had an insufficient sample size and
many patients were lost to follow-up. Therefore, we
initiated a large-scale RCT to confirm the efficacy of NTIT
[11]
in patients with colorectal cancer . Furthermore, we
considered a collateral study to obtain basic proof for this
clinical trial. We thought that significant data would be
needed to confirm the presence or absence of CTCs in
the portal vein blood or peripheral blood intraoperatively
or postoperatively. However, we were unable to estab
lish this accompaniment study because of cost.

Do CTCs increase during the radical excision of

colorectal cancer?
[15]

Weitz et al
used cytokeratin 20 reverse transcription
polymerase chain reaction (RT-PCR) to detect CTCs
in the peripheral vein preoperatively, intraoperatively,
and postoperatively. Blood samples were taken from
65 patients who were undergoing resection of primary
colorectal cancer. As the depth of tumor invasion deep
ened, the rate of detection of CTCs increased. Also, as
the lymph node metastatic degree advanced, the rate
of detection of CTCs increased. In addition, regarding
the timing of the measurement, the rate of detection
of CTCs was the highest intraoperatively. These data
indicate that surgery enhances the release of CTCs into
circulation.

CONCLUSION
Although the results of basic and clinical studies support
the benefit of NTIT, a previous controlled prospective
trial was not able to confirm the clinical efficacy of NTIT,
but it had an insufficient sample size and many patients
were lost to follow-up. Therefore, we are currently
conducting a large-scale high-quality RCT to confirm the
efficacy of NTIT in patients with colorectal cancer.

Do CTCs increase during the resection of colorectal

cancer liver metastasis?
[16]

Koch et al also used cytokeratin 20 RT-PCR to detect

CTC in the central vein preoperatively, intraoperatively,
and postoperatively. Blood samples were taken from
37 patients who were undergoing resection of liver
metastases. Concerning the timing of the measure
ment, the rate of detection of CTCs was highest intra
operatively. This was similar to the finding of colorectal
cancer primary tumor surgery. When CTCs were
detected during the resection of liver metastasis, the
prognosis was poor.

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They examined a ratio of CTCs of intraoperative portal
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and NTIT. For the conventional technique, CTCs were
confirmed in 73% of cases, but for NTIT, CTCs were
only confirmed in 14% of cases. As the use of NTIT
reduces CTCs during surgical manipulation, they con
cluded that this technique may be effective for pre
venting metastases in those with colorectal cancer.

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P- Reviewer: Mayol J, Stamos MJ

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