Malignant transformation of inguinal endometriosis is rare. A 56-year-old woman underwent surgery for advanced gastric cancer 5 years ago and received postoperative adjuvant chemotherapy. She had no recurrence since then. However, 5 years after surgery, contrast-enhanced computed tomography (CT) showed a mass in the right inguinal region suspected to be a hydrocele of the canal of Nuck, with a blood test showing a slightly elevated CA19-9 level (63.0 U/mL). Six months later, CT showed an enlarged mass in the right inguinal region and inflammation in the surrounding area. In addition, both inguinal lymph nodes and those in the right iliac artery area were enlarged, suggesting the possibility of malignancy. For diagnostic purposes, a right inguinal mass was excised. Histopathological examination revealed that it was endometrioid adenocarcinoma with ectopic endometriois as the origin. The differential diagnoses for inguinal masses in women include an inguinal hernia, hydrocele of the canal of Nuck, ectopic endometriosis, lymphoma, and metastatic malignancy. The presence of a primary malignancy in the inguinal region is sporadic but must be differentiated. This is the first case of malignant transformation of inguinal endometriosis developed during postoperative follow-up of another cancer.

進行食道癌に対して,化学療法,放射線療法,化学放射線療法,免疫療法などが行われるが,癌による狭窄のために食事が十分に摂取できないだけでなく,癌による慢性炎症によって体重減少や栄養障害をきたしていることが多い.治療前の栄養状態が不良な場合,治療の有害事象が増えるだけでなく,予後が悪化するため,ガイドラインでは治療前からの栄養評価が推奨されている.栄養不良である場合には,チーム医療で食事栄養指導,経腸栄養剤の投与など栄養介入を行うことによって有害事象を低減できる可能性がある.しかし,栄養介入が予後を改善するかどうかについては,ランダム化比較試験が乏しく今後の研究課題である.(著者抄録)

症例は74歳,男性。食道癌に対し,食道亜全摘,胸腔内高位胃管吻合後,下咽頭癌CRT後で経過観察中であった。フォローの内視鏡検査で胃管下部に潰瘍性病変を認め,生検でgroup 5,tub1を認めた。内視鏡的切除は困難であり,手術の方針となった。右開胸胃管切除,皮下有茎空腸再建を行った。術後乳び胸水を認めた。経腸栄養を中止,TPN管理とし,オクトレオチド持続皮下注,エチレフリン持続点滴を開始した。保存的治療開始後も右胸腔ドレーンから2,000mL/日ほどの胸水を認めた。術後14日目に左鼠径リンパ節からリピオドールリンパ管造影を行った。一時的に胸水500mL/日以下まで減少を認めたが,再度1,000mL/日の排液を認めるようになった。術後30日目に肺炎・膿胸が原因と思われる炎症上昇あり,その後に排液が徐々に減少した。乳び胸が治癒したと判断し,術後41日目にドレーン抜去した。術後72日目に自宅退院した。(著者抄録)

症例:症例は76歳,男性。検診で異常を指摘され,精査目的に当院紹介受診となった。上部消化管内視鏡検査で,十二指腸下行脚～水平脚に凹凸不整を伴う全周性の平坦な病変を認めた。生検で乳頭腺癌と診断された。腹部造影CTではリンパ節腫大や遠隔転移を認めなかった。内視鏡的深達度はM癌と推定されたが,大きさは約60mmで全周性,Vater乳頭近傍に位置していた。そのため,内視鏡的切除は困難と判断した。亜全胃温存膵頭十二指腸切除術を施行した。術後病理診断で0-IIa型,tub1>pap,pTis,Ly0,V0,80×50mm,BD1,Ex0,Pn0,pPM0,pDM0,pN0,pStage 0であった。その後,再発なく経過している。側方発育型の十二指腸癌はまれな疾患であり,内視鏡的切除や縮小手術,膵頭十二指腸切除などが報告されている。広範な側方発育型十二指腸癌の1切除例を経験したため,文献的考察を加えて報告する。(著者抄録)

症例は79歳,男性。労作時息切れを主訴に前医を受診した。CTで右胸水貯留,腹水貯留を認め,胸水細胞診で腺癌を認めた。上部消化管内視鏡検査で幽門狭窄を伴う胃前庭部腫瘍を認め,同部位からの生検にてGroup 5(tub2)と判明した。幽門狭窄,腹膜・胸膜播種を伴う切除不能進行胃癌と診断した。化学療法を施行する方針となり,幽門部狭窄に対し消化管ステントを留置した後にSOX療法を開始した。ステント留置から3ヵ月後,化学療法効果判定目的のCTにてステント内狭窄および口側ステントの一部破損,胃内への脱落を認めた。腹痛などの症状はなく,待機的に脱落ステントの回収を行う方針とした。内視鏡的に脱落ステントを回収し,stent in stentで追加留置した。以降通過障害なく,現在も化学療法を継続中である。切除不能進行胃癌の化学療法中の消化管ステント破損はまれな偶発症であり,文献的考察を含め報告する。(著者抄録)

A 79-year-old man with shortness of breath on exertion had right pleural effusion and ascites effusion on CT, and was diagnosed with adenocarcinoma on pleural cytology. Upper gastrointestinal endoscopy revealed a gastric cancer with pyloric stenosis, and biopsy from the same site revealed Group 5(tub2). The patient was diagnosed as unresectable advanced gastric cancer with pyloric stenosis and peritoneal and pleural dissemination. After placement of an uncovered metallic stent for the pyloric stenosis, SOX therapy was started. Three months after stent placement, a CT scan to determine the effect of chemotherapy showed stenosis in the gastrointestinal stent, partial breakage of the stent on the mouth side, and prolapse of the stent into the stomach. There were no symptoms such as abdominal pain, and the patient was placed on standby for retrieval of the dislodged stent. The prolapsed stent was retrieved endoscopically, and a covered metallic stent was additionally implanted as a"stent in stent". The patient has had no further passage obstruction and is currently undergoing chemotherapy. We report a case of fracture of a gastrointestinal stent during chemotherapy for unresectable advanced gastric cancer.

BACKGROUND: Undifferentiated carcinoma is a very rare histologic subtype, representing only 0.8% to 5.7% of all pancreatic exocrine neoplasms. Additionally, spontaneous abdominal hemorrhage is a particularly rare, life-threatening cause. CASE PRESENTATION: A 68-year-old man was taken by ambulance to our hospital because of sudden-onset abdominal pain. Contrast-enhanced abdominal computed tomography revealed a huge mass measuring 99 × 70 mm in the pancreatic tail with enhanced rim staining in the peripheral area. Imaging also showed extravasation and fluid collection beside the tumor. Hence, spontaneous rupture of the pancreatic tumor and intra-abdominal bleeding were diagnosed. Emergency laparotomy was performed because of acute abdominal pain with peritoneal signs. With an intraoperative diagnosis of rupture of the pancreatic tumor, distal pancreatectomy was successfully performed. Histologically, hematoxylin and eosin staining showed round to spindle-shaped, highly pleomorphic mononuclear cells and multinucleated giant cells as well as a component of ductal adenocarcinoma. Immunohistochemical staining showed that the tumor cells were negative for AE1/AE3, whereas the non-neoplastic osteoclast-like giant cells were positive for CD68. Taken together, these results led to a diagnosis of undifferentiated carcinoma with osteoclast-like giant cells. The patient's postoperative course was uneventful. CONCLUSION: We experienced an extremely rare case of spontaneous rupture of an undifferentiated carcinoma with osteoclast-like giant cells presenting as intra-abdominal bleeding. Obtaining a correct preoperative diagnosis is quite difficult at the first evaluation. Undifferentiated carcinoma should be considered as a differential diagnosis in the case with spontaneous rupture of a pancreatic tumor.

BACKGROUND: Patients with lateral node metastasis in low rectal cancers have a poor prognosis. However, variability in patient survival in terms of lateral metastatic status has not been thoroughly investigated. This study was conducted to assess the prognostic value of lateral node involvement and to review nodal classification. METHODS: Patients with stage III low rectal cancers who underwent lateral node dissection were retrospectively reviewed. Two cohorts were set: the first one (1995-2006) was selected using a Japanese multi-institutional database and was used for development of a new nodal system, and the second (2007-2013) was collected from referral institutions for validation of findings. Variables correlated with poor prognosis were investigated. Next, a modified classification of lateral-positive nodal cancers was created. Finally, this new classification was compared with TNM and Japanese classification-based systems according to the Akaike information criterion (AIC) and concordance index (c-index). RESULTS: Overall, 742 and 508 patients were selected for cohorts 1 and 2, respectively. Based on the analyses on cohort 1, patients with two or more lateral metastatic nodes partially spreading into regions outside of internal iliac area exhibited poor prognosis; accordingly, a modified N classification was created, where TNM-N1 and N2a cancers with this feature were upgraded, respectively, to N2a and N2b. The modified N classification yielded the most favourable indices (AIC = 2661.08; c-index = 0.6477) compared with the TNM (AIC = 2662.36; c-index = 0.6457) and Japanese classification-based systems (AIC = 2684.06; c-index = 0.6302). All findings were confirmed by analysing cohort 2. CONCLUSION: A modified nodal system is proposed to account for the significance of lateral node metastasis.

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

This report presents an extremely rare case of synchronous gastric cancer and primary adrenal diffuse large B-cell lymphoma (DLBCL). An 82-year-old man underwent computed tomography, which revealed a heterogeneous appearing and hypodense adrenal mass and a gastric mass with no enlarged lymph nodes in the neck, mediastinum, abdomen, and inguinal region. Upper gastrointestinal endoscopy revealed a protruding gastric tumor. The specimens obtained from endoscopic biopsy were histologically confirmed to be adenocarcinoma. The hormonal findings eliminated functional adrenal tumor. The patient underwent distal gastrectomy with regional lymph node resection for gastric cancer and incisional biopsy of the adrenal mass. Based on the pathological findings, diagnoses of mixed mucinous and tubular adenocarcinomas of the stomach and adrenal DLBCL were confirmed. Postoperation, the patient received rituximab combined with low-dose doxorubicin, cyclophosphamide, vincristine, and prednisone (R-miniCHOP). Six courses of R-miniCHOP were planned, but were completed in only one course at the patient's request. The patient died 2 months after surgery.

Hepatocellular adenoma (HCA) is a rare benign liver tumor that has been reported to occur particularly more often in women who use contraceptives. A 72-year-old woman with no history of using contraceptives presented to our hospital for further examination of a liver tumor. Contrast-enhanced computed tomography and gadoxetic acid-enhanced magnetic resonance imaging revealed a huge solitary hepatic tumor measuring 83 × 76 mm in segments 4, 5, and 8. The differential diagnoses were cholangiocarcinoma and mixed-type hepatocellular carcinoma. Percutaneous needle biopsies were performed twice, and no malignant components were found. Central bi-segmentectomy of the liver was successfully performed. Immunohistochemical staining showed that β-catenin was positive in the membrane of the tumor cells, while fatty acid-binding protein, glutamine synthetase, and amyloid A were negative. These results led to a diagnosis of HCA, hepatocyte nuclear factor-1α-inactivated subtype. The patient's postoperative course was uneventful, and she developed no recurrence for 10 months after surgery. We experienced a rare case of benign HCA. Obtaining a correct preoperative diagnosis is sometimes difficult at the first evaluation. HCA should be considered as a differential diagnosis of liver tumors.

Introduction and importance: Chylous ascites (CA) is an infrequent, intractable complication that may arise after abdominal surgery. Although various attempts at treatment have been adopted, to date, none of them have been consistently effective. We describe the successful treatment of CA using lymphangiography and embolization with lipiodol.Case presentation: A 79-year-old woman underwent laparoscopic surgery for rectum cancer at another hospital. She was discharged on postoperative day (POD) 9; however, she had to be treated and hospitalized for CA three times until POD 76. She visited our hospital to undergo treatment for CA on POD 90 because the previous conservative treatment had not improved her condition. The computed tomography (CT) scans revealed ascites effusion. We performed lymphangiography and embolization with lipiodol two times. Repeated CT on POD 134 showed that the ascites had not increased.Clinical discussion: Lymphangiography and embolization with lipiodol effectively resolved chylous leakage that occurred after abdominal surgery. Additionally, we compare the features of two groups of cases of CA: one group in which patients were treated by lymphatic intervention and the second in which patients were treated through surgical procedures.Conclusion: We were thus able to demonstrate the clinical effectiveness of lipiodol lymphangiography in treating CA.

INTRODUCTION AND IMPORTANCE: We describe the case of a patients with a diaphragmatic hernia associated with radiofrequency ablation for hepatocellular carcinoma who was treated by laparoscopic repair. CASE PRESENTATION: An 82-years-old man with history of HCC with hepatitis C virus-related liver cirrhosis (Child-Pugh B). The patient was treated RFA to HCC for segment 4, 5, 6, 8. After 16 months from latest RFA for segment 8, the patient was admitted to our hospital because of mild dyspnea. Computed tomography revealed a diaphragmatic herniation of bowel loops into the right thoracic cavity. The patients electively underwent laparoscopic repair of the diaphragmatic hernia. The patient was discharged from hospital without any post-operative complications. CLINICAL DISCUSSION: The only treatment to diaphragmatic hernia is surgery, but liver cirrhosis patients limits this possibility. For the surgical treatment of patients with severe cirrhosis, the operation should be carefully assessed. We believe that a laparoscopic approach should be used for repairing diaphragmatic hernia. In the present case, we considered that a laparoscopic approach was safer and more feasible than open laparotomy. CONCLUSION: Diaphragmatic hernia is a rare late-onset complication associated with RFA for HCC. And patients with HCC often have severe liver dysfunction and cirrhosis. A laparoscopic approach is safe and minimally invasive for sever cirrhosis patients.

BACKGROUND: Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure. METHODS: We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients. RESULTS: Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7-14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10-16 days). CONCLUSION: The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

A 74-year-old woman visited her local doctor with stomach ache and weight loss. Abdominal ultrasonography showed a mass in the hepatic flexure of the transverse colon. She was referred to our hospital. Colonoscopy revealed transverse colon cancer in the hepatic flexure. Upper endoscopy showed redness of the mucosa and stenosis in the descending portion of the duodenum. Therefore, duodenal invasion was suspected. The CT scan showed a regional lymph node metastasis, but there were no obvious signs of distant metastases. From the aforementioned findings, we diagnosed the patient with duodenal invasion of transverse colon cancer(cT4b, N1, M0, cStage Ⅲ). There was no intraoperative peritoneal dissemination or liver metastasis, and we performed right hemicolectomy and pancreatoduodenectomy for transverse colon cancer. On histopathological examination, we diagnosed pT4b(Duo, Pan), N1b(3/35), M0, pStage Ⅲb. The patient had delayed gastric emptying after surgery. She recovered conservatively and was discharged on POD 37. She underwent adjuvant chemotherapy( capecitabine therapy)and has been alive without recurrence 8 months after surgery. In some cases of colon cancer invasion of other organs, long-term survival can be achieved if R0 resection is possible, and we should consider extended resection.

症例は42歳、男性。左背部痛を主訴に近医を受診し、腹部CT検査で肝腫瘍を指摘され当院紹介受診となった。血液検査では肝障害を認めず、肝炎ウイルス、腫瘍マーカーは陰性であった。腹部エコー検査で肝左葉外側区域に血流豊富な8cm大の類円形高エコー腫瘤を認めた。腫瘤は造影エコー検査の動脈相で全体に不均一に、門脈相で全体に均一に染影され、胸腹部造影CT検査ではwash outは認めなかった。EOB-MRI検査では肝細胞相で低信号を示した。以上より、悪性の可能性を否定しきれず有症状であったため肝左葉切除術を施行し、肝血管筋脂肪腫(AML)と診断した。肝AMLは成熟脂肪細胞、血管内皮細胞、平滑筋細胞から構成されるperivascular epithelioid cell tumor(PEComa)の一種である。画像診断においては、血管成分と脂肪成分の証明や流出路血管が肝静脈である所見が鑑別に用いられる。脂肪成分が豊富な場合は画像所見で診断可能であるが、自験例は脂肪成分をほとんど含まず術前診断に難渋したものと考えられた。(著者抄録)

症例は69歳、女性。当院でB型慢性肝炎の加療中に肝細胞癌(S6、単発)を発症し、肝切除術を施行した。その後、肝内再発を認めRFA治療を2回施行した。肝切除術から7ヵ月後に左副腎転移を切除した。肝切除術から1年5ヵ月後に脾臓転移を切除し、さらに肝切除術から3年7ヵ月後に肝内再発に対して2回目の肝切除術と右副腎転移を切除した。初回肝切除術から5年8ヵ月後に腹部造影CTで上行結腸近傍に増大傾向を示す結節病変を認めた。腹膜播種再発と診断したが、その他に肝内再発や肝外転移を認めなかったため腹膜播種摘出術を施行した。病理組織学的所見は肝細胞癌の腹膜播種と診断した。術後6ヵ月経過現在、当院外来通院中であるが無再発生存中である。本症例のように肝内病巣の制御が良好であれば、切除する適応はあると考えられる。今回、肝細胞癌術後腹膜播種の1切除例を経験したので文献的考察を加えて報告する。(著者抄録)

症例は74歳、女性。腹痛、体重減少を主訴に近医を受診した。腹部エコーにて横行結腸肝彎曲部に腫瘤を認め、当院紹介受診となった。下部消化管内視鏡検査にて肝彎曲部に横行結腸癌を認めた。上部消化管内視鏡検査にて十二指腸下行脚に粘膜の発赤、狭窄を認め、十二指腸浸潤が疑われた。CTで所属リンパ節転移を認めたが、明らかな遠隔転移は認めなかった。以上から、横行結腸癌、十二指腸浸潤(cT4b、N1、M0、cStage III)と診断した。術中に腹膜播種や肝転移を認めずR0手術が可能と判断し、結腸右半切除術・膵頭十二指腸切除術を施行した。病理組織学的所見にてpT4b(Duo、Pan)、N1b(3/35)M0、Stage IIIbと診断した。術後胃排泄遅延となったが保存的に治療を行い、第37病日に退院となった。外来にて術後補助化学療法(capecitabine単独療法)施行中であり、術後8ヵ月現在無再発生存中である。結腸癌の他臓器浸潤例ではR0切除ができれば長期生存が得られるという報告もあり、拡大切除を積極的に検討すべきと考えられた。(著者抄録)

症例は67歳、男性。食欲不振を主訴に前医を受診し、内視鏡検査で胃癌を指摘され紹介となった。内視鏡検査では胃角部に6cm大の0-I型の腫瘍を認めた。造影CT検査では明らかな所属リンパ節転移や遠隔転移は認めなかった。幽門側胃切除術、Billroth I再建を行った。経過は良好で術後11日目に退院された。術後病理組織学的診断はpT2N0M0、pStage IBで、術後経過観察の方針となった。術後4ヵ月の採血でCA19-9、AFP、PIVKA-II高値、CTで多発肝腫瘍を認めた。原発性肝癌の可能性を鑑別にあげ、肝生検が行われた。肝生検の結果、胃癌の肝転移と診断された。化学療法が開始されたが、最終的に門脈腫瘍塞栓、腹水貯留を認め、再発後1年で原病死された。AFPおよびPIVKA-II産生胃癌は、進行・切除不能症例が多いとされている。AFPおよびPIVKA-II産生胃癌について若干の文献的考察を加えて報告する。(著者抄録)

A 42-year-old man complaining of left back pain was admitted to our hospital. The hepatis B and C surface antigens were negative. The serum levels of tumor markers were within the reference ranges. Abdominal ultrasound revealed an 8 cm-sized, primarily round and hyperechoic mass in the left lateral segment. Contrast-echo showed non-uniform enhancement in the arterial phase and uniform enhancement in the portal phase. This mass did not indicate"wash-out"on contrast- enhanced CT. It showed hypointensity in the hepatobiliary phase on MRI. The definitive diagnosis could not be obtained, and the patient was suspected with malignancy, such as hepatocellular carcinoma(HCC). Therefore, left hemi-hepatectomy was performed for the diagnostic treatment. Based on the immunochemical staining results, he was diagnosed with angiomyolipoma( AML). AML is composed of fat, blood vessels, and smooth muscles. It is regarded as a tumor of perivascular epithelioid cell tumor(PEComa). Early venous return and adipose tissues in the tumor were the distinctive features of this tumor. The preoperative diagnosis of AML without any fatty component as in this case is very difficult.

A 69-year-old woman with a hepatocellular carcinoma(HCC)was followed-up for type B chronic hepatitis and underwent partial hepatectomy(S6)at our hospital. Afterwards, she underwent radiofrequency ablation(RFA)therapy twice because of intrahepatic recurrence. Seven months after the first hepatectomy, a left adrenalectomy was performed for a left adrenal metastasis. Seventeen months after the first hepatectomy, a splenectomy was performed for a splenic metastasis. Forty-three months after the first hepatectomy, a second hepatectomy was performed for intrahepatic recurrence, and a right adrenalectomy was performed for an adrenal metastasis. Sixty-eight months after the first hepatectomy, an abdominal CT revealed a growing solitary lesion in the ascending colon, which was diagnosed as a peritoneal metastasis. The peritoneal dissemination was removed because there were no other extrahepatic or intrahepatic recurrences. Histologically, the resected specimen was diagnosed as a peritoneal metastasis from a HCC. The patient survived, and there were no recurrences for 6 months after the operation. We report this case of a peritoneal metastasis from a HCC after surgery with a review of the literature.

A 67-year-old man visited his doctor because of anorexia and was diagnosed with gastric cancer based on endoscopic findings. Endoscopy revealed a 0-Ⅰ type tumor, 6 cm in size, at the gastric angle. Preoperative CT showed no apparent lymph node or distant metastases. Distal gastrectomy was performed for gastric cancer with Billroth Ⅰ reconstruction. He had no complications and was discharged on postoperative day 11. The pathological Stage was pT2N0M0, pStage ⅠB, and he underwent no adjuvant chemotherapy. Four months postoperatively, serum CA19-9, AFP, and PIVKA-Ⅱ were elevated, and CT revealed multiple liver tumors. A liver biopsy was performed for the definitive diagnosis. The patient was diagnosed with liver metastases from gastric cancer. It is considered that AFP and PIVKA-Ⅱ were produced by the liver metastasis from gastric cancer. He received chemotherapy for liver metastasis and died 1 year after the recurrence.

BACKGROUND: The stomach has many incoming vessels and is resistant to ischemia due to the rich microvascular network within its submucosal layer. Although reports of gastric remnant necrosis after gastrectomy have been rare, mortality rates remain substantially high when present. A double elementary diet (W-ED) tube, which can be used for both enteral feeding and gastrointestinal tract decompression, has been developed for anastomotic leakage and postoperative nutritional management after upper gastrointestinal surgery. The current report presents a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment with a W-ED tube. CASE PRESENTATION: A 73-year-old male was referred to our hospital for an additional resection after endoscopic submucosal dissection (ESD) for gastric cancer. Endoscopic findings showed an ESD scar on the posterior wall of the upper portion of the stomach, while computed tomography (CT) showed no obvious regional lymph node enlargement and distant metastases. The patient subsequently underwent laparoscopic proximal gastrectomy and esophagogastrostomy but developed candidemia on postoperative day 7. On postoperative day 14, endoscopy revealed gastric ischemic changes around the anastomotic site, suggesting that the patient's candidemia developed due to gastric necrosis. His vital signs remained normal, while the gastric remnant ischemia was localized. Given that surgery in the presence of candidemia was considered extremely risky, conservative treatment was elected. A W-ED tube was placed nasally, after which enteral feeding was initiated along with gastrointestinal tract decompression. Although the patient subsequently developed anastomotic leakage due to gastric remnant necrosis, local control was achieved and conservative treatment was continued. On postoperative day 52, healing of the gastric remnant necrosis and anastomotic leakage was confirmed, after which the patient started drinking water. Although balloon dilation was required due to anastomotic stenosis, the patient was able to resume oral intake and was discharged on postoperative day 88. CONCLUSIONS: Herein, we present our experience with a case of gastric remnant necrosis after proximal gastrectomy, wherein conservative management was achieved using a W-ED tube. In cases involving high operative risk, the management should be mindful of gastric remnant necrosis as a post-gastrectomy complication.

Aim: The prognostic value of the stage III subclassification system based on the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma has not yet been clarified. This study aimed to develop a modified system with optimal risk stratification and compare its performance with the current staging systems. Methods: Clinicopathological data from 6855 patients with stage III colorectal cancers who underwent D3 dissection were collected from a nationwide multicenter database. After determining patient survival rates across 13 divisions based on pathological N stage (N1, N2a, and N2b/N3) and tumor depth (T1, T2, T3, T4a, and T4b), except for T1N2a and T1N2b/N3 due to the small number, we categorized patients into three groups and developed a trisection staging system according to the Akaike information criterion. We then compared the Akaike information criterion of the developed system with those of the current staging systems. Results: The T1N1[rank, 1] division (98.5%) had the most favorable prognosis in terms of 5-year cancer-specific survival, followed by T2N1[2] (93.9%), T2N2a[3] (92.0%), T3N1[4] (87.0%), T3N2a[5] (78.8%), T4aN1[6] (78.7%), T2N2b/N3[7] (77.8%), T4aN2a[8] (75.2%), T4bN1[9] (73.5%), T3N2b/N3[10] (64.7%), T4aN2b/N3[11] (61.5%), T4bN2b/N3[12] (43.0%), and T4bN2a[13] (42.5%). Compared to the categorizations of the Japanese and tumor-node-metastasis systems (Akaike information criterion, 22 684.6 and 22 727.1, respectively), the following stage categorizations were proven to be the most clinically efficacious: T1N1[1 ]-T3N1[4], T3N2a[5 ]-T4bN1[9], and T3N2b/N3[10 ]-T4bN2a[13] (Akaike information criterion, 22 649.2). Conclusion: The proposed modified system may be useful in the risk stratification of patients with stage III colorectal cancer who had undergone D3 dissection.

症例は56歳の男性で,15年前より痔瘻と診断され近医で加療されていた.難治性痔瘻増悪の診断で当科を紹介受診された際には,臀部から陰嚢および陰茎にかけて多数の瘻孔と排膿が認められた.肛門管後壁の瘻孔からの生検にて痔瘻癌と診断した.また,腸管同士の瘻孔形成を認め,尿道・膀胱への瘻孔形成が疑われた.痔瘻は広汎かつ深部に及び,会陰部の炎症が強いため,まずS状結腸人工肛門造設術を行い,全身状態と会陰部の炎症所見を改善させたうえで,外性器を含む広汎な会陰皮膚組織切除を伴う骨盤内臓全摘を行い,会陰欠損部に対して腹直筋皮弁形成術を施行した.現在,術後19ヵ月無再発生存中である.本例のように,腸管や尿道・膀胱への浸潤に加え,広汎な会陰部の皮膚浸潤が疑われる局所進展痔瘻癌に対しては,根治のために外性器切除を含めた広範囲の一塊切除が必要であると考えられる.(著者抄録)

BACKGROUND: Gallbladder neuroendocrine tumors (GB-NETs) are extremely rare, representing only 0.5% of all NETs because no neuroectodermal cells are present in the gallbladder. In 2019, the World Health Organization updated the classification of NETs based on their molecular differences. The mutation status of DAXX and ATRX has been added to the criteria for well-differentiated NETs. CASE PRESENTATION: A 50-year-old man presented to our hospital for further examination of a gallbladder polyp. He had no right quadrant pain, fever, jaundice, weight loss, or carcinoid syndrome-related symptoms. The patient hoped to avoid cholecystectomy. During the 3-year observation period, the polyp gradually increased in size from 8.3 to 9.9 mm. He decided to undergo surgery, and whole cholecystectomy was successfully performed. Immunohistochemical staining revealed positivity for chromogranin A, synaptophysin, and CD56. The Ki-67 index was < 3%. Taken together, these results led to a diagnosis of a grade 1 GB-NET. We also performed immunohistochemical staining of DAXX and ATRX, which revealed that DAXX protein expression was negative. The patient's postoperative course was uneventful, and he developed no recurrence for 8 years after surgery. CONCLUSION: We experienced a very rare case of GB-NET. Obtaining a correct preoperative diagnosis is quite difficult at the first evaluation. A GB-NET should be considered as a differential diagnosis of gallbladder tumors.

BACKGROUND: Regional lymphadenopathy is more commonly noted in gastric schwannomas than in other gastric submucosal tumors. Most of the swollen lymph nodes associated with gastric schwannomas are non-metastatic lymphadenopathy. CASE PRESENTATION: A 69-year-old Japanese woman was referred to our hospital with a chief complaint of abdominal discomfort. Contrast-enhanced computed tomography (CT) of the abdomen revealed an extraluminal tumor with heterogeneous enhancement at the middle stomach on the lesser curve, accompanied with one swollen lymph node approximately 10 mm in size and several small lymph nodes in the perigastric region. These lymph nodes were flat; therefore, we considered them to be non-metastatic. The main tumor was removed via wedge resection. Soft and slightly swollen lymph nodes, which were compatible with the lymph nodes noted in the preoperative CT, were found near the main tumor in the fatty tissue at the lesser curvature of the stomach. An excisional biopsy of the largest lymph node was performed for the diagnosis. Based on pathological findings, a diagnosis of gastric schwannoma and follicular lymphoma (FL) was confirmed. The patient is doing well without recurrence of either the gastric schwannoma or FL 28 months postsurgery. CONCLUSIONS: The present report detailed an extremely rare case of FL coincidentally discovered in the swollen regional lymph node of gastric schwannoma.

Intraoperative visualization of lymphatic flow could guide surgeons performing laparoscopic colon cancer surgery on the extent of intestinal resection required. The purpose of this study was to investigate indocyanine green fluorescence imaging for intraoperative detection of lymphatic flow and nodes in such patients. All patients undergoing elective laparoscopic surgery for colorectal cancer from October 2016 to July 2017 were included in this study. Indocyanine green was injected submucosally around the tumors via a colonoscope and lymphatic flow assessed with a laparoscopic near-infrared camera system intraoperatively. Lymphatic flow was visualized perioperatively in 43 of 57 patients (75.4%). The rate of visualized lymphatic flow was significantly higher in patients with a lower clinical stage than in those with a higher clinical stage (p = 0.0103). Among the 14 patients in whom lymphatic flow was not visualized, 10 (71.4%) had cStage III or IV cancer. Our results indicate the potential role of intraoperative navigation in colon cancer surgery in early-stage colon cancers. This method allows the surgeon to clearly identify lymphatic flow during surgery and allows the determination and individualization of the lymph node dissection range.

BACKGROUND: The prognostic significance of lymph node ratio (LNR) is not constant among studies. Exploration of appropriate location-specific cutoffs might be necessary because the number of lymph nodes harvested is generally higher in right than in left colon cancer. We aimed to determine appropriate cutoff values of LNR in right and left colon cancer and to clarify its clinical significance. METHODS: The clinicopathologic data of 5463 patients with stage III colon cancer were collected. The best cutoff for LNR as a prognostic indicator for patients with right and left colon cancer was studied separately. We compared the prognostic impact between LNR and the number of lymph node metastasis using the Akaike information criterion (AIC), and evaluated the prognostic significance of LNR in each stage III subcategory. RESULTS: The best performance was noted when LNR was categorized by cutoffs of 0.16 and 0.22 for right and left colon cancer, respectively. AIC scores were better with these categorizations than with subgrouping by number of positive nodes. LNR-low right colon cancer patients showed better cancer-specific survival than LNR-high in stage IIIA (95.7% vs. 89.3%), IIIB (86.7% vs. 77.2%), and IIIC (71.2% vs. 58.7%). The same results were obtained in left colon cancer patients with stage IIIB (88.3% vs. 80.7%) and IIIC (79.8% vs. 68.4%). CONCLUSIONS: We demonstrated the difference in the appropriate cutoffs of LNR between right and left colon cancer. Categorization by location-specific cutoff of LNR may be useful for risk stratification of patients with stage III cancer.

Mesenteric cysts are rare intra-abdominal masses. They do not show classic clinical findings and are detected incidentally during imaging because of their absent or nonspecific clinical presentation. We herein report 2 cases of mesenteric cysts that were successfully diagnosed and resected through a laparoscopic approach. In a 35-year-old man underwent a comprehensive medical checkup at another hospital, during which ultrasound incidentally revealed a cystic mass in his right retroperitoneum. The patient was referred to our hospital for surgical treatment. He was asymptomatic and his medical history was unremarkable. Physical examination revealed no palpable abdominal mass, and all laboratory test results were within normal ranges. Contrast-enhanced computed tomography showed a 7.2-cm-diameter smooth-surfaced, well-demarcated mass behind the right colon without a contrast effect (Fig. 1). We considered the cyst to be benign and localized in the mesentery of the ascending colon. In one patient, the cyst was located in the mesentery of the ascending colon and removed via a right hemicolectomy; in the other patient, the cyst was located in the sigmoid mesentery, which was completely resected through the operative wound under an open procedure after laparoscopic mobilization of the sigmoid mesentery. We chose the laparoscopic approach in both cases because the cysts were considered benign, noninfectious, and nonhemorrhagic. Histologic examination revealed cystic lymphangioma in both cases. For mesenteric cysts, laparoscopy could be a preferred approach in properly selected patients.

BACKGROUND: Complete mesocolic excision is becoming popular in colon cancer surgery in Western countries, and in the tumor-node-metastasis (TNM) classification of rectal cancer, a part of the lateral pelvic lymph nodes is classified as regional. However, the appropriateness of TNM staging according to the assessment of nodal status exclusively by extended lymphadenectomy remains unclear. PATIENTS AND METHODS: Using a nationwide multicenter database in Japan, we retrospectively analyzed 6866 patients with stage III colorectal cancer (CRC) treated with extended (D3) dissection. First, the best cutoff values for the number of metastatic nodes were explored. Second, the utility of the metastatic status of the main lymph nodes (i.e., at the origin of the feeding artery) and the lateral pelvic lymph nodes ("jN3" category in the Japanese staging system) as N staging criteria was evaluated. The modified N staging system that had the best risk stratification power was determined according to the Akaike information criterion (AIC). RESULTS: Excellent performance was noted when the number of metastatic nodes was categorized by cutoff values of "3/4" and "6/7." Categorization of nodal metastasis was proven the most clinically efficacious when classified as modified-N1 (N1 and jN3-negative), modified-N2a (N2a and jN3-negative), and modified-N2b (N2b and/or jN3-positive; AIC, 22,810.8), rather than the classification based on the TNM (AIC, 22,849.2) or Japanese staging system (AIC, 22,811.1). CONCLUSIONS: We structured a modified N staging system according to the number and extent of lymph node metastases. The modified system may be used in stage III cases for precise risk stratification.

We report a relatively rare case of cecal cancer with dermatomyositis. An 81-year-old man was diagnosed with dermatomyositis associated with the symptoms of eruption, limb muscle weakness, and difficulty swallowing. Colonoscopy revealed a type 2 tumor in the cecum. The patient underwent laparoscopic ileocecal resection. Although it was impossible for the patient to stand before the surgery, he could stand 10 days after the surgery and walk without assistance 14 days after the surgery. In addition, the eruption disappeared, and the preoperatively high creatine kinase(CK)value normalized. Dermatomyositis with malignant tumor has been reported to be associated with poor prognosis. Symptoms related to dermatomyositis may be improved by the resection of the associated tumor. Therefore, it is important to treat the malignant tumor when the patient's condition permits.

BACKGROUND: Chemoradiotherapy (CRT) is a standard treatment for anal canal cancer although many patients with anal canal cancer undergo surgery in Japan. The efficacy of CRT for anal canal cancer was evaluated retrospectively. METHODS: Medical charts of 13 patients with anal canal cancer treated by definitive CRT from October 2004 to May 2016 were reviewed. Twelve patients had squamous cell carcinoma and one had adeno-squamous carcinoma. PET/CT simulation was performed in nine patients. The median total dose was 59.4 Gy (range 57.6-63.4 Gy) with fractions of 1.8-2.0 Gy. Ten patients received chemotherapy with mitomycin C (10 mg/m2) and fluorouracil (5-FU) (800 mg/m2 over 4 days) in weeks 1 and 5, while two patients were treated with cisplatin (40 mg) and 5-FU (750 mg over 5 days) in weeks 1 and 5. One elderly patient received radiotherapy (RT) alone. RESULTS: All 13 patients were alive after a median follow-up period of 102 months (range 16-121 months). Local failure only occurred in the patient with adeno-squamous cell carcinoma, while there was no loco-regional recurrence or distant metastasis in the other 12 patients. The 5-year loco-regional control rate (LRC) and 5-year overall survival rate (OS) were 92% and 100%, respectively. Acute toxicities of ≥ grade 3 were observed in six patients (46%), mainly being dermatitis around the anal verge, and late toxicity of ≥ grade 3 occurred in one patient. CONCLUSION: CRT for squamous cell carcinoma of the anal canal achieved good LRC and OS with acceptable toxicities.

The purpose of this study was to evaluate the prognostic significance of programmed cell death-ligand 1(PD-L1)expression and CD8+T cells in the immune microenvironment. From January 2011 to December 2011, we retrospectively examined 31patients with Stage III colorectal cancer. PD-L1expression and CD8+T cell counts were evaluated by immunohistochemical study using whole-tumor slides. PD-L1expression in cancer cells(PDCC)and in tumor-infiltrating stromal cells(PDSC)was divided into high(H)and low(L)groups. CD8+T cells were counted in the core of the tumor(CDCT)and in the invasive margin of the tumor area(CDIM), and divided into high(H)and low(L)groups. Based on a median follow-up time of 69.3 months, the 5-year overall survival and disease-free survival of all patients were 74.2% and 64.5%, respectively. The overall survival was significantly longer for patients in the CDIM-H group(82.6%)than those in the CDIM-L group(50.0%; p= 0.034). Patients in the PDSC-H group also tended to have superior overall survival than those in the PDSC-L group(84.2% and 58.3%, respectively, p=0.094). In conclusion, both CD8+T cells and tumor-infiltrating immune cells with PD-L1may indicate antitumoral function in patients with Stage III colorectal cancer.

BACKGROUND: The presence of main or lateral lymph node metastasis in colorectal cancer is classified as jN3 by the Japanese Society for Cancer of the Colon and Rectum. Whether information on jN3 status adds value to the TNM classification remains unclear.OBJECTIVE: We aimed to assess the prognostic relevance of colorectal cancer nodal staging through the Japanese jN3 categorization compared with that through TNM.DESIGN: This was a retrospective study.SETTING: The study used the multi-institutional database of the Japanese Society for Cancer of the Colon and Rectum.PATIENTS: Clinical and pathological data of 6866 patients with histologically proven stage III colorectal cancer who underwent curative surgery (R0) with D3 dissection between 1995 and 2006 were derived from the database.MAIN OUTCOME MEASURES: We investigated the prognostic significance of jN3 status in each TNM N class N1/N2a/N2b) and stage (IIIA/IIIB/IIIC) based on cancer-specific survival.RESULTS: Comparison of cancer-specific survival rates revealed significant differences between jN3+ and jN3-colorectal cancer patient groups according to the TNM N status (5-year cancer-specific survival; N1, 70.4% (jN3+) vs 85.5% (jN3-), p<0.001; N2a, 59.2% vs 77.0%, p<0.001; N2b, 39.2% vs 68.7%, p<0.001) and the TNM stage (stage IIIA, 72.5% vs 94.9%, p<0.001; stage IIIB, 67.9% vs 84.0%, p<0.001; stage IIIC, 42.4% vs 70.6%, p<0.001).LIMITATIONS: This study was limited by its retrospective nature.CONCLUSIONS: Assessment and inclusion of jN3 status are of clinical importance for patients with stage III colorectal cancer with D3 dissection, because it contributes to improved understanding of recurrence risk and subsequent decision-making for follow-up procedures and adjuvant therapy. See Video Abstract at http://links.lww.com/DCR/A506.

We previously reported a phase I clinical trial of a peptide vaccine ring finger protein 43 (RNF43) and 34-kDa translocase of the outer mitochondrial membrane (TOMM34) combined with uracil-tegafur (UFT)/LV for patients with metastatic colorectal cancer (CRC), and demonstrated the safety and immunological responsiveness of this combination therapy. In this study, we evaluated vaccination-induced immune responses to clarify the survival benefit of the combination therapy as adjuvant treatment. We enrolled 44 patients initially in an HLA-masked fashion. After the disclosure of HLA, 28 patients were in the HLA-A*2402-matched and 16 were in the unmatched group. In the HLA-matched group, 14 patients had positive CTL responses specific for the RNF43 and/or TOMM34 peptides after 2 cycles of treatment and 9 had negative responses; in the HLA-unmatched group, 10 CTL responses were positive and 2 negative. In the HLA-matched group, 3-year relapse-free survival (RFS) was significantly better in the positive CTL subgroup than in the negative-response subgroup. Patients with negative vaccination-induced CTL responses showed a significant trend towards shorter RFS than those with positive responses. Moreover, in the HLA-unmatched group, the positive CTL response subgroup showed an equally good 3-year RFS as in the HLA-matched group. In conclusion, vaccination-induced CTL response to peptide vaccination could predict survival in the adjuvant setting for stage III CRC.

The safety and immunological responsiveness of a peptide vaccine of ring finger protein 43 and 34-kDa translocase of the outer mitochondrial membrane combined with uracil-tegafur/leucovorin (UFT/LV) was previously demonstrated in metastatic colorectal cancer (CRC) in a phase I clinical trial. To clarify the survival benefit of a peptide vaccine combined with UFT/LV as adjuvant treatment, a phase II clinical trial was conducted involving patients with stage III CRC. All enrolled patients, whose human leukocyte antigen (HLA)-A status was double-blinded, were administered the same regime of a peptide vaccine and UFT/LV chemotherapy. The primary objective of the study was to compare relapse-free survival (RFS) in patients with HLA-A*2402 vs. those without HLA-A*2402. Secondary objectives included comparisons between the two groups regarding overall survival, safety, tolerability and peptide-specific activities of cytotoxic T lymphocytes (CTLs) as measured by the ELISPOT assay. Between December 2009 and December 2014, a total of 46 patients were enrolled to the present study. Three-year RFS was not significantly different between HLA-A*2402 matched and unmatched groups [67.8 vs. 73.6%, respectively; hazard ratio (HR)=1.254, 95% confidence interval (CI): 0.48-4.63; P=0.706]. Three-year RFS was significantly better in patients with positive CTL responses in the HLA-A*2402 matched group compared with those without (85.7 and 33.3%, respectively; HR=0.159, 95% CI: 0.023-0.697; P=0.011). In conclusion, vaccination-induced immune responses combined with UFT/LV were positively associated with survival benefit in patients with HLA-A*2402-positive stage III CRC. Further study is required to clarify whether vaccination-induced immune responses shortly following the initiation of therapy can predict the therapeutic effect and help develop a promising therapeutic strategy for patients with stage III CRC.

症例は67歳、女性。主訴は血便。直腸診で、AV 3cmに表面平滑、弾性硬、径5cm大の腫瘤を触知した。生検結果はgastrointestinal stromal tumor(GIST)で、画像診断では肛門挙筋への浸潤が疑われた。肛門温存の希望が強く、術前補助療法としてメシル酸イマチニブ(IM)400mg/dayを投与した。投与開始23日目には、腫瘍は2cm大に縮小したが、紅斑型薬疹(Grade 3)を認めたためIMの休薬およびステロイド療法を施行した。薬疹消退の後、IMを200mg/日で再開し、36日目に経肛門的局所切除術を施行した。術後1年の時点で無再発生存中であり、ステロイド併用IM投与を継続している。術前IM療法に関する適応や至適投与期間は現時点で明確ではなく、今後も引き続き症例を蓄積する必要があると考えられる。(著者抄録)

PURPOSE: The goal of the study was to examine prediction of lateral pelvic lymph node (LPLN) metastasis from lower rectal cancer using a logistic model including risk factors for LPLN metastasis and magnetic resonance imaging (MRI) clinical LPLN (cLPLN) status, compared to prediction based on MRI alone. METHODS: The subjects were 272 patients with lower rectal cancer who underwent MRI prior to mesorectal excision combined with LPLN dissection (LPLD) at six institutes. No patients received neoadjuvant therapy. Prediction models for right and left pathological LPLN (pLPLN) metastasis were developed using cLPLN status, histopathological grade, and perirectal lymph node (PRLN) status. For evaluation, data for patients with left LPLD were substituted into the right-side equation and vice versa. RESULTS: Left LPLN metastasis was predicted using the right-side model with accuracy of 86.5%, sensitivity 56.4%, specificity 92.7%, positive predictive value (PPV) 61.1%, and negative predictive value (NPV) 91.2%, while these data using MRI cLPLN status alone were 80.4, 76.9, 81.2, 45.5, and 94.5%, respectively. Similarly, right LPLN metastasis was predicted using the left-side equation with accuracy of 83.8%, sensitivity 57.8%, specificity 90.4%, PPV 60.5%, and NPV 89.4%, and the equivalent data using MRI alone were 78.4, 68.9, 80.8, 47.7, and 91.1%, respectively. The AUCs for the right- and left-side equations were significantly higher than the equivalent AUCs for MRI cLPLN status alone. CONCLUSIONS: A logistic model including risk factors for LPLN metastasis and MRI findings had significantly better performance for prediction of LPLN metastasis compared with a model based on MRI findings alone.

PURPOSE: This study seeks to evaluate lateral pelvic lymph node (LPLN) and perirectal lymph node (PRLN) status on magnetic resonance imaging (MRI) as potential risk factors for lymph node metastasis. METHODS: The subjects were 394 patients with lower rectal cancer who underwent MRI prior to mesorectal excision (combined with lateral pelvic lymph node dissection in 272 patients) at 6 institutes. No patients received neoadjuvant therapy. Cases were classified as cN(+) and cN(-) based on the short axis of the largest lymph node ≥5 and <5 mm, respectively. LPLN and PRLN status and other clinicopathologic factors were analyzed by multivariate logistic regression. The importance of identified risk factors for lymph node metastasis was examined using the area under the curve (AUC). RESULTS: Independent risk factors for right LPLN metastasis included histopathological grade (G3 + G4), pPRLN(+), M1, cLPLN(+) [odds ratio (OR) 10.73, 95 % confidence interval (CI) 4.59-27.1], and those for left LPLN metastasis were age (<64), histopathological grade (G3 + G4), pPRLN(+), and cLPLN(+) (OR 24.53, 95 % CI 9.16-77.7). ORs for cLPLN(+) were highest. The AUCs for right and left cLPLN status of 0.7484 (95 % CI 0.6672-0.8153) and 0.7904 (95 % CI 0.7088-0.8538), respectively, were significantly higher than those for other risk factors. In contrast, the ORs for cPRLN(+) and cPRLN status of 2.46 (95 % CI 1.47-4.18) and 0.6396 (95 % CI 0.5917-0.6848) were not much higher than for other factors. CONCLUSIONS: An LPLN-positive status with a short axis ≥5 mm on MRI is an important predictor of LPLN metastasis, but PRLN status is not a strong predictor of PRLN metastasis.

PURPOSE: To investigate the optimum cutoff for lymph node size to identify cases positive for perirectal lymph node (PRLN) and lateral lymph node (LPLN) metastasis of lower rectal cancer on magnetic resonance imaging (MRI). METHODS: The subjects were 449 patients who underwent preoperative MRI. Mesorectal excision was performed in all patients (combined with lateral pelvic lymph node [LN] dissection in 324) between 2004 and 2013 at 6 institutes. Cases were classified as cN positive and cN negative on the basis of the short axis of the largest LN being greater than or equal to a cutoff or less than a cutoff, respectively. PRLN and LPLN diagnoses using 5 and 10 mm cutoffs were compared with histologic diagnoses. Of the 449 patients, 55 received preoperative chemoradiotherapy. MRI was only performed after this therapy in all of these patients. RESULTS: For PRLNs, 5 and 10 mm cutoffs gave area under the curve (AUC) values of 0.6364 and 0.5794, respectively. The 5 mm cutoff gave a significantly higher AUC value (P = 0.0152), with an accuracy of 63.7 %, sensitivity of 72.6 %, and specificity of 54.7 %. For right LPLNs, the respective AUC values were 0.7418 and 0.6326 (P = 0.0034), and the variables (5 mm cutoff) were 77.6, 68.6, and 79.7 %. For left LPLNs, AUC values were 0.7593 and 0.6559, respectively (P = 0.0057), and the variables (5 mm cutoff) were 79.3, 70.8, and 81.0 %. CONCLUSIONS: Identification of LN-positive cases on the basis of PRLN and LPLN sizes was superior at a short-axis 5 mm cutoff. Size-based diagnosis of LN metastasis is simple and useful, but further investigation is needed to clarify whether it is superior to diagnosis based on morphology, such as shape, border, and signal intensity.

BACKGROUND: Increased rates of long-term survival after CRC diagnosis are accompanied by increases in the incidence of BMs. Here, we retrospectively evaluated the outcomes of patients with BMs from CRC. MATERIALS AND METHODS: We reviewed the records of 1364 patients with CRC treated between January 1999 and December 2010 at Kinki University Hospital in Japan. Twenty-five of these patients developed BMs. Log-rank tests and Cox regression analyses were used to assess potential prognostic factors for survival. RESULTS: Among the patients with BMs, BMs developed a median of 25.3 (range, 11.4-111) months after primary CRC surgery. There was a median of 2 BMs per patient. Eleven patients had solitary BMs. Concomitant extracerebral metastases, particularly lung metastases, were found in 23 patients. Twenty-three patients were receiving systemic chemotherapy at the time of diagnosis with BMs. After the development of BMs, the median survival time (MST) was 2.8 months. The MST was 4.8 months among patients who underwent neurosurgical resection (n = 6) or stereotactic surgery (n = 9, including combined therapy in 2 patients) and 1.5 months among patients who underwent whole-brain radiotherapy only or best supportive care (n = 12). In multivariate analysis, single BMs and additional systemic chemotherapy after BMs diagnosis were significantly associated with overall survival (P = .022 and .023, respectively). CONCLUSION: Our results suggest that advancements in continuing systemic chemotherapy prolong survival among patients with BMs from CRC. Clinicians should be especially aware of BMs in patients with lung metastases.

The local recurrence rate after total mesorectal excision (TME) appears to be markedly lower than that after conventional operations. We reviewed all relevant articles identified from the MEDLINE databases and clarified the rationale for TME. It is clear that distal intramural spread is rare. Even when present, such spread is not likely to extend beyond 2 cm. Data with attention to mesorectal cancer deposits suggest that mesorectal clearance of at least 4-5 cm distal to the tumor should be sufficient. TME should be performed for most tumors of the mid- and lower rectum. This does not mean that the gut tube needs to be divided at the same level in every case. Dissection of the distal mesorectum off the gut tube can be performed, so the distal line of division of the bowel wall can be made at a minimum of 2 cm below the tumor if such a maneuver would ensure that the sphincters are preserved. In cases with cancer in the upper third of the rectum, the mesorectum and gut tube can safely be divided 5 cm below the tumor without jeopardizing the recurrence rates. Our findings indicate that TME is an essential treatment approach for rectal cancer, and lateral lymph node dissection and preoperative chemoradiotherapy are additional therapies that should be considered for advanced rectal cancer.

We conducted a clinical trial of a seven-peptide vaccine in combination with tegafur-uracil/Leucovorin for advanced colorectal cancer. These antigenic peptides were derived from 5 proteins identified as cancer-testis antigens(ring finger protein 43 [RNF43], translocase of outer mitochondrial membrane 34[TOMM34], maternal embryonic leucine zipper kinase[MELK], forkhead box M1[FOXM1], and holliday junction recognition protein[HJURP])and 2 vascular endothelial growth factor receptors(VEGFR1 and VEGFR2). Thirty patients with advanced colorectal cancer were enrolled. We found that 25 patients had Grade 1 injection-site redness/induration and 1 patient had Grade 3 anaphylaxis. Tumor imaging revealed that 3 patients had a partial response (PR), 15 had stable disease(SD)and 12 had progressive disease(PD). This trial showed that treatment with the seven-peptide vaccine and UFT/LV was well tolerated and feasible for advanced colorectal cancer.

Complementary DNA( cDNA) microarray technology coupled with laser microdissection has been used to identify human leukocyte antigen (HLA)-A24-restricted epitope peptides as potential targets for cancer vaccination in colorectal cancer patients. These antigenic peptides were derived from 2 different cancer-testis antigens, ring finger protein 43 (RNF43) and translocase of outer mitochondrial membrane 34( TOMM34). We conducted a clinical trial of colorectal cancer-specific peptide( RNF43, TOMM34) vaccines with uracil/tegafur( UFT)+Leucovorin( LV) for the treatment of advanced or recurrent colorectal cancer. The vaccinations were well tolerated without any serious adverse events. There were long-term survivors in the group showing cytotoxic T lymphocyte (CTL) responses against both RNF43 and TOMM34, as well as in the group showing CTL responses against either RNF43 or TOMM34. A new study has been planned to obtain more immunological responses. We started a clinical trial of vaccines against multiple peptides (RNF43, TOMM34, forkhead box protein M1 [FOXM1], maternal embryonic leucine zipper kinase [MELK], holliday junction recognition protein[HJURP], vascular endothelial growth factor receptor 1[VEGFR1], and VEGFR2) for the treatment of advanced or recurrent colorectal cancer.

Background: Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR.Methods: The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score.Results: The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 +/- 2.6 and 9.1 +/- 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture.Conclusions: The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.

In rectal cancer surgery, it is unclear whether the inferior mesenteric artery (IMA) should be ligated as high as possible, at its origin, or low, below the origin of the left colic artery. We reviewed all relevant articles identified from MEDLINE databases and found that despite a trend of improved survival among patients who underwent high ligation, there is no conclusive evidence to support this. High ligation of the IMA is beneficial in that it allows for en bloc dissection of the node metastases at and around the origin of the IMA, while enabling anastomosis to be performed in the pelvis, without tension, at the time of low anterior resection. High ligation of the IMA does not represent a source of increased anastomotic leak in rectal cancer surgery and postoperative quality of life is improved by preserving the hypogastric nerve without compromising the radicality of the operation. More importantly, high ligation of the IMA improves node harvest, enabling accurate tumor staging. Although the prognosis of patients with node metastases at and around the origin of the IMA is poor, the survival rate of patients with rectal cancer may be improved by performing high ligation of the IMA combined with neoadjuvant and adjuvant therapy.

cDNA microarray technology coupled with laser microdissection has been used to identify HLA-A24-restricted epitope peptides as potential targets for cancer vaccination in colorectal cancer patients. These antigenic peptides were derived from two different cancer-testis antigens, RNF43 and TOMM34. We conducted a clinical trial of colorectal cancer specific peptides (RNF43, TOMM34) vaccines with UFT/LV for the treatment of advanced or recurrent colorectal cancer. The vaccinations were well tolerated without any serious adverse events. Of the 21patients, CTL responses were induced against both RNF43 and TOMM34 in 8 patients and against RNF43 or TOMM34 in 12 patients, while 1 patient had no CTL response. Long-term survivors were observed in the group showing CTL responses against both RNF43 and TOMM34, followed by the group showing CTL responses against only RNF43 or TOMM34. There was poor survival with no CTL response. Although cancer vaccines for colorectal cancer have many problems, such as evaluation of clinically effective, monitoring immune responses, and concomitant chemotherapy, their overall clinical effect will be evaluated with clinical trials.

The present study aims to define the prognostic impact of the lymph node ratio (LNR) in patients with stage III distal rectal cancer. We analyzed data from 501 patients who underwent curative resection (total mesorectal excision, TME) for stage III distal rectal cancer at 12 institutions between 1991 and 1998. Patients were divided into four groups according to quartiles based on LNR. Among the 501 patients, 381 underwent TME with pelvic sidewall dissection (PSD). The median numbers of lymph nodes retrieved with and without PSD were 45 and 17, respectively (P < 0.0001). Forty-nine patients with lymph node retrieved less than 12 were excluded from further analyses. Among various clinicopathological parameters, univariate analysis identified age (P = 0.0059), histological grade (P < 0.0001), depth of tumor invasion (P = 0.0003), and number of positive nodes (P < 0.0001) and LNR (P < 0.0001) as prognostic factors. The Cox proportional hazards model revealed that age (P = 0.014), histological grade (P < 0.0001), depth of tumor invasion (P = 0.0002), and LNR (group 3, P = 0.0012; group 4, P < 0.0001) were independent prognostic factors. When the American Joint Committee on Cancer (AJCC) seventh staging system was added as a covariate, both AJCC stage (P < 0.0001) and LNR (P < 0.0001) were independent prognostic factors. Adding the LNR concept to the AJCC cancer staging system will improve accuracy in evaluating the nodal status of distal rectal cancer.

To test the safety and immune responses of a novel peptide vaccine derived from RNF43 (ring finger protein 43) and TOMM34 (34-kDa translocase of the outer mitochondrial membrane) administered in combination with chemotherapy in patients with metastatic colorectal cancer, a phase I clinical trial with 21 HLA-A2402-positive metastatic colorectal cancer patients was conducted. Patients received a weekly peptide vaccine (1 mg of each peptide in incomplete Freund's adjuvant) in combination with oral UFT (300 mg/m(2)/day) and UZEL (75 mg/day) for 4 weeks, followed by 1 week of rest. The protocol consisted of at least two cycles of this regimen. After the 2nd cycle, vaccinations were given biweekly or monthly, depending on the condition of the patient. Clinical responses were judged 10 weeks after the 2nd cycle by performing computed tomography (CT) scans and assessing the cytotoxic T lymphocyte (CTL) responses against RNF43 and TOMM34 in peripheral lymphocytes. The vaccinations were well tolerated without any serious adverse events. CTL responses were induced against both antigens in 8 patients and against one antigen in 12 patients, while 1 patient had no CTL response. The rate of stable disease was 83%. The group with CTL responses against both antigens had the most long-term survivors, followed by the group showing CTL responses against one antigen (p=0.0079). The patients with no CTL responses had the lowest survival. The safety and immunological responsiveness of the present combination therapy suggests that it is clinically beneficial for metastatic colorectal cancer. Further clinical trials are warranted.

The goal of this multicenter study was to clarify the determinants of local excision for patients with T1-T2 lower rectal cancer. Data from 567 consecutive patients who underwent radical resection for T1-T2 lower rectal cancer at 12 institutions between 1991 and 1998 were reviewed. Rates of lymph node metastasis were investigated using a tree analysis, which was hierarchized using independent risk factors for nodal involvement. The independent risk factors for lymph node metastasis were female gender, depth of tumor invasion, histology other than well-differentiated adenocarcinoma, and lymphatic invasion. According to the first three parameters that can be obtained preoperatively, only 0.99% of the patients without risk factors had lymph node metastasis. On the other hand, even if the lower rectal cancer was at stage T1, women with histological types other than well-differentiated adenocarcinoma had an approximately 30% probability of having lymph node metastasis. Lymphatic invasion was most useful to predict nodal involvement among patients with T2 lower rectal cancer. The rates of lymph node metastasis in T2 patients with and without lymphatic invasion were 32.9% and 9.1%, respectively. Gender is one of the most important predictors for lymph node metastasis in patients with early distal rectal cancer. Three parameters, including depth of tumor invasion, histology, and gender, are useful determinants for local excision. Additional studies are required to establish the minimum optimal treatment for T2 lower rectal cancer.

Many retrospective studies have found that the functional outcome after a low anterior resection for rectal cancer is better with colonic J-pouch reconstruction than with conventional straight anastomosis. This advantage was demonstrated in prospective, randomized trials and meta-analyses. However, despite its increasing popularity there are several areas of controversy about the use of the colonic J-pouch reconstruction. These issues include anastomotic leaks, the part of the colon used for the pouch, the pouch size, causes of difficulty in evacuation, indications (the optimum level of anastomosis), appropriateness for the elderly, and long-term (2 years or more after surgery) functional outcome. All relevant articles identified from MEDLINE databases were reviewed. The incidence of anastomotic leaks is apparently reduced by colonic J-pouch reconstruction. A 5-cm colonic J-pouch using the sigmoid colon increases the reservoir function without compromising evacuation, and provides better functional outcome than straight anastomosis, even 2 years or more after surgery, in patients whose anastomosis is less than 8 cm from the anal verge. Patients with ultralow anastomoses, less than 4 cm from the verge, appear to benefit the most. At a time when the indications for abdominoperineal excision appear to be reduced for low rectal cancer, the demand for colonic J-pouch reconstruction (the best technique in pouch operations) is therefore likely to increase.

The patient was a 55-year-old female who had multiple liver metastases of rectal cancer. This patient underwent hepatic arterial infusion chemotherapy after low anterior resection for rectal cancer. Hepatic arterial infusion was discontinued due to severe diarrhea, and the administration of UFT (300 mg/day) and LV(75 mg/day) was then begun. The carcinoembryonic antigen (CEA) level was normalized immediately after the start of this administration. One year later, liver metastases disappeared on computed tomography (CT) and a complete response (CR) was achieved. No adverse events were noted, and CR was maintained for 2 years. This therapy can serve as one of the chemotherapies for advanced colorectal cancer.

We prospectively compared changes in function between colonic J-pouch and straight anastomoses from 1 to 5 years after low anterior resection for rectal cancer. At 1, 3, and 5 years after surgery, functional outcome was compared between 48 patients with J-pouch reconstruction (J group) and 51 with straight anastomosis (S group), using a 17-item questionnaire (overall best, 0; overall worst, 26). At 5 years, patients with ultralow anastomoses (less than 4 cm from anal verge), had fewer bowel movements during day or night, and less urgency and soiling in the J than S group. At that time, patients with low anastomoses (5 to 8 cm above the verge) had fewer bowel movements at night and less urgency in the J than S group. Functional scores improved significantly over time for both anastomotic levels, especially in the S group. Mean scores with ultralow anastomoses were J-group, 5.6 at 1 year vs. 5.3 at 3 years (P=0.0304) vs. 3.7 at 5 years (P<0.0001); and S group, 10.2 at 1 year vs. 9.6 at 3 years (P=0.0063) vs. 7.3 at 5 years (P<0.0001). Mean scores with low anastomoses were J group, 3.4 at 1 year vs. 3.1 at 3 years (P=0.0052) vs. 2.1 at 5 years (P=0.0003); and S group, 5.2 at 1 year vs. 3.8 at 3 years (P<0.0001) vs. 2.7 at 5 years (P<0.0001). Functional outcome improved in the J and especially the S group over 5 years. However, function was better in the J than S group at all time points.

Patients with rectal cancer who undergo an abdominoperineal resection (APR) are physically handicapped by the presence of a permanent colostomy. We compared physical conditions of patients treated by APR with those of patients treated by anterior resection (AR), and found out whether the choice of operation technique had any influence on their social and psychological conditions. We compared the postoperative physical, social, and psychological conditions of 40 patients who underwent an APR with those of 116 patients who received an AR using a questionnaire. Physical conditions in the APR group were significantly worse than those in the AR group. There were no significant differences in social conditions between the two groups and social conditions were satisfactory in both groups. However, the will to carry on life in the APR group was significantly emptier than that in the AR group. While most patients who undergo an APR return to their normal level of social condition following surgery, their will to carry on life are empty due to physical discomforts including bowel dysfunction, urinary dysfunction, and sexual dysfunction. The quality of life is impacted by multiple factors, one of which may be the presence of the colostomy.

Functional outcome after anterior resection (AR) for rectal cancer is improved by colonic J-pouch reconstruction compared with straight anastomosis. The indications for colonic J-pouch reconstruction have yet to be determined. Therefore, we attempted to determine the level at which J-pouch reconstruction provides an advantage over straight anastomosis. There were 48 patients who underwent 5-cm colonic J-pouch reconstruction (J-pouch group) and 80 patients who underwent straight anastomosis (straight group) who were subjected to functional assessment 1 year postoperatively. The functional outcome in the J-pouch group was significantly better than that in the straight group when the distance of the anastomosis from the anal verge was less than 8 cm. The difference was particularly obvious when the level of the anastomosis was below 4 cm. However, functional outcome in the straight group when the anastomosis was between 9-12 cm from the anal verge also was satisfactory, and did not differ from that in the J-pouch group when the anastomosis was between 5 and 8 cm from the anal verge. Colonic J-pouch reconstruction is indicated when the distance of anastomosis from the anal verge is less than 8 cm, and it is particularly essential when less than 4 cm.

In colon cancer surgery, it is recommended to perform en bloc resection involving extended lymphadenectomy, characterized as a hemicolectomy, by ligating the primary feeding artery at a high position and resecting proximal and distal 5 to 10 cm bowel margins. However, there is little evidence to unequivocally support such extensive lymphovascular resection. The distribution of nodal metastases was obtained by the clearing method in 164 patients with colon cancer. For pericolic spread: for pT1 tumors, the distance from the primary tumor to a diseased node was 2.5 cm; for pT2, the distance was less than 5 cm; for 97.0% of pT3 tumors and 93.3% of pT4 tumors with nodes involved, the distance was less than 7 cm. For central spread: for pT1 tumors, the rate of spread to central nodes was 0%; for pT2, the rate of spread was 20.0% to intermediate nodes (for tumors more than 5 cm from the feeding artery, the rate for central nodes was 0%); for pT3, the rate was 30.6% to intermediate nodes and 15.3% to main nodes; for pT4, the rate was 44.4 % to intermediate nodes and 22.2% to main nodes. For curative resection cases with pT3 tumors more than 7 cm from the feeding artery, the rate to central nodes was 0%. In T1 tumors, central node dissection is not required, but proximal and distal 3-cm margins of resection are required; in T2, central node dissection that includes the intermediate node should be performed, as well as proximal and distal 5-cm margins of resection. In T3 and T4, central node dissection that includes the main node should be performed, as well as proximal and distal 7-cm margins of resection. However, for T2 more than 5 cm from the primary feeding artery, and for T3 more than 7 cm from the primary feeding artery, proximal and distal resection alone may be adequate.

It hits been reported that functional outcome following low anterior resection of rectal cancer is improved by construction of a colonic J-pouch compared with straight anastomosis. Hence, we tried to justify use of the sigmoid colon in the construction of a J-pouch by the analysis of regional lymph node metastases. A total of 198 patients underwent resection for rectal cancer. Node metastases were examined by the clearing method. According to Japanese General Rules, nodes were classified into the perirectal nodes (PR-N), pericolic nodes (PC-N), central intermediate nodes (C-IM-N), central main nodes (C-M-N). Metastatic rate (number of patients with node metastases/total number of patients) of PR-N was 56.6%. Metastatic rate of C-IM-N was 19.2% and that of C-M-N was 8.6%. Metastatic rate of PC-N was only 1.0%. In low anterior resection, high ligation of the inferior mesenteric artery and dissection of C-M-N, C-IM-N and PR-N are necessary. Resection of sigmoid colon is not required, and therefore, a J-pouch can be constructed using the sigmoid colon.

We examined the survival benefit of pelvic exenteration for locally advanced colorectal cancer with lymph node metastases, because this issue remains controversial. Medical records of 56 patients who underwent curative pelvic exenteration for colorectal cancer were reviewed retrospectively. Nodal metastases were examined by the clearing method in 29 patients and by the conventional manual method in 27 patients. Invasion to contiguous pelvic organs was present in 45 patients (80.4%) and absent in 11 patients (19.6%). Node metastases were present in 38 patients (67.9%). Operative morbidity and mortality rates were 23.2% (13 patients) and 5.4% (3 patients), respectively. Respective 5-year survival rates were 62.2 and 81.8% in the groups with and without organ invasion (no significant difference). Five-year survival in patients with nodal metastases was 56.4% but was significantly higher, 84.6%, in patients without nodal metastases. Five-year survival in 32 patients with both organ invasion and nodal metastases was 55.6%. Long-term survival was afforded by pelvic exenteration for locally advanced colorectal cancer with nodal metastases.

In rectal cancer surgery, preservation of urinary and sexual function is attempted by means of operations preserving the autonomic nerves of the pelvic plexus. Emergence of residual cancer because of a more shallow plane of dissection is a problem feared with these methods, so we examined indications for pelvic plexus preservation. We studied 198 patients with rectal carcinoma who underwent abdominopelvic lymphadenectomy. Lymph nodes along the superior hemorrhoidal artery and middle hemorrhoidal artery medial to the pelvic plexus were defined as perirectal nodes (PRN), and nodes along the middle hemorrhoidal artery lateral to the pelvic plexus and along the internal iliac artery represented lateral intermediate nodes (LIN). Node metastases were examined by the clearing method. Metastasis to PRN occurred in 12.5% in patients with pT1 tumors, 28.9% of those with pT2, and 50.0% of those with rectosigmoid junctional cancer. Metastasis to LIN was absent in patients with pT1 or pT2 and was as rare as 2.5% in patients with rectosimoid junctional cancer. In patients with T1, T2 and rectosigmoid junctional cancer, perirectal node dissection is necessary, but chances of residual cancer should remain minimal when the pelvic plexus is preserved.

Background/Aims: We prospectively compared changes in function between colonic J-pouch and straight anastomoses from 1 to 5 years after low anterior resection for rectal cancer. Methodology: At 1, 3, and 5 years after surgery, functional outcome was compared between 48 patients with J-pouch reconstruction (J group) and 51 with straight anastomosis (S group), using a 17-item questionnaire (overall best, 0; overall worst, 26). Reservoir function was evaluated manovolumetrically. Results: At 5 years, patients with ultralow anastomoses (<= 4 cm from anal verge) had fewer bowel movements during day or night, and less urgency and soiling in the J than S group. At that time, patients with low anastomoses (5 to 8cm Above the verge), had fewer bowel movements at night and less urgency in the J than S group. Manovolumetric results were better in the J than S group for both anastomotic levels. Functional scores improved significantly over time for both anastomotic levels, especially in the S group. Mean scores with ultralow anastomoses were J-group, 5.6 at 1 year vs. 5.3 at 3 years (P=0.0304) vs. 3.7 at 5 years (P < 0.0001); and S group, 10.2 at 1 year vs. 9.6 at 3 years (P=0.0063) vs. 7.3 at 5 years (P < 0.0001). Mean scores with low anastomoses were J group, 3.4 at 1 year vs. 3.1 at 3 years (P=0.0052) vs. 2.1 at 5 years (P=0.0003); and S group, 5.2 at 1 year vs. 3.8 at 3 years (P < 0.0001) vs; 2.7 at 5 years (P < 0.0001). Mano- volumetric results improved. overtime in both groups. Conclusions: Functional outcome improved in the J and especially the S group over 5 years. However, function was better in the J than S group at all time points.

Purpose: In rectal cancer surgery, whether extended lymphadenectomy contributes to survival remains debatable. This study estimated the therapeutic efficacy of extended lymph node dissection in terms of local recurrence and survival in rectal cancer by examining metastasis to lymph nodes using the clearing method. Methods: Subjects comprised 198 patients who underwent resection of rectal carcinoma between August 1979 and December 1988. Abdominopelvic lymphadenectomy was performed for all patients. Dissected nodes were examined after xylene clearance. Results: 1) High ligation of the IMA: Frequency of metastasis to the IMA root node was 8.6%. The 5-year survival rate in patients with IMA root nodal metastasis was 38.5%, significantly lower than the 73.4% in patients without IMA root node metastasis. 2) Lateral node dissection: Frequency of metastasis to lateral nodes was 11.1%, and occurred more frequently with lower rectal cancer classified as pT3 or pT4 in the TNM system. Rate of local recurrence was 12.5% and 5-year survival rate with metastasis to lateral nodes was 25.1%, significantly lower than the 5-year survival rate of 74.3% in patients without metastasis to lateral nodes. Conclusions: 1) Although 5-year survival rate was lower in patients with IMA root nodal metastases than in patients without metastases, IMA root nodal dissection should be performed after high ligation of the IMA for patients with pT3 and pT4 cancers. 2) Prognosis is poor for patients with lateral nodes metastases, and improvements in survival rate from lateral node dissection are minimal.

66歳男.直腸癌で経肛門腹式直腸切除術を施行した.術後経過は良好であったが,労作性努力呼吸の症状が出現した.胸部X線所見で両肺野に浸潤陰影を認めた.病態と治療経過から感染性肺炎は否定的であった.術後急性胃潰瘍の治療のためファモチジンの投与を開始した頃から呼吸器症状が出現したことより,ファモチジンによる薬剤性肺炎を強く疑った.全身性炎症反応症候群(SIRS)の診断基準を満たし,胸部X線検査で両肺野の浸潤陰影があり,P/F比が157mmHgであったことから,SIRSに伴う急性肺障害と診断し,シベレスタットナトリウムの持続投与を開始した.投与4日目には酸素投与が不要となり,投与9日目はP/F比が280mmHgへと上昇し,胸部X線所見の浸潤陰影も改善した.シベレスタットナトリウムは,投与9日目で終了した.シベレスタットナトリウム投与中に副作用は認めなかった

Purpose: To evaluate the long-term functional outcome of colonic J-pouch reconstruction after low anterior resection (LAR) for rectal cancer in a prospective study. Methods: We compared the functional outcome of 46 patients who underwent J-pouch reconstruction (J-group) and 49 patients who underwent straight anastomosis (S-group) after LAR for rectal cancer. We evaluated clinical function using a 17-item questionnaire about different aspects of bowel function. Physiologic reservoir function was evaluated by manovolumetry. Results: Among the patients with an ultralow anastomosis (<= 4 cm from the anal verge), those in the J-group had fewer bowel movements during the day and at night, and less urgency, soiling, protective pad use, incontinence, and dissatisfaction with bowel function than those in the S-group. Among the patients with a low anastomosis (5-8 cm from the verge), those in the J-group had fewer bowel movements at night, and less urgency and soiling than those in the S-group. Moreover, reservoir function (reflected by the maximum tolerable volume, threshold volume, and compliance) was better in the J-group than in the S-group in both the ultralow and low anastomosis groups. Conclusions: J-pouch reconstruction after low anterior resection creates a better stool reservoir than straight anastomosis, especially when the anastomosis is less than 4 cm from the anal verge, resulting in a better quality of life 3 years after rectal cancer resection.

直腸癌における低位前方切除術について、看護師の観点より図を用いて解説した。

Creation of a neorectum by constructing a colonic J-pouch has been shown to improve bowel function during the first year following low anterior resection. However, few studies of long-term reservoir function have been published. This prospective study compared the reservoir function of J-pouch and straight anastomosis 5 years after low anterior resection for rectal cancer. Bowel function was compared in 46 patients who underwent J-pouch reconstruction (J-group) and 48 patients with a straight anastomosis (S-group). Clinical status was evaluated using a 17-item questionnaire inquiring about different aspects of bowel function. Reservoir function was evaluated by manovolumetry. Among patients with a ultralow anastomosis (less than 4 cm from the anal verge), the number of bowel movements during the day and at night and urgency and soiling were less in the J-group than in the S-group. Among patients with a low anastomosis (5 to 8 cm from the verge), patients in the J-group had fewer bowel movements at night and less urgency. Reservoir function was better in the J-group than in the S-group in both the ultralow and low anastomosis groups. J-pouch reconstruction increased reservoir function and provided better a functional outcome than straight anastomosis, even 5 years after low anterior resection.

Bowel function after low anterior resection for rectal cancer with colonic J-pouch reconstruction is more normal than after conventional straight anastomosis. However, few reports have examined the function of colonic J-pouch reconstruction in the elderly. Good function would obviate the need for colostomy, which is sometimes performed because of concern over fecal incontinence, which increases with age. The present study evaluated the function of colonic J-pouch reconstruction in elderly individuals 75 years or older. Functional outcome was compared in 20 patients 75 years or older (older group) and 87 patients 74 years or younger (younger group) 3 years after colonic J-pouch reconstruction, using a functional scoring system with a 17-item questionnaire (score range, 0 (overall good) to 26 (overall poor)). Function in the older group was satisfactory and was similar to that in the younger group (functional score: older group, 4.2 vs. younger group, 4.1). Of the 17 items in the questionnaire, only the use of laxatives or glycerine enemas was more common in the older than in the younger group (85.0% vs. 59.8%; P= 0.0335). Elderly patients with low anterior resection with colonic J-pouch reconstruction provides excellent functional outcome, including continence. Colonic J-pouch reconstruction is a highly preferable alternative to permanent colostomy in elderly patients undergoing low anterior resection.

PURPOSE: In colon cancer surgery, it is recommended that en bloc resection involving extended lymphadenectomy, characterized as a hemicolectomy, be performed by ligating the primary feeding artery at a high position and resecting proximal and distal with 5-cm to 10-cm bowel margins. However, there is little evidence to unequivocally support such extensive lymphovascular resection. METHODS: The distribution of nodal metastases was obtained by the clearing method in 164 patients with colon cancer. RESULTS: For pericolic spread, for pT1 tumors, the distance from the primary tumor to a diseased node was 2.5 cm; for pT2, the distance was less than 5 cm; for 97.0 percent of pT3 tumors and 93.3 percent of pT4 tumors with nodes involved, the distance was less than 7 cm. For central spread, for pT1 tumors, the rate of spread to central nodes was 0 percent; for pT2, the rate of spread was 20.0 percent to intermediate nodes (for tumors more than 5 cm from the feeding artery, the rate for central nodes was 0 percent); for pT3, the rate was 30.6 percent to intermediate nodes and 15.3 percent to main nodes; for pT4, the rate was 44.4 percent to intermediate nodes and 22.2 percent to main nodes. For curative resection cases with pT3 tumors more than 7 cm from the feeding artery, the rate to central nodes was 0 percent. CONCLUSIONS: In T1 tumors, central node dissection is not required, but resection with proximal and distal 3-cm margins are required; in T2, central node dissection that includes the intermediate node should be performed in addition to resection with proximal and distal 5-cm margins. In T3 and T4, central node dissection that includes the main node should be performed in addition to resection with proximal and distal 7-cm margins. However, for T2 more than 5 cut from the primary feeding artery, and for T3 more than 7 cm from the primary feeding artery, proximal and distal resection alone may be adequate.

BACKGROUND: One of the unresolved issues related to immunotherapy for cancers is how to predict the degree of growth of tumor stroma at the periphery of the tumor. We examined the feasibility of predicting stromal growth by measuring the glutathione (GSH) level in monocytes as an indicator of the local redox state of cancer, reflecting anti-tumor immune responses. METHODS: Blood was drawn preoperatively from 21 patients with colorectal cancer. Monocytes were isolated from each blood sample and observed under a fluorescent microscope after fluorescent dye staining. The chromatic responses were rated on a three-grade scale: strongly positive, moderately positive and weakly positive. The monocytes were counted in each grade, and the GSH score was calculated. After surgery, pathology specimens of resected tissue were observed under a microscope to measure the percentage of the surface area of stroma in a given visual field at a magnification of x200. The percentage of stromal surface area was measured for three visual fields (near the deepest area of the tumor) to calculate the stroma score. RESULTS: The mean GSH score was 290.2. The mean stroma score was 60.8. There was a significant correlation between the GSH score and the stroma score (r = 0.421, p < 0.05). CONCLUSION: The monocyte GSH level may serve as a predictor of stromal growth.

大腸癌イレウスに対する具体的な治療方針を右側大腸癌、左側大腸癌に分けて解説した

BACKGROUND: Metastasis to regional lymph nodes from colon cancer is an important prognostic factor. In the TNM classification, node metastases are classified into three grades based on the number of metastatic nodes. In the japanese General Rules for Clinical and Pathologic Studies on Cancer of the Colon, Rectum, and Anus (JGR), node metastases are classified into four grades based on the distribution of metastatic nodes. STUDY DESIGN: Based on the findings of node metastases in 164 patients with colon cancer obtained by the clearing method, node classifications by the JGR and TNM classifications were compared. RESULTS: The case distribution by the JGR grading was 41.5% in n (-), 29.3% in n1 (+), 18.3% in n2 (+), and 11.0% in n3 (+) disease. In the TNM classification, the distribution was 23.8% in pN1 and 34.8% in pN2 disease. The 5-year survival rate by the JGR was 98.4% in n (-), 74.3% in n1 (+), 51.2% in n2 (+), and 30.0% In n3 (+) disease; in TNM classification, this rate was 76.0% in pN1 and 45.0% in pN2 disease. CONCLUSIONS: In the classification of regional node metastases from colon cancer, the JGR classification showed a wider range in distribution and 5-year survival rate compared with the TNM system.

下部直腸癌切除後の再建術式として良好な術後排便機能を保つための結腸J-pouch再建とColoplastyの手術術式をそれぞれ解説した

This study investigated the curability and functional results of intersphincteric resection (ISR) for very low rectal adenocarcinoma. From April 2001 to May 2004, eleven patients were studied retrospectively. Abdominotransanal. rectal resection and colonic-J pouch reconstruction were performed. Five patients underwent total ISR (tISR), and 6 patients had partial ISR (pISR). Three out of all patients went on to have additional partial (pESR) or subtotal external sphincteric resection (sESR). All patients had a curative operation with histological examination. Morbidity was identified in four patients (leakage: 1; anastomotic stenosis: 1; prolapse of colonic-J pouch: 2). Two of these patients required operative intervention. Four patients developed recurrence (liver: 1; liver and lymph nodes: 1; liver and lung: 1; pelvic wall: 1) during the median 19 months follow-up. Five patients received stoma closure and their anal function was acceptable except for one patient in whom anastomotic stenosis occurred. Stoma closure could not be performed for patients that underwent additional sESR. We obtained sufficient results for curability and anal function of pISR and tISR in patients without sESR. Therefore, this procedure may be recommended for pT2 rectal cancer patients at least.

Few reports on the long-term functional outcome of colonic J-pouch reconstruction have been published, and data comparing J-pouch and straight reconstruction are contradictory. This prospective study compares the functional outcome of colonic J-pouch and straight anastomosis five years after low anterior resection for rectal cancer. METHODS: Functional outcome was compared in 46 patients with J-pouch reconstruction (J-group) and 48 patients with straight anastomosis (S-group). Clinical status was evaluated with a 17-item questionnaire inquiring about different aspects of bowel function. Reservoir function was evaluated by manovolumetry. The Fisher's exact test and Wilcoxon's rank-sum test were used to compare categoric and quantitative data, respectively. RESULTS: Among patients with an ultralow anastomosis (less than or equal to4 cm from the anal verge), the number of bowel movements during the day (greater than or equal to5, 4.3 vs. 29.2 percent; P = 0.028)and at night (>1/week, 4.3 vs. 33.3 percent; P = 0.013) and urgency (4.3 vs. 33.3 percent; P = 0.013) and soiling (21.7 vs. 50.0 percent; P = 0.043) were less in the J-group than in the S-group. Among patients with a low anastomosis (5 to 8 cm from the verge), patients in the J-group had fewer bowel movements at night (>1/week, 0 vs. 20.8 percent; P = 0.028) and less urgency (0 vs. 20.8 percent; P = 0.028). Reservoir function was better in the J-group than in the S-group in both the ultralow (maximum tolerable volume (mean), 101.7 vs. 76.3 ml; P = 0.004; threshold volume (mean), 46.5 vs. 30.4 ml; P < 0.001; compliance (mean), 4.9 vs. 2.5 ml/cm H2O; P < 0.001) and low-anastomosis (maximum tolerable volume, 120.4 vs. 97.9 ml; P < 0.001; threshold volume, 58.3 vs. 40.8 ml; P < 0.001; compliance, 5.2 vs. 3.1 ml/cm H2O; P < 0.001) groups. CONCLUSIONS: J-pouch reconstruction increased reservoir function and provided better functional outcome than straight anastomosis, even five years after surgery, especially in patients whose anastomosis is less than 4 cm from the anal verge.

PURPOSE: Bowel function after low anterior resection for rectal cancer with colonic J-pouch reconstruction is more normal than after conventional straight anastomosis. However, few reports have examined the function of colonic J-pouch reconstruction in the elderly. Good function would obviate the need for colostomy, which is sometimes performed because of concern about fecal incontinence, which increases with age. This study evaluated the function of colonic J-pouch reconstruction in elderly patients aged 75 years or older. METHODS: Functional outcome was compared in 20 patients aged 75 years or older (older group) and 27 patients aged 60 to 74 years (old group) and 60 patients aged 59 years or younger (young group), 3 years after colonic J-pouch reconstruction, using a functional scoring system with a 17-item questionnaire (score range, 0 (overall good) to 26 (overall poor)). RESULTS: The functional scores in the three age groups were satisfactory and similar. Among patients with anastomoses 1 cm to 4 cm from the anal verge, all 17 categories on the questionnaire in the three age groups were similar. Among patients with anastomoses 5 cm to 8 cm from the anal verge, only the use of laxatives or glycerine enemas was more common in the older group than in the old and young group (90 vs. 38.5 percent and 43.3 percent; P = 0.01). CONCLUSIONS: Low anterior resection with colonic J-pouch reconstruction provides excellent functional outcome, including continence, for elderly patients. Colonic J-pouch reconstruction is a highly preferable alternative to permanent colostomy in elderly patients undergoing low anterior resection.

当科では1998年3月以降, 緊急手術を要する左側大腸癌イレウスに対して経肛門的イレウス管による術前管理を第1選択として治療してきた。今回, 2002年3月までに経験した13例を対象に, 一期再建で経過良好であった5例をA群, イレウス管留置による合併症を認めた症例およびイレウス管で減圧できたが一期再建で縫合不全をきたした症例の計8例をB群に分類し, 腫瘍による狭窄長, 拡張した口側の最大腸管径, イレウス管留置前のイレウス期間について比較した。いずれの項目についてもA群, B群間に有意差は認められなかったが, B群はA群に比し腸管径が大きく, イレウス期間が長かった。文献的にイレウス管を留置できなかった症例やイレウス管による穿孔・穿通例の頻度は少なくなく, 今回の検討からは口側腸管の拡張が高度な症例 (径7cm以上), イレウス期間が長い症例 (7日以上) ではリスクが高いと考えられた。

下部直腸癌に対する低位前方切除後の結腸J-pouch再建の手術手技を解説するとともに術後排便機能についても解説を加えた

Liver resection is the only potentially curative treatment currently available for patients with liver metastases. However, recurrent metastatic disease develops in most patients after liver resection, and nearly half of the recurrences arise in the liver. As our previous study of hepatic arterial infusion of interleukin-2-based immuno-chemotherapy demonstrated a high response rate of patients with unresectable liver metastases, we applied this therapy to the prevention of liver recurrence in patients after potentially curative resection of liver metastases. A pilot study was conducted of 20 patients with liver metastases from colorectal cancer underwent potentially curative liver resection, followed by adjuvant immuno-chemotherapy. The regimen consisted of a weekly hepatic arterial infusion of interleukin-2 (1.4 - 2.1 X 106 units) and 5-fluorouracil (250 mg) and a bolus of mitomycin C (2 - 4 mg) for six months. Of 20 patients, 13 are still alive with a median postoperative survival of 86 months (as of Jan. 2002). The 5-year overall survival rate was 74%. Although recurrent cancer has developed in 7 of the 20 patients, no patients had recurrence in the residual liver. This complete prevention of the liver recurrence is believed to have contributed to the high 5-year survival rate (74%) as compared with the survival rate of patients with surgery alone (average: 30-40%), or with several other forms of adjuvant therapy. We conclude that IL-2-based immuno-chemotherapy is useful in combination with liver resection for the prevention of liver recurrence in colorectal cancer patients with liver metastases.

A 47-year-old woman was presented with positive fecal occult blood test.
Colonofiberscopy revealed a submucosal tumor on the right posterior wall of the rectum. A biopsy of the lesion resulted in erosive colonic mucosa. Two months later, colonofiberscopy and endoscopic ultrasonography revealed the submucosal tumor which had grown to compress the wall outward. However, a biopsy specimen was diagnosed as erosion of the colonic mucosa. Because a passibility of malignant disease could not be ruled out, we performed a low anterior resection with a left ovary resection. Histologically, the tumor was diagnosed as endometriosis of the rectum with pararectal lymph node metastasis. There have been no signs of reccurence, as of five years after operation. It is very rare that endometriosis of the digestive tract has regional lymph node involvement. There are some cases of intestinal endometriosis with aberration to the regional lymph nodes in a short time, which present difficulty in differentiation from malignant diseases.

大腸癌肝転移を予測するためのDNAアレイ法による遺伝子発現プロファイル解析の実際を解説し、今後の展望を述べた

直腸癌低位前方切除後のJ型結腸嚢再建の手技を解説し、術後排便機能に与える影響を考察した

DNAマイクロアレイを用いた大腸癌の新しい遺伝子発現解析の試みと臨床応用の可能性を解説した

特集「高度進行大腸癌の治療」においてこれまでに施行された免疫療法のうちエビデンスのある臨床研究を中心に論評した

直腸癌前方切除術におけるＪ型結腸嚢再建について術後排便機能を検討し長期機能改善が得られることがわかった。

PURPOSE: We examined the usability of a newly developed, compact-sized DNA array filter for studying the gene expression pattern of individual colorectal cancer. METHODS: Complementary DNA probes were prepared from mRNA extracted from colonic cancer specimens and adjacent normal mucosa and then were labeled with chemiluminescence. These labeled probes were allowed to bind to the gene fragments on the filter. A specialized scanning charge-coupled device camera measured the intensity of each chemiluminescent spot, which is an indicator of the degree to which a specific gene is expressed. Gene expression image was quantified into intensity of signals by using computer software. RESULTS: Characteristic gene expression patterns were obtained from the colonic cancer cell line, RPMI4788, and the leukemia cell line, HL60, by using this compact-sized DNA array filter in the preliminary experiment. Up-regulation of nm23, TIMP1, VEGF, and cyclin E and down-regulation of some tumor suppressor genes (p53, TOSO, and SIVA), β-catenin, and metallothionein were observed in colonic cancer specimen when compared with those of normal mucosa. CONCLUSIONS: We have obtained unique gene expression patterns from colorectal cancer and normal tissue by using a newly developed compact-sized DNA array filter system. Collecting, storing, and analyzing of gene expression data from many samples of colorectal cancer will enable us to identify distinct subsets of patients based on molecular characteristics in the near future.

直腸癌に対する手術療法、特に低位前方切除術における根治性と術後排便機能について、Ｊ型結腸嚢再建と従来のストレート再建で比較し１～５年にわたる長期排便機能をもとにＪ型結腸嚢再建の適応を検討した。

PURPOSE: Although the functional outcome after low anterior resection for rectal cancer using colonic J-pouch reconstruction is superior to that using conventional straight reconstruction, the one drawback of colonic J-pouch reconstruction is difficulty with evacuation. Recently it has been suggested that construction of a larger colonic J-pouch causes the evacuation difficulty. The purpose of this study was to elucidate the cause of evacuation difficulty with colonic J-pouch reconstruction. METHODS: We compared pouthography of 26 patients with 10-cm colonic J-pouch reconstructions (10-J group) and 27 patients with 5-cm colonic J-pouch reconstructions (5-J group) at three months, one year, and two years after surgery. Functional assessments were performed one year postoperatively. Clinical function was evaluated using a questionnaire. Evacuation function was evaluated by the balloon expulsion and saline evacuation tests. RESULTS: The greatest width of the pouch in the 10-J group in the anteroposterior view was significantly greater than that in the 5-J group at all three measurement times (3 months, 4.9 vs. 4 cm; P = 0.0011; 1 year, 9 vs 5.6 cm; P < 0.0001; 2 years, 9.2 vs. 5.8 cm; P < 0.0001). The value in the 10-J group at one year after surgery was 1.9 times that at three postoperative months; in the 5-J group this ratio was 1.4. There was a significant difference between these ratios (P < 0.0001). No significant difference existed between the values at two years and one year after surgery in either the 10-J or the 5-J group. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. Evacuation function in the 10-J group was significantly inferior to that in the 5-J group. CONCLUSIONS: The evacuation difficulty observed in patients with larger colonic J-pouch reconstructions is associated with excessive distention of the pouch occurring within one year of surgery.

Galectin-3 is a beta-galactoside-specific lectin that binds to laminin sugar-sites and is involved in tumor malignancy. Galectin-3 expression in relation to primary tumor and liver metastasis of colorectal cancer was examined to determined its involvement in cancer progression and metastasis. Immunohistochemical staining of galectin-3 was performed on 117 primary lesions and 15 liver metastases of colorectal cancer using TIB166 monoclonal antibody. The expression of galectin-3 was evaluated by grading the intensity of the staining as either negative, weakly positive, or strongly positive. Normal mucosa of all patients were strongly positive for galectin-3, but the staining in these tissues was still significantly less than in the primary lesions of the cancer (31.6%). Galectin-3 expression in the primary lesions was significantly increased, correlating with the progression of clinical stage (p=0.0224), liver metastasis (p<0.0001), venous invasion (p=0.0048), and lymph node metastasis (p=0.0289). Liver metastatic lesions also showed up-regulated levels of galectin-3 compared to the primary lesions (p=0.0030). The group showing strongly positive galectin-3 had a significantly poorer prognosis than the negative/weakly positive group in terms of disease-free survival (p=0.0224). The strong expression of galectin-3 in colorectal cancer correlates with cancer progression, liver metastasis, and poor prognosis for patients.

PURPOSE: In rectal cancer surgery preservation of urinary and sexual function is attempted by means of operations preserving the autonomic nerves of the pelvic plexus. Emergence of residual cancer because of a more shallow plane of dissection is a problem of concern with these methods, so we examined indications for pelvic plexus preservation. METHODS: We studied 198 patients with rectal carcinoma who underwent abdominopelvic lymphadenectomy. Lymph nodes along the superior hemorrhoidal artery and middle hemorrhoidal artery medial to the pelvic plexus were defined as perirectal nodes, and nodes along the middle hemorrhoidal artery lateral to the pelvic plexus and along the internal iliac artery represented lateral intermediate nodes. Node metastases were examined by the clearing method. RESULTS: Metastasis to perirectal nodes occurred in 12.5 percent in patients with pT1 tumors, 28.3 percent-of those with pT2 tumors, and 50.0 percent of those with rectosigmoid junctional cancer. Metastasis to lateral intermediate nodes was absent in patients with pT1 or pT2 tumors and was as low as 2.5 percent in patients with rectosigmoid junctional cancer. CONCLUSIONS: In patients with T1, T2, and rectosigmoid junctional cancer, perirectal, node dissection is necessary, but chances of residual cancer should remain minimal when the pelvic plexus is preserved.

We describe herein a technique of performing upward node dissection following high ligation of the inferior mesenteric artery for patients with T3 and T4 rectal carcinomas. The course of the hypogastric nerve is confirmed macroscopically during the procedure to ensure its preservation. This technique offers both increased radicality and the prevention of ejaculatory dysfunction.

PURPOSE: Functional outcome after low anterior resection for rectal cancer is improved by the construction of a colonic J-pouch. One disadvantage of this type of reconstruction is evacuation difficulty, which has been associated with large pouches. The purpose of this study was to elucidate the causes of evacuation difficulty in large pouches using pouchography. METHODS: The angle between the longitudinal axis of the pouch and the horizontal line (pouch-horizontal angle) on lateral pouchography was determined in 26 patients with 10-cm J-pouch reconstructions (10-J group) and 27 patients with 5-cm J-pouch reconstructions (5-J group). Measurement were made at three months, one year, and two years after surgery. Clinical function was evaluated using a questionnaire one year postoperatively. RESULTS: The pouch-horizontal angle in the 10-J group was significantly smaller than that in the 5-J group at all three time points. In both groups the pouch-horizontal angle at one pear was significantly smaller than that at three months. There were no significant differences between the pouch-horizontal angles at one and two years. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. CONCLUSIONS: The evacuation difficulty observed in patients with large colonic J-pouch reconstructions may be attributed to the develop ment of a horizontal inclination within one year of surgery.

The functional outcome after a low anterior resection for rectal cancer is improved by a colonic J-pouch reconstruction. One functional problem with J-pouches is difficulty in evacuation, which is more common with large reconstructions. Since rectoceles are common findings on defecography in patients with evacuation difficulties, we proposed that a rectocele-like prolapse may be thus found in patients with large J-pouches. Pouchography was used to identify a rectocele-like prolapse (RP) in 26 patients with a 10-cm J-pouch (10-J group) and 27 patients with a 5-cm J-pouch (5-J group). Pouchography was performed at 3 months, 1 year, and 2 years after surgery. Functional assessments were performed 1 year postoperatively. Clinical function was evaluated using a questionnaire. The evacuation function was evaluated by the balloon expulsion and saline evacuation test. No patients had an RP at 3 months or 1 year after surgery. An RP was significantly more common in the 10-5 group than in the 5-5 group at 2 years after surgery (P = 0.0374). An evacuation difficulty was significantly more common in the 10-5 group than in the 5-5 group. The evacuation function in the 10-J group was also significantly inferior to that in the 5-J group. An RP appearing 2 years after surgery is more common in patients with evacuation difficulties and large colonic J-pouch reconstructions.

長所としては,平均8.9日の長い貼用期間,漏れの少なさ,皮膚保護剤の剥がし易さ,排泄物処理の簡便さ,ストーマケア及び観察の容易さ,早期のセルフケア指導などが確認された.また,短所としては,トータルシステム指導の遅れ,創感染の発見の遅れ,長期間使用時の袋汚染などが指摘された.安全性については問題なかった

PURPOSE: In surgery for rectal cancer, it is unclear whether the inferior mesenteric artery should be ligated at a high or low position. The study contained herein was undertaken to clarify the indications for high ligation of the inferior mesenteric artery. METHODS: Subjects included 198 patients with rectal cancer who underwent resection with high ligation of the inferior mesenteric artery. Nodal metastases were examined by the clearing method. RESULTS: The incidence of metastases to the lymph nodes surrounding the origin of the inferior mesenteric artery (root nodes) was 8.6 percent. Inferior mesenteric artery root nodal metastases occurred more frequently with pT3 and pT4 cancer. The five-year survival rate in patients with inferior mesenteric artery root nodal metastases was 38.5 percent; this rate was significantly lower than in those without inferior mesenteric artery root nodal metastases (73.4 percent). CONCLUSIONS: Although the five-year survival rate in patients with inferior mesenteric artery root nodal metastases was lower than in those without metastases, inferior mesenteric artery root nodal dissection should be performed after high ligation of the inferior mesenteric artery for patients with pT3 and pT4 cancers.

PURPOSE: Functional outcome after anterior resection for rectal cancer is improved by colonic J-pouch reconstruction compared with straight anastomosis. The indications for colonic J-pouch reconstruction have pet to be determined. Therefore, we attempted to determine the level at which J-pouch reconstruction provides an advantage over straight anastomosis. METHODS: A total of 48 patients who under went 5-cm colonic J-pouch reconstruction (J-pouch group) and 80 patients who underwent straight anastomosis (straight group) underwent functional assessment one year postoperatively. RESULTS: The functional outcome in the J-pouch group was significantly better than that in the straight group when the distance of the anastomosis from the anal verge was less than 8 cm. The difference was particularly obvious when the level of the anastomosis was below 4 cm. However, functional outcome in the straight group when the anastomosis was between 9 and 12 cm from the anal verge was also satisfactory and did not differ from that in the J-pouch group when the anastomosis was between 5 and 8 cm from the anal verge. CONCLUSIONS: Colonic J-pouch reconstruction is indicated when the distance of anastomosis from the anal verge is less than 8 cm, and it is essential when the distance is less than 4 cm.

PURPOSE: We examined the survival benefit of pelvic exenteration for locally advanced colorectal cancer with lymph node metastases, because this issue remains controversial METHODS: Medical records of 50 patients who underwent curative pelvic exenteration for colorectal cancer were reviewed retrospectively. Nodal metastases were examined by the clearing method in 29 patients and by the conventional manual method in 21 patients. RESULTS: Invasion to contiguous pelvic organs was present in 40 patients (80 percent) and absent in 10 patients (20 percent). Node metastases were present in 33 patients (66 percent). Operative morbidity and mortality rates were 22 percent (11 patients) and 6 percent (3 patients), respectively. Respective five-year survival rates were 60 and 80 percent in the groups with and without organ invasion (no significant difference). Five-year survival rates in patients with nodal metastases was 54.6 percent but was significantly higher, 82.4 percent, in patients without nodal metastases. Five-year survival in 28 patients with both organ invasion and nodal metastases was 53.6 percent. CONCLUSIONS: Long-term survival was afforded by pelvic exenteration for locally advanced colorectal cancer with nodal metastases.

BACKGROUND: Our previous study of hepatic arterial infusion of interleukin-2 (IL-2)-based immunochemotherapy demonstrated a high response rate of patients with unresectable liver metastases. In this study, we applied this therapy to the prevention of liver recurrence in patients who underwent potentially curative resection of liver metastases. STUDY DESIGN: A pilot study was conducted of 18 patients with liver metastases from primary colorectal cancer who underwent potentially curative liver resection followed by adjuvant immunochemotherapy. The regimen consisted of a weekly hepatic arterial infusion of IL-2 (1.4-2.1 X 10(6) U) and 5-fluorouracil (250 mg) and a bolus of mitomycin C (2-4 mg) for 6 months. RESULTS: Among 18 patients, 14 are still alive with a median postoperative survival of 52 months (as of April 1998). The 5-year overall survival rate was 75%. Although recurrent cancer developed in 6 of the 18 patients, no patients had recurrence in the residual liver. This complete prevention of liver recurrence is believed to have contributed to the high 5-year survival rate (75%) as compared with the survival rate of patients treated with surgery alone (average, 30%-40%) or with several other forms of adjuvant therapy. CONCLUSIONS: Interleukin-2-based immunochemotherapy is useful in combination with liver resection for the prevention of liver recurrence in colorectal cancer patients with liver metastases. A multicenter randomized trial is recommended.

In anterior resection with anastomosis using the double-staple technique for low-lying rectal cancer in male patients, the approach to the anal canal with a stapling instrument ria the abdominal area is limited by the narrow pelvis. The stapling and transection of the anal canal via the posterior transsacral approach prior to performing an anterior resection thus enables the lower rectum and anal canal to be visualized, so that the anal canal can bet accurately stapled and transected even in male patients with a narrow pelvis.

BACKGROUND. The surgeon is no longer able to palpate the mesocolon for lymph node metastases during laparoscopic colectomy. The extent of lymph node dissection should be determined beforehand for cancer control. METHODS. The distribution of lymph node metastases was obtained by the clearing method on colon carcinomas for 164 patients. RESULTS. For pericolic spread: for pT1 tumors, the distance from the primary tumor to a metastatic lymph node was 2.5 cm; for pT2, the distance was within 5 cm; for 97.0% of pT3 tumors with lymph node metastases, the distance was within 7 cm; for 93.3% of pT4 tumors with lymph node metastases, the distance was within 7 cm. For central spread: for pT1 tumors, the rate of metastasis to central lymph nodes was 0%; for pT2, the rate of metastasis was 20.0% to intermediate lymph nodes; for pT3, the rate of metastasis was 30.6% to intermediate lymph nodes and 15.3% to main lymph nodes; for pT4, the rate of metastasis was 44.4% to intermediate lymph nodes and 22.2% to main lymph nodes. CONCLUSIONS. Central lymph node dissection is not required for patients with T1 carcinomas, but proximal and distal 3-cm margins of resection are required. For T2, central lymph node dissection that includes the intermediate lymph node should be performed, as well as 5-cm proximal and distal margins of resection. For T3 and T4, central lymph node dissection including the main lymph node should be performed, as well as 7-cm proximal and distal margins of resection. (C) 1997 American Cancer Society.

BACKGROUND: Total mesorectal excision effectively reduces the local recurrence rate of carcinoma of the rectum. This study was undertaken to clarify the rationale for total mesorectal excision. STUDY DESIGN: We retrospectively reviewed the records of 198 patients who underwent resection of a carcinoma of the rectum. The presence of nodal metastases in the mesorectum distal to the primary tumor was examined by the clearing method. RESULTS: The metastatic rate in the distal mesorectum was 20.2 percent. The metastatic rates according to the extent and site of the tumor were as follows: pT1, 0 percent; pT2, 0 percent; pT3, 21.9 percent; pT4, 50 percent; rectosigmoid, 10 percent; upper rectum, 26.3 percent; and lower rectum, 19.2 percent. The longest distal spread from the primary tumor to the metastatic node was 2 cm in carcinoma of the rectosigmoid, 4 cm in carcinoma of the upper rectum, and 3 cm in carcinoma of the lower rectum. CONCLUSIONS: Total mesorectal excision is required for patients with T3 and T4 tumors in the lower rectum, and excision of all mesorectal tissue down to at least 5 cm below the tumor is required for patients with T3 and T4 tumors in the upper rectum.

BACKGROUND: The treatment of rectal carcinoma by lateral lymph node dissection has risks and benefits, Therefore, we investigated the therapeutic efficacy of lateral lymph node dissection. STUDY DESIGN: We studied 198 patients with rectal carcinoma who underwent lateral lymph node dissection. Metastases to the lymph nodes were examined by the clearing method. The incidence of urinary and male sexual dysfunction was determined by measuring the residual urine volume and individual interview 1 year after operation. RESULTS: The rate of metastasis to lateral lymph nodes was 11.1 percent, and metastasis to the lateral lymph nodes occurred more frequently with lower rectal carcinoma classified as pT3 or pT4 in the TNM system. The rate of local recurrence was 12.5 percent and the B-year survival rate after curative resection was 70.1 percent. The 5-year survival rate in patients with metastasis to the lateral lymph nodes was 25.1 percent, and this rate was significantly lower than the 5-year survival rate of 74.3 percent in patients without metastasis to the lateral lymph nodes. Urinary dysfunction was observed in 67.5 percent of patients, and male sexual dysfunction was found in 97.4 percent of men younger than 60 years of age with prior sexual ability. CONCLUSIONS: The prognosis for patients with metastasis to the lateral lymph nodes is poor, and the improvement in survival rate from lateral lymph node dissection is minimal.

The optimal extent of intestinal resection was investigated for cancer control. Node metastases were examined by the clearing method in 164 patients with colon cancer and 198 patients with rectal cancer. For pericolic spread of colon cancer, the distance from the primary tumor to a metastatic node was within 7 cm. For central spread of colon cancer, the rate of metastatis to main nodes was 11.6%. For rectal cancer, the rate of distal intramural spread was 10.6% and the maximum distal spread was 2 cm. The metastatic rate in the distal mesorectum was 20.2% and the longest distal spread from the primary tumor to the metastatic node was 4 cm. The rate of metastasis to pericolic nodes that lie along the last sigmoid artery was only 1.0%. In T1 colon cancer, central node dissection is not required, but 3-cm proximal and distal margins of resection are required. In T2, central node dissection that includes the intermediate node should be performed, and 5-cm proximal and distal margins of resection are required. In T3 and T4, central node dissection that includes the main node should be performed, and 7-cm proximal and distal margins of resection are required. A 3-cm distal mural resection is required for rectosigmoid and upper rectal cancer, a 2-cm distal mural resection for lower rectal cancr. and a 1-cm distal mural resection for T1 and T2. Total mesorectal excision is required for T3 and T4 in the lower rectum, and excision of all mesorectal tissue down to at least 5 cm below the tumor is required for T3 and T4 in the upper rectum. A J-pouch can be constructed by using the sigmoid colon.

The functional outcome after low anterior resection (LAR) using the colonic J-pouch was compared with that after LAR using straight anastomosis. Colonic J-pouch construction was performed in 58 patients who underwent resection of tumors located 5-10 cm from the anal verge (J-pouch group). Functional assessment was performed 1 year postoperatively. Clinical function was evaluated using a scoring system, while physiologic sphincter and reservoir function were evaluated by anorectal manometry. The historical control group consisted of 20 patients who underwent LAR with straight anastomoses (straight group). The functional score of the J-pouch group was significantly better than that of the straight group. Although sphincter function was similar in the two groups, reservoir function was significantly better in the J-pouch group than in the straight group, These results demonstrated that the functional outcome following LAR for rectal cancer is improved by the colonic J-pouch construction.

BACKGROUND: Metastasis to regional lymph nodes from carcinoma of the colon is an important prognostic factor. In the tumor, node, metastasis classification, node metastases are classified into four grades based on the number and distribution of metastatic nodes. In the Japanese General Rules for Clinical and Pathological Studies on Cancers of the Colon, Rectum and Anus, node metastases are classified into four grades based solely on the distribution of metastatic nodes. STUDY DESIGN: Based on the findings of node metastases in 152 patients with carcinoma of the colon obtained by the clearing method, the node classifications by the Japanese General Rules and tumor, node, metastasis classifications were compared. RESULTS: The case distribution by the Japanese General Rules grading was 38.2 percent in n(-), 30.3 percent in n(1)(+), 19.7 percent in n(2)(+), and 11.8 percent in n(3)(+) disease. In the tumor, node, metastasis classification, the distribution was 22.4 percent in pN1 and pN3 and 17.1 percent in pN2 disease. The five-year survival rate by the Japanese General Rules was 97.9 percent in n(-), 72.6 percent in n(1)(+), 51.2 percent in n(2)(+), and 30.0 percent in n(3)(+) disease, whereas in tumor, node, metastasis classification, this rate was 79.4 percent in pN1, 45.2 percent in pN2, and 44.8 percent in pN3 disease. CONCLUSIONS: In the classification of regional node metastases from carcinoma of the colon, the Japanese General Rules showed a wider range in distribution and 5-year survival rate compared with the tumor, node, metastasis system.

PURPOSE: It has been reported that functional outcome following low anterior resection of rectal cancer is improved by construction of a colonic J-pouch compared with straight anastomosis. Hence, we tried to justify use of the sigmoid colon in the construction of a J-pouch by the analysis of regional lymph node metastases. METHODS: A total of 182 patients underwent resection for rectal cancer. Node metastases were examined by the clearing method. According to Japanese General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus (JGR), nodes were classified into the perirectal nodes (PR-N), pericolic nodes (PC-N), central intermediate nodes (C-IM-N), central main nodes (C-M-N), lateral intermediate nodes (L-IM-N), and lateral main nodes (L-M-N). RESULTS: Metastatic rate (number of patients with node metastases/total number of patients) of PR-N was 57.1 percent. Metastatic rate of C-IM-N was 18.7 percent and that of C-M-N was 7.1 percent. Metastatic rates of L-LM-N and L-M-N were 8.8 and 3.3 percent, respectively, and both were highest in the case of lower rectal cancer. Metastatic rate of PC-N was only 1.1 percent. The number of cases without node metastases (n(-) cases) was 78, that with only PR-N metastases (PR-N cases) was 63, that with intermediate but not main node metastases (IM-N cases) was 29, and that with main node metastases (M-N cases) was 12. Five-year survival rate after curative resection was 88.5 percent for n(-) cases, 70.9 percent for PR-N cases, 65.9 percent for IM-N cases, and 41.7 percent for M-N cases. CONCLUSIONS: In low anterior resection, high ligation of the inferior mesenteric artery and dissection of C-M-N, C-IM-N and PR-N are necessary, with the addition of the L-IM-N and L-M-N in the case of lower rectal cancer. Resection of sigmoid colon is not required, and therefore, a J-pouch can be constructed using the sigmoid colon. Nodal classification according to the JGR was predictive of case distribution and five-year survival rate.

PURPOSE: Functional outcome after low anterior resection with ultralow coloanal anastomosis for rectal cancer is improved by construction of a colonic J-pouch vs. straight anastomosis. Optimum size of this pouch has yet to be determined. Therefore, we initiated a prospective, randomized trial using 5-cm and 10-cm pouches to determine this size. METHODS: Patients with tumors 5 to 10 cm from the anal verge were included in the study. Before a low anterior resection anastomosis was performed, patients were randomized to either a 5-cm J-pouch group (5-J group) or a 10-cm J-pouch group (10-J group). Functional assessments were performed one year postoperatively. Clinical functions were evaluated using a functional scoring system. Physiologic functions, such as sphincter and reservoir function, were evaluated by anorectal manometry and evacuation function by the balloon expulsion and saline evacuation tests. RESULTS: Forty patients among 43 randomized patients were assessed for functional outcome one year postoperatively (5-J group, n = 20; 10-J group, n = 20). The functional score was similar for the two groups, although reservoir function in the 5-J group was significantly less than in the 10-J group. Sphincter function was similar between the two groups. Evacuation function in the 5-J group was significantly superior to that in the 10-J group. CONCLUSIONS: The 5-cm J-pouch conferred adequate reservoir function without compromising evacuation.

PURPOSE: The usefulness of postoperative carcinoembryonic antigen (CEA) monitoring and improvements in imaging techniques have renewed enthusiasm for second-look operations (SLO) as the most effective treatment, for recurrent colorectal cancer by reresection following early detection. The aim of our study is to evaluate the role of CEA and imaging techniques-directed SLO. METHODS: Seven hundred fifty-six patients with Dukes Stages B and C, who had undergone curative resection, were monitored postoperatively using CEA and imaging techniques. An SLO was performed on any potentially resectable recurrence, and in addition, an SLO was done when a persistently rising CEA. value was detected. RESULTS: Recurrence developed in 18.8 percent (142/756) of patients, and 90.8 percent (129/ 142) of the recurrences mere detected within the first three years following curative resection. When comparing carcinomas of the colon with that of the rectum, the former were associated with significantly more hepatic and intraabdominal recurrences, whereas the latter had significantly more locoregional and pulmonary recurrences. Seventy-two patients underwent SLO. Of these patients, 54.2 percent (39/72) had all of their disease resected, and 1.4 percent (1/72) had no detectable disease at the SLO. Among the 142 patients with recurrence, 71 (50 percent) patients underwent SLO. The resectable group at SLO carried a significantly better survival than the unresectable recurrence group (41.3 vs. 5.2 percent; P < 0.01). CONCLUSIONS: Complete removal of colorectal cancer recurrences by SLO, on the basis of postoperative, follow-up CEA and imaging technique findings, results in improved survival.

The prognostic significance of clinicopathologic factors in colorectal cancer was evaluated in a multivariate analysis. The most important independent factor affecting survival was stage (depth of penetration through the bowel wall and the presence of positive lymph nodes). All other clinicopathologic factors were of less importance than stage in determining prognosis. Although the prognostic relevance of biologic and molecular variables has been investigated extensively, the importance of these factors as prognostic predictors remains uncertain and further studies are needed.

Background. Basement membrane (BM) is a specialized extracellular matrix component that plays a key role in tumor invasion and metastasis. Methods. Immunohistochemical staining for two major components of BM, type IV collagen (C IV), and laminin (LN), utilizing avidin-biotin-peroxidase complex detection to examine 182 primary colorectal cancers (pT2 or greater) and 20 liver metastases. Results. The distribution of C IV was the same as of LN in colorectal cancer tissue, and in normal tissue. Both C IV and LN staining were more frequently positive in the superficial zone but infrequently in the deep zone of the primary tumor. BM preservation, C IV and LN staining in both the superficial and deep zones, was seen in 18.7% of the subjects. The rate of BM preservation significantly decreased with increasing histologic grade (P < 0.01). No correlation was observed between pT number and BM preservation. The rate of BM preservation in cases of liver metastasis was 84.4%, significantly higher than the rate in cases without liver metastasis (P < 0.001). BM was observed even at the advancing front of tumor invasion and was preserved in 95.0% of the liver metastases. Conclusions. BM is a functional substance that appears to accompany cancer rather than function as a structural barrier against cancer invasion and liver metastasis.

PURPOSE: The aim of this study was to clarify the distribution of lymph node metastasis in colorectal cancer. We also examined the relationship between the primary tumor (T) and the regional node (N) categories of the TNM (primary tumor, regional nodes, metastasis) classification. METHOD: Lymph nodes of surgical specimens in 311 consecutive patients with colorectal cancer were studied using the modified clearing method. RESULTS: Lymph node metastasis was seen in 59.2 percent of the total cases. The upward metastasis rate was 30.7 percent. In the longitudinal spread, most of the lymph node metastasis was seen within 10 cm. On the oral side in rectal cancer, there was no metastasis beyond 4 cm. The lateral metastasis rate in rectal cancer was 8.8 percent and in the lower rectum, the rate of cancer within 6 cm from the anal verge or beyond pT3 was much higher. CONCLUSION: In the TNM classification, there was no significant difference between colon and rectal cancer except pT1 with rectal cancer. In the lower rectal cancer within 6 cm from the anal verge or beyond pT3, there is a high risk of lateral metastasis, and lateral lymph node dissection or radiation therapy should be performed.

study of regional lymph node metastases was performed using the clearing method in 322 patients with carcinoma of the colon and rectum (140 with carcinoma of the colon and 182 with carcinoma of the rectum) who had undergone surgical resection. The mean number of nodes examined per patient was 76.4 and the metastatic rate (patients with metastases divided by the total of patients) was 61.4 percent, with a metastatic incidence (nodes with metastases divided by the total of examined nodes) of 6.4 percent for carcinoma of the colon using the clearing method. For carcinoma of the rectum, the mean number of nodes examined was 73.7 with a metastatic rate of 57.1 percent and a metastatic incidence of 7.1 percent. In contrast, node analysis by the conventional manual method resulted in a mean of 18.1 nodes being examined, with a metastatic rate and incidence of 42.1 and 12.8 percent, respectively, for carcinoma of the colon. Manual examination of lymph nodes in carcinoma of the rectum resulted in a mean of 21.2 nodes being examined, with a metastatic rate and incidence of 50.0 and 16.8 percent, respectively. Compared with the manual method, the clearing method provided a greater number of nodes, a higher metastatic rate and a lower metastatic incidence. These differences may be explained by the detection of metastatic regional nodes smaller than 4 millimeters in maximum diameter by the clearing method. By TNM classification there were more pN3 than pN2 lesions. The five year survival rate after curative resection was 78.5 percent for pN1 lesions, 45.7 percent for pN2 lesions and 45.4 percent for pN3 lesions for carcinoma of the colon and 72.7 percent for pN1 lesions, 75.0 percent for pN2 and 53.9 percent for pN3 lesions for carcinoma of the rectum. There was no significant survival difference between the patients with pN1, pN2 and pN3 carcinomas. The presence of regional nodes metastases should be examined in detail. Therapies and prognosis of carcinoma of the colon and rectum should be discussed based on accurate staging.

Colonic and gastric carcinomas were studied by immunohistochemical staining of laminin (LN), a structural component of the basement membrane. High rates of liver metastasis and recurrence of liver metastasis were found in cases in which LN activity was noted in the basement membrane of cancer tissue. In addition, sites which stained positive for type IV collagen (CIV), likewise a component of basement membrane, showed good correspondence to the pattern obtained for LN, indicating that LN-positive sites corresponded to basement membrane. Prospective studies on the recurrence of liver metastasis associated with colonic cancer, performed by LN staining since 1987, indicated that the recurrence of liver metastasis was able to be predicted in a high proportion of cases. Cell culture studies were additionally performed to investigate why carcinomas with LN-positive basement membrane have a high rate of liver metastasis. In culture, some carcinomas formed basement membrane whereas other did not, but all cells elaborated LN and CIV. The foregoing results demonstrated that some carcinomas of the colon and stomach form basement membrane while others do not. Basement membrane-producing cancers (BMPC) were found to be associated with a high rate of liver metastasis. © 1993, The Japanese Society of Gastroenterological Surgery. All rights reserved.

Primary hepatic lymphoma is a rare disease. We report five cases here and summarize clinical and pathologic features of our own and reported cases from Western countries and Japan. The total number of cases was 68. The age of patients ranged from 7 to 87 years (median 55) with a male-to-female ratio of 3.1:1. Chronic hepatitis or cirrhosis before onset of hepatic lymphoma was noted in 44% of Japanese cases and 9.6% of Western cases. Macroscopically, the liver was occupied by solitary mass (60%), multiple masses (35%), or a diffuse lesion without nodule formation (5%). Histologically all cases were non-Hodgkin's lymphoma with the diffuse large cell type being most common. Three cases (4.4%) were follicular lymphoma. Immunohistochemically about 80% of the cases were B-cell type. Follow-up study showed that hepatic lymphoma had a relatively favorable prognosis when early detection of the disease was possible.

In 192 patients with colorectal cancer and 17 with liver metastatic lesions, immunohistological study (ABC method) of laminin (LN) was made to clarify the relation of localization of LN and invasion or metastasis of the cancer, LN was commonly localized on epithelial basement membrane of normal colonic tissue in all cases, but unevently stained over the primary lesion of colorectal cancer. Therefore, the foci were divided into 3 layers: superficial, intermediate and deep layers. Positive cases were defined as those with positive LN staining in all or 2 of 3 layers. The positive staining was found in 83.3% of primary lesion with liver metastasis with significant difference from the rate of 19.0% in those without liver metastasis (p< 0.01). The cases with liver metastasis were characterized by remarkable LN staining at the deepest part of invasive lesion, which frequently maintained glandular structure. LN staining was also found around the small nests invading stroma or veins. In liver metastatic lesions, LN was almost uniformly stained at the basal part of glandular structure in 94.1% of the cases. From the above results, cases with positive LN staining frequently develop liver metastasis, and LN is concomitant with cancer and unbelievable to be a barrier to intramural invasion. © 1991, The Japanese Society of Gastroenterological Surgery. All rights reserved.

Rectal cancer surgery causes often postoperative morbidities such as defecation disturbance, dysuria and male sexual impotence. Compatibility of cancer eradication and function preservation are the problem should be resolved in the rectal cancer surgery. Defecation function were preserved in the patients with middle and upper rectal cancer by anterior resection transsacral resection, invagination or pull-through operation. Since 1984, usage of suture instruments made it practicable to increase sphincter preserving operation up to more than 65% of rectal cancer. Postoperative 5-years survivals were 81% of anterior resection, 71% of invagination operation and 57% of pull-through. Autonomic nerves preserving operation (ANP), aimed to prevent the urinary and sexual disfunction were studied both sides of the cancer spreads and extend of nerve plexuses. And ANP were adopted to the 185 cancers, limited to the submucosa or the proper muscle coat, by Study Group of Welfare Ministry. Their postoperative disfunction decreased to 15% of urination and 21% of male potency, while 33% and 81% respectively following conventional operation. Local excision for early cancer, which are defined as mucosal or submucosal cancer are discussed.

欧米guidelineはJ-pouch (J)で機能改善とありevidenceはA~EのBと強い。しかし2年以上の長期機能の報告は少なく、かつJによる長期の機能改善に賛否両論ある。1,3,5年にJ(46例)とS(48例)を17項の問診からなる点数0(良)~26(不良)のスコアーと内圧測定で評価した。５年でもJはSより機能良好。４cm以下の超低位吻合にJは必須。

日本は世界一の長寿国であり，直腸癌患者の3割が70歳以上である．直腸癌手術の8割を占める前方切除において，J型結腸嚢再建（J）の機能は従来のストレート再建より優れているが，加齢に伴って増加する便失禁を考慮して直腸切断やハルトマン手術が選択されることのある高齢者に対するJの機能評価は少ない．高齢者のJの機能を評価した．高齢者に対するJの機能は，下剤／浣腸の使用が多くなること以外はコンチネンスを含め良好である．

第20回国際大学結腸直腸外科医会議（ブダペスト）において発表した大腸癌肝転移に対する肝切除と術後IL-2, MMC, 5-FU肝動注による集学的治療の成績を方法、結果、図表、考察、文献を加えて論文形式にして単行本として出版された（英文）

開講から25年にわたる近畿大学第一外科大腸グループの臨床成績と臨床研究成果を述べた。

目的：癌と主幹動脈(FA)流入部の位置関係を考慮して至適主幹動脈結紮レベルとAW・OWを検討した。方法：結腸癌164 例のリンパ節転移をクリアリング法で調べた。結果：腸軸転移はT1は癌から2.5cm、T2は5cm以内、T3T4は10cm以遠に転移のあった非治癒(nc)3例を除くと7cm以内であった。癌から5cm以内にFAがある124例(全症例の75%に相当)の腸軸転移率（転移症例数/全症例数）は癌から5cm以内27％、5-7cm以内6％、10cm以遠1％(nc)、中枢転移率は中間リンパ節(IN)31(T1:0,T2:26,T3:34,T4:50)％、主リンパ節(MN)13(T2:0,T3:18,T4:21)％、主リンパ節以遠(MC)4(T3:5,T4:7)％(nc)で、5-7cmにFAがある32例(20%)の転移率は5cm以内28％、5cm-FA 9％、FA以遠3％(nc)、IN16(T1T2:0,T3:21,T4:25)％、MN6(T3:5,T4:25)％、MC3(T3:0,T4:25)％（nc）で、7cm以遠にFAがある8例(5%)の転移率は5cm以内25％、5-7cm以内13％、10cm以遠 13％(nc)で、中枢転移はIN, MN, MCに転移のあったT3の1例13％(nc)であった。結論：T1 は3cmの腸切、T2はINを頂点とした5cmの腸切、T3T4はMNを頂点とした7cmの腸切。T2

目的/方法：従来のストレート再建(S)を用いた低位前方切除(LAR)では吻合が低位になるほど機能は不良となる.つまり結腸肛門管吻合では貯留能の減少により排便回数の増加や排便我慢できなくなり,下着の汚染や失禁も増える.J型結腸嚢再建(J)による機能改善はrandomized studyで確認され,meta-analysisで証明されたが,Jの2年以上の長期機能報告は少なく,かつJによる長期機能改善に賛否両論あり,さらにJとSの機能の経時的変化を比較した報告はない.術後1,3,5年にJ(46例)とS(48例)の機能を17項の問診からなる点数域0(良)-26(不良)のScoreと貯留能(内圧測定)で評価.結果：Score:[1年]肛門縁から吻合部までの距離が1-4 cmではJ 5.6,S 10.2で17項中差があったのは(a)日中と(b)夜間の排便回数,(c)我慢,(d)soiling,パッド,失禁,自己評価の7項.吻合が5-8cmではJ 3.4, S 5.2で差があったのは(b),(c),(d)の3項. [3年]吻合部が1-4cmではJ 5.3, S 9.6, 5-8cmではJ 3.1, S 3.8で差があったのはそれぞれ1年と同じ7, 3項. [5年]1-4cmではJ 3.7, S 7.3で差があったのは

目的：癌と主幹動脈(FA)流入部の位置関係を考慮して至適主幹動脈結紮レベルとAW・OWを検討した。方法：結腸癌164 例のリンパ節転移をクリアリング法で調べた。結果：腸軸転移はT1は癌から2.5cm、T2は5cm以内、T3T4は10cm以遠に転移のあった非治癒(nc)3例を除くと7cm以内であった。癌から5cm以内にFAがある124例(全症例の75%に相当)の腸軸転移率（転移症例数/全症例数）は癌から5cm以内27％、5-7cm以内6％、10cm以遠1％(nc)、中枢転移率は中間リンパ節(IN)31(T1:0,T2:26,T3:34,T4:50)％、主リンパ節(MN)13(T2:0,T3:18,T4:21)％、主リンパ節以遠(MC)4(T3:5,T4:7)％(nc)で、5-7cmにFAがある32例(20%)の転移率は5cm以内28％、5cm-FA 9％、FA以遠3％(nc)、IN16(T1T2:0,T3:21,T4:25)％、MN6(T3:5,T4:25)％、MC3(T3:0,T4:25)％（nc）で、7cm以遠にFAがある8例(5%)の転移率は5cm以内25％、5-7cm以内13％、10cm以遠 13％(nc)で、中枢転移はIN, MN, MCに転移のあったT3の1例13％(nc)であった。結論：T1 は3cmの腸切、T2はINを頂点とした5cmの腸切、T3T4はMNを頂点とした7cmの腸切。T2

大腸癌肝転移に対する最近の集学的治療法とその成績を紹介した（英文）

【背景】結腸癌の治療と予後は適切なリンパ節転移分類に基づいて論じられるべきである。規約では所属リンパ節を腸管傍、中間、主リンパ節に分類し転移の広がりでn1～n3に分類する。一方、TNMでは個数でN1 (1～3個)、N2 (4個以上) に分類する。【方法】結腸癌切除164症例のリンパ節転移を最大径4mm未満の転移リンパ節を検索できるクリアリング法で調べ、両分類を比較した。【結果】検索リンパ節総数12,496個、転移リンパ節総数724個で転移率（転移症例数/全症例数）は58.5％ (96/164)。症例数の分布：規約ではn(-) 41.5%, n1 29.3%、n2 18.3%、n3 11.0%と順次少なくなる。TNMはN1 23.8%、N2 34.8%とN2がN1より多い。治癒切除126例の5生率：規約ではn(-) 98.4%、n1 74.3%、n2 51.2%、n3 30.0% [n(-) vs. n1, n1 vs. n2, n2 vs. n3 各々p＜0.05]、TNMではN1 76.0%、N2 45.0% [N0 vs. N1, N1 vs. N2 各々p＜0.05]である。【結論】検索リンパ節数が多くなるほど転移率は高くなりリンパ節転移分類の評価は正確になる。規約はTNMより症例数の分布と5生率

欧米の直腸癌手術ガイドラインによるとAWは理想的には2cmであるが下部直腸では1cmでもよしとし、器械吻合を用いた超低位前方切除あるいは経肛門吻合で括約筋温存をfirst choiceにすべきとある。今日では直腸癌手術の約80%が器械を用いた前方切除であり直腸切断術は20%以下である。しかし従来のストレート（S）再建では吻合が低位になるほど排便機能は不良となる。つまり結腸肛門管吻合では便貯留能の減少により排便回数の増加や排便我慢できなくなり（便意切迫）、下着の汚染や失禁も増える。排便機能改善のためにJ型結腸嚢（J）再建が行われる。フランスとオ－ストラリアのガイドラインにはJ再建で機能改善するべしとあり、このlevel of evidenceはそれぞれA-EのB、I-IVのIIと強い。欧米論文と著者らの検討から吻合部が肛門縁より8cm以下、特に4cm以下の超低位吻合の際にはS状結腸を用いた5cmのJ再建が必須であり、これにより局所再発および排便困難を増加させることなく術後早期から2

今日では直腸癌手術の約80%が器械を用いた前方切除であり直腸切断術は20%以下である。しかし従来のストレート（S）再建では吻合が低位になるほど排便機能は不良となる。つまり結腸肛門管吻合では便貯留能の減少により排便回数の増加や排便我慢できなくなり（便意切迫）、下着の汚染や失禁も増える。排便機能改善のためにJ型結腸嚢（J）再建が行われる。J再建による機能改善、すなわち貯留能の増加による排便回数、便意切迫、失禁の減少は多数のnon-randomized studyで報告され、9つのrandomized studyで確認され、さらに2006年になってmeta-analysisで証明されている。しかし従来の報告では、pouch作製に用いる結腸はS状か下行であるが、これらの結腸が局所再発と術後機能に及ぼす影響について検討されていないことが問題である。S状結腸を用いたpouch作製は下行結腸より吻合部にかかる緊張が少ないという利点があるが、欠点は局所再発の増加、下腸間膜動脈（IMA）高位結紮による虚血、憩

今日では直腸癌手術の約80%が器械を用いた前方切除であり直腸切断術は20%以下である。しかし従来のストレート（S）再建では吻合が低位になるほど排便機能は不良となる。つまり結腸肛門管吻合では便貯留能の減少により排便回数の増加や排便我慢できなくなり（便意切迫）、下着の汚染や失禁も増える。排便機能改善のためにJ型結腸嚢（J）再建が行われる。J再建による機能改善、すなわち貯留能の増加による排便回数、便意切迫、失禁の減少は多数のnon-randomized studyで報告され、9つのrandomized studyで確認され、さらに2006年になってmeta-analysisで証明されている。しかし従来の報告によるとpouchの大きさ（結腸の折り返しの長さ）は4-12cmまであり至適サイズについて検討されていないことが問題である。J再建の唯一の欠点に排便困難がある。最近になってこの排便困難の原因は大きなpouchの作製であることが示唆された。しかし至適サイズすなわちpouchによる貯留能増加で得られる排便回数

今日では直腸癌手術の約80%が器械を用いた前方切除であり直腸切断術は20%以下である。しかし従来のストレート（S）再建では吻合が低位になるほど排便機能は不良となる。つまり結腸肛門管吻合では便貯留能の減少により排便回数の増加や排便我慢できなくなり（便意切迫）、下着の汚染や失禁も増える。排便機能改善のためにJ型結腸嚢（J）再建が行われる。J再建による機能改善、すなわち貯留能の増加による排便回数、便意切迫、失禁の減少はrandomized studyで確認され、meta-analysisで証明されている。しかし従来の報告では肛門縁から吻合部までの距離は0.5cm(歯状線)-8cmまであり、J再建の適応（吻合部までの距離の上限）が決まっていないことが問題である。前方切除後の貯留能は残存直腸の長さに相関する。すなわち肛門縁から吻合部までの距離が長ければS再建でも十分な貯留能が得られるのでJ再建の必要性はなくなる。著者らのスコアーを用いた術後1年の機能評価によると吻合部ま

目的：腹会陰式直腸切断（APR）をうけた患者は永久的な人工肛門によって身体的なハンデイーをもつ．APRと前方切除（AR）の選択が患者に与える身体的，社会的，精神的影響を検討した．方法：APR 40例とAR 116例の術後平均3（1～6）年の機能を問診で比較した．APR群とAR群の年齢，性，壁深達度，病期分類に差はないが，占居部位はAPR群に下部直腸が有意に多かった（直腸S状部：上部：下部，0：0：40 vs. 32：63：21；p＝0.0001）．結果：APRの身体的状況はARより有意に不良であった（排便1日5回以上or不規則な排便有，58％ vs. 33%；p＝0.006；排ガス過剰有，30 vs. 14；0.02；食事制限有，50 vs. 31；0.03；排便状況の自己評価で満足，43 vs. 73；0.0004；残尿感有，65 vs. 25；0.0001；自己導尿要，28 vs. 7；0.0006；性欲有，35 vs. 65；0.02；勃起有，25 vs. 54；0.03；射精有，15 vs. 40；0.04；オルガスム有，25 vs. 52；0.04）．但し不快臭有（28％ vs. 16％），会陰部痛有（20 vs. 11），下剤／止痢剤使用有（38 vs. 24）に差はなかった

【目的】直腸癌局所再発防止のために側方郭清が行われるが排尿・性機能障害は高率である。自律神経温存では剥離面の縮小による癌遺残とリンパ節郭清の不十分さが問題である。自律神経温存の適応をリンパ節転移から検討し，さらに排尿・性機能を調べた。【方法】側方郭清を行った直腸癌198例を対象に最大径4mm未満のリンパ節をpick upできるクリアリング法で転移を検索した。側方郭清48例と自律神経温存56例の機能を排尿、性、社会生活、心理状況を考慮した9項目の問診で評価した。【結果】リンパ節転移率（転移症例数/全症例数）は57％（112/198）で側方転移率は11％（22/198）（T1、T2: 0％、T3: 12％、T4: 29％．Rs: 3％、Ra: 8％、Rb: 19％）であった。術後平均3（1～6）年の自律神経温存と側方郭清の機能は残尿感有（7％、67％）、自己導尿要（0％、29％）、性欲有（92％、30％）、勃起可（88％、17％）、射精可（81％、0％）、オルガスム有（88％、13％）、外出制限有（7％、38％）、復職可

【目的】低位前方切除の排便機能はJ型結腸嚢再建（J）を用いることで従来の端々吻合より改善される。しかし大きな結腸嚢は排便困難をもたらすことが報告されている。結腸嚢の大きさと排便困難の関連を検討した。【方法】結腸の折り返しの長さ10cmのJ（10J）26例と5cmのJ（5J）27例の術後3月、1年、2年の結腸嚢造影所見を比較し、排便機能との関連をみた【結果】側面像で結腸嚢の長軸と水平線のなす角度（pouch-horizontal angle）はすべての時期で10Jは5Jより有意に小さかった。10J、5Jともに術後1年は3月より有意に小さいが、術後1年と2年に差はなかった。術後1年、排便困難の愁訴は10Jが5Jよりも有意に多く、バルーン排出テスト及び生理食塩水排出テストで10Jの排出能は5Jよりも有意に不良であった。【考察】大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する（英文）。

目的と方法:欧米guidelineはJ-pouch (J)で機能改善とありevidenceはA-EのBと強い。しかし2年以上の長期機能の報告は少なく、かつJによる長期の機能改善に賛否両論あり、さらにJとstraight再建(S)の機能の長期にわたる経時的変化の比較はない。1,3,5年にJ(46例)とS(48例)を17項の問診からなる点数0(良)-26(不良)のスコアーと内圧測定で評価した。結果:スコアー;[1年]肛門縁から吻合部までの距離が1-4cmではJ 5.6, S 10.2で17項中差があったのは日中と夜間の排便回数、我慢、soiling、パッド、失禁、自己評価の7項。吻合部が5-8cmではJ 3.4, S 5.2で差があったのは夜間の排便回数、我慢、soilingの3項。[3年]吻合部が1-4cmではJ 5.3, S 9.6, 5-8cmではJ 3.1, S 3.8で差があったのはそれぞれ1年と同じ7, 3項。[5年]吻合部が1-4cmではJ 3.7, S 7.3で差があったのは日中と夜間の排便回数、我慢、soilingの4項。吻合部が5-8cmではJ 2.1, S 2.7で差があったのは夜間の排便回数、我慢の2項。スコアーの経時的変化をみるとJ, Sともに1-5年にかけて改善

目的：癌と主幹動脈(FA)流入部の位置関係を考慮して至適主幹動脈結紮レベルとAW・OWを検討した。方法：結腸癌164 例のリンパ節転移をクリアリング法で調べた。結果：腸軸転移はT1は癌から2.5cm、T2は5cm以内、T3T4は10cm以遠に転移のあった非治癒(nc)3例を除くと7cm以内であった。癌から5cm以内にFAがある124例(全症例の75%に相当)の腸軸転移率（転移症例数/全症例数）は癌から5cm以内27％、5-7cm以内6％、10cm以遠1％(nc)、中枢転移率は中間リンパ節(IN)31(T1:0,T2:26,T3:34,T4:50)％、主リンパ節(MN)13(T2:0,T3:18,T4:21)％、主リンパ節以遠(MC)4(T3:5,T4:7)％(nc)で、5-7cmにFAがある32例(20%)の転移率は5cm以内28％、5cm-FA 9％、FA以遠3％(nc)、IN16(T1T2:0,T3:21,T4:25)％、MN6(T3:5,T4:25)％、MC3(T3:0,T4:25)％（nc）で、7cm以遠にFAがある8例(5%)の転移率は5cm以内25％、5-7cm以内13％、10cm以遠 13％(nc)で、中枢転移はIN, MN, MCに転移のあったT3の1例13％(nc)であった。結論：T1 は3cmの腸切、T2はINを頂点とした5cmの腸切、T3T4はMNを頂点とした7cmの腸切。T2

目的：直腸癌術後再発の約半数が局所再発である。日本では局所再発防止のために側方郭清が行われるが、欧米では局所再発の主な原因は癌肛門側間膜内の癌遺残であるとし、骨盤筋膜壁側葉に沿って肛門挙筋のレベルまで剥離し間膜を全切除する全直腸間膜切除（TME）が行われ6-11%の低い局所再発率が報告されている。局所再発防止を目的に癌の占居部位と壁深達度による癌肛門側の間膜切除範囲を検討した。方法：直腸癌198例［T1（pSM）：8、T2（pMP）：38、T3（pSS、pSE、pA）：128、T4（pSI、pAI）：24、RS：40、Ra：80、Rb：78］を対象に従来の触診法では見落とされることの多い最大径4mm未満のリンパ節をpick upできるクリアリング法で転移を検討するとともに癌肛門側の壁内進展を調べた。結果：検索リンパ節は14,553個、転移リンパ節は1,018個で検索リンパ節の78%、転移リンパ節の33%が最大径4mm未満の小さいリンパ節であった。リンパ節転移率（転移症例数/全症例数）は57%(112/198)であった。癌肛

目的：癌と主幹動脈(FA)流入部の位置関係を考慮して至適主幹動脈結紮レベルとAW・OWを検討した。方法：結腸癌164 例のリンパ節転移をクリアリング法で調べた。結果：腸軸転移はT1は癌から2.5cm、T2は5cm以内、T3T4は10cm以遠に転移のあった非治癒(nc)3例を除くと7cm以内であった。癌から5cm以内にFAがある124例(全症例の75%に相当)の腸軸転移率（転移症例数/全症例数）は癌から5cm以内27％、5~7cm以内6％、10cm以遠1％(nc)、中枢転移率は中間リンパ節(IN)31(T1:0,T2:26,T3:34,T4:50)％、主リンパ節(MN)13(T2:0,T3:18,T4:21)％、主リンパ節以遠(MC)4(T3:5,T4:7)％(nc)で、5~7cmにFAがある32例(20%)の転移率は5cm以内28％、5cm~FA 9％、FA以遠3％(nc)、IN16(T1T2:0,T3:21,T4:25)％、MN6(T3:5,T4:25)％、MC3(T3:0,T4:25)％（nc）で、7cm以遠にFAがある8例(5%)の転移率は5cm以内25％、5~7cm以内13％、10cm以遠 13％(nc)で、中枢転移はIN, MN, MCに転移のあったT3の1例13％(nc)であった。結論：T1 は3cmの腸切、T2はINを頂点とした5cmの腸切、T3T4はMNを頂点とした7cmの腸切。T2

今日では直腸癌手術の約80%が器械吻合を用いた前方切除であり直腸切断術は20%以下である。しかし従来のストレート再建（S）では吻合が低位になるほど排便機能は不良となる。つまり結腸肛門管吻合では便貯留能の減少により排便回数の増加や排便我慢できなくなり（便意切迫）、下着の汚染や失禁も増える。排便機能改善のためにJ型結腸嚢再建（J）が行われる。Jによる機能改善、すなわち貯留能の増加による排便回数、便意切迫、失禁の減少は多数のnon-randomized studyで報告され、9つのrandomized studyで確認され、さらに去年meta-analysisで証明されている。欧米の4つの直腸癌手術ガイドラインによるとAWは理想的には2cmであるがアメリカは下部直腸では1cmでもよしとし、術式は器械を用いた低位前方切除をfirst choiceにすべきとある。さらにフランスとオ－ストラリアのガイドラインにはJで機能改善するべしとあり、このlevel of evidenceはそれぞれA-EのB、I-IVのIIと強い。欧米論文と著者らの検討

【目的と方法】高齢者は術前併存疾患が多いので拡大手術の選択に論争があり、直腸癌では機能温存手術の選択も論点となる。直腸癌350例を年齢別[74歳以下(A)275例,75-79歳(B)46例,80歳以上(C)29例]に比較した。【結果】術前併存疾患有がA群28%、B群48%、C群52%でB、C群はA群より有意に多かったが、術後合併症有はA群36%、B群39%、C群41%、手術死亡率はA群1%、B群2%、C群0%で差はなかった。Stage分類ではA群（I：18%、II：20、III：46、IV：16）、B群（20、30、37、13）、C群（14、38、34、14）で差はないが、治癒切除率はA群85%、B群83%、C群66%でC群はA、B群より有意に低く、5生率(全例, 治癒切除例)はC(43%, 55%)はA(64%, 72%)B(58%, 65%)より有意に低いが,治癒切除例で他病死を除けば差がない[A(76%)B(73%)C(68%)]。術中出血量はA群420ml、B群382ml、C群196mlでC群はA、B群より有意に少なく、手術時間もC群（146分）はA群（200分）、B群（170分）より有意に短かった。術式はA群（前方切除：82%、腹会陰式直腸切断術：15%、ハルトマン手術

日本と欧米の大腸癌治癒切除後のサ－ベイランスと補助化学療法の違いを欧米論文と邦文論文に著者らの成績を加えreviewし、今後の展開について考察した。

背景：ステロイド（ST）抵抗性の潰瘍性大腸炎(UC)にサイクロスポリン(CS)の有効性が報告された。一方、Pneumocystis carinii (PC)はimmunocompromised host に日和見肺炎を発症させる。症例：56歳男性。外来でmesalazineとbetamethasone坐薬で治療していた。血性下痢と発熱出現し入院。内視鏡は全大腸炎型。total parenteral neutrition施行。prednisolone経口とmesalazineで 2週、次にprednisolone静注を2週行った。解熱したが血性下痢続くため、白血球除去療法を4回したが効なく、次にCS持続静注療法を10日したが効ないため3週後に大腸全摘。術後4日に呼吸苦と発熱出現。単純撮影で全肺野にスリガラス様間質性陰影、CTで両肺にreticular shadowあり。日和見肺炎としてエンピリックな治療開始。肺炎治療開始後3日呼吸苦改善せず、間質影増強し、同日呼吸器管理となる。また同日、喀痰のGomori染色でPC陽性。sulfamethoxazole・trimethoprimを増量したが間質影はさらに増強し、術後15日（肺炎治療開始後11日）に死亡。考察： CSは大腸全摘

目的：腹腔鏡下結腸癌手術では術中に結腸間膜の触診ができないので術前に切除範囲を決めておく必要がある。腹腔鏡手術で根治性を損なわない切除範囲を検討した。方法：結腸癌164 [C:12、A:24、T:24、D:16、S:88、T1(sm):18、T2(mp):30、T3(ss, se):98、T4(si):18] 例を対象に最大径4mm未満のリンパ節を検索できるクリアリング法で転移を調べた。結果：検索リンパ節総数は12,496個、転移リンパ節数は724個でうち最大径4mm未満が33％を占めた。リンパ節転移率（転移症例数/全症例数）は59 (96 /164)%であった。腸管軸方向の転移は、T1は腫瘍から2.5cm、T2は5cm以内、T3、T4は非治癒例（各々2, 1例）を除くと7cm以内であった。中枢方向の転移はT1には無く、T2は中間リンパ節（転移率20%）まで、T3は中間リンパ節転移率31%、主リンパ節転移率15%, T4はそれぞれ44%、22%であった。考察：結腸癌腹腔鏡手術は従来の開腹手術より術後疼痛が少ない、入院期間が短いといった利点がある一方で、リンパ節郭清と腸切除が少なく

欧米の直腸癌手術ガイドラインによるとAWは理想的には2cmであるが下部直腸では1cmでもよしとし、器械吻合を用いた超低位前方切除あるいは経肛門吻合で括約筋温存をfirst choiceにすべきとある。今日では直腸癌手術の約80%が器械を用いた前方切除であり直腸切断術は20%以下である。しかし従来のストレート（S）再建では吻合が低位になるほど排便機能は不良となる。つまり結腸肛門管吻合では便貯留能の減少により排便回数の増加や排便我慢できなくなり（便意切迫）、下着の汚染や失禁も増える。排便機能改善のためにJ型結腸嚢（J）再建が行われる。フランスとオ－ストラリアのガイドラインにはJ再建で機能改善するべしとあり、このlevel of evidenceはそれぞれA-EのB、I-IVのIIと強い。欧米論文と著者らの検討から吻合部が肛門縁より8cm以下、特に4cm以下の超低位吻合の際にはS状結腸を用いた5cmのJ再建が必須であり、これにより局所再発および排便困難を増加させることなく術後早期から2

ステロイド（ST）抵抗性の潰瘍性大腸炎(UC)にサイクロスポリン(CS)の有効性が報告されている。CSは大腸全摘回避のために選択されるが免疫抑制によるPneumocystis carinii (PC)肺炎が報告されている。ST抵抗性UCに大腸全摘か、CSで手術を回避すべきかは論点であるが、CSに反応せず大腸全摘となる時はPC肺炎発生を認識すべし。

【目的】低位前方切除の排便機能はJ型結腸嚢再建（J）を用いることで従来の端々吻合より改善される。しかし大きな結腸嚢は排便困難をもたらすことが報告されている。結腸嚢の大きさと排便困難の関連を検討した。【方法】結腸の折り返しの長さ10cmのJ（10J）26例と5cmのJ（5J）27例の術後3月、1年、2年の結腸嚢造影所見を比較し、排便機能との関連をみた【結果】側面像で結腸嚢の長軸と水平線のなす角度（pouch-horizontal angle）はすべての時期で10Jは5Jより有意に小さかった。10J、5Jともに術後1年は3月より有意に小さいが、術後1年と2年に差はなかった。術後1年、排便困難の愁訴は10Jが5Jよりも有意に多く、バルーン排出テスト及び生理食塩水排出テストで10Jの排出能は5Jよりも有意に不良であった。【考察】大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する。

直腸癌手術の8割を占める前方切除において、J型結腸嚢再建の機能が従来のストレート再建に勝ることはrandomized studyとmeta-analysisで証明されている。しかしpouch作製に用いる結腸はS状か下行であるが、これら結腸が局所再発に及ぼす影響について検討されていない。最大径4mm未満のリンパ節を検索できるクリアリング法で直腸癌198例の転移を調べた。転移率をみると直腸傍57％、中枢方向の中間と主リンパ節はそれぞれ19％、9％あるが、Sudeckより口側の下部S状結腸傍は1％とまれであった。下腸間膜動脈の高位結紮は必要であるがS状結腸をpouchに用いても局所再発は増加しない。そしてS状結腸は下行結腸より吻合部にかかる緊張が少ないという利点がある。S状結腸でpouch作製という結論。

側方郭清の適応をクリアリング法によるリンパ節転移から検討した。結果：側方郭清198例のリンパ節転移率（転移症例数/全症例数）は57％（112/198）で、側方転移率は11％（22/198）（T1、T2：0％、T3：12％、T4：29％. Rs：3％、Ra：8％、Rb：19％）であった。治癒切除144例の局所再発率は13％で5生率は70％で、うち側方転移陽性例の局所再発率は50％で５生率は25％であった。側方転移が高率にみられるRbのT3、T4にはen blocな側方郭清を行って放射線化学補助療法を追加する必要がある。

目的/方法:従来のストレート再建(S)による前方切除では吻合が低位になるほど貯留能が減少し機能は不良となる。そして欧米GuidelineにはJ型結腸嚢再建(J)で機能改善するべしとあり,そのevidenceはA~EのBと強い。すなわち術後1年までのJの機能がSに勝ることはrandomized studyで証明されたが,Jの適応(肛門縁から吻合部までの距離の上限)が問題。術後1年にJ(48例)とS(80例)の機能を17項の問診からなる点数域0(良)~26(不良)のスコアと貯留能(内圧測定)で評価。スコア:吻合部までの距離が1-4 cmではJ5.6,S10.2(P=0.0002)で17項中差があったのは(a)日中と(b)夜間の排便回数,(c)我慢,(d)soiling,パッド,失禁,自己評価の7項。吻合が5-8cmではJ3.5,S5.2(P=0.0038)で差があったのは(b),(c),(d)の3項。吻合が9-12 cmのSは3.4で5-8 cmのJと差がない(P=0.9404)。Jの適応は吻合部までの距離が8 cm以下,特に4 cm以下の超低位吻合にJは必須。

目的：加齢に伴い増加する便失禁を考慮して直腸切断やハルトマンが選択される高齢者に対するJ型結腸嚢再建(J)の長期機能を評価。方法：術後3年に 75歳以上のJ 20例（肛門縁から吻合部までの距離1～4cm; 10例(Oer-U), 5～8cm; 10例(Oer-L)）と60～74歳のJ 27例（1～4cm; 14(O-U), 5～8cm; 13(O-L)）と59歳以下のJ 60例（1～4cm; 30(Y-U), 5～8cm; 30(Y-L)）の機能を17項の問診からなる点数域0（良好）～26（不良）のスコアーで比較。結果：Oer-Uのスコアーは良好(5.4)でO-U(5.2), Y-U(5.2) と差なく、Oer-Lのスコアーも良好(3.0)でO-L(3.0), Y-L(2.9) と差はない。問診をみると、日中の排便回数、夜間の排便回数、我慢、排便困難、残便感、3回≦のsplit defecation、下着汚染、パット使用、便失禁、便・ガス識別、排ガス時便がでる、肛門痛、食事制限、外出に支障、社会活動、自己評価に差はないが、下剤／浣腸の使用（Oer-U, O-U, Y-U 及びOer-L, O-L, Y-L: 80％ vs 71% vs 77% 及び 90％ vs 39% vs 43%）はOer-LがO-L, Y-Lより多い(p=0.012)。結論：高齢者に対

直腸癌術後再発の約半数が局所再発である。局所再発の主な原因は腫瘍肛門側間膜内の癌遺残であり、骨盤筋膜の壁側葉に沿って肛門挙筋のレベルまで剥離し間膜を全切除する全直腸間膜切除（Total Mesorectal Excision：TME）で5-15％の低い局所再発率が報告されている。局所再発防止を目的に癌の占居部位と壁深達度による腫瘍肛門側の間膜切除範囲を検討した。直腸癌198例［T1（sm）：8、T2（mp）：38、T3（ss、se、a1、a2）：128、T4（si、ai）：24、Rs：40、Ra：80、Rb：78］を対象に従来の触診法では見落とされることの多い最大径4mm未満のリンパ節をpick upできるクリアリング法で転移を検討した。RbのT3、T4にはTMEでRaのT3、T4には5cmの腫瘍肛門側間膜切除で局所再発を防止する。

結腸癌の治療と予後は適切なリンパ節転移分類に基づいて論じられるべきである。規約では所属リンパ節を腸管傍、中間、主リンパ節に分類し転移の広がりでn1～n3に分類する。一方、TNMでは個数でN1 (1～3個)、N2 (4個以上) に分類する。結腸癌切除164症例のリンパ節転移を最大径4mm未満の転移リンパ節を検索できるクリアリング法で調べ、両分類を比較した。検索リンパ節数が多くなるほど転移率は高くなりリンパ節転移分類の評価は正確になる。規約はTNMより症例数の分布と5生率がwider rangeでありかつ切除すべき範囲を示すので臨床的に有用である。

腹膜炎の疑いにて入院・手術施行するも，有意な所見なくドレナージ術のみ施行した症例．術後の急激はショック症状を呈し，術後の病態よりA群溶連菌感染症と診断し，empiric therapyを施行した．以後改善し退院となった．

サイクロスポリン(CS)は大腸全摘回避のために選択されるが免疫抑制によるPneumocystis carinii (PC)肺炎が4例報告されている。ステロイド抵抗性潰瘍性大腸炎に大腸全摘か、CSで手術を回避すべきかは論点であるが、CSに反応せず大腸全摘となる時はPC肺炎発生を認識すべし。

目的：加齢に伴い増加する便失禁を考慮して直腸切断やハルトマンが選択される高齢者に対するJ型結腸嚢再建(J)の長期機能を評価。方法：術後3年に 75歳以上のJ 20例（肛門縁から吻合部までの距離1～4cm; 10例(Oer-U), 5～8cm; 10例(Oer-L)）と60～74歳のJ 27例（1～4cm; 14(O-U), 5～8cm; 13(O-L)）と59歳以下のJ 60例（1～4cm; 30(Y-U), 5～8cm; 30(Y-L)）の機能を17項の問診からなる点数域0（良好）～26（不良）のスコアーで比較。結果：Oer-Uのスコアーは良好(5.4)でO-U(5.2), Y-U(5.2) と差なく、Oer-Lのスコアーも良好(3.0)でO-L(3.0), Y-L(2.9) と差はない。問診をみると、日中の排便回数、夜間の排便回数、我慢、排便困難、残便感、3回≦のsplit defecation、下着汚染、パット使用、便失禁、便・ガス識別、排ガス時便がでる、肛門痛、食事制限、外出に支障、社会活動、自己評価に差はないが、下剤／浣腸の使用（Oer-U, O-U, Y-U 及びOer-L, O-L, Y-L: 80％ vs 71% vs 77% 及び 90％ vs 39% vs 43%）はOer-LがO-L, Y-Lより多かった(各々p=0.012)。結論：高

目的/方法:従来のストレート再建(S)による前方切除では吻合が低位になるほど貯留能が減少し機能は不良となる.そして欧米GuidelineにはJ型結腸嚢再建(J)で機能改善するべしとあり,そのevidenceはA~EのBと強い.すなわち術後1年までのJの機能がSに勝ることはrandomized studyで証明されたが,Jの適応(肛門縁から吻合部までの距離の上限)とJによる2年以上の機能改善の有無が問題.1,3,5年にJ(48例)とS(80例)の機能を17項の問診からなる点数域0(良)~26(不良)のスコアと貯留能(内圧測定)で評価.結果:スコア:[1年]吻合部までの距離が1-4 cmではJ5.6,S10.2(P=0.0002)で17項中差があったのは(a)日中と(b)夜間の排便回数,(c)我慢,(d)soiling,パッド,失禁,自己評価の7項.吻合が5-8cmではJ3.5,S5.2(P=0.0038)で差があったのは(b),(c),(d)の3項.吻合が9-12 cmのSは3.4で5-8 cmのJと差がない(P=0.9404).[3年]吻合が1-4cmでJ5.3,S9.6, 5-8cmでJ3.1,S3.8で差があったのはそれぞれ1年と同じ7,3項. [5年]吻合が1-4cmではJ3.7,S7.3で差があったのは(a),(b),(c),(d)の4項.5-8cmではJ2.1,S2.7

結腸癌の治療と予後は適切なリンパ節転移分類に基づいて論じられるべきである。規約では所属リンパ節を腸管傍、中間、主リンパ節に分類し転移の広がりでn1～n3に分類する。一方、TNMでは個数でN1 (1～3個)、N2 (4個以上) に分類する。結腸癌切除164症例のリンパ節転移を最大径4mm未満の転移リンパ節を検索できるクリアリング法で調べ、両分類を比較した。検索リンパ節総数12,496個、転移リンパ節総数724個で転移率（転移症例数/全症例数）は58.5％ (96/164)。検索リンパ節数が多くなるほど転移率は高くなりリンパ節転移分類の評価は正確になる。規約はTNMより症例数の分布と5生率がwider rangeでありかつ切除すべき範囲を示すので臨床的に有用である。

従来のストレート再建(S)を用いた低位前方切除(LAR)では吻合が低位になるほど機能は不良となる.つまり結腸肛門(管)吻合では貯留能の減少により排便回数や我慢不可が増え,下着の汚染や失禁も増える.そして欧米GuidelineにはJ型結腸嚢再建(J)でこれら機能障害が改善とあり,そのevidenceはA~EのBと強い.すなわち術後1年までのJの機能がSに勝ることはRandomized Study(RS)で証明されている.しかしJの欠点に排便困難(Ed)がある.またJの2年以上の長期機能報告は少なく,かつJによる長期機能改善に賛否両論あり,さらにJとSの機能の経時的変化を比較した報告はない.我々はEdは結腸嚢の大きさに関係すると考え5cmと10cm JのRSで結腸嚢のsizeは排出能を損なうことなく貯留能が得られる5cmでよいことを報告した.術後1,3,5年にJ(size 5cm,46例)とS(48例)の機能を17項の問診からなる点数域0(良)~26(不良)のスコアーと内圧測定による貯留能で評価した. 経時的機能改善はSでより大きいが,５年でもJはSより機能良好.LAR特に４cm以

食生活の欧米化と平均寿命の延長により大腸癌の増加は著しく、2003年大腸癌死亡数は38,909人と30年前の4.6倍である。大腸癌死亡数は2015年には65,000人と予想され数年以内に胃癌を抜いて消化器癌死亡の1位になると心配されている。大腸癌は化学療法、放射線療法などの治療効果が低いため手術が最優先する。治療の中心である手術について自験例を含めreviewした。いかに示す6項目である。1. 早期癌、 2. 結腸進行癌、 3. 直腸進行癌： i) 排便機能温存、ii) 骨盤内リンパ節拡大郭清（側方郭清）と自律神経温存手術、 iii) 全直腸間膜切除(Total Mesorectal Excision: TME)、 iv) 隣接臓器合併切除 4. 治癒切除後サーベイランス 5. 高齢者大腸癌6. 癌イレウス。まとめ：大腸癌手術では安全性に対する努力がなされ、根治のための拡大手術と機能温存手術が癌の部位と進行度により採用され個々の患者に対して最も適切な術式が選択される。この選択の根拠はデーターの積み重ねの上にたつ客観的評価である

壁深達度は大腸癌治癒切除後の独立した予後規定因子である。大腸癌取扱い規約（第6版）では、漿膜浸潤と多臓器浸潤で壁深達度を区別していたが、改定された取扱い規約（第7版）では漿膜浸潤の有無での区別はなくなり、リンパ節転移を認めない多臓器浸潤例(pN0かつpSI,pAI)がstageⅡに変更された。n0結腸癌が固有筋層を越えて浸潤する場合、大腸癌取扱い規約（第7版）が旧規約(第6版）やTNM分類(2002)と比較して予後をより反映しているのかを検討した。その結果、第7版は第6版に比してTNM分類と同等に予後を反映すると考えられた。また、予後が向上した背景として、術前診断能の向上、術後補助化学療法の進歩ならびに多臓器浸潤症例(SI)でも積極的に合併切除を行ったためと考えられる。新規約においてpN0,pSI症例がStageⅡとなったが、術後補助化学療法、サーベイランススケジュールに関しては熟考する必要がある。

Tension-free法は成人鼠径ヘルニアに対する標準術式である．しかし，術後再発を起こした場合，前方到達法では癒着が強く神経，精索などを損傷する危険性が高くなる．今回過去2回の手術で再発した鼠径ヘルニアに対し，腹腔鏡下修復術を施行したので報告する．腹腔鏡下鼠径ヘルニア修復術はヘルニア門を中心として広い範囲で剥離操作が行うことができ，大きなメッシュで覆うため再発率が低い．また、腹腔内からの観察により、再発部位の確定ならびに不顕在性ヘルニアの診断もでき有用と考える．

目的：加齢に伴い増加する便失禁を考慮して直腸切断やハルトマンが選択される高齢者に対するJ型結腸嚢再建(J)の長期機能を評価。方法：術後3年に 75歳以上のJ 20例（肛門縁から吻合部までの距離1～4cm; 10例(Oer-U), 5～8cm; 10例(Oer-L)）と60～74歳のJ 27例（1～4cm; 14(O-U), 5～8cm; 13(O-L)）と59歳以下のJ 60例（1～4cm; 30(Y-U), 5～8cm; 30(Y-L)）の機能を17項の問診からなる点数域0（良好）～26（不良）のスコアーで比較。結果：Oer-Uのスコアーは良好(5.4)でO-U(5.2), Y-U(5.2) と差なく、Oer-Lのスコアーも良好(3.0)でO-L(3.0), Y-L(2.9) と差はない。問診をみると、日中の排便回数、夜間の排便回数、我慢、排便困難、残便感、3回≦のsplit defecation、下着汚染、パット使用、便失禁、便・ガス識別、排ガス時便がでる、肛門痛、食事制限、外出に支障、社会活動、自己評価に差はないが、下剤／浣腸の使用（Oer-U, O-U, Y-U 及びOer-L, O-L, Y-L: 80％ vs 71% vs 77% 及び 90％ vs 39% vs 43%）はOer-LがO-L, Y-Lより多い(p=0.012)。結論：高齢者に対

stage II 大腸癌術後の患者に対し術後化学療法を行った群と行っていない群の予後を含めた比較検討を行い発表を行った．

結腸癌において、n0で固有筋層を越えて浸潤する症例では、新しい大腸癌取扱い規約(第7版）は前回の規約（第6版）に比してTNM分類と同等に予後を反映すると考えられた。また、観察期間の後半5年間で予後が向上した背景として、術前診断能の向上ならびに多臓器浸潤症例(SI)でも積極的に合併切除を行ったためと考えられる。

直腸癌における拡大リンパ節拡大の意義を本邦の成績を中心に解説した（英文）。

ステロイド（ST）抵抗性の潰瘍性大腸炎(UC)にサイクロスポリン(CS)の有効性が報告されている。症例は56歳男性。外来でmesalazineとbetamethasone坐薬で治療していた。血性下痢と発熱出現し入院。total parenteral neutrition施行。prednisolone経口とmesalazineで 2週、次にprednisolone静注を2週行った。解熱したが血性下痢続くため、白血球除去療法を4回したが効なく、次にCS持続静注療法を10日したが効ないため3週後に大腸全摘。術後4日に呼吸苦と発熱出現。単純撮影で全肺野にスリガラス様間質性陰影、CTで両肺にreticular shadowあり。日和見肺炎としてエンピリックな治療開始。肺炎治療開始後3日呼吸苦改善せず、間質影増強し、同日呼吸器管理となる。また同日、喀痰のGomori染色でPC陽性。sulfamethoxazole・trimethoprimを増量したが間質影はさらに増強し、術後15日（肺炎治療開始後11日）に死亡。考察：ST抵抗性UCに大腸全摘か、CSで手術を回避すべきかは論点であるが、CSに反応せず大腸全摘となる時はPC肺炎発生

目的：加齢に伴い増加する便失禁を考慮して直腸切断やハルトマンが選択される高齢者に対するJ型結腸嚢再建(J)の長期機能を評価。方法：術後3年に 75歳以上のJ 20例（肛門縁から吻合部までの距離1～4cm; 10例(Oer-U), 5～8cm; 10例(Oer-L)）と60～74歳のJ 27例（1～4cm; 14(O-U), 5～8cm; 13(O-L)）と59歳以下のJ 60例（1～4cm; 30(Y-U), 5～8cm; 30(Y-L)）の機能を17項の問診からなる点数域0（良好）～26（不良）のスコアーで比較。結果：Oer-Uのスコアーは良好(5.4)でO-U(5.2), Y-U(5.2) と差なく、Oer-Lのスコアーも良好(3.0)でO-L(3.0), Y-L(2.9) と差はない。問診をみると、日中の排便回数、夜間の排便回数、我慢、排便困難、残便感、3回≦のsplit defecation、下着汚染、パット使用、便失禁、便・ガス識別、排ガス時便がでる、肛門痛、食事制限、外出に支障、社会活動、自己評価に差はないが、下剤／浣腸の使用（Oer-U, O-U, Y-U 及びOer-L, O-L, Y-L: 80％ vs 71% vs 77% 及び 90％ vs 39% vs 43%）はOer-LがO-L, Y-Lより多かった(各々p=0.012)。結論：高

規約では所属リンパ節を腸管傍、中間、主リンパ節に分類し転移の広がりでn1～n3に分類する。一方、TNMでは個数でN1 (1～3個)、N2 (4個以上) に分類する。結腸癌切除164症例のリンパ節転移を最大径4mm未満の転移リンパ節を検索できるクリアリング法で調べ、両分類を比較した。症例数の分布：規約ではn(-) 41.5%, n1 29.3%、n2 18.3%、n3 11.0%と順次少なくなる。TNMはN1 23.8%、N2 34.8%とN2がN1より多い。治癒切除126例の5生率：規約ではn(-) 98.4%、n1 74.3%、n2 51.2%、n3 30.0% [n(-) vs. n1, n1 vs. n2, n2 vs. n3 各々p＜0.05]、TNMではN1 76.0%、N2 45.0% [N0 vs. N1, N1 vs. N2 各々p＜0.05]である。規約はTNMより症例数の分布と5生率がwider rangeでありかつ切除すべき範囲を示すので臨床的に有用である。

背景：ステロイド（ST）抵抗性の潰瘍性大腸炎(UC)にサイクロスポリン(CS)の有効性が報告された。一方、Pneumocystis carinii (PC)はimmunocompromised host に日和見肺炎を発症させる。症例：56歳男性。外来でmesalazineとbetamethasone坐薬で治療していた。血性下痢と発熱出現し入院。内視鏡は全大腸炎型。total parenteral neutrition施行。prednisolone経口とmesalazineで 2週、次にprednisolone静注を2週行った。解熱したが血性下痢続くため、白血球除去療法を4回したが効なく、次にCS持続静注療法を10日したが効ないため3週後に大腸全摘。術後4日に呼吸苦と発熱出現。単純撮影で全肺野にスリガラス様間質性陰影、CTで両肺にreticular shadowあり。日和見肺炎としてエンピリックな治療開始。肺炎治療開始後3日呼吸苦改善せず、間質影増強し、同日呼吸器管理となる。また同日、喀痰のGomori染色でPC陽性。sulfamethoxazole・trimethoprimを増量したが間質影はさらに増強し、術後15日（肺炎治療開始後11日）に死亡。考察： CSは大腸全摘

目的と方法:欧米guidelineはJ-pouch (J)で機能改善とありevidenceはA~EのBと強い。しかし2年以上の長期機能の報告は少なく、かつJによる長期の機能改善に賛否両論ある。1,3,5年にJ(46例)とS(48例)を17項の問診からなる点数0(良)~26(不良)のスコアーと内圧測定で評価した。結果:スコアー;[1年]肛門縁から吻合部まで1-4cm の時J5.6, S10.2で差があったのは(a)日中と(b)夜間の排便回数、(c)我慢、(d)soilingとpad、失禁、自己評価の7項で、5-8cm J3.4, S5.2で差があったのはb,c,dの3項。[3年]1-4cm J5.3, S9.6、5-8cm J3.1, S 3.8で差があったのは1年と同じ項。[5年]1-4 cm J3.7, S7.3で差があったのはa,b,c,dの4項で、5-8 cm J 2.1, S 2.7で差があったのはb,cの2項。貯留能;1,3,5年 JはSより大きい。考察:５年でもJはSより機能良好。４cm以下の超低位吻合にJは必須。

目的：日本は世界一の長寿国であり，直腸癌患者の3割が70歳以上である．直腸癌手術の8割を占める前方切除において，J型結腸嚢再建（J）の機能は従来のストレート再建より優れているが，加齢に伴って増加する便失禁を考慮して直腸切断やハルトマン手術が選択されることのある高齢者に対するJの機能評価は少ない．高齢者のJの機能を評価した．方法：術後3年に 75歳以上のJ 20例（E）と74歳以下のJ 87例（Y）の機能を問診からなる点数域0（良好）～26（不良）のスコアーで比較した．結果： Eのスコアーは良好でYと差はなかった（E 4.2 vs. Y 4.1）．日中の排便5回≦，夜間の排便週2回≦，我慢不可，排便困難有り，排便後爽快感無し，残便感消失に要する排便3回≦，下着汚染有り，パット使用有り，便失禁有り，便・ガス識別不可，排ガス時便がでる，肛門痛有り，食事制限有り，外出に支障有り，社会活動低下有り，自己評価で不満に差はないが，下剤／浣腸の使用はEで有意に多かった

【背景】結腸癌の治療と予後は適切なリンパ節転移分類に基づいて論じられるべきである。規約では所属リンパ節を腸管傍、中間、主リンパ節に分類し転移の広がりでn1～n3に分類する。一方、TNMでは個数でN1 (1～3個)、N2 (4個以上) に分類する。【方法】結腸癌切除164症例のリンパ節転移を最大径4mm未満の転移リンパ節を検索できるクリアリング法で調べ、両分類を比較した。【結果】検索リンパ節総数12,496個、転移リンパ節総数724個で転移率（転移症例数/全症例数）は58.5％ (96/164)。症例数の分布：規約ではn(-) 41.5%, n1 29.3%、n2 18.3%、n3 11.0%と順次少なくなる。TNMはN1 23.8%、N2 34.8%とN2がN1より多い。治癒切除126例の5生率：規約ではn(-) 98.4%、n1 74.3%、n2 51.2%、n3 30.0% [n(-) vs. n1, n1 vs. n2, n2 vs. n3 各々p＜0.05]、TNMではN1 76.0%、N2 45.0% [N0 vs. N1, N1 vs. N2 各々p＜0.05]である。【結論】検索リンパ節数が多くなるほど転移率は高くなりリンパ節転移分類の評価は正確になる。規約はTNMより症例数の分布と5生率

大腸癌肝転移にRFAを応用し、肝切除にRFA併用すれば化学療法単独治療より予後は改善していた。RFAの局所制御能を肝細胞癌と比較したところ、腫瘍サイズで両者に差はないが、3cmを超えるものは局所再発率が20%を超え適応外と考えられた。

大腸癌肝転移の診断と治療につき解説した（英文）。

目的：腹腔鏡下結腸癌手術は従来の開腹手術より疼痛が少ない、経口摂取の開始がはやい、創感染が少ない、腸閉塞が少ない、入院期間が短いといった利点がある一方で、リンパ節郭清と腸切除が少なくなることが指摘されている。さらに術中に結腸間膜の触診ができないので転移リンパ節の広がりを検索できないという欠点がある。術前に切除範囲を決めておく必要がある。腹腔鏡手術で根治性を損なわない切除範囲を検討した。方法：結腸癌164 [C:12、A:24、T:24、D:16、S:88、T1(sm):18、T2(mp):30、T3(ss, se):98、T4(si):18] 例を対象に最大径4mm未満のリンパ節を検索できるクリアリング法で転移を調べた。結果：結腸癌の検索リンパ節総数は12,496個、転移リンパ節数は724個でうち最大径4mm未満が33％を占めた。リンパ節転移率（転移症例数/全症例数）は59 (96 /164)%であった。腸管軸方向の転移は、T1は腫瘍から2.5cm、T2は5cm以内、T3、T4は非治癒例（各々2, 1例）を除くと7cm以内であった。中枢方向の転移

【目的】直腸癌の低位前方切除において大きな結腸嚢作製は排便困難をもたらすことが報告されている．一方rectoceleは排便困難と関係深いことは知られている．大きな結腸嚢作製でみられる排便困難とrectocele-like prolapse（RP）の関連を検討した．【方法】結腸の折り返しの長さ10cmのJ型結腸嚢再建（10J）26例と5cmのJ（5J）27例の術後3月、1年、2年の結腸嚢造影所見を比較し、排便機能との関連をみた．【結果】RPは術後3月と1年ではみられないが、術後2年で10Jの4例にみられ5Jより有意に多かった（4 / 26 vs. 0 / 26；p = 0.0374）．排便困難の愁訴は10Jが5Jより有意に多く（1回排便に15分以上かかること有、21 vs. 0％；排便後残便感有、26 vs. 4％；残便感消失に要する排便回数が3回以上、26 vs. 4％）、また10JにおいてRP（+）の排便困難の愁訴はRP（-）より有意に多かった．バルーン排出テスト（バルーン排出可能症例数、53 vs. 89％；努責時最大結腸嚢内圧、101 vs. 130 cmH2O）及び生理食塩水排出テスト（500ml

直腸癌術後再発の約半数が局所再発である。局所再発の主な原因は腫瘍肛門側間膜内の癌遺残であり、骨盤筋膜の壁側葉に沿って肛門挙筋のレベルまで剥離し間膜を全切除する全直腸間膜切除（Total Mesorectal Excision：TME）で5-15％の低い局所再発率が報告されている。局所再発防止を目的に癌の占居部位と壁深達度による腫瘍肛門側の間膜切除範囲を検討した。方法：直腸癌198例［T1（sm）：8、T2（mp）：38、T3（ss、se、a1、a2）：128、T4（si、ai）：24、Rs：40、Ra：80、Rb：78］を対象に従来の触診法では見落とされることの多い最大径4mm未満のリンパ節をpick upできるクリアリング法で転移を検討した。結果：検索リンパ節は14,553個、転移リンパ節は1,018個で検索リンパ節の78％、転移リンパ節の33％が最大径4mm未満の小さいリンパ節であった。リンパ節転移率（転移症例数/全症例数）は57％（112/198）であった。腫瘍肛門側の間膜内リンパ節転移率は20％で、T1、T2：0％、T3：22％、T4：50％、Rs：10％、Ra

ステロイド（ST）抵抗性の潰瘍性大腸炎(UC)にサイクロスポリン(CS)の有効性が報告された。一方、Pneumocystis carinii (PC)はimmunocompromised host に日和見肺炎を発症させる。症例：56歳男性。外来でmesalazineとbetamethasone坐薬で治療していた。血性下痢と発熱出現し入院。内視鏡は全大腸炎型。total parenteral neutrition施行。prednisolone経口とmesalazineで 2週、次にprednisolone静注を2週行った。解熱したが血性下痢続くため、白血球除去療法を4回したが効なく、次にCS持続静注療法を10日したが効ないため3週後に大腸全摘。術後4日に呼吸苦と発熱出現。単純撮影で全肺野にスリガラス様間質性陰影、CTで両肺にreticular shadowあり。日和見肺炎としてエンピリックな治療開始。肺炎治療開始後3日呼吸苦改善せず、間質影増強し、同日呼吸器管理となる。また同日、喀痰のGomori染色でPC陽性。sulfamethoxazole・trimethoprimを増量したが間質影はさらに増強し、術後15日（肺炎治療開始後11日）に死亡。考察： CSは大腸全摘回避の

J-pouch(J)の機能が従来の端々吻合に勝ることはrandomized studyとmeta-analysisで証明されている。Jの問題点とされる至適サイズ、排便困難、J作製結腸部位、適応、長期排便機能改善の有無を我々のデータを加えreviewした。

欧米guidelineはJ-pouch (J)で機能改善とありevidenceはA~EのBと強い。しかし2年以上の長期機能報告は少なく、かつ長期改善に賛否両論あり、Jとstraight再建(S)の経時的変化の比較はない。1,3,5年にJ(46例)とS(48例)を17項の問診からなる0(良)~26(不良)のスコアーと内圧測定で評価。スコアー:[1年]肛門縁から吻合部まで1-4cm の時J5.6, S10.2で(a)日中と(b)夜間の排便回数、(c)我慢、(d)soilingとpad、失禁、自己評価の7項に差あり、5-8cm J3.4, S5.2でb,c,dの3項に差あり。[3年]1-4cm J5.3, S9.6、5-8cm J3.1, S 3.8で差があるのは1年と同じ項。[5年]1-4 cm J3.7, S7.3でa,b,c,dの4項に差あり、5-8 cm J 2.1, S 2.7でb,cの2項に差。スコアーはJ,Sともに経時的に改善しその改善はSで大きい。貯留能:1,3,5年 JはSより大きく、J, Sともに経時的に大きくなる。経時的改善はSで大きいが５年でもJはSより良好。４cm以下の超低位吻合にJは必須。

リンパ節転移を伴わない結腸癌が固有筋層を越えて浸潤する場合、現行の大腸癌取扱い規約とTNM分類のいずれの分類が予後をより反映しているかをKaplan-Meier法を用いて累積生存率を求め、両分類を比較検討した。 大腸癌取扱い規約ではstageⅡ、Ⅲa間に差を認めなかったが、TNM分類ではStageⅡA、ⅡBの間に有意差を認めた(p=0.007)。 これらより結腸癌において、n0で固有筋層を越えて浸潤する症例では、漿膜浸潤と多臓器浸潤で壁深達度を区別している現行の大腸癌取扱い規約よりも、漿膜浸潤の有無での区別はないTNM分類方がより予後を反映しているといえた。 これは、多臓器浸潤症例（si）でも積極的に合併切除が行われた結果、予後が向上したためと考えられた。

同時性肝転移で単純肝切除可能であれば予後は最も良い。予後不良となる両葉多発肝転移は肝動注先攻肝切除やラジオ波熱凝固療法併用肝切除で予後を改善する。

結腸癌の治療と予後は適切なリンパ節転移分類に基づいて論じられるべきである。規約では所属リンパ節を腸管傍、中間、主リンパ節に分類し転移の広がりでn1～n3に分類する。一方、TNMでは個数でN1 (1～3個)、N2 (4個以上) に分類する。結腸癌切除164症例のリンパ節転移を最大径4mm未満の転移リンパ節を検索できるクリアリング法で調べ、両分類を比較した。規約はTNMより症例数の分布と5生率がwider rangeでありかつ切除すべき範囲を示すので臨床的に有用である。

J型結腸嚢再建(J)の術後2年以上の機能報告は少なく、さらにJとストレート再建(S)の機能の長期にわたる経時的変化を比較した報告はない。術後1, 3, 5年にJ(46例)とS(48例)の機能を17項の問診からなるスコアーと内圧測定で評価。術後５年にわたる経時的機能改善はSでより大きいが５年でもJはSより機能良好。

加齢に伴い増加する便失禁を考慮して直腸切断やハルトマンが選択される高齢者に対するJ型結腸嚢再建(J)の長期機能を評価。方法：術後3年に 75歳以上のJ 20例（肛門縁から吻合部までの距離1～4cm; 10例, 5～8cm; 10例）と60～74歳のJ 27例（1～4cm; 14, 5～8cm; 13）と59歳以下のJ 60例（1～4cm; 30, 5～8cm; 30）の機能を17項の問診からなるスコアーで比較。75歳以上の高齢者に対するJの機能は、吻合部までの距離が5～8cmの症例で下剤／浣腸の使用が多くなること以外はコンチネンスを含め良好である。

ステロイド（ST）抵抗性の潰瘍性大腸炎(UC)にサイクロスポリン(CS)の有効性が報告された。一方、Pneumocystis carinii (PC)はimmunocompromised host に日和見肺炎を発症させる。CSは大腸全摘回避のために選択されるが免疫抑制によるPC肺炎が3例報告されている。ST抵抗性UCに大腸全摘か、CSで手術を回避すべきかは論点であるが、CSに反応せず大腸全摘となる時はPC肺炎発生を認識すべし。

検索リンパ節数が多くなるほど転移率は高くなりリンパ節転移分類の評価は正確になる。転移の広がりで分類する規約は転移の個数で分類するTNMより症例数の分布と5年生存率がwider rangeであり、かつ切除すべき範囲を示すので臨床的に有用である。

大腸癌肝転移に対する肝切除と免疫化学肝動注による集学的治療の成績を報告した（英文）。

術後1年までの前方切除の排便機能はJ型結腸嚢再建（J）を用いることで従来のストレート再建（S）より改善されるが、Jによる術後2年以上の機能改善の有無が問題である。JとSの機能を17項目の問診からなる排便スコアーと内圧測定による貯留能で比較した。術後3年でもJの機能はSより良好である。肛門縁から吻合部までの距離が8 cm以下、特に4 cm以下の超低位吻合にJは必須である。

転移の広がりで分類する規約は転移の個数で分類するTNMより症例数の分布と5年生存率がwider rangeであり、かつ切除すべき範囲を示すので臨床的に有用である。

1991年12月から2004年12月の期間に当科で手術を行った直腸癌566例のうち、直腸局所切除術を施行した19例（カルチノイド2例を含む）について検討した。局所切除術式は経肛門的局所切除11例（TEM １例）、経括約筋的局所切除5例、経仙骨的局所切除3例であった。局所再発を来たした症例は1例のみであり、この症例はsm1、ly1、v0であった。11例のsm massive症例、6例のly(+)症例では局所再発、転移は認めていない。これらよりRa、Rb直腸癌では深達度がsm massiveであっても、厳重な経過観察の下、局所全層切除によりQOLを損なわずに十分に根治を得られるものと考えられた。

ロジスティック解析を用いた多変量解析により、大腸癌の先進部間質のCD68発現細胞が少なく、中心部間質でのOpn発現細胞が多い症例では、異時性肝転移の発症が予測されるため厳重な経過観察が必要と考えられた。

超高齢者の胃癌、大腸癌手術について同時期に施行した開腹手術症例と腹腔鏡手術について検討し、腹腔鏡手術の利点と欠点について述べた。

低位前方切除術におけるＪ型結腸嚢再建について長期排便機能について、吻合部までの距離と７５歳以上、７４歳～６０歳、５９歳以下の各年齢群について比較検討し、高齢者のＪ型結腸嚢再建の利点と欠点について報告した。

大腸癌肝転移に対する治療戦略として肝切除を第一選択としてきたが肝切除不能であればRFAやneoadjuvant chemotherarpyを用いて肝切除の適応拡大に努めた結果、予後の改善が得られた。

術後1年までのJ型結腸嚢再建(J)の機能は従来のストレート再建(S)より良好であるが、2年以上の長期機能の報告は少なく、かつJによる長期の機能改善には賛否両論ある。経時的機能改善は従来のSでより大きいが、術後5年でもJの機能はSより良好である。4cm以下の超低位吻合にJは必須である。

直腸固有筋膜の外面に沿って剥離し神経叢の授動なしに温存する結果、90-100%の排尿機能温存と80-90%の性機能温存であった。T1, T2, Rsには固有筋膜外面に沿った剥離で神経叢を温存し術後QOLの向上を計る。

高齢者では安全性を優先し拡大手術を控える一方で、積極的に機能温存が行われる。但し、社会活動レベルと将来の介護の可能性を考慮してハルトマン手術は選択される。

術中に結腸間膜の触診ができない腹腔鏡手術で根治性を損なわない切除範囲は、T1では腫瘍から3cmの腸切除、T2では中間リンパ節と5cmの腸切除、T3T4では主リンパ節と7cmの腸切除である。

J型結腸嚢再建(J)と従来の端々吻合の機能を17項目の問診による排便スコアーと内圧測定による貯留能で比較した。Jの適応は吻合部までの距離が8（特に４）cm以下で、術後5年でもJの機能は端々吻合より良い。

高齢者大腸癌において腹腔鏡手術の利点と欠点について検討した。

壁深達度T1は3cmの腸切、T2は中間リンパ節を頂点とした5cmの腸切、T3T4は主リンパ節を頂点とした10cmの腸切。T2で5cm以内に主幹動脈(FA)がない時とT3T4で10cm以内にFAがない時は腸切のみでよい。

術中に結腸間膜の触診ができない腹腔鏡手術で根治性を損なわない切除範囲は、T1では腫瘍から3cmの腸切除、T2では中間リンパ節(low ligation)と5cmの腸切除、T3T4では主リンパ節(high ligation)と7cmの腸切除である。

J型結腸嚢再建(J)の術後2年以上の機能評価の報告は少ない。術後5年にわたる経時的機能改善は、Jよりストレ－ト再建(S)で大きいが、5年でもJはSより機能良好である。低位前方切除、特に吻合部が4cm以下の超低位吻合にJは必須である。

T1は腫瘍口側・肛門側 3cmの腸切、T2は中間リンパ節を頂点とした5cmの腸切、T3T4は主リンパ節を頂点とした10cmの腸切。T2で5cm以内に主幹動脈(FA)がない時は5cmの腸切のみで、T3T4で10cm以内にFAがない時は10cmの腸切のみでよい。

術後合併症と5年生存率からリンパ節転移を伴う局所進展癌に対しても骨盤内臓全摘術の適応はある。社会復帰は良好であるが、double stoma（人工肛門と尿路ストーマ）の心理的負担は大きい。

大腸癌肝転移に対して肝切除と術後補助免疫化学肝動注によって治療成績が著明に改善できることを報告した

大腸癌術後の経過観察における大腸内視鏡検査の有用性について検討した。

直腸癌手術におけるＪ型結腸嚢再建と自律神経温存手術について長期機能について検討した。

J-pouch(J)の機能が従来の端々吻合に勝ることはrandomized studyで示されている。Jの問題点とされる至適サイズ、排便困難、J作製結腸部位、適応、長期機能改善の有無を我々のデ－タを加えreviewした（英文）。

欧米ガイドラインにはJ型結腸嚢再建(J)で機能改善とあるが、２年以上の長期機能の報告は少なく、かつJによる長期の機能改善には賛否両論ある。経時的機能改善は従来のストレート再建(S)でより大きいが、術後5年でもJの機能はSより良好である。４cm以下の超低位吻合にJは必須である。

壁深達度T1は3cmの腸切、T2は中間リンパ節を頂点とした5cmの腸切、T3T4は主リンパ節を頂点とした10cmの腸切。T2で5cm以内に主幹動脈(FA)がない時とT3T4で10cm以内にFAがない時は腸切のみでよい。

高齢者直腸癌手術では、安全性を優先し側方郭清、骨盤内臓全摘、肝切除などの拡大手術は控えられるがpouch operationと自律神経温存で積極的に機能温存が行われ良好なQOLが保たれた。社会活動レベルと将来の介護の可能性を考慮したハルトマン手術は選択される。

J型結腸嚢再建(J)の機能が従来の端々吻合に勝ることはrandomized studyで示されている。Jの問題点とされる至適サイズ、排便困難、J作製結腸部位、適応、長期機能改善の有無について我々のデ－タを加えreviewした。

大きな結腸嚢作製は排便困難をもたらす。排便困難によるいきみはrectoceleの原因になる。大きな結腸嚢作製では排便困難によるいきみのため術後2年でrectocele-like prolapseが出現すると考えられた。

J型結腸嚢再建(J)と従来の端々吻合の機能を17項目の問診による排便スコアーと内圧測定による貯留能で比較した。Jの適応は吻合部までの距離が8（特に４）cm以下で、術後3年でもJの機能は端々吻合より良い。

直腸癌に対する骨盤内臓全摘術の適応について検討した。

結腸癌腹腔鏡手術では術中に結腸間膜の触診ができないので術前に根治性を損なわない切除範囲を決めておく必要がある。T1は腫瘍から3cmの腸切、T2は中間リンパ節と5cmの腸切、T3T4は主リンパ節と7cmの腸切。

医学教育コアカリ(2001)は6年を通じて身につけるべき最も重要な患者中心の医療を展開するための基本事項としてチ－ム医療をあげている。チ－ム医療の中心が医師であることを認識してクリクラに臨むべき。

下腸間膜動脈(IMA)をhigh tieすべきかlow tieでよいかは論点である。IMA根部の転移率は9%、転移例の5生率は39%と従来の報告より高率であったのはクリアリング法で小さいリンパ節を検索したからである。

局所再発防止を目的に癌の占居部位と壁深達度による腫瘍肛門側の間膜切除範囲を検討した。RbのT3T4には全直腸間膜切除で、RaのT3T4には5cmの腫瘍肛門側間膜切除で局所再発を防止する。

腹腔鏡手術は従来の開腹術よりリンパ節郭清と腸切除が少なくなることが指摘されている。根治性を損なわない切除はT1は腫瘍から3cmの腸切、T2は中間リンパ節と5cmの腸切、T3T4は主リンパ節と7cmの腸切。

高齢者は術前併存疾患が多い。側方郭清、骨盤内臓全摘、肝切を控えて術後合併症を減らす一方で、生理的な排便排尿障害が多いのでpouch operationと自律神経温存で積極的に機能温存が行われる。

下腸間膜動脈(IMA)high tieの利点はen bloc郭清と吻合部の緊張が少ないことで、欠点は下腹神経損傷と吻合部血流減少である。IMA根部転移率は9%、転移例の5生率は39%でhigh tieの適応は転移が高率なT3, T4。

局所再発の主な原因が腫瘍肛門側間膜内の癌遺残であるとし、全直腸間膜切除(TME)で5-15%の低い局所再発率が注目されている。リンパ節転移からTMEの適応は下部直腸T3,T4の進行癌である。

腹腔鏡結腸癌手術では術中に結腸間膜の触診ができないので術前に根治性を損なわない切除範囲を決めておく必要がある。T1は腫瘍から3cmの腸切、T2は中間リンパ節と5cmの腸切、T3T4は主リンパ節と7cmの腸切。

シンポジウム「大腸癌の転移に対する治療とその成績」においてわれわれが実施してきた外科切除と術後補助免疫化学肝動注の効果を発表した

大腸癌手術の中心は手術である。結腸癌に対する腹腔鏡手術、直腸癌に対する拡大郭清、骨盤内臓全摘、排便・排尿・性機能温存手術について日本論文、欧米論文に我々のデ－タを加え問題点をreviewした。

直腸癌手術で下腸間膜動脈(IMA)を根部でhigh tieすべきか low tieでよいかは論争点である。転移が高率にみられるT3, T4にはIMA high tieでIMA根部リンパ節を郭清する必要がある。

局所再発防止を目的に癌の占居部位と壁深達度による癌肛門側の間膜切除範囲を検討した。RbのT3T4には全直腸間膜切除で、RaのT3T4には5cmの癌肛門側間膜切除で局所再発を防止する。

T1は3cmの腸切、T2は中間リンパ節を頂点とした5cmの腸切、T3T4は主リンパ節を頂点とした10cmの腸切。T2で5cm以内に主幹動脈(FA)がない時とT3T4で10cm以内にFAがない時は腸切のみでよい。

高齢者直腸癌の疫学、診断、治療を日本論文と欧米論文と当科のデ－タを用いてreviewし、至適手術について述べた。

加齢に伴い増加する便失禁を考慮して直腸切断やハルトマン術が選択される高齢者のJ型結腸嚢再建(J)の機能評価は少ない。高齢者のJの機能は下剤の使用が多くなること以外コンチネンスを含め良好である。

J-pouch(J)の機能が従来の端々吻合に勝ることはrandomized studyで示されている。Jの問題点とされる至適サイズ、排便困難、J作製結腸部位、適応、長期機能改善の有無を我々のデ－タを加えreviewした（英文）。

術後5年にわたる経時的機能改善は、J型結腸嚢再建(J)よりストレ－ト再建(S)で大きいが、５年でもJはSより機能良好である。低位前方切除、特に吻合部が4cm以下の超低位吻合にJは必須である。

直腸癌術後再発の半数を占める局所再発の原因の一つに腫瘍肛門側間膜内の癌遺残がある。クリアリング法でリンパ節転移を検討した。RbのT3,T4には全直腸間膜切除で局所再発を防止する。

術中に結腸間膜の触診ができない腹腔鏡手術で根治性を損なわない切除範囲は、T1では腫瘍から3cmの腸切除、T2では中間リンパ節と5cmの腸切除、T3T4では主リンパ節と7cmの腸切除である。

下腸間膜動脈(IMA)を根部でhigh tieすべきか low tieでよいかは論争点である。IMA根部転移陽性例の予後は陰性例より悪いが転移が高率なT3, T4にはhigh tieを行ってIMA根部リンパ節を郭清する必要がある。

術後1年から5年にわたりJ型結腸嚢再建(J)、ストレ－ト再建(S)ともに機能は改善し貯留能も増加し、その機能改善はSでよりおおきいが、術後５年でもJの機能はSより良好である。

ワークショップ「各科癌治療の工夫」において転移性肝癌に対する治療とその成績につき解説した

直腸癌手術における超低位前方切除術の再建法であるＪ型結腸嚢再建における排便機能について検討した。術後１年から５年にわたり経時的変化を排便スコアーと貯留能で検討した。

至適切除はT1は3cmの腸切、T2は中間リンパ節と5cmの腸切、T3T4は主リンパ節と10cmの腸切。T2で5cm以内に主幹動脈がない時は5cmの腸切のみ、T3T4で10cm以内に主幹動脈がない時は10cmの腸切のみでよい。

Ｊ型結腸嚢再建と従来のストレート再建の長期排便機能の経時的変化について検討し、Ｊ型結腸嚢再建の利点について論じた。

大きな結腸嚢作製でみられる排便困難とrectocele-like prolapse (RP)の関連を調べた。排便困難によるいきみはrectoceleの原因とされている。大きな結腸嚢では排便困難によるいきみのため術後2年でRPが出現する。

日本は世界一の長寿国であり直腸癌手術の３割が７０歳以上である。便失禁を考慮して直腸切断やハルトマン手術が選択されることのある高齢者に対するJ型結腸嚢再建の機能は、下剤の使用が多くなること以外はコンチネンスを含め良好。

術後合併症と5年生存率からリンパ節転移陽性の局所進展癌に対しても骨盤内臓全摘術の適応はある。社会復帰は良好であるが、人工肛門と尿路ストーマの心理的負担は大きい。

側方郭清と神経温存の適応をクリアリング法によるリンパ節転移から検討し、問診で長期機能を評価した。前者の適応はRbのT3, T4、後者はT1, T2, Rsである。神経温存の長期排尿性機能、社会復帰は良好である。

直腸癌低位前方切除術においてＪ型結腸嚢再建と従来のストレート再建について長期排便機能の経時的変化について検討しＪ型結腸嚢再建の意義についてまとめた。

直腸癌低位前方切除術の再建法についてＪ型結腸嚢再建と従来のストレート再建について術後長期排便機能の経時的変化について検討した。

直腸癌前方切除において大きな結腸嚢再建は排便困難をもたらす。排便困難によるいきみはrectoceleの原因になる。大きな結腸嚢では排便困難によるいきみのため術後2年でrectocele-like prolapseが出現する。

直腸癌患者の３割が７０歳以上である。加齢で増加する便失禁を考慮し直腸切断やハルトマン手術が選択される高齢者のJ型結腸嚢再建の機能評価は少ない。下剤/浣腸の使用が多くなること以外コンチネンスを含め良好。

側方郭清を伴う自律神経温存では郭清の不十分さと温存神経の繊維化による機能障害が問題となる。転移が高率に見られるRbのT3, T4はen blocな側方郭清の適応である。T1, T2, Rsは神経温存でQOL向上を計る。

加齢に伴って増加する便失禁を考慮して直腸切断やハルトマン手術が選択されることのある高齢者に対するJ型結腸嚢再建の機能は、下剤/浣腸の使用が多くなること以外はコンチネンスを含め良好である。

排便困難によるいきみがrectoceleの原因になることが報告されている。大きな結腸嚢作製では排便困難によるいきみのため術後2年でrectocele-like prolapseが出現すると考えられた。

直腸固有筋膜の外面に沿って剥離し神経叢の授動なしに温存する結果、90-100%の排尿機能温存と80-90%の性機能温存であった。T1, T2, Rsには固有筋膜外面に沿った剥離で神経叢を温存し術後QOLの向上を計る。

Ｊ型結腸嚢再建を用いた直腸癌低位前方切除術の術後排便機能を長期にわたり経過かんさつし、その機能の経時的変化について検討した。

側方転移が高率に見られるRbのT3,T4には側方郭清を行って放射線化学療法を追加する必要がある。T1,T2,Rsには神経温存を行って術後QOLの向上を計る。

直腸癌前方切除術におけるＪ型結腸嚢再建における長期排便機能の改善の意義について検討した。

下部直腸癌の手術術式の人工肛門を有する腹会陰式直腸切断術と人工肛門がない前方切除術の術後ＱＯＬについて検討した。

直腸癌前方切除術において機能温存の観点からＪ型結腸嚢再建の適応と意義について検討した。

大きな結腸嚢作製は排便困難をもたらす。排便困難によるいきみはrectoceleの原因になる。大きな結腸嚢作製では排便困難によるいきみのため術後2年でrectocele-like prolapseが出現すると考えられた。

自律神経温存では剥離面の縮小による癌遺残が問題である。適応をリンパ節転移から検討し排尿・性機能を調べた。側方転移が少ないT1, T2, Rsには神経温存を行い術後QOL向上を計る。

術後合併症と5年生存率からリンパ節転移を伴う局所進展癌に対しても骨盤内臓全摘術の適応はある。社会復帰は良好であるが、人工肛門と尿路ストーマの心理的負担は大きい。

J型結腸嚢再建(J)の機能はストレート再建より優れているが高齢者に対するJの評価は少ない。高齢者に対するJは下剤と浣腸の使用が多くなること以外はコンチネンスを含め良好である。

直腸癌手術における前方切除術でもＪ型結腸嚢再建の適応を検討した。（英文）

前方切除におけるJ型結腸嚢再建の機能は良好であるが大きな結腸嚢は排便困難をもたらす。大きな結腸嚢（折り返しの長さ10cm）でみられる排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する。

術中にリンパ節を触診できない腹腔鏡下結腸癌手術で根治性を損なわないためには、T1では腫瘍から3cmの腸切除、T2では中間リンパ節と5cmの腸切除、T3,T4では主リンパ節と7cmの腸切除が必要である。

J型結腸嚢再建の機能は端々吻合に勝るが、大きな結腸嚢は排便困難をもたらす。大きな結腸嚢作製（折り返しの長さ10cm）でみられる排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する。

前方切除で吻合部までの距離が8cm (特に4cm)以下の時にはJ型結腸嚢再建を行い、壁深達度T1, T2, 占居部位Rsには自律神経温存を行い術後長期にわたるQOL向上を計る。

低位前方切除の排便機能はJ型結腸嚢再建を用いることで従来の端々吻合より改善されるが大きな結腸嚢は排便困難をもたらす。この排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する。

規約はリンパ節転移の広がりで、TNMは転移個数で分類する。4mm未満のリンパ節を検索できるクリアリング法で両者を比較した。規約はTNMより症例数分布と5年生存率がwider rangeでありかつ郭清すべき領域を示すので臨床的に有用である。

pouch operationと自律神経温存で積極的に機能温存が行われるが、80歳以上では社会活動レベルと将来の介護の可能性を考慮してハルトマン手術は選択される。術前に人工肛門とストーマケアの利点を説明する必要がある。

J型結腸嚢再建(J)の適応（肛門縁から吻合部までの距離の上限）とJによる術後2年以上の機能改善の有無が問題である。適応は吻合部までの距離が8（特に４）cm以下で、術後5年でもJの機能は端々吻合より良い。

結腸の折り返し10cmと5cmのJ-pouchの術後3月、1年、2年の造影所見を比較し、排便機能との関連を見た。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する。

J型結腸嚢の大きさと排便困難の関連を検討した。回腸嚢の容量が経時的に増加することで排便困難がおこることは報告されている。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢の過膨張が関与する。

術前併存疾患が多いので拡大手術の選択に論争がある。治癒切除率は低く、出血量は少なく、手術時間は短く、5生存率は低い。安全性を優先し75歳以上で側方郭清が、80歳以上で骨盤内臓全摘や肝切除が控えられる。

J型結腸嚢再建(J)と従来の端々吻合の機能を17項目の問診による排便スコアーと内圧測定による貯留能で比較した。Jの適応は吻合部までの距離が8（特に４）cm以下で、術後5年でもJの機能は端々吻合より良い。

結腸嚢の傾きが水平に近くなるほど排便は効果的に行えず排便困難の愁訴が増加すると考えられた。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する。

検索リンパ節数が多くなるほど転移率は高くなりリンパ節転移分類の評価は正確になる。規約はTNMより症例数分布と5年生存率がwider rangeでありかつ郭清すべき領域を示すので臨床的に有用である。

安全性を優先し側方郭清、骨盤内臓全摘、肝切除は控えられるがpouch operationと自律神経温存で積極的に機能温存が行われ良好なQOLが保たれた。社会活動レベルと将来の介護の可能性を考慮したハルトマン手術は選択される。

J型結腸嚢再建の適応は肛門縁から吻合部までの距離が8cm以下であり、特に４cm以下の超低位吻合には必須である。術後5年でもJ型結腸嚢再建の機能は従来のストレート再建（端々吻合）より良好である。

直腸癌前方切除術術後における排便機能について、Ｊ型結腸嚢再建と従来のストレート再建を術後１年、３年、５年で排便スコアーと貯留能で比較してＪ型結腸嚢再建の適応と機能改善の有無を検討した。

結腸嚢造影で結腸嚢長軸と水平線のなす角（pouch-horizontal angle）は10cmの結腸嚢が5cmの結腸嚢より小さく、排便困難の愁訴は10cmの結腸嚢に多かった。大きな結腸嚢でみられる排便困難に結腸嚢長軸の水平化が関与する。

直腸癌前方切除術術後における排便機能について、Ｊ型結腸嚢再建と従来のストレート再建を術後１年、３年、５年で排便スコアーと貯留能で比較しＪ型結腸嚢再建の適応と機能改善の有無を検討しＪ型結腸嚢再建の意義を論じた。

高齢者では安全性を優先し側方郭清、骨盤内臓全摘、肝切除を控える一方で、pouch operationと自律神経温存で積極的に機能温存が行われる。但し、社会生活レベルと将来の介護の可能性を考慮してハルトマン手術は選択される。

J型結腸嚢再建の術後機能は従来の端々吻合より良いが大きな結腸嚢作製は排便困難をもたらす。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢長軸の水平化が関与する。

適応は肛門縁から吻合部までの距離が8cm以下であり、特に４cm以下の超低位吻合には必須である。術後5年でも従来のストレート再建より機能良好である。

J型結腸嚢再建を用いた低位前方切除の排便機能は良好であるが、大きな結腸嚢作製は排便困難の原因となる。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢の過膨張が関与する。

結腸癌切除152例のリンパ節転移をクリアリング法で調べた。規約（転移の広がりで分類）はTNM（1992年版：転移の数と広がりで分類、1997年版：転移の数で分類）より症例数分布と5年生存率がwider rangeでありかつ郭清すべき領域を示すので臨床的に有用である。

肝切除後合併症として胆汁漏が考えられ、その予防にRTBDチュ-ブドレナ－ジを用いたところ、発生率は変わりないが漏出期間、入院期間が短縮された。

大腸癌原発の肺転移症例に対する胸腔鏡下切除術の妥当性を検討した。単発例であれば完全切除が可能であるが、多発例では不完全切除になる可能性がある。

直腸癌前方切除術術後１年と３年と５年における排便機能をＪ型結腸嚢再建とストレート再建を排便スコアーと貯留能で比較して適応と機能改善の有無を検討した。

結腸癌切除152例のリンパ節転移をクリアリング法で調べた。規約はTNMより症例数分布と5年生存率がwider rangeでありかつ郭清すべき領域を示すので臨床的に有用である。

J型結腸嚢再建を用いた低位前方切除の排便機能は良好であるが、大きな結腸嚢作製は排便困難の原因となる。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢の過膨張が関与する。

直腸癌に対する低位前方切除術における再建について、Ｊ型結腸嚢再建とストレート再建を術後１年と３年で比較して適応と排便機能改善の有無を検討した。

J型結腸嚢再建を用いた低位前方切除の排便機能は良好であるが、大きな結腸嚢作製は排便困難の原因となる。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢の過膨張が関与する。

直腸癌に対する前方切除術術後1年、3年、5年における排便機能を、J型結腸嚢再建とストレート再建を排便スコアーと貯留能で比較して適応と機能改善の有無を検討した。

術後機能改善のためにJ型結腸嚢再建が行われるが唯一の欠点に排便困難があり、これは結腸嚢の大きさに関係する。10cmの大きな結腸嚢作製でおこる排便困難に術後1年以内におこる結腸嚢の過膨張が関与する（英文）。

J型結腸嚢再建を用いた低位前方切除の排便機能は良好であるが、大きな結腸嚢作製は排便困難の原因となる。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢の過膨張が関与する。

高齢者では安全性を優先し拡大手術を控える一方で、積極的に機能温存が行われる。但し、社会活動レベルと将来の介護の可能性を考慮してハルトマン手術は選択される。

J型結腸嚢再建を用いた低位前方切除の排便機能は良好であるが、大きな結腸嚢作製は排便困難の原因となる。大きな結腸嚢作製でみられる排便困難に術後1年までにおこる結腸嚢の過膨張が関与する。

直腸癌前方切除術後１年と３年における排便機能をJ型結腸嚢再建とストレート再建を比較して適応と機能改善の有無を検討した。