花井 恒一

A 69-year-old woman, who complained of loss of appetite, was admitted to our hospital and diagnosed with clinical Stage Ⅳgastric cancer and paraaortic lymph node metastases(cT4aN3M1[#16b1LYM], cStage Ⅳ). She underwent 2 cycles of SP therapy(combination of S-1 and CDDP). A partial response of the primary tumor was noted, with no distant metastases, except for the paraaortic lymph nodes. She underwent robotic total gastrectomy with D2 plus paraaortic lymph node dissection. Histopathology showed no residual tumor cells in the stomach or lymph nodes. Postoperatively, the patient underwent 3 cycles of SOX therapy(combination of S-1 and oxaliplatin)and survived for over 6 postoperative months, with no recurrences. For advanced gastric cancers with paraaortic lymph node dissection with no evidences of other distant metastases, gastrectomy with paraaortic lymph node dissection combined with chemotherapy could be a therapeutic option to achieve R0 resection.

BACKGROUND: Although hepatectomy for metastatic colorectal cancer (mCRC) prolongs survival in up to 40% of people, recurrence rates approach 70%. We used a multidisciplinary approach to treat recurrent liver metastases, including chemotherapy, surgery, and palliative care. On the other hand, development of chemotherapeutic agents is remarkable and improves long-term survival. However, whether chemotherapy and repeat hepatectomy combination therapy improve survival or not is still unclear. The aim of this study was to analyze the outcomes of repeat hepatectomy with systemic chemotherapy for mCRC. METHODS: Following Institutional Review Board approval, we reviewed the records of all patients who underwent hepatectomy for mCRC between 1974 and 2015 at Fujita Health University Hospital. We used the Kaplan-Meier method to estimate overall survival from the first and last hepatectomy in multi hepatectomy cases after 2005 and compared outcomes between groups using the log-rank test. RESULTS: A total of 426 liver resections were performed for mCRC; of these, 236 cases were performed after 2005 (late group). In 118 (50%) cases, the site of recurrence was the liver, 59 (50%) underwent repeat hepatectomy, and 14 cases had ≥ 2 repeat hepatectomies. Overall survival (OS) before and after 2005 was 42.2 and 64.1 months, respectively, with the late group having better OS compared to the early (1974-2004) group. OS for single hepatectomy cases was 83.2 months, for two hepatectomies was 42.9 months, and for three hepatectomies was 35.3 months. In total, 59 patients did not undergo surgery after recurrence with an OS of 28.7 months. Mortality of the second and third repeat hepatectomy was 1.7% and 15.3%, respectively. CONCLUSION: Repeat hepatectomy with systemic chemotherapy for mCRC is feasible and might achieve improved survival in carefully selected patients.

A 63-year-old woman was admitted to our hospital with a right lower abdominal mass and general fatigue. Preoperative examination suggested a large ovarian tumor or cecal carcinoma. However, her intraoperative diagnosis was colon cancer; we therefore performed an ileocecal resection with oophorectomy. The tumor was pathologically diagnosed as adenosquamous carcinoma T4bN1M-stage IIIa. We administrated CapeOX adjuvant chemotherapy for 6 months. Adenosquamous carcinoma is extremely rare, at around 0.1% of all colorectal cancers, and usually has a poor prognosis. The patient is still alive without recurrence after 84 post-operative months, even with later developments of metachronous early colorectal cancer and breast cancer. We herein report a rare case of cecal ASC with good prognosis.

This case involved a 69-year-old female patient with peritoneal dissemination of an advanced gastric cancer. She underwent chemotherapy comprisingintravenous and intraperitoneal paclitaxel combined with S-1. After 20 courses, a staging laparoscopy was performed, and pathological analysis of the peritoneal dissemination and cytologic analysis of ascites fluid yielded negative results. A radical robot-assisted total gastrectomy was successfully performed. The pathological stage was determined to be ypT4aN2M0, ypStage ⅢB. We continued to administer the same chemotherapy regimen for 15 courses (total: 35 courses)after surgery. No recurrence has been detected during the 1-year period after surgery.

A 60-year-old male was admitted to our hospital on account of a duodenal submucosal tumor on the opposite side of Vater's papilla identified on a screening gastroduodenoscopy. The tumor was diagnosed as a duodenal gastrointestinal stromal tumor(GIST)due to positive c-kit and DOG1tests. Gastroduodenography and enhanced computed tomography showed a 50mm tumor widely invadingthe descendingportion of the duodenum close to the papilla of Vater and indicated the need for extended resection includingpancreaticoduodenectomy to achieve curation. Preoperative chemotherapy was initiated with imatinib mesylate(imatinib)to preserve the pancreas. A 16 month course of imatinib shrunk the tumor up to 21mm and laparoscopic partial duodenectomy was performed as a curative resection. So far, no local tumor recurrence has been seen for 26 months after the surgery. Herein, we report this case with a review of the literature.

OBJECTIVE: The treatment policy of colorectal cancer in elderly patients is controversial due to a lack of specific guidelines. To clarify the present management of colorectal cancer for aged patients, a questionnaire survey was conducted by the Japanese Society for Cancer of the Colon and Rectum. METHODS: Questionnaire forms were sent to the 430 member institutions of the Japanese Society for Cancer of the Colon and Rectum. RESULTS: The response rate of the surgical department to the questionnaire was 39%. Performance status was used for preoperative assessments, and electrocardiogram and ultrasonic cardiograms were conducted for cardiovascular evaluations in many institutions. The same extent of surgical procedures was often adopted for elderly and younger patients, and the frequency of a laparoscopic procedure was the same regardless of a patient's age. A simultaneous hepatectomy for hepatic metastasis was considered in one-third of institutions. In many institutions, intersphincteric resection for patients with possible sphincter-saving surgery was not considered for elderly patients with low rectal cancer. CONCLUSION: Japanese Society for Cancer of the Colon and Rectum member institutions often used the same surgical treatment strategies for both elderly and younger patients with the exception of performing intersphincteric resection.

Rectovaginal fistula caused by a tension-free vaginal mesh (TVM) is a rare condition. Moreover, a rectovaginal fistula is a challenging issue to address for surgeons regardless of causes. Due to a low rate of occurrence, treatment modality for a rectovaginal fistula caused by a TVM has previously received little attention. A successful surgery using several key techniques to address a rectovaginal fistula caused by a TVM is herein reported. A 78-year-old woman who underwent a TVM for a rectocele three months ago was referred to our hospital with a two-month history of anal bleeding. Mesh protruding into both the vagina and the rectum was confirmed. The patient was operated on under diagnosis of a rectovaginal fistula caused by TVM. TVM was removed by transvaginal dissection of the rectovaginal septum with division of both anterior and posterior arms of the TVM. Layer-to-layer sutures of rectal and vaginal walls were crossly performed with a drain placed in the rectovaginal septum after saline irrigation followed by a covering sigmoid colostomy. The wound healed without infection after surgery, and a water-soluble contrast enema demonstrated the healing of the rectovaginal fistula two months after surgery. No recurrent fistula was confirmed 15 months after stoma closure.

INTRODUCTION: Previous randomized controlled trials demonstrated similar oncological outcomes between laparoscopic and open colectomies, except for cases involving transverse colon and splenic flexure colon cancer. The objective of this study was to confirm the oncological safety and advantages of the short-term results of laparoscopic surgery for transverse and descending colon cancer in comparison with open surgery. METHODS: The study data were retrospectively collected from the databases of 45 hospitals. Patients with transverse or descending colon cancer who underwent laparoscopic or open R0 resection were registered. The primary end-points were the 3-year overall survival and relapse-free survival rates according to pathological stage. The secondary end-points were the short-term results, including blood loss, operative time, diet intake, hospital stay, and postoperative complications. RESULTS: Of the 1830 eligible patients, 872 underwent open colectomy and 958 underwent laparoscopic colectomy. The median follow-up period was 38.4 months. The conversion rate to open resection was 4.5%. The 3-year overall survival rate of the laparoscopic group was significantly higher than that of the open group for stage I patients (96.2% vs 99.2%; P = 0.04); it was also higher for stage II (94.0% vs 95.5%) and stage III (87.4% vs 90.2%) patients, but there were no significant differences. The 3-year relapse-free survival rate of the laparoscopic group was significantly higher than that of the open group for stage I patients; there were no differences between the open and laparoscopic groups among the stage II and III patients. In the multivariate analyses, laparoscopic resection was a significant factor in relapse-free survival. Laparoscopic patients had significantly lower blood loss and a significantly longer operative time than the open groups. Also, postoperative hospital stay was significantly shorter and postoperative morbidity was significantly lower in the laparoscopic group. CONCLUSION: Although this retrospective study has limitations, we can conclude that laparoscopic surgery for transverse and descending colon cancer is oncologically safe and yields better short-term results than open surgery.

Robotic surgery offers advantages for operating in a narrow space such as inside the pelvis. We report on the technique of robotic-assisted laparoscopic total proctocolectomy with lymphadenectomy and ileal pouch-anal anastomosis for ulcerative colitis with transverse colitic cancer, using the single cart position. A 46-year-old female patient was diagnosed with colitic cancer of the transverse colon during the surveillance of ulcerative colitis. Six port sites were used. Mobilization of the left-sided colon through to the rectum and mobilization of the transverse colon with lymphadenectomy around the middle colic artery were performed using the robotic surgical system. After rectal mobilization was conducted near the anus, the right side of the colon was mobilized and the ileum resected laparoscopically. Thereafter, a mucosectomy of the proctorectum was carried out through a trans-anal approach, and a hand-sewn J-pouch was performed. Finally, a diverting ileostomy was constructed through the right lower abdomen. The operative time was 460 minutes, including the console time of 361 minutes. The amount of blood loss was 76 g. The patient was discharged on postoperative day nine. Pathological results demonstrated that the depth of the lesion was T3, and the positive lymph node was 1 of 115 retrieved lymph nodes. There were no complications or mortality. Robotic-assisted total proctocolectomy and lymphadenectomy with ileal pouch-anal anastomosis for transverse colitic cancer of ulcerative colitis was performed safely using the single cart position.

INTRODUCTION: Anastomotic surgical recurrence after bowel resection is a major problem in patients with Crohn's disease. The aim of this prospective observational study was to evaluate the efficacy of a novel technique for restoring bowel continuity after resection involving either the small or the large intestine. METHODS: The first case was instructed by Dr. Kono at Fujita Health University. The involved bowel segment was divided transversely with a linear stapler. The edges of two stapled lines are then connected to create a supporting column, which prevented surgical recurrence from anastomotic distortion due to mesenteric longitudinal ulcers. Thereafter, an antimesenteric longitudinal enterotomy was performed on each side to create a large-sized handsewn end-to-end anastomosis. RESULTS: Thirty consecutive patients underwent Kono-S anastomoses from December 2009 to August 2013. Neither anastomotic leakage nor surgical recurrence was observed during a median follow-up period of 35 months. Endoscopic surveillance was performed in 18 cases (69.2%) undergoing ileo-colonic or ileo-rectal anastomosis with an average Rutgeert's score of 0.78 (0-3) at a mean of 14.5 months postoperatively. CONCLUSION: The Kono-S anastomosis for Crohn's disease has been a safe and feasible technique. Long-term outcomes are required to confirm its advantage in preventing surgical recurrence at the anastomosis.

Laparoscopic gastrointestinal surgery with lymphadenectomy is rarely performed for multiple gastrointestinal cancers. We report four patients undergoing laparoscopic surgery for synchronous cancer of the stomach and colon. Resection of each organ with lymphadenectomy was performed by each specialist and the region of the lymphadenectomy was determined according to the lesion of cancer and its depth. The selection of gastric anastomosis, whether intracorporeal or extracorporeal, depended on the resecting areas of the large bowel to allow a small incision. All four cases were male with the median age of 69 (range 59-77) years. The median number of trocars used were 6 (range 5-8) and median length of incision was 4.5 cm (range 4-4.5 cm). The median operative time and blood loss were 495.5 minutes (range 390-605) and 88 g (range 36-245), respectively. In all four cases, laparoscopic surgery with a lymphadenectomy on each region was successfully accomplished according to the respective progression stage. Anastomosis was completed with a small incision by using techniques and devices to provide a variation of anastomosis methods and incision positions. Laparoscopic surgery with lymphadenectomy was also undertaken for a patient with gastric remnant cancer and colorectal cancer. The median length of the postoperative hospital stay was 14.5 days (range 12-29). No complications were observed after the surgery. There was no case of recurrence during a median follow-up of 84.3 months (range 54.9-111.5). Laparoscopic surgery was feasible for patients with double cancer of the stomach and colon.

Solitary fibrous tumors (SFTs) develop most commonly in the pleura, although they have occasionally been reported to arise in the pelvic cavity. We report a case of an SFT presenting as a painless nodule in the pelvis of a 56-year-old woman. Histologically, the tumor was composed of spindle-shaped cells arranged without pattern, with short and narrow fascicles and interspersed bundles of thick collagen, and numerous blood vessels with a focally hemangiopericytoma-like appearance. Immunohistochemically, the tumor cells strongly expressed vimentin, CD34, and bcl-2. The tumor was excised via a trans-sacral approach, without preoperative transcatheter embolization, and the patient remains well more than 2 years after her operation. To our knowledge, this is the first case of an SFT in the pelvis, which was excised completely via a trans-sacral approach.

We evaluated the effect of hepatic arterial infusion(HAI)chemotherapy for liver metastases from colorectal cancer. A total of 65 patients received HAI chemotherapy. The chemotherapy regimen consisted of weekly 5-FU (1, 500 mg/body) or 5-FU (400 mg/mm2) and l-LV (200mg/mm2). The survival and response rates were assessed according to RECIST. Median survival time with HAI chemotherapy was 13. 5 months, 5-year survival rate 8% and response rates 55%. There was no evidence of myelosuppression, and HAI could be continued for a long time even for poor PS patients. There were no differences in survival time between synchronous, metachronous and postoperative metachronous liver metastases. In the patients who underwent curative hepatectomy after HAI chemotherapy, the 5-year survival rate was 21%, which was better than in patients with HAI chemotherapy alone. HAI chemotherapy could thus be an option for unresectable liver metastases, which could be well tolerated.

Metachronous multiple carcinomas at the site of a stoma is a rare condition after surgery. A 67-year-old man with a second tumor at the stoma site 15 years after abdominoperineal resection for rectal carcinoma is reported herein with a review of the Japanese literature. The patient visited our hospital 20 years after initial surgery, presenting with constipation and increasing tumor size in the stoma. A biopsy specimen of the tumor revealed adenocarcinoma. Block resection of the sigmoid colon and colostomy with the adjacent abdominal wall was performed. Histopathological examination showed a well-differentiated adenocarcinoma in the stoma invading the adjacent skin. A median of 144 months from the initial operation was documented in 23 cases reported.

We reviewed 7 cases of clinical record with preoperative chemo-radiotherapy to evaluate the clinical effectiveness of the chemo-radiotherapy for T4 rectal cancer. The preoperative radiation therapy consisted of 40-45 Gy delivered in fractions of 1.8-2.0 Gy per day, five days a week. A treatment of 5-fluorouracil, 500 mg/body per day intravenously, or oral UFT-E (300 mg/m2) with l-leucovorin (75 mg) per day, or oral S-1 (80 mg/m2) per day five days a week, was given during radiotherapy. Grade 1 or 2 adverse effects occurred in 3 patients during chemo-radiotherapy, but the completion of chemo-radiotherapy was achieved in all of the 7 patients. Tumor invasion identified by CT and MRI to other organs in the pelvis disappeared in four cases with complete or partial response after a month of chemo-radiotherapy. Although the other organs were also removed during surgery in 4 patients, curative surgery was performed in 5 patients. There was no histological invasion seen to other organs in 4 patients, and one patient had histological complete disappearance of tumor. Although complications after surgery were found in all of the patients, they were improved by conservative treatment. One of 4 patients with curative surgery had liver and local recurrence, but others survived without recurrence. Preoperative chemo-radiotherapy was expected to be a safe and effective treatment to improve the resection rate and prognosis for T4 rectal cancer.

BACKGROUND: The conventional double-stapling technique (DST) using a standard linear stapler horizontally is sometimes difficult to apply to an anastomosis where the pelvis is narrow or the anastomosis is ultralow. In this report, we review our experiences of a novel DST (IO-DST) that employs vertical division of the rectum using an endostapler. MATERIALS AND METHODS: One-hundred and five consecutive patients who underwent low anterior resection for rectal carcinoma below the peritoneal reflection were enrolled into this study. The clinical, oncological, and functional outcomes were studied retrospectively. RESULTS: The median distance from the anal verge to the tumor was 5.0 cm in "high risk" T1 tumors and 6.5 cm in more-advanced tumors. More than 2 cm of distal surgical margin was obtained in 80.6% of the patients with tumors deeper than T1. The median distance from the anal verge to the anastomosis was 4.2 cm in T1 tumors and 4.0 cm in more-advanced tumors. The median blood loss was 315 ml, and the median operative time was 262 min. There was no mortality in the IO-DST. Recurrence presented in 12 (13.0%) of the patients who underwent curative surgery, with local recurrence in four patients (4.3%) during a median follow-up of 46.2 months. However, no patients experienced suture-line recurrence. The early bowel frequency was four times/day after stoma closure in patients with transient covering colostomy and 3.5 times/day in patients without colostomy. The late bowel frequency was three times/day in patients with transient covering colostomy, and two times/day in patients without colostomy. CONCLUSIONS: The IO-DST is a feasible and safe procedure for facilitating lower anastomosis in rectal carcinoma below the peritoneal reflection.

当院で1974〜2005年に肝切除術を行った大腸癌肝転移196例の治療成績を単発転移群と多発転移群,同時性転移群と異時性転移群,大腸癌取扱い規約H分類別などに分けて比較検討した.全症例の初回肝切除後5年生存率は42.2%,10年生存率は33.4%であった.単発転移群は5年生存率54.7%,10年生存率46.9%,多発転移群はそれぞれ27.9%,18.8%で,多発転移群が有意に予後不良であった.同時性転移群は5年39.2%,10年28.2%,異時性群はそれぞれ44.9%,38.4%で,両群間に有意差は認められなかった.大腸癌取扱い規約(旧)H分類による比較ではH1群がH2・H3群に比べて有意に予後良好であった.残肝再発に対する再肝切除群,肺転移切除群,肝肺3回以上繰り返し切除群の再切除後5年生存率はそれぞれ31.1%,39.6%,22.5%であった.術前検査として血管造影下CTを施行された群と非施行群とで5年生存率を比較すると,それぞれ42.6%,43.2%で有意差は認められなかった

PURPOSE: The original double-stapling technique (DST) using a standard linear stapler horizontally can be difficult in patients with a narrow pelvis or an ultralow anastomosis. We review our experience of performing a modified DST (IO-DST) with vertical division of the rectum achieved using an endostapler. METHODS: We retrospectively studied the clinical outcomes of 90 patients who underwent low anterior resection (LAR) for lower rectal carcinoma. Low anterior resection was performed with IO-DST in 34 patients (IO-DST group), with the single-stapling technique (SST) in 47 (SST group), and with per anal anastomosis (PAA) in 9 (PAA group). RESULTS: The distances from the anal verge to the tumor and to the anastomosis were significantly shorter in the IO-DST group than in the SST group (5.8 cm, 4.0 cm vs 7.0 cm, 5.0 cm, respectively), whereas it was equivalent in the IO-DST and PAA groups (5.0 cm, 4.0 cm). Blood loss was less in the IO-DST group than in the SST and PAA groups (400 ml vs 578 ml and 950 ml, respectively). The operative time was shorter in the IO-DST group than in the PAA group (281 min vs 327 min, respectively). There were no significant differences in the length of the distal surgical margin among the three groups. The IO-DST group patients suffered less bowel frequency than the SST group patients 1 month after surgery (2.5 times/day vs 4.0 times/day, respectively) and less than the PAA group patients more than 1 year after surgery (2.0 times/day vs 3.5 times/day, respectively). There were no significant differences in the incidence of complications or local recurrence among the three groups. CONCLUSIONS: IO-DST is a feasible and safe procedure for performing low anastomosis, which results in less bowel frequency after LAR for lower rectal carcinoma.

Intra-arterial infusion chemotherapy via the internal iliac artery was performed in 5 patients with locally advanced rectal cancer or recurrent rectal cancer. Arterial infusion chemotherapy was conducted into the internal iliac artery via bilateral femoral artery following a blood flow change with a coil. 5 FU 500 mg and l-leucovorin 125 mg/m2 were injected weekly. An average time of injections or its duration was 40 (17-74) times or 12.8 (5-23) months, respectively. Disappearance or improvement of symptoms was observed in 4 cases. A decrease of tumor size observed by CT was in 2 cases and a decrease of blood CEA level was in 3 cases. As for the complication of arterial infusion chemotherapy, dermatopathy was found in all of the cases, and sensory disturbance of lower extremities was in 3 cases, infection was in 2 cases and catheter obstruction was in 2 cases. A decrease of dosage or abundance of continuation was done during the course due to complications. Two patients with primary cancer died 1-3 years after the treatment, and 2 patients with recurrence died 7 months to 1 year after the treatment. One patient with primary cancer is continuing the treatment for the last 2 years though multiple metastatic diseases have been confirmed.