Akiharu Kurihara

Transanal rectal dissection: A procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis

BACKGROUND Laparoscopic approaches for colorectal surgery have been improved recently; however, it is often difficult to achieve total mesorectal excision (TME) for lower rectal cancer laparoscopically because of a narrow pelvis and a thickened mesentery. METHODS TME was successfully performed in 6 patients (4 men, 2 women) with dissection of the rectum transanally from the anal side of the tumor. The preoperative stage was T3N1M0 in 1 patient and T3N0M0 in 5 patients. The mean body mass index was 29.8 kg/m(2) (range, 28.7-31.2 kg/m(2)), and the mean tumor size was 46.5 mm (range, 30-60 mm). RESULTS The mean duration of the anal portion of the operation was 64 minutes (56 minutes in women, 79 minutes in men). No complications occurred during surgery or postoperatively. CONCLUSION This technique is a simple and effective procedure for successfully performing laparoscopic TME of lower rectal cancer in patients with bulky tumors, narrow pelvises, and thickened mesenteries.

Chemoradiation therapy with S-1 for primary squamous cell carcinoma of the rectum: report of three cases

PurposeAlthough successful treatment of squamous cell carcinoma (SCC) of the rectum using chemoradiation therapy (CRT) has been reported, a standard protocol has yet to be established. The aim is to ascertain the effectiveness of CRT with S-1 for three patients with SCC of the rectum.Case presentationWe treated three female patients complaining of rectal bleeding. The patients were diagnosed as having primary SCC of the rectum by means of routine examinations; one of them was a very rare case because of the presence of two lesions in the lower rectum. We treated the patients using CRT with S1 at a radiation dose of 1.8 Gy/fraction given five times weekly (Monday to Friday) to a median dose of 59.4 (45 to 59.4) Gy; S-1 (80 mg/m2/day) was administered orally during radiation therapy. One of three patients had an adverse event involving massive hemorrhage from the tumor. All patients exhibited an excellent response to CRT with S-1; two patients had a complete response, and one patient had a partial response and underwent a posterior pelvic exenteration with advancement flap reconstruction as a salvage treatment. Pathological examination of the resected specimen and lymph nodes revealed no tumor cells indicating a pathological complete response. In this series, the response rate was 100%.ConclusionsWe suggest that CRT with S-1 be chosen as the first-line therapy for SCC of the rectum. However, a large study will be required to establish a safe and effective regimen.

Massive cutaneous metastases in the lower part of the body of a patient with rectal cancer.

tion grew rapidly and became hard, verrucous and nodular. The nodules fused, became necrotic and ulcerated, and extended upward progressively; the artificial anus was covered by tumor ( fig. 2 ). Histological examination of an incisional biopsy of one of the skin lesions revealed metastatic adenocarcinoma. He died of cachexia 7 months after the skin metastases had appeared. At the final stage, there was no evidence of liver and lung metastases. We suspect that occlusion of the lymph flow by the tumor in the right leg caused a new pathway of lymph flow to develop under the skin. The lymph flow carried the cancer cells to the skin, where metastases developed. A 66-year-old man presented with a rectal tumor and bilateral inguinal swelling. His rectal tumor was 2 cm from the anal verge, and the biopsy showed an adenocarcinoma. Distant metastasis was not evident at that time. An abdominoperitoneal resection of the rectum was performed, and histologic examination of the surgical specimen demonstrated a moderately differentiated adenocarcinoma measuring 11 cm in maximal diameter and extending into the perirectal fat. Regional and inguinal lymph nodes showed metastatic change. Twelve months after the operation, a brown eruption appeared in the edematous right thigh ( fig. 1 ). The erupPublished online: July 8, 2009

An Influence of Perforation on Prognosis of Colorectal Cancer Patients

目的: 穿孔を合併した大腸癌患者の術後のサーベイランスについては, いまだ統一した見解は得られていないのが現状であることら, 穿孔を伴った大腸癌患者の長期予後を含めた臨床的特徴について検討を行った. 対象と方法: 1984～2004年の20年間に腹膜炎で発見された大腸癌28例を対象とし, 臨床病理組織学的背景と術後の再発形式および予後を検討した. 成績: 男女比は20: 8で, 平均年齢61.5歳 (45～82歳). 部位としてはS状結腸 (56%) に多く, 穿孔部位は病変の口側13例, 腫瘍部15例で, 遊離穿孔は18例 (64.3%) に認められた. 組織学的進行度は, stage II17例, stage III7例, stage IV3例, 不明1例で, 対象の半数以上の60%がstage IIであった. 手術は22例 (78%) に根治術が行われたが, 4例がDICによる術後合併症死であった. 再発例は32%(7/22) で, stage IIおよびIIIの29%に認められた. 再発形式は肝臓2例, 肺+局所1例, 腹膜2例, 吻合部1例, 局所再発1例で, 再発時期は平均33.6か月 (2年10か月) であった. 生存率は63.5%で, これは深達度ss以上の非穿孔153例 (コントロール群) のstage IIIに相当するものであった. 結論: 穿孔と大腸癌の予後との関連性が示唆された. 穿孔症例の再発は穿孔に関連するものが多く, 慎重な経過観察が必要と考えられた.