Tatsuo Teramoto

Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer

Rectal resection with total mesorectal excision is perhaps the most technically challenging of laparoscopic procedures, and the purpose of this study was to show that laparoscopic ultralow anterior resection is feasible for lower rectal cancer. Seven patients with lower rectal cancer were treated in this way with a satisfactory outcome in each case, and on the basis of this limited study, we suggest that extension of laparoscopy to the treatment of very low rectal lesions may be of advantage.

Development and validation of a modified fecal incontinence quality of life scale for Japanese patients after intersphincteric resection for very low rectal cancer

PurposeFecal incontinence is a frequently observed symptom after lower rectal surgery with sphincter manipulation. The aim of this study was to evaluate a proposed modification to the fecal incontinence quality of life (FIQL) scale for the assessment of the quality of life among patients with very low rectal cancer who have undergone intersphincteric resection.MethodsA single 14-item composite scale was prepared that was derived from items in the “Lifestyle” and “Coping” subscales of the original FIQL. The scale was tested with a convenience sample of 152 postoperative patients. In addition to classic psychometric evaluation, newer statistical techniques, such as a multiple correspondence analysis and partial credit model, were performed to evaluate the item response patterns.ResultsThe proposed scale exhibited an item-rest correlation of 0.66–0.84 and a Cronbach’s alpha of 0.96, and was correlated with concurrently measured Social Functioning subscale of the Medical Outcomes Study Short Form 36 (−0.70), physical role limitation (−0.61), and Wexner continence grading scale (−0.61). Multiple correspondence analysis supported a uni-dimensional construct, and the partial credit model showed a varying yet overlapping range of item response thresholds across items. Several items, such as “Locating bathroom whenever going out”, reflected more a serious condition than items such as “Avoiding eating-out.” Weighted item scores based on estimated thresholds provided results comparable with those based on non-weighted scores.ConclusionsThe proposed modification to the FIQL scale exhibited high internal consistency and satisfactory concurrent and convergence validity. The modified scale is practical to administer and is sensitive to a range of functional problems associated with fecal incontinence among patients who have undergone intersphincteric resection.

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.

Timing of Relapse and Outcome after Curative Resection for Colorectal Cancer: A Japanese Multicenter Study

Background: The aim of this multicenter study was to clarify the influence of timing of relapse after curative resection for colorectal cancer on prognosis. Methods: We enrolled 5,230 consecutive patients who underwent curative resection for colorectal cancer at 14 hospitals from 1991 to 1996. All patients were intensively followed up. Time to relapse (TR) was classified into three groups as follows: group A, TR ≤1 year; group B, TR >1 year and ≤3 years, and group C, TR >3 years. The prognoses after relapse were compared among the three groups. Results: Of the 5,230 patients, 906 experienced relapse (17.3%). The curative resection rates for recurrent tumors were 35.2% in group A, 46.6% in group B, and 45.1% in group C (p = 0.0045). There were significant differences in the prognoses after relapse among the three TR groups in patients with relapse to the liver (p = 0.0175) and in those with local relapses (p = 0.0021), but not in those with pulmonary or anastomotic recurrence. There were no differences in prognoses after relapse in any recurrence site among the three groups in patients who underwent curative resection for relapse. Conclusion: If patients can undergo curative resection for relapse, they receive a survival benefit regardless of the timing of relapse.

Disappearance of HCV after cessation of immunosuppression in a patient with ulcerative colitis and renal transplantation

We report a patient, a 45-year-old Japanese woman, who underwent living-related donor renal transplantation in 1986 and 1988, with the second procedure being successful. Ulcerative colitis (UC) was diagnosed in 1987 while she was receiving immunosuppressive therapy after the renal transplantation. She became positive for serum anti-hepatitis C virus (HCV) in November 1990, although her serum aminotransferase levels were normal. In June 2001, she had frequent episodes of melena with abdominal pain, as control of her UC deteriorated. In July 2001, she was admitted to the Department of Surgery at our hospital, and her daily dose of prednisolone was increased from 40 mg to 80 mg. After 2 weeks of high-dose prednisolone therapy, there was a significant increase of serum aminotransferases, and serum HCV-RNA rose above 850 KIU/ml (by reverse transcription-polymerase chain reaction [RT-PCR]). Control of UC was still poor, so cyclosporine A (CyA) was added at a dose that maintained a high serum concentration. The daily dose of prednisolone was tapered and leukapheresis was performed three times weekly. As result, serum aminotransferases decreased to the normal range. However, total colectomy and colostomy were required because the UC could not be controlled by these therapies. Serum aminotransferase levels increased transiently 2 months after the cessation of immunosuppressive therapy (prednisolone, azathioprine [AZP], and CyA). Subsequently, serum aminotransferases rapidly declined below normal, and the serum level of HCV-RNA (by RT-PCR) fell from 480 KIU/ml to less than 0.5 KIU/ml. She was discharged on April 25, 2002. During follow-up as an outpatient, serum HCV-RNA became negative and remained negative for 7 months. To confirm clearance of HCV, liver biopsy was performed, and no HCV-RNA was detected in the liver tissue by RT-PCR. These findings suggested that HCV was cleared by the cessation of immunosuppressive therapy, as a rebound effect.

Clinical Outcome of Laparoscopic Intersphincteric Resection Combined with Transanal Rectal Dissection for T3 Low Rectal Cancer in Patients with a Narrow Pelvis

Purpose. The purpose of this study was to analyze the safety and feasibility of laparoscopic intersphincteric resection (ISR) combined with transanal rectal dissection (TARD) for T3 low rectal cancer in a narrow pelvis. Methods. We studied 20 patients with a narrow pelvis of median body mass index 25.3 (16.9–31.2). Median observation period was 23.6 months (range 12.2–56.7). Results. Partial, subtotal, and total ISR was performed in 15, 1, and 4 patients, respectively. Median duration of TARD was 83 min (range 43–135). There were no major complications perioperatively or postoperatively. Surgical margins were histologically free of tumor cells in all patients, and there was no local recurrence. Excluding urgency, frequency of bowel movements, and incontinence status improved gradually after stoma closure. Conclusion. Laparoscopic ISR combined with TARD is technically feasible for selective T3 low rectal cancer in patients with a narrow pelvis.

A rare case of repeated anastomotic recurrence due to tumor implantation after curative surgery for sigmoid colon cancer

BackgroundAnastomotic recurrence is often experienced at colocolic or colorectal anastomoses. Tumor cell implantation has been reported as the mechanism of anastomotic recurrence. However, anastomotic recurrence occurring repeatedly after curative surgery is rare. We herein report a rare case of repeated anastomotic recurrence after curative surgery for sigmoid colon cancer.Case presentationA 51-year-old man underwent radical surgery for sigmoid colon cancer. However, anastomotic recurrence developed three times during three years and six months after the initial operation in spite of irrigation with 5% povidone-iodine before anastomosis. The serum carcinoembryonic antigen (CEA) level had been within normal limits after sigmoidectomy. Finally, the patient underwent abdominoperineal resection. The clinico-pathological findings revealed that possible tumor cell implantation caused these anastomotic recurrences. The patients survived without recurrence during the follow-up period of seven years and nine months.ConclusionWe experienced a rare case of repeated anastomotic recurrence due to possible tumor implantation after curative surgery for sigmoid colon cancer; however the prognosis was ultimately very good. CEA monitoring was insensitive for detection of anastomotic recurrence in this case.

Clinical feasibility of sphincter-preserving resection with transanal rectal dissection for low-lying rectal cancer in Japanese patients: a single-center cohort study

Aim: Recently, the transanal down-to-up rectal dissection, a new approach to improve the difficult total mesorectal excision (TME) for low-lying rectal cancer, has been popularized. This study assessed the long-term oncologic and functional outcomes after sphincter-preserving resection combined with transanal rectal dissection (TARD) under direct vision for both complete TME and preservation of the internal anal sphincter (IAS) as much as possible to clarify the clinical feasibility of this approach. Methods: A prospective cohort study was conducted in 90 Japanese patients between April 2003 and March 2012. Results: Abdominoperineal resection (APR) was needed in 17 patients (18.9%) including 14 salvage APRs. Local recurrences occurred in 5 sphincter-preserving resection patients (6.8%). No significant between-group differences were observed in overall survival or 5-year disease-free survival. A significant benefit of preserving the internal anal sphincter completely in sphincter-preserving resection was found on the Wexner incontinence score (P = 0.005), low anterior resection syndrome score (P = 0.002), and visual analogue scale (P = 0.047). Conclusion: TARD, performed under direct vision for both complete TME and preservation of the IAS as much as possible in sphincter-preserving resections for low-lying rectal cancers in Japanese patients, does not negatively impact oncologic outcomes and could have the benefit of minimizing postoperative anorectal dysfunction by preserving the internal anal sphincter.

Long-term assessment of anorectal function after extensive resection of the internal anal sphincter for treatment of low-lying rectal cancer near the anus

Objectives: Intersphincteric resection (ISR) for low-lying rectal cancer (LRC) may induce major problems associated with anorectal function. In this study, we assessed the severity of ISR-induced impairment in anorectal function. Methods: In total, 45 patients followed up regularly ≥2 years after diverting ileostoma closure were eligible. The patients underwent ISR (n=35) or conventional coloanal anastomosis without resection of the internal anal sphincter (IAS) (n=10) for treatment of LRC from January 2000 to December 2011. We retrospectively compared anorectal function [stool frequency, urgency, Wexner incontinence scale (WIS) score, and patient satisfaction with bowel movement habits on a visual analog scale (VAS) score] for ≥2 years after stoma closure between the two groups. Results: The median follow-up period was 4.0 years (range, 2.0-6.5 years). Of the total, 17 (48.6%) patients who underwent ISR had poor anorectal function, including two with complete incontinence. Significant differences were found between the groups in the incidence of urgency (p=0.042), WIS score (p=0.024), and defecation disorder with a WIS score of ≥10 (p=0.034) but not in stool frequency. Based on the VAS score, 45.7% of patients who underwent ISR were dissatisfied with their bowel movement habits (p=0.041). Conclusions: Extensive resection of the IAS has negative short- and long-term effects on anorectal function.

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.