Yasumi Araki

Oncologic and functional results of total mesorectal excision and autonomic nerve-preserving operation for advanced lower rectal cancer.

PURPOSE:Total mesorectal excision contains two different procedures: autonomic nerve preservation, and autonomic nerve sacrifice. It is unclear whether autonomic nerve preservation is suitable curative procedure. We clarify the significance of autonomic nerve preservation for an advanced lower rectal cancer.METHODS:All 403 patients curatively resected between 1975 and 1999 were clinicopathologically studied. Between 1975 and 1984, all patients routinely received total mesorectal excision without autonomic nerve preservation (TME-P(−) group). Since 1985, total mesorectal excision with autonomic nerve preservation has been performed in 81 percent of patients (TME-P(+) group). The remaining patients received TME-P(−) because of suspicious invasion to autonomic nerve plexus. All clinical and pathologic data were entered into a computer database. Long-term follow-up was used to analyze the oncologic and functional results of TME-P(+) group compared with TME-P(−) group.RESULTS:The follow-up rate was 98.1 percent. In either Dukes A+B or Dukes C disease, the TME-P(+) group did not increase local recurrence or decrease ten-year disease-free survival compared with the TME-P(−) group of Period 1975 to 1984. The TME-P(−) group of Period 1985 to 1999 had the highest distant metastasis and the lowest survival rates than any other groups. Urinary or sexual function was well preserved in the TME-P(+) group. CONCLUSIONS:Autonomic nerve preservation is oncologically and functionally excellent and suitable for almost all patients with advanced lower rectal cancer. Intensive chemotherapy is needed for patients whose autonomic nerves were killed in suspicion of nerve invasion.

A new ultimate anus-preserving operation for extremely low rectal cancer and for anal canal cancer

Abstract.To avoid permanent colostomy, we perform a new ultimate anus preserving operation for extremely low rectal cancer or for anal canal cancer. According to our pathologic study, two different removal methods of anal canal were theoretically considered. One is internal sphincter resection (ISR method), and the other is both deep-superficial external sphincter and internal sphincter resection (ESR method). Six patients received ISR and ten patients ESR. No severe intraoperative complications occurred and the postoperative course was uneventful. All patients receiving ISR had excellent anal function without soiling. Some patients receiving ESR sometimes complained of night soiling but satisfied the anus preservation. The median follow-up was 15 months, (range, 3–28 months). We had recurrences in two female patients receiving ISR. One had para-aortic and lateral lymph node recurrences without anastomotic recurrence. She underwent lateral and para-aortic lymphadenectomy, but died of lung metastasis, regardless of intensive chemotherapy. Another had pelvic recurrence with abdominal dissemination. She underwent abdominoperineal resection and is alive with pelvic re-recurrence. ISR and ESR are excellent procedures for anus preservation, but ISR needs a strict indication.

Expression of tumor rejection antigens in colorectal carcinomas

The authors recently reported that the SART2 and SART3 antigens encode tumor epitopes recognized by HLA‐A24‐restricted and tumor‐specific cytotoxic T lymphocytes (CTLs) established from esophageal carcinoma patients. The current study investigated these antigens to explore a potential molecule for specific immunotherapy for colorectal carcinoma patients.

Clinical efficacy of video-assisted gasless transanal endoscopic microsurgery (TEM) for rectal carcinoid tumor

BackgroundWe used video-assisted gasless transanal endoscopic microsurgery (TEM) to evaluate 12 consecutive patients for carcinoid tumor with pathologically typical features in the proximal rectum. The study parameters included feasibility, results and final outcome.MethodsA scope with an optical angle of 25° and a 7-mm diameter was used for TEM. The carcinoid tumor was resected in full thickness. Primary closure was accomplished using a running suture of 3-0 braided absorbable suture.ResultsThe tumor in these patients was <15 mm in diameter. It was localized within the submucosal layer on the oral side from the peritoneal reflection and unreachable via Park’s transanal approach. The mean duration of the operation was 63 min. The postoperative course in all patients was free from significant complications, and all patients were discharged within 1 week. None of the patients had postoperative pain or required sedatives.ConclusionVideo-assisted gasless TEM is a simple and minimally invasive procedure to treat benign carcinoid tumors in the proximal rectum.

Functional results of colonic J-pouch anastomosis for rectal cancer.

The purpose of this study was to clarify the functional outcomes of colonic J-pouch anastomosis (J-LAR) for lower rectal cancer in comparison with those of traditional straight anastomosis (S-LAR). A questionnaire regarding anorectal function was conducted 1 year after operation on patients who underwent J-LAR (n=15) and S-LAR (n=30). The clinical functions were assessed by an incontinence scoring system. The physiologic function was assessed by anorectal manometry and the balloon expulsion test. No patients demonstrated a diverting stoma. The bowel frequency (range) 1 year after operation was 4.8 (3–6) in the S-LAR group and significantly decreased to 1.8 (1–3) in the J-LAR group (P<0.05). Complete evacuation was 50.2% (40%–60%) in the S-LAR group and significantly increased to 80.6% (60%–90%) in the J-LAR group (P<0.05). Neorectal compliance was 2.2 (1.4–2.9) ml/mmHg in the S-LAR group and significantly increased to 3.1 (1.3–3.5) ml/mmHg in the J-LAR group (P<0.01). No significant difference was observed between the two groups regarding the maximum resting or maximum voluntary squeezing pressure. In conclusion, our findings suggested colonic pouch anastomosis performed after a low anterior resection to support the compliance of the (neo)rectum to be an important factor for retaining a satisfactory bowel frequency.

Perianal Paget's disease treated with a wide excision and gluteal fold flap reconstruction guided by photodynamic diagnosis: report of a case.

P erianal extramammary Paget’s disease is a malignant tumor of the skin invading the epidermis, and the first-choice treatment is a wide excision of the skin. In many cases, however, it is very difficult to know whether the disease is localized or extends to the anus. Photodynamic diagnosis (PDD) is a method more convenient and less invasive than biopsy for the detection of cutaneous infiltration before surgical incision. We present here a case of perianal Paget’s disease in which PDD was used to delineate the skin to be excised before preservation of the anal sphincter, wide skin excision, and reconstruction with gluteal fold flap and a full-thickness pedicle flap and which had a favorable postoperative course without any anal stenosis.

Perianal Paget’s Disease Treated With a Wide Excision and Gluteal Fold Flap Reconstruction Guided by Photodynamic Diagnosis

P erianal extramammary Paget’s disease is a malignant tumor of the skin invading the epidermis, and the first-choice treatment is a wide excision of the skin. In many cases, however, it is very difficult to know whether the disease is localized or extends to the anus. Photodynamic diagnosis (PDD) is a method more convenient and less invasive than biopsy for the detection of cutaneous infiltration before surgical incision. We present here a case of perianal Paget’s disease in which PDD was used to delineate the skin to be excised before preservation of the anal sphincter, wide skin excision, and reconstruction with gluteal fold flap and a full-thickness pedicle flap and which had a favorable postoperative course without any anal stenosis.

Leukocytapheresis for the treatment of active pouchitis: a pilot study

BackgroundPouchitis is a major long-term complication of ileal pouch-anal anastomosis for ulcerative colitis. The aim of this study is to investigate the efficacy of leukocytapheresis for the treatment of active pouchitis.MethodsEight patients with active pouchitis received leukocytapheresis weekly for 5 weeks in an open-label treatment protocol together with baseline therapy.ResultsPatients showed significant improvement in their pouchitis disease activity index scores, from 9.5 (range, 8–10) to 4.0 (range, 2–8) (P < 0.05). Six (75%) of the 8 treated patients achieved remission. No adverse events were observed.ConclusionsLeukocytapheresis therapy could be a new therapeutic strategy for patients with pouchitis after ileal pouch-anal anastomosis for ulcerative colitis. These encouraging results lead us to propose a randomized controlled trial.

Clinicopathologic characteristics of large bowel cancer developing after radiotherapy for uterine cervical cancer

PURPOSE: This study was designed to clarify the characteristics of large bowel cancer developing after radiotherapy for uterine cervical cancer. METHODS: A retrospective chart review was performed. RESULTS: The latent period was a mean of 20.5 years. The most common site was in the rectum (16/32). Mucin-producing carcinoma was observed in 53.1 percent, with an especially high rate of 75 percent in the rectum. Histologic radiation damage was also demonstrated at a high rate of 64.3 percent. CONCLUSIONS: It was difficult to judge from clinicopathologic findings whether large bowel cancer developed with relation to radiation effect. We emphasize, however, that the characteristics are different from ordinary large bowel cancer. Particular consideration should be given to the high incidence of mucin-producing carcinoma.

Effectiveness of the portable ultrasound bladder scanner in the measurement of residual urine volume after total mesorectal extirpation

The measurement of residual urine volume by bladder catheterization causes quite some suffering to the patient and sometimes causes urinary tract infections. To evaluate the postoperative measurement of residual urine volume with a portable ultrasound bladder scanner (Bladder Scan BVI 3000) and the cost-benefit analysis as compared with postoperative catheterization we carried out a study on 30 patients with primary rectal cancer. The data were then compared with actual urine volumes. This was a prospective study dealing with the economical benefit of ultrasound scanning over catheterization during the hospital stay. The ultrasound bladder scanner was found to be a reliable method of estimating residual urine volume since its data correlated with actual volumes with a coefficient of 0.9. The results satisfied both physicians and patients. Ultrasound scanning of the bladder to measure residual urine volume reduced the frequency of catheterization by 38% as compared with the patients on intermittent catheterization, with 17.4 catheters saved for each patient. In conclusion, the ultrasound bladder scanner could protect patients from the discomfort and urethral injury which might have been caused by bladder catheters, thus decreasing medical expenses. This technique will play an important role in determining whether to conduct invasive urethral catheterization for postoperative urinary disturbance in rectal cancer.