堀江 久永

Background Routine creation of a diverting stoma (DS) in every patient who undergoes low anterior resection (LAR) remains controversial. We aimed to investigate the effect of DS on symptomatic anastomotic leakage (AL) after LAR. Study Design Patients with rectal cancer within 10 cm from the anal verge were eligible for this prospective, multicenter, cohort study (UMIN-CTR, number 000004017). Propensity score matching (PSM) was used to compare groups of patients with and without DS. Results One thousand fourteen consecutive patients were registered, of whom 936 patients who underwent LAR were analyzed. Before PSM, the overall rate of symptomatic AL was 13.2% (52 of 394) in patients with DS vs 12.7% (69 of 542) in cases without DS (p = 0.84). Symptomatic AL requiring re-laparotomy occurred in 4.7% (44 of 936) of all patients, occurring in 1.0% (4 of 394) of patients with DS vs 7.4% (40 of 542) of patients without DS (p &lt 0.001). After PSM, the 2 groups were nearly balanced, and the incidence rates of symptomatic AL in patients with and without DS were 10.9% and 15.8% (p = 0.26). The incidences of AL requiring re-laparotomy in patients with and without DS were 0.6% and 9.1% (p &lt 0.001). Multivariate analysis identified male sex (p &lt 0.001 odds ratio [OR] 3.2 95% confidence interval [CI] 1.8 to 5.7) and tumor size (p &lt 0.001 OR 1.2 95% CI 1.1 to 1.4) as independent risk factors of symptomatic AL. Conclusions Diverting stoma did not have a significant relationship with symptomatic AL before and after PSM. However, DS does seem to mitigate the consequences of leakage, reducing the need for urgent abdominal reoperation.

Background: Improvement in the prognosis of colorectal cancer (CRC) patients has led to increasing occurrences of multiple primary malignancies (MPMs) alongside CRC but little is known about their characteristics. This study was undertaken to clarify the clinical and pathological features of MPMs, especially those at extra colonic sites, in patients with CRC. Methods: We reviewed 1,111 patients who underwent operations for primary sporadic CRC in Saitama Medical Center, Jichi Medical University between April 2007 and March 2012. Two patients with familial adenomatous polyposis, one with hereditary non-polyposis colorectal cancer, two with colitic cancer, and any patients with metastasis from CRC were excluded. We compared the clinicopathological features of CRC patients with and without MPMs. As a control, we used a database compiled of patients with gastric cancer (GC) detected by mass screening performed in the Saitama Prefecture in Japan 2010 and compared these with CRC patients with synchronous GC. Results: Multiple primary malignancies at extracolonic sites were identified in 117 of 1,111 CRC patients (10.5%). The median age was 68 (range, 29 to 96) versus 71 (50 to 92) (P < 0.001). The incidence of GC (44.4% (52 of 117)) was the highest of all MPMs. All CRC patients with GC were older than 57 years. Synchronous GC was detected in 26 patients. By contrast, out of 200,007 screened people, 225 people were diagnosed as having GC in the Saitama Prefecture. The age-standardized incidence of synchronous GC in CRC patients was significantly higher (0.53%) than in the control group (0.03%) (odds ratio, 18.8; 95% confidence interval, 18.6 to 19.0; P < 0.001). Conclusion: Patients with CRC who were older than 50 years preferentially developed GC synchronously and metachronously. Thus, this patient group should undergo careful perioperative screening for GC.

Background: The objective of this phase I study was to determine the maximum tolerated dose (MTD) and recommended dose (RD) of preoperative chemoradiotherapy (CRT) with S-1 plus oxaliplatin in patients with locally advanced rectal cancer. Methods: Patients received radiotherapy in a total dose of 50.4 Gy in 28 fractions. Concurrent chemotherapy consisted of a fixed oral dose of S-1 (80 mg/m(2)/day) on days 1-5, 8-12, 22-27, and 29-33, plus escalated doses of oxaliplatin as an intravenous infusion on days 1, 8, 22, and 29. Oxaliplatin was initially given in a dose of 40 mg/m(2)/week to three patients. The dose was then increased in a stepwise fashion to 50 mg/m(2)/week and the highest dose level of 60 mg/m(2)/week until the MTD was attained. Results: Thirteen patients were enrolled, and 12 received CRT. Dose-limiting toxicity (DLT) occurred in two of six patients (persistent grade 2 neutropenia, delaying oxaliplatin treatment by more than 3 days) at dose level 3; there were no grade 3 or 4 adverse events defined as DLT. The RD was 60 mg/m(2)/week of oxaliplatin on days 1, 8, 22, and 29. Twelve patients underwent histologically confirmed R0 resections, and two out of six patients (33%) given dose level 3 had pathological complete responses. Conclusions: The RD for further studies is 80 mg/m(2) of S-1 5 days per week plus 60 mg/m(2) of oxaliplatin on days 1, 8, 22, and 29 and concurrent radiotherapy. Although our results are preliminary, this new regimen for neoadjuvant chemoradiotherapy is considered safe and active.

右側肝円索は，胎生期における右側臍静脈遺残に起因するとされ，門脈右枝に臍部が存在し，同部に肝円索が付着する解剖学的変異と考えられている．今回，複雑な胆管分岐形態を示した右側肝円索を伴う肝門部胆管癌の切除例を経験した．症例は62歳の男性．皮膚黄染を主訴に当院を受診，造影CTで胆管壁の肥厚と肝内胆管の拡張を認め，さらに胆嚢が肝円索の左側に位置する右側肝円索を認めた．胆汁細胞診からはClass IVが検出され，右側肝円索を伴う肝門部胆管癌と診断した．門脈分岐形態を考慮し後区域枝のみ塞栓術を行い，手術は肝後区域切除・肝外胆管切除・胆管空腸吻合術を行った．本症例では胆管分岐においてB2から後区域枝が分岐する形態を示す他，その他の胆管分岐形態からも，右側肝円索における左右対称性の理論に合致するものと考えられた．右側肝円索には脈管の分岐異常を伴うことが多く，術前の詳細な画像検索と慎重な手術計画が重要と考える．

Conclusions. The positive correlations between IMA and both SOFA and APACHE II scores suggest that serum IMA measurements reflect the severity of systemic failure in patients admitted for colorectal surgery in the preoperative phase. Results. The mean IMA level was 0.5 AU, and the median CRP level was 0.6 mg/dL. Median scores for SOFA and APACHE II were 2 and 12 points, respectively. Significant positive correlations between IMA and SOFA (r = 0.45, P &lt 0.05) and IMA and APACHE II (r = 0.45, P &lt 0.05) were identified which remained significant in confounder-adjusted analyses. In contrast, weak correlations were observed between CRP and the SOFA and APACHE II scores. Methods. We examined 27 patients with advanced colorectal cancers (mean age 69 years, men/women = 15/12). Correlations between SOFA and APACHE II scores in addition to preoperative serum IMA and C-reactive protein (CRP) levels were analyzed. Purpose. Critical illnesses are assessed according to the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) II. Circulating ischemia-modified albumin (IMA) is a biomarker generated under ischemic and oxidative conditions and may reflect disease severity in preoperative patients. This study investigated the correlations of IMA with SOFA and APACHE II scores in inpatients admitted for colorectal surgery.

AIM: To prospectively investigate the detection rate of laterally spreading tumors (LSTs) of the colorectum by computed tomography (CT) colonography (CTC). METHODS: Patients with LSTs measuring >= 20 mm detected during colonoscopy were prospectively enrolled in the study. All patients underwent colonoscopy and subsequent CTC on the same day. CTC was performed using multi-detector CT without contrast in the prone and supine positions. Two radiologists blinded to the existence of LSTs read the virtual endoscopic images as well as 2-D images. LSTs were classified into granular and non-granular types based on colonoscopic appearance. RESULTS: Forty-seven pathologically proven LSTs were evaluated prospectively. Histology included adenomas in 19, mucosal cancers in 19 and T1 cancers in 9. The mean diameter of the LSTs was 35.1 mm. Twenty-eight (60%) LSTs were correctly identified by CTC, and the configuration was similar to the colonoscopic appearance in most cases. Detection rate for the granular type was significantly higher than that for the nongranular type (71% vs 31%, P = 0.013). Detection rate of adenomas was significantly lower than mucosal cancers (32% vs 79%, P = 0.008) and T1 cancers (32% vs 78%, P = 0.042). CONCLUSION: The detection rate of LSTs by CTC, particularly the non-granular type was not acceptable. Practitioners should be aware of the relatively low detection rate when using CTC. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

The purpose of this study was to evaluate the clinical features, pathology, and etiology of adenocarcinoma in patients with anal fistulae.We identified seven patients diagnosed with adenocarcinoma associated with anal fistulae from a retrospective chart review.Five patients were diagnosed with primary adenocarcinoma associated with anal fistulae. Two patients were diagnosed with secondary adenocarcinoma associated with anal fistulae originating from rectal cancer on the proximal side. The primary adenocarcinomas included cancers arising from long-standing anal fistulae fulfilling established diagnostic criteria in two patients, and cancer arising from short-duration anal fistulae in three patients. Excision of the fistula was performed based on the initial diagnosis of the anal fistula for all five patients. Increased suspicion of cancer was due to the existence of gelatinous material in the anal fistula in three patients and induration in the resected specimens in two patients. The etiologies of the secondary adenocarcinomas associated with anal fistulae included implantation in the anal fistula from rectal cancer and fistula formation originating due to the progression of rectal cancer.Anal fistulae are commonly seen in the coloproctology clinic, but special attention to similar conditions associated with malignant disease is needed.

Potent application of topoisomerase I inhibitor plus PARP inhibitor has been suggested to be an effective strategy for cancer therapy. Reportedly, mismatch repair (MMR)-deficient colon cancer cells are sensitive to topoisomerase I inhibitor, presumably due to microsatellite instability (MSI) of the MRE11 locus. We examined the synergy of SN-38, an active metabolite of irinotecan, in combination with the PARP inhibitor olaparib in colon cancer cells showing different MMR status, such as MSI or microsatellite stable (MSS) phenotype. Treatment with SN-38 and olaparib in combination almost halved the IC50 of SN-38 for a broad spectrum of colon cancer cells independent of the MMR status. Furthermore, olaparib potentiated S-phase-specific double-strand DNA breaks (DSB) induced by SN-38, which is followed by Rad51 recruitment. siRNA-mediated knockdown of Rad51, but not Mre11 or Rad50, increased the sensitivity to olaparib and/or SN-38 treatment in colon cancer cells. In vivo study using mouse xenograft demonstrated that olaparib was effective to potentiate the antitumor effect of irinotecan. In conclusion, olaparib shows a synergistic effect in colon cancer cells in combination with SN-38 or irinotecan, potentiated by the Rad51-mediated HR pathway, irrespective of the Mre11-mediated failure of the MRN complex. These results may contribute to future clinical trials using PARP inhibitor plus topoisomerase I inhibitor in combination. Furthermore, the synergistic effect comprising topoisomerase I-mediated DNA breakage-reunion reaction, PARP and Rad51-mediated HR pathway suggests the triple synthetic lethal pathways contribute to this event and are applicable as a potential target for future chemotherapy. (C) 2014 AACR.

The purpose of this study was to compare the degree of colorectal distention between manual insufflation using room air and automatic insufflation using carbon dioxide for computed tomography colonography performed as a preoperative examination for patients with colon cancer. Participants comprised 200 patients who underwent computed tomography colonography immediately after colonoscopy from October 2011-2012. The first 100 patients were examined using manual insufflation, and the remaining 100 patients were examined using automated insufflation. Two radiologists independently assessed colorectal distention using a 4-point scale in six segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. Mean scores of the two radiologists were used to analyze whether any differences existed between techniques in terms of the degree of distention per segment. Mean distention values for the colonic lumen were better using the automated technique than with the manual technique in both positions (p < 0.05). In segments, distention was significantly better using the automated technique than using the manual technique in the sigmoid and descending colon for prone patients, and in all segments for supine patients. Automated carbon dioxide insufflation offered significantly improved colorectal distention scores compared to manual room air insufflation.

35歳男。慢性的に腹痛が出現し、検診で便鮮血を指摘された。下部内視鏡検査を施行され、回腸末端に潰瘍性病変を指摘された。経肛門的ダブルバルーン内視鏡(DBE)を施行した。回盲弁は破壊され、回腸末端から5cm程の長さで、不整形の潰瘍を認めた。腹部造影CTでは、盲腸から回腸末端にかけて壁肥厚、造影効果を認め周囲脂肪織の索状影や濃度の上昇を認めた。回腸末端に深い潰瘍、狭窄を認め、腹痛も改善傾向ないため診断、治療目的に腹腔鏡下補助下回盲部切除術を行う方針とした。口腔内アフタ、ブドウ膜炎、外陰部潰瘍などの既往なく、Behcet病の診断基準を満たさないため単純性潰瘍と診断した。合併症の発症なく、術後9日目に退院となった。