Objective: Along with the popularization of stapled functional end-to-end anastomosis using automatic stapling devices in colon cancer surgery, the number of reports of anastomotic recurrence of colon cancer has increased. We investigated the existence of free cancer cells in the intestine, which may contribute to anastomotic recurrence.
Subjects and Method: Sixty-seven (67) patients with colon cancer who underwent laparotomy in our department at the hospital between November 2005 and August 2007 were enrolled in this study. After the intestine was separated, swab cytology of the anastomotic intestinal mucosa was performed before or after the mucosa was cleaned three times using povidone-iodine pledgets. From October 2006, both ends of the lesion in the intestine were ligated immediately after laparotomy. Classes IV and V were determined as cancer cell-positive.
Result: The cancer cell-positive rate in the before-cleaning group was 12.5% and 21.2% at the proximal and distal surgical margins, respectively. All cases of the after-cleaning group were diagnosed as Class I. There were no significant differences in the presence or absence of intestinal ligation, the location, the length of the proximal and distal surgical margins, the depth of invasion, and macroscopic findings. In terms of the distal surgical margins, significant differences were noted in the groups with a tumor diameter of 50mm or more or circumference of the tumor >80%. In terms of the presence or absence of preoperative treatment of the intestine, the cancer cell-positive rate was higher at the distal surgical margins of the non-preoperative treatment group.
Discussion: These results indicated the existence of free cancer cells in the intestine, which may contribute to anastomotic recurrence. Apart from the effects of intra-operative procedures, free cancer cells were observed in the intestines of some cases. However, free cancer cells were removed by cleaning the surgical margins using hand-sewn anastomosis. The results suggest that cleaning procedures of the intestinal lumen are also required when stapled anastomosis is employed in colon cancer surgery.

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[Purpose] We investigated the bowel function, patient satisfaction and health-related QOL of patients who underwent reconstructive proctectomy for rectal cancer and reviewed the effectiveness of the Transverse Coloplasty Pouch (T-pouch).
[Patients and Methods] Questionnaires were mailed to 78 patients with rectal cancer (Rs, Ra and Rb). Patients with stage 4, recurrence, but without severe complications. The questionnaires included Wexner incontinence score, SF-36 and EORTC QLQ-30, and an original questionnaire.
[Results] The questionnaire was collected from 50 cases, and 42 cases were considered eligible: 15 with Rs, 10 with Ra, 17 with Rb (7 with T-pouch, 10 with straight anastomosis). The demographics showed that BMI and the ratio of D3 lymph-node dissection were high in the Rs group. The average postoperative period was 859 days. In the Rb and Ra groups, fecal frequency, Wexner incontinence score and QOL were worse than for those in the Rs group. In the Ra group, only one score of General Health in SF-36 was higher than in the Rb group. There was no difference in bowel function, patient satisfaction and QOL between T-pouch and straight groups.
[Conclusions] Reconstructive proctectomy for both Rb and Ra rectal cancer severely affected bowel function and QOL, so patient satisfaction remained low. T-pouch for low rectal cancer was not found to be effective in long-term functional outcome and QOL score.

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We assessed anal function after the Seton technique for lateral or anterior lower intrasphincter fistula (Type II) with special focus on the correlation of anal pressure and the period of rubber band installation. Anal resting pressure (ARP) significantly decreased at the point of POD one month and recovered to the vicinity of the preoperative value at six months, although there was no definite change of maximum voluntary contraction pressure. A significant positive correlation was obtained between the postoperative complaints and rubber dropout days, the decreasing rate of ARP. Preoperative high ARP and age such as younger and older are positively correlated with the postoperative decreasing rate of ARP. As for the duration of rubber band installation, the best satisfaction of the patient and minimum rate of decrease of ARP are acquired on POD 32 days. These results suggest that we can usually make the duration of rubber band installation at POD 32 days and peri-operative ARP monitoring may be efficient in the Seton technique for Type II fistula.

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A survey of colonoscopic complications which occurred between 2000 and 2004 in 13 hospitals in Niigata prefecture was conducted. A total of 85,507 colonoscopies were performed during this period;40,149 colonoscopies were observation only and 45,358 colonoscopies involved treatments. Complications occurred in 186 cases (0.23%), including 159 cases of hemorrhage (0.19%), and 27 cases of perforation (0.03%). The complication rate of colonoscopies involving treatments was eight times higher than that of observation-only colonoscopies. Hemorrhage was often associated with EMR (76.7%) and endoscopic clippings were performed in 66%. Perforations most often occurred in the left-sided colon (96.3%); the majority were in the sigmoid colon (51.8%), followed by the rectum and the descending colon. Surgery to repair a perforation was performed in 23 cases (85.2%). There were 2 deaths (0.002%), both of which were due to perforation.

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PURPOSE: The purpose of this study was to consider anastomotic stenosis after rectal anterior resection.
METHOD: Thirty patients who suffered anastomotic stenosis among 266 patients who underwent rectal anterior resection using a circular stapling device were compared in terms of the level of anastomosis, method of diagnosis, and treatment.
RESULT: Anastomotic stenosis developed in 30 patients (11.3%). The finger dilatation technique revealed many recurrences (63.2%). The term from primary operation to stenosis was 202.1 days. The distance from the anus was 6.2cm. The size of the anastomotic stenosis was 11.0mm.
CONCLUSION: The finger dilatation in anastomotic stenosis after using the circular stapling device is easy, but there are many recurrences. In addition, for treatment, it seemed that STENO-CUTTER and dilatation by a balloon produced an adequate effect.

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Anorectal malignant melanoma is a relatively rare disease with poor prognosis. Herein, we report three cases of anorectal melanoma. Case 1: A 50's man complained of rectal bleeding at evacuation. A soft, soy-bean-sized mass was palpated by digital rectal examination, and the biopsy specimen showed malignant melanoma. He underwent abdominoperineal rectal resection (APR) and four cycles of DAV as postoperative adjuvant chemotherapy. Currently, he has been disease-free for 9 years. Case 2: A 60's woman with bloody stool was found to have a black, easily-bleeding mass on a dentate line. Histological examination of the biopsy revealed malignant melanoma. DAVferon chemotherapy and local administration of IFNβ were performed, followed by APR. Twenty-six months after operation, she was found to have liver and lung metastasis, and died 9 months thereafter. Case 3: A 40's woman was accidentally found to have pigmentation of the rectum while undergoing an operation for myoma uteri. It was surgically removed, but since it was shown to be malignant melanoma by histology, APR was performed subsequently. In addition, she received four cycles of DAVferon postoperative adjuvant chemotherapy. She has remained alive for 21 months without recurrence.

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A 66-year-old woman was admitted to the hospital because of vomiting and abdominal distention. Computed tomography (CT) revealed ascending colon cancer with swelling of lymph nodes, and CT portography demonstrated a tumor thrombosis in the superior mesenteric vein (SMV). At laparotomy, the colon cancer and lymph nodes formed a large mass, and SMV was obstructed with a tumor thrombosis. Right hemicolectomy combined with lymph nodes dissection (D3), partial duodenectomy and resection of the SMV including the tumor thrombosis were performed. Histopathological examination revealed that the colon cancer and the tumor thrombosis in SMV showed the same histological form (moderately differentiated adenocarcinoma: tub2), and lymphatic ducts and veins around the main tumor were severely invaded with cancer cells (ly2, v3). The final diagnosis was pSI (greater omentum and duodenum), pN1, cP0, cH0, cM0, f-Stage IIIa. Chemotherapy with FOLFIRI regimen was performed after surgery. There has been no recurrence for 22 months.

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A 69-year-old man was brought to our hospital for treatment of systemic lupus erythematosus and gastrointestinal tract bleeding. He had previously undergone argon plasma coagulation treatment for telangiectasia of the stomach and was receiving intravenous hyperalimentation. After administration of antibiotics and antimycotic agent for catheter fever, diarrhea and abdominal pain developed. Clostridium difficile-associated colitis was identified from fecal examination, so oral vancomycin was immediately administered. After 4 days, he underwent emergency subtotal colectomy due to aggravation of distended abdomen and peritonitis with shock. A surgical specimen showed pseudomembranous colitis (PMC), which had produced a pseudomembrane over the entire colon mucosa. Despite postoperative intensive care, the patient died 27 days later. Autopsy revealed that the cause of death was systemic mucormicosis.
Patients with PMC can be cured by conservative therapy in most cases, but delayed diagnosis may necessitate surgical intervention for a severe state. These patients often present with unexplained abdominal illness with marked leukocytosis that rapidly progresses to shock and peritonitis. Mortality from fulminant PMC remains high under the requirement for vasopressors or immunosuppressive condition. Rapid diagnosis and treatment are crucial for positive outcomes, and early surgical intervention should be used in medically unresponsive patients.

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A 61-year-old man, with a 6-year history of repeated hospital admission for ulcerative colitis (UC), was again admitted to our hospital with a month-long duration of bloody diarrhea. Colonoscopy performed on admission suggested that his UC was exacerbated, so he was given intravenous predonisolone and predonisolone enemas. His abdominal symptoms gradually resolved, however, 26 days after predonisolone was started, he had a spiking temperature of 39°C associated with chills. Abdominal CT-scan and ultrasonagraphy showed a 10-cm diameter space occupied lesion in the S4 of the liver, suggesting liver abscess. Ultrasonagraphy-guided percutaneous transhepatic aspiration and drainage were performed and culture of the pus revealed Klebsiella pneumoniae. The drainage catheter was removed 11 days later and he was discharged.
Liver abscess is a rare complication in UC. To our knowledge, there are nine reported cases of liver abscesses in UC including the present case.

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We reported a case of a resected solitary brain metastasis from rectal cancer.
The patient was a 70-year-old male. Low anterior resection was performed for rectal cancer. After the operation, he received adjuvant chemotherapy (UFT+LV) for 12 months. Thirteen months after the operation, he noticed dizziness and nausea. Magnetic resonance imaging (MRI) revealed a mass about 3cm in diameter that had clear edges in his right cerebellum. He was diagnosed as having solitary brain metastasis without any other metastatic lesions. The brain tumor was removed surgically and diagnosed as metastatic adenocarcinoma which was similar to his primary rectal cancer. His nervous symptoms disappeared after the operation. Since the craniotomy, he has been followed up for 20 months without any further evidence of recurrence. In cases with no other lesions, such as in this case, resection of a solitary brain metastasis may produce a good prognosis.

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A 56-year-old man, who was born in an endemic area of strongyloidiasis and who was a carrier of HTLV-1, presented with anorexia, diarrhea, and hyponutrition.
Colonoscopic findings were unusual; multiple minute nodules were found in the entire colon and strongyloidiasis infection was proved by histologic examination.

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We report a case of colorectal carcinoma that achieved a pathological complete response (CR) and subsequently recovered from disseminated intravascular coagulation (DIC) syndrome due to bone marrow metastasis following modified FOLFIRI chemotherapy. A 70-year-old man visited a nearby clinic due to constipation. A rectal tumor was detected by digital examination, so he was referred to our hospital. Computed tomography, a gastrograffin enema, bone scintigraphy, and a submucosal biopsy revealed a poorly differentiated adenocarcinoma with multiple bone metastases. The case was diagnosed as inoperable rectal cancer because of bone metastases. A stoma was built due to progressive obstruction, followed by administration of modified FOLFOX 6 (mFOLFOX6) chemotherapy. However, as mFOLFOX 6 was ineffective, it was replaced with modified FOLFIRI (mFOLFIRI). The mFOLFIRI was very effective, resulting in tumor reduction and disappearance of the osteosclerotic changes. Abdominal peritoneal resection of the rectum demonstrated complete disappearance of carcinoma cells, so the case was considered to have achieved a pathological CR. After surgery, DIC syndrome due to disseminated carcinomatosis of bone marrow occurred, presumably due to the interruption of chemotherapy required during surgery. Anti-DIC therapy and re-initiation of modified FOLFIRI effectively restored the pathological CR which has now been maintained for 5 months.

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A 40-year-old man with radiation therapy for inoperable stage IV rectal cancer followed by chemotherapy, who had undergone sigmoid colonostomy, was hospitalized because of massive hemorrhage in a stoma and anal bleeding. Bleeding could not be controlled by conservative treatment with blood transfusion. Therefore, selective angiograms of the inferior mesenteric artery were obtained and releaved marked contrast extravasation from a branch of the superior rectal artery. Gel-form sponge fragments failed to achieve hemostasis completely, and embolization with NBCA (n-butyl-2-cyanoacrylate) led to immediate hemostasis. Neither rebleeding nor symptoms of possible ischemic complications were observed after intervention until he died 4 months later.

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