Transanal total mesorectal excision (taTME) has been developed to overcome the difficulty of laparoscopic dissection and transection in the deep pelvis. TaTME has several clinical benefits over laparoscopic surgery, such as better exposure of the distal rectum and direct determination of distal resection margin. Although evidence demonstrating the true benefits of taTME over laparoscopic TME (LapTME) is still insufficient, accumulating data have revealed that, as compared with LapTME, taTME is associated with shorter operative time and a lower conversion rate without jeopardizing other short-term outcomes. However, taTME is a technically demanding procedure with specific complications such as urethral injury, and so sufficient experience of LapTME and step-by-step acquisition of the skills needed for this procedure are requisite. The role of transanal endoscopic surgery is expected to change, along with the recent progress in the treatment of rectal cancer, such as robotic surgery and the watch-and-wait strategy. Optimization of treatment will be needed in the future in terms not only of oncological but also of functional outcomes.

We systematically reviewed literature regarding "Lewy body constipation", i.e., constipation due to Lewy body diseases (LBD), with minimal neurologic symptoms. Epidemiology and pathology studies showed that LBD can start with constipation alone, mostly due to neuronal loss and appearance of Lewy bodies in the myenteric plexus. Because LBD significantly increases with age, "Lewy body constipation" may also increase with age. Neuroimaging methods such as metaiodobenzylguanidine (MIBG) scintigraphy and dopamine transporter (DAT) scan provide a way to detect "Lewy body constipation." Key for "Lewy body constipation" includes minimal non-motor features such as REM sleep behavior disorder (night talking). Add-on therapy may be required to ameliorate constipation in patients. Diagnosis is not always easy; therefore, collaboration of gastroenterologists and neurologists is highly recommended to maximize patients' quality of life. In conclusion, "Lewy body constipation" might become a distinct category among geriatric constipation, regarding patients' follow-up and their management.

Objectives: There are differences in each country with regards to histopathological managements of colorectal cancer (CRC), such as definition of Tis and lymphatic and venous invasion. In this study, we compared Tis and T1 CRC in Japan and Korea. Methods: We retrospectively compared various clinical characteristics of consecutive patients who had Tis and T1 CRCs and who were newly diagnosed between 2010 and 2014 at the Kyoto Prefectural University of Medicine (Japan) and the Konkuk University (Korea). Results: Three hundred and sixty-five cases of T1 cancer and 510 cases of Tis cancer from 726 Japanese and 149 Korean patients were included. The rate of Tis in Japan was higher than in Korea (59.8% vs. 51.0%, P = 0.047), according to the difference of definition of Tis. In the analyses of 365 T1 CRCs, median age was higher in Japan than Korea (67.8 ± 10.6 vs. 62.2 ± 10.1, P < 0.001). Right-sided lesions were more frequent in Japan than they were in Korea (38.7% vs. 22.2%, P < 0.001). The rates of venous and lymphatic invasion were higher in Japan than they were in Korea (venous: 18.6% vs. 1.4%, P < 0.001, lymphatic: 25.3% vs. 13.7%, P = 0.042), according to the different methods of immunohistochemical examinations used (Japan: E-HE and D2-40, Korea: ERG). Conclusions: Our study of T1 CRC showed that there were differences between Japan and Korea in tumor location, elderly incidence, and histopathological lymphatic and venous invasion. Additionally, rates of Tis were different between the two countries. In this international study for CRC, it is considered that we have to pay attention regarding the difference of histopathological definition and method in each country.

Objectives: The aim of this pilot study was to confirm the safety and feasibility of the induction of robotic-assisted laparoscopic rectal surgery (RRS) at a local municipal hospital. A municipal hospital does not indicate a small hospital. The most significant difference between a municipal hospital and a center or university hospital is that most surgeons in a municipal hospital are general surgeons. Methods: The first 30 patients who underwent RRS at the municipal hospital were enrolled between April 2015 and June 2016. All surgeries were performed by a single trained surgeon using the da Vinci^® Si surgical system. The primary endpoint was the incidence of postoperative major complications. Results: Of the study patients, 29 had adenocarcinoma and 1 had ulcerative colitis. The surgical procedures included anterior resection (n = 22), intersphincteric resection (n = 2), abdominoperineal resection (n = 4), Hartmann's procedure (n = 1), and total coloproctectomy (n = 1). There were no intraoperative complications and conversion cases. The median operative time and blood loss were 283.5 min and 9 ml, respectively. The incidence rate of postoperative major complications was 10%, which included anastomotic leakage in 2 patients and ileus in 1 patient. Postoperative urinary dysfunction did not occur in any patient. Complete resection was achieved for all patients. Conclusions: We demonstrated that the induction of RRS was safe and feasible, even at a local municipal hospital, given that the surgeons had the sufficient skills and experience in both laparoscopic and colorectal surgery. *The study protocol was registered at the University Hospital Medical Information Network (UMIN000017022).

Objectives: Colonic diverticular disease is widespread in Western countries and its associated with aging. In Japan, diverticulitis and colovesical fistula are also occurring more frequently. Colonic resection for diverticula-related fistulas is frequently technically demanding because of associated acute or chronic inflammation. We evaluated the safety and efficacy of a standardized laparoscopic procedure. Methods: Data from 39 consecutive patients who had undergone laparoscopic surgery for colovesical fistula between October 2006 and August 2017 were retrospectively reviewed. Results: The patients' median age was 60 years and comprised 35 men and four women. Sigmoidectomy was performed in 33 patients, Hartmann's procedure in four, and anterior resection in two. The median operative time was 203 minutes and estimated blood loss 15 mL. There were no intraoperative complications or conversion to open surgery. No patients required bladder repair; three had minor postoperative complications, and none had recurrent diverticulitis or fistula at a mean follow-up of 5.1 years. Conclusions: The magnified vision and minimal invasiveness make a laparoscopic approach the ideal means of managing colovesical fistula. To our knowledge, this is the largest study of colovesical fistula managed by a standardized laparoscopic procedure.

Objectives: To clarify the safety and efficacy of celecoxib combined with chemoradiotherapy using S-1 for lower rectal cancer. Methods: Twenty-one patients with pathologically proven lower rectal adenocarcinoma (cT3-T4, Tx N+, M0) were included in this study. A total dose of 45 Gy was administered in daily fractions of 1.8 Gy. Celecoxib was given orally twice daily with S-1 on the day of irradiation. The dose of celecoxib was set at 400 mg/day. In Phase I, the S-1 dose was started at 80 mg/m²/day; in Phase II, S-1 was administered in the same dose as Phase I. Patients underwent surgery six to eight weeks after completing chemoradiotherapy, followed by six months of postoperative adjuvant chemotherapy. Results: The S-1 recommended dose was 80 mg/m²/day. The pathological complete remission rate was 15.8%, the rate of protocol completion was 14.3%, and the rate of adverse events exceeding Grade 3 was 19.0%. Surgery was performed in 19 cases, with a sphincter-sparing rate of 31.6%. Postoperative complications exceeding Grade 3 occurred in 52.4% of cases. The three year overall survival and relapse-free survival rates were 89.3% and 67.0%, respectively. Conclusions: We failed to show a synergistic or additive therapeutic effect of preoperative CRT using S-1, combined with celecoxib, for lower advanced rectal cancer beyond CRT using 5 FU or capecitabine alone. The incidence of complications, evidently involving intestinal ischemia, was relatively high. This treatment strategy is not recommended at present.

Most cases of adult intussusception are caused by neoplastic lesions, and idiopathic adult intussusception is very rare. We present a case in which laparoscopic surgery was performed for idiopathic adult intussusception initially reduced by colonoscopy. A 53-year-old woman presented to the emergency department of our hospital with intermittent lower abdominal pain. Contrast-enhanced computed tomography and ultrasonography of the abdomen showed a concentric structure in the ascending colon. We diagnosed intussusception. Colonoscopy achieved successful reduction before surgery. Twelve days after this reduction, laparoscopic surgery was performed. Histopathological examination did not reveal any causative pathology; therefore, idiopathic adult intussusception was diagnosed. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. Preoperative colonoscopy should be utilized to diagnose the main lesion and may be useful for reducing adult intussusception. Laparoscopic surgery is both minimally invasive and safe and can be performed following endoscopic reduction.