Ligation and excision of hemorrhoids, as devised by Milligan and Morgan, is an excellent method of open hemorrhoidectomy in comparison with Whitehead's operation, because the former approach preserves strips of the anoderm among the operation wounds. However, open ligation and excision also has a drawback in that more complete hemorrhoidectomy is aimed at, the remaining anoderm is less well preserved, and the greater the amount of anoderm preserved the more hemorrhoids remain.
To improve this drawback, I have advocated “anoderm-preserving hemorrhoidectomy” and so far have applied the method to many cases of hemorrhoids. However, I have also recognized a further drawback in the anoderm-preserving method, which involves the loss of surrounding soft tissue, since this will obviously be excised along with the hemorrhoidal varices. This results in decreased tissue softness and also decreased continence postoperatively. The connective tissue that packs the hemorrhoidal varices was called the “cushion” by Thomson.
I have designed a form of “cushion-and anoderm-preserving hemorrhoidectomy” and this is presently being applied to clinical cases. The method consists of meticulous maneuvers involving 1) preservation of the cushion and excision of intrawoven hemorrhoidal varices and 2) preservation of the anoderm as far as possible by excision of intermediate hemorrhoids under the preserved anoderm. The results of this surgical method were excellent when analyzed in 50 cases and compared with the conventional open method of ligation and excision.

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Clinical and manometric anal function after sphincter-preserving operation for lower rectal cancer was analyzed in relation to the level of anastomosis (above 4cm vs. within 4cm from the anal verge) and the range of lymph node dissection (lateral lymph node dissection vs. no lateral lymph node dissection).
In the early postoperative stage, the group with a level of anastomosis within 4cm from the anal verge showed poor internal anal sphincter function and poor fecal reservoir function compared with the group with a level above 4cm from the anal verge. However, after more than one postoperative year, anal dysfunction recovered to a satisfactory level.
There was no significant difference in anal function in relation to the range of lymph node dissection.
The function of the external anal sphincter was completely preserved in all types of sphincter-preserving operation.
These results suggest that when an adequate surgical margin with preservation of the anal canal are confirmed, sphincter-preserving operation is justified in the treatment of lower rectal cancer.

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[in Japanese]

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Seventy-four “plaque-like” lesions of the large intestine 0.6-2 cm in diameter were analyzed histologically, radiologically and endoscopically in 68 cases. There were 7 focal cancers limited to the mucosa, 14 sm cancers, 5 pm cancers, 40 adenomas and 8 metaplastic polyps. Histologically, plaque-like lesions had a higher incidence of malignancy than other polypoid lesions. The majority of plaque-like cancers were sm or pm cancers less than 1 cm in diameter, and were not accompanied by adenoma. All plaque-like lesions with a central depression were confirmed to be cancers histologically. About half the cases of plaque-like lesions were detected by radiology or endoscopy, and were without symptoms. Both radiology and endoscopy provided good rates of detectability (more than 90%) of plaque-like lesions on initial examination. Endoscopy confirmed the central depresion more easily than radiology. Radiology was most useful for diagnosis of depth of invasion by showing marginal deformity of the colonic wall, which was wemonstrated in sm or pm plaque-like cancers.

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A study was performed to investigate the incipient phase and the growth pattern of infiltrative ulcerative colon cancer in dogs following induction with N-ethyl-N'-nitro-N-nitrosoguanidine (ENNG). Infiltrative ulcerative cancer was followed from an early stage by sequential endoscopic examination. Histological investigation of the incipient phase was also done. Endoscopically, the incipient phase was first detected as redness and erosion, followed by a II a like small protrusion. As the protrusion grew, a central depression appeared, which then developed into infiltrative ulcerative cancer. Histologically, the cancer was found to invade into the submucosa through gaps in the muscularis mucosa. The results of this study revealed that cancer invaded and proliferated in the submucosa and that subsequently, as the cancer grew, it pushed the surface mucosa upward to form a tumor-like protrusion into the colonic lumen, finally forming an ulcer at the center of the protrusion.

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This report analyzes our experience with 55 patients who underwent hepatic resection for metastatic colorectal carcinoma at Osaka National Hospital over the past 9 years. They consisted of 22 patients with colon carcinoma and 33 with rectal carcinoma, 41 being synchronous and 14 metachronous. Hepatic metastases were solitary in 29 patients and multiple in 26, being unilobar in 40 and bilobar in 15. Operative procedures included 11 right hepatic lobectomies, 4 left lobectomies, 25 segmentectoies and 15 wedge resections.
Three-and 5-year survival rates for the curatively resected cases were 34.6% and 17.4%, respectively. The survival rate was higher in cases of unilobar metastasis than in those of bilobar metastases. Othewise, there was no significant difference in the survival rates between sollitary and multiple, and between synchronous and metachronous. Twenty-seven patients suffered relapse during the study. These recurrences were hepatic in 14 patients, extrahepatic in 5 patients, and intra-and extrahepatic in 8 patients. We conclude that surgery alone is an inadequate form of therapy for colorectalcarcinoma metastases to the liver, and that adjuvant therapy, including regional chemotherapy via the hepatic artery to the residual liver tissue, should be considered.

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An epidemiological survey was conducted on 4, 484 patients diagnosed as having ulcerative colitis in nationwide hospitals up to June 1981. Among these patients, 640 who underwent surgery were investigated.
The ages of the patients who had surgery ranged from 3 to i9years, and the average ages were 33.8 years for males and 38.0 years for females. Mast of the patients were in their twenties, followed by those in their thirties. The duration of the disease was one year or less in 40.0%, longer than one year in 59.1% and longer than 5 years in 14.5%. According to the pathological classification, many of the patients who underwent surgery were of colitis type, in the active stage, severe and of the relapsing-remitting type.
One third of the surgical procedures were emergency operations and the remaindes were elective. The indications for emergency patients were major hemorrhage, perforation, peritonitis, toxic megacolon, etc. The indications for the elective patients included repeated recurrence, and limitations of medical treatment. The mortality was 6.0% for the elective operations and 35.4% for the emergency operations, The mortality was high in patients with perforation, peritonitis and toxic megacolon as complications.

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The process of morphogenesis of colorectal cancer was investigated by microangiographic study of surgical specimens. Two hundred forty-eight patients with colorectal cancers treated surgically since 1978 in our department were used for present study. The lesions consisted of 108 adenomas, 27 early cancers and 250 advanced cancers which had invaded beyond the proper muscle layer. 1) Polyps were classified into 4 vascular patterns as follows : pedunculated type with long stalk, pedunculated type with short stalk, broad-based type and sessile type. The malignancy rate in adenoma was 6 % for short stalk, 18 % for long stalk, 22 % for broad-based and 27 % for sessile type. Also a highes rate of malignancy was observed as the tumor size increased. It thus seems that colonic adenomas carry a potential risk for cancer development. 2) The vascular patterns of protruded cancers were similar to those of adenoma, which might have evolved following stalk invasion. 3) In the morphogenesis of ulcerative cancers, two developmental courses were cofirmed : about 65% involved ulcer formation following cancerous invasion into the stalk of the pedunculated or broad-based type of adenoma, and the other 20 % involed development o flat adenoma of the sessile type.
In conclusion, most colorectal cancers might develop following cancerous invasion into the stalk of an adenomatous polyp.

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Recently, studies have been made of plasma fibronectin (pFN) and blood coagulant factor XIII (factor XIII) in various diseases. The present study examined the relationship of these substances to ulcerative colitis (UC).
pFN, factor XIII, platelet and fibrinogen (Fbg) in 32 cases of UC were measured a total of 46 times-19 cases in the active stage and 27 cases in the remission stage. pFN was measured using the partigen plate method, and factor XIII using the monodancyl cadaverin method. Both pFN and factor XIII levels were lower in the active stage than in the remission stage (p<0.01), while platelet and Fbg were higher in the active stage (p<0.05). In severe cases and in cases of total colitis, pFN and factor XIII were present at very low levels.
These levels increased from the active to the remission stage, and the increase was highest in total colitis. The low level in the active stage was due to blood consumption during tissue recovery, blood coagulation and opsonization, and a decrease in the production of pFN and factor XIII.
We concluded that pFN and factor XIII indicators of the severity and stage of UC, and that measuermert of their levels is very useful as a means of following up patients with UC.

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Intractable cases of ulcerative colitis treated in our department were analyzed. During the past fifteen years, 54 patients were diagnosed as having ulcerative colitis. Ten of these 54 patients (18.5%) satisfied the definition for intractable cases set by the Research Committee for Intractable Intestinal Disease, the Ministry of Welfare, Japan. Intractable cases were more frequently seen in severe cases, in cases with early onset and in cases with extensive colitis compared with non-intractable cases. On the other hand, intractable cases were encountered less frequently among mild cases and those with proctitis. Both systemic and local complications were encountered more frequently in intractable cases. Surgical intervention was performed in five out of the 10 patients. Up to the present, none of the remaining five cases has become a non-intractable case. Therefore it seems appropriate to consider intractable cases as potential candidates for surgical treatment.

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The colonic contents are to be considered for the factors of incomplete suturing or the infection at the damaged site as a complication after the surgery of colonic and rectal cancer.
We reviewed the importance of colon preparation for the variation of micro flora in the colon experimentally and clinically.
Rats of Wistar strain were used for the experimental review. After the parenteral nutritional method (ED) was performed, the antibiotics such as Kanamycin (KM), Metronidazole (MTN), and KM+MTN were orally administered for 4 days each. Then, we reviewed the variations of aerobic bacteria and unaerobic bacteria upon the colonic contents compared with ED single group. Moreover, we similarly reviewed by forming stenosis at the colon of each rate.
In the clinical review, we bacteriologically reviewed ED single group, ED+KM group, ED+MTN group and ED+KM+MTN group for the colonic and rectal cancer cases with not so severe stenosis, in other words, the cases to be able to perform enough mechanical preparations.

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To evaluate chronological changes in the incidence of diverticulosis of the digestive tract, we studied the annual detection rates of diverticulosis of the esophagus, stomach, duodenum and colon in out-and in-patients who underwent upper gastrointestinal fluorography or barium enema examination in our department between 1972 and 1986.
Diverticuloses of the esophagus, stomach and duodenum were observed in 1.02 %, 0.15 and 3.94, respectively, among 15, 274 patients who has undergone upper gastrointestinal fluorography over the past 15 years. Colonic diverticulosis was found in 4.88 % of 9, 066 who and erwent barium enema study during the same period. The annual detection rates of esophageal and dudenal colonic diverticuloses gradually increased between 1972 and 1988, the increase in colonic diverticulosis being prominent.
For birth cohort analysis, the patients were divided into 5 groups according to their birth years, 1905 and 1954. This analysis revealed that the detection rate of duodenal and colonic diverticulosis increased each group with increasing age. The patients born in more recent years had a higher detection rate than those born earlier.
These results suggest that aging plays an important role in the pathogenesis of diverticulosis the digestive tract, and that additional factor (s) may be involved in duodenal and colonic diverticulosis.

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Leiomyosarcoma of the gastrointestinal tract is often seen in the stomach and small intestine, whereas it is very rare in the colon. We have recently experienced an extremely rare case of leiomyosarcoma of the colon showing three separate lesions and associated with pan-peritonitis-like symptoms due to intraperitoneal hemorrhage.
The patient was a 67-year-old man who visited our hospital with a complaint of abdominal pain. CT scan suggested submucosal tumor of the colon, and emergency surgery was performed. Three separate lesions were found in the transverse colon and descending colon, and intraperitoneal hemorrhage was attributed to the most anal exocolic growing tumor. At surgery, there was no lymph node or hematogenous metastasis to the liver or other organs. Left hemicolectomy was performed.
To our knowlodge, 59 cases, including the present case, of leiomyosarcoma of the colon have ber previously reported in Japan.
A discussion of these cases is also presented in this report.

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Two cases of anorectal malignant melanoma are reported with a brief discussion of the tumor nuclear DNA content. Case 1 was a 66-year-old woman with anal pain. Proctoscopy showed a black tumor of the anal canal. Case 2 was a 68-year-old woman with anal itching. Proctoscopy showed a pale red tumor of the anal canal. Abdomino-perineal resection was performed in both cases, and the histological findings of the surgical specimens were malignant melanoma. In both cases, the tumor nuclear DNA histograms showed aneuploidy. Many investigators have reported that the tumor nuclear DNA content in cancers may be an important prognostic factor and that aneuploid cases have a worse prognosis than diploid cases. However, we were unable to find any report about the relationship between anorectal malignant melanoma and tumor nuclear DNA ploidy. In the future, this aspect will require investigation.

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A 42-year-old man was evaluated for perineal pain. Computed tomography of the pelvis revealed recurrence of rectal cancer, which was impossible to treat sugically. Though irradiation therapy was started, As it had to be discantinued beccuse of the appearance of inflammation in the perineal region and lower abdominal pain after 800 rad. Small intestinal gastrography revealed a perforation of the ileum, and intestinal resection was performed. Pathological studies showed cancer invasion, bleeding and edema due to acute radiation damage. The radiosensitive nature of the small intestine in this case led to a fatal outcome. Effective therapeutic and examination methods have not yes been established for cases such as this ore. It is concluded that lowdose radiation may induce severe intestial complications.

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