We report herein a case of stercoral perforation of the sigmoid colon, presenting a re-attack during treatment of hemodialysis for chronic renal failure, and adding a discussion of 60 cases documented in the Japanese literature. A 76-year-old female, who had had an episode of stercoral perforation of the sigmoid colon and had undergone Hartmann's procedure about 3 years previously, had sudden abdominal pain and was readmitted to our hospital. Abdominal X ray and CT findings showed free air and the colon impacted with a large number of scybala. Laparotomy revealed a perforation of the sigmoid colon, and scybala were seen in the abdominal cavity near the perforation and inside the total colon. Hartmann's procedure was performed, and she was discharged on postoperative day 18, uneventfully. In addition to the pressure of scybala on the colon wall, tight adhesion to colon mucosa of fecal mass, and a decrease of mucinous secretion from colon mucosa, are conceivable causes of a continuous local disturbance of blood flow of the colon wall. This mechanism might induce stercoral perforation of the colon.

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The patient was a 45-year-old female, who was admitted to our hospital complaining of constipation and melena during a menstrual period in 1995. She had a history of receiving hormone therapy for endometriosis since age 27. A barium enema study and colonofiberscopy showed a stenosis of the rectum. We diagnosed the case as endometriosis of the rectum from these findings and her past history. Four years of hormone therapy did not relieve her symptoms. Therefore, a low anterior resection, total hysterectomy, and left oophorectomy were performed on August 2, 1999. Histologically, endometrial tissue was found in the proper muscle layer of the colon. After surgery her complaints disappeared, and there has been no recurrence of the endometriosis.

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A rare case of CCP accompanied by rectal adenocarcinoma, seven years after the onset of CCP, is presented.
The patient was a 43-year-old male, who received abdominoperineal resection of the rectum due to an intraabdominal abscess in March 2001. Pathological study revealed CCP accompanied by well-differentiated adenocarcinoma deep to the muscularis mucoua, and lymph node metastasis was found. The epithelium of mucous cyst was atypical.
CCP is a rare, non-malignant polypoid lesion regarding which there have been very few reports as to concurrence with CCP and adenocarcinoma, or neoplastic change of CCP.

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A 89-year-old woman complaining of melena and anemia was referred to our hospital. Barium enema radiography revealed a circular shadow in the rectum. Colonofiberscopy detected a tumor elevating into the lumen of the rectum with malignant ulcer. Pathohistological diagnosis of a biopsy specimen from the tumor showed well differentiated adenocarcinoina, so it was diagnosed as type 2 primary rectal cancer. Operative findings showed appendical tumor penetrating into the rectum, and lower anterior resection of the rectum and combined ileocecal resection were performed. Pathohistological diagnosis was mucinous cystadenocarci-noma of the appendix with direct invasion to the rectum. Primary carcinoma of the appendix occurs rarely and is difficult to diagnose preoperatively due to lack of specific symptoms and established examinations. Furthermore, this case showed uncommon extension and invasion of the tumor. The tumor penetrating into the rectum led us to misdiagnosis because barium enema, colonofiberscopy and histopathological findings suggested that it might be primary rectal cancer. So we reviewed retrospectively each finding and discussed the specific characters of the primary carcinoma of the appendix.

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We experienced a rare case of primary appendical signet ring cell carcinoma. A 71-year-old man with appetite loss and anemia was admitted to our hospital. On physical examination, an elastic hard tumor was palpable in the right lower abdomen. Abdominal CT scan showed a 5cm-sized tumor located on the medial side of the cecum. Colonofiberscopy revealed a deformity of the cecum and an elevated edematous mucosal lesion around the orifice of the appendix. Histological examination of a biopseid specimen showed poorly differen-tiated adenocarcinoma of the appendix. At laparotomy, there was an appendical carcinoma with peritorinal dissemination in Stage IV. Histopathological findings showed signet ring cell carcinoma. He received postoperative chemotherapy, but the therapy could not be continued due to his physical condition. He was well without symptoms 12 months after operation. The prognosis of colonic signet ring cell carcinoma is very poor. This case had a singular course.

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We report three cases of coccygeal cyst.
Case 1 : A 24-year-old woman demonstrated a well-defined homogeneous area with colic approximately 6 cm in diameter on the posterior wall of the rectum by CT examination. A transsacral tumorectomy was performed. The tumor was an intestinal duplication cyst.
Case 2 : A 60-year-old man had a mass on his rectum untreated for three years. A discrete area about 2 cm in diameter, with calcification, was noted on the right side of the rectum about 3 cm oral from the anus, and per anum tumorectomy was undertaken. The tumor was an intestinal duplication cyst.
Case 3 : A 28-year-old woman was found to have a mass in the coccygeal region with colic, and a transsac-ral cystectomy was performed two months later. A tailgut cyst was suspected. The duplication cyst is composed of a smooth muscle layer and the serosa. The tailgut cyst is devoid of muscle layers and has a tubular structure covered with two to four layers of stratified columnar epithelium. As it is difficult to make a definite diagnosis of cystic disorders of the coccygeal region from preoperative examinations and as such disor-ders may become malignant, the mass should be excised en bloc.

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A 76-year-old woman, whose complaint was constipation, was referred to a hospital. She had received a barium enema examination, and a severe stenosis in the lower rectum was found, so she was transferred to our hospital for admission. A few days later, her condition worsened, and bowel obstruction was observed. We performed bowel decompression by a trans-anal tube using colonofiberscopy. We obtained transient decompression, but the symptom was observed again. Next, we performed bowel decompression by trans-appendical intubation under general anesthesia. The effect of decompression by this technique was effective, and her symptom improved immediately. Seven days later, we were able to perform a curative operation safely (low anterior resection). At surgery, no intestinal expansion was observed. The postoperative course was uneventful except for a minor wound infection. We think this technique (decompression by a trans-appendical tube) is worthwhile when trying to avoid a colostomy and emergency resection of the colon with bowel obstruction.

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The patient was a 49-year-old man. Since he had repeated episodes of melena for approximately 2 years, he had a detailed examination at a local clinic. However, the cause of the melena could not be determined. During his stay in our hospital for further examinaton, he suddenly had massive melena. Abdominal angiography successfully localized the source of bleeding at the end of the jejunal branch. We injected a dye during surgery from a microcatheter placed ultra-selectively in the artery in the vicinity of the bleeding site and, after confirming a change in the color of the intestinal serosa, performed small bowel resection. On gross examination of the resected specimen, the source of bleeding was observed as a blood-blister-like tumor 2 mm in diameter, which was histopathologically diagnosed as pyogenic granuloma. The patient's postoperative course was uneventful, and the patient was discharged on the 8^th day after surgery. Although pyogenic granu-loma of the small intestine is extremely rare, it should be considered as one of the causes of small intestinal bleeding. Intraoperative dye injection from an indwelling arterial catheter in cases of small intestinal bleeding where the lesion is difficult to confirm during surgery was useful for determining the extent of resection.

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We investigated the significance of surgical treatment for pulmonary metastases from colorectal cancer in patients with previous liver metastasectomies.
Both liver and pulmonary metastases were resected in 12 patients from January 1977 through December 2000 in our institute. Seven patients had liver metastases synchronously with primary tumor, three of whom also had lung metastases synchronously. Of the other five patients who had metachronous liver metastases, pulmonary metastases were detected simultaneously with liver metastases in 2 patients and they were de-tected later in 3 patients. No perioperative morbidity occurred and all patients were discharged.
Five-year survival rate and the disease-free survival rate of 12 patients after the last metastasectomy were 40.0% and 12.5%, respectively. One patient is still alive without recurrence more than 10 years after the last metastasectomy.
The average interval between detection of each metastasis of 9 patients in whom metastases recurred within one year after the last metastasectomy was significantly shorter than that of 3 patients without early recurrence (7.1 vs. 37.0 months, p<0.01).
Patients with both liver and pulmonary metastases from colorectal cancer should be considered for surgical treatment, especially when the interval between detection of each metastasis is long.

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A total of 38, 212 patients underwent colonoscopic examination at Tokorozawa Proctologic Hospital (TPH) from 1995 to 2001. Colorectal cancers (advanced cancer : 498, early cancer : 264) were found in 762 patients (2.0%). The incidence of advanced cancers was higher in male patients than that in females (p<0.01). The mean age of patients with advanced cancer (62.4) was significantly older than that of patients with early cancer (59.8 ; p<0.02). Most of our patients with colorectal cancer underwent surgical treatment at National Defense Medical College Hospital (NDMCH). From 1995 to 1999, 743 operations for colorectal cancer were performed at NDMCH, of which 257 (34.6%) were referred from our hospital. We compared the clinical features between patients from our hospital and those from other hospitals. Significant differences in characteristics of our patients were found in the chief complaint (hemorrhage), the location of the tumors (rectum), mean age (younger), and advanced clinical stage.
Patients with chronic anal disease seemed to overlook hematochezia as a symptom of colorectal cancer. Proctologists should pay attention to this point.

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