Nihon Daicho Komonbyo Gakkai Zasshi
Online ISSN : 1882-9619
Print ISSN : 0047-1801
ISSN-L : 0047-1801
Volume 63, Issue 10
Displaying 1-13 of 13 articles from this issue
Special Articles Theme I.
  • Jun-ichi Saigusa, Naoto Saigusa, Sumio Saigusa
    2010 Volume 63 Issue 10 Pages 813-818
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Hemorrhoidal disease is one of the oldest-known diseases in human beings. In ancient times, treatments for anal disorders came in the form of local applications made from different plants and trees, and sometimes blood-loving animals were used. Hippocrates proposed that hemorrhoids be cured by a white-hot iron or simply burning them off. In Hebrew writings, the anus was referred to as "the secret part" and thereafter it was called an "undiscussable disease". For a long time, this negative attitude toward anal disease was a major impediment to rational treatment. Throughout the Middle Ages, attempts were made to inject various chemical materials into hemorrhoids, but these treatments sometimes caused severe complications; treatment was in the hands of quacks in the 19th century. At about this time, various hemorrhoidectomy procedures were invented and later modified. The founding of St. Mark's Hospital and hemorrhoidectomy with high ligation originally developed by Salmon marked historical turning points. Japan introduced modern western medicine at the beginning of the Meiji Era and replaced conventional domestic methods.
    In the West in the 19th century, necrotizing injection treatment spread widely. Whitehead's technique, which had been abandoned in England several decades earlier, continued to be commonplace in Japan. At present, in addition to Milligan-Morgan's technique, recently developed sclerosing agents and operative devices are used.
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  • Tetsuo Yamana, Akihiro Ohori
    2010 Volume 63 Issue 10 Pages 819-825
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    There have been few articles regarding the epidemiology of hemorrhoids, therefore the prevalence of hemorrhoids is not well documented. In the USA, an annual nationwide health questionnaire showed a prevalence rate of 4.4%. In both sexes, a peak in prevalence was noted from age 45-65 years. There seems to be a fall in the rate of hospital visits in both the USA and the UK. The etiology and pathophysiology is uncertain as well. Between the 18th and 19th Centuries, several hypotheses were postulated. Examples include the abnormal venous dilatation theory and erectile tissue metaplasia theory. In the late 20th Century, several studies argued that little evidence was found supporting abnormal venous dilatation, and that hemorrhoidal symptoms may arise from distal displacement of the anal vascular cushion. Since then, the sliding anal lining theory has been thought of as the main etiology of hemorrhoids. Despite the fact that the pathogenesis of hemorrhoids still remains elusive because of the diversity and complexity of their pathophysiology, it is reasonable to assume that both vascular tissue factors and the connective tissue factors contribute to the etiology of hemorrhoids.
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  • Syusaku Yoshikawa, Naoki Inatsugi, Tsutom Masuda, Hideki Uchida, Hiroy ...
    2010 Volume 63 Issue 10 Pages 826-830
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Traditionally, the divided ligation technique for hemorrhoids has been used by Seishu Hanaoka, Soken Honma and K. Hata in Japan. Y. Masuda et al. carried out the divided ligation of hemorrhoids with some modifications. This method is indicated for 3rd-degree or 4th degree internal hemorrhoids. Mean length of healing was 29.1-35.5 days. As for postoperative complications, 0.51-0.84% of patients developed minor bleeding, and only a few patients required catheterization for urination.
    Rubber band ligation is indicated for 2nd-degree or 3rd-degree internal hemorrhoids, but is not indicated for very small or fibrosed ones. This method may not require anesthesia. It is effective in 80-90%, with 1.2-12% of patients being operated on afterwards. As for postoperative complications, 0-18% of patients developed minor bleeding and 0.8-33.2% patients had some pain.
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  • Makoto Matsushima, Yasuhiro Shimojima
    2010 Volume 63 Issue 10 Pages 831-837
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Hemorrhoid treatment strategies are chosen depending on the size and form of the hemorrhoid. Surgery is considered to be appropriate for Grade III hemorrhoids, which requires manual reduction. Hemorrhoidectomy based on the Milligan-Morgan procedure has been improved for a long time, and has been regarded as the standard procedure because of its many advantages: anal functions are conserved, complete cure can be achieved, the procedure is safe, and serious complications are rare. Delayed massive bleeding, which is a problem of this operative procedure, occurred in 2.2% of cases, 81% of which happened within 14 days after the operation. Postoperative anal stenosis and recurrence were found in 0.1% and 0.2% of cases, respectively. In addition, 46.2% of hemorrhoid patients had comorbid lesions different from hemorrhoids. We therefore consider that a different anal hemorrhoidectomy procedure is required that safely provides persistent therapeutic effects for all hemorrhoid cases.
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  • Satoru Umegae, Kouichi Matsumoto, Tatusi Kitagawa, Midori Noji, Takayu ...
    2010 Volume 63 Issue 10 Pages 838-845
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    The procedure for prolapse and hemorrhoids (PPH), which was first described by Longo in 1998, reduces the prolapse of hemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane by using a circular stapling device. This technique has rapidly spread all over the world because it is associated with less pain and better quality of life postoperatively. In Japan, since 2001 it has been successfully introduced in the management of third-degree hemorrhoids, and has been reported to be associated with less postoperative pain, rapid recovery and low recurrence rate. The incidence of postoperative complications has been reduced with advances in stapling devices and techniques. However, PPH is not indicated for all types of hemorrhoids, and should be used selectively under strict indications. Therefore, it should be performed by skilled and experienced surgeons who are familiar with not only this technique but also other treatments such as ligation and excision (LE) and ALTA. From our experience, PPH is a highly effective treatment for selected patients with hemorrhoids.
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  • Yoshikazu Hachiro, Tatsuya Abe, Masao Kunimoto
    2010 Volume 63 Issue 10 Pages 846-850
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Aluminum potassium sulfate and tannic acid (ALTA) are able to induce noninvasive sclerosis and involution of hemorrhoids through initiation of inflammatory reaction. ALTA therapy is an effective treatment for all cases of internal hemorrhoids, but not all cases of hemorrhoids are treatable by ALTA therapy alone. The current treatment strategy for internal hemorrhoids at our hospital is based on (1) determination of whether ALTA therapy is possible for the given type of hemorrhoid, and (2) ligation and excision (LE) of those types for which ALTA therapy is difficult to perform.
    Between May 2006 and May 2010, 1,630 patients with grade II to IV hemorrhoids underwent surgery at Kunimoto Hospital.
    A total of 645 patients were treated with ALTA therapy alone (Group A), 912 patients received a combination of LE and ALTA therapy (Group B), and 73 received LE alone (Group C). The overall recurrence rate was 2.8% (18/645) and 0.4% (4/912) in Group A and B, respectively. There was no recurrence in Group C. In Group A, 9 patients required an additional injection therapy procedure, and 6 required LE. In Group B, 2 patients required LE. Five patients (0.8%) had rectal ulcers to the injection site in Group A. These patients were cured by conservative therapy for several months.
    ALTA injection is an effective, established treatment for internal hemorrhoids. ALTA sclerotherapy is a simple and safe treatment for the management of symptomatic hemorrhoids and has few complications.
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  • Tokiko Yamaguchi
    2010 Volume 63 Issue 10 Pages 851-854
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Important issues in outpatient hemorrhoid surgery are intra- and postoperative pain relief and reduction of postoperative bleeding. In particular, because patients leave hospital after the surgery and recuperate at home, delayed hemostatic treatment may result in the worst-case scenario of massive bleeding. Among hemorrhoid treatments, aluminum potassium sulfate tannic acid (ALTA) therapy is the most useful for reducing these risks; injecting ALTA into internal hemorrhoids reduces their size. Pain after the therapy is mild, no analgesics were required in about 40% of our patients, and none of the patients had postoperative massive bleeding. Although ALTA therapy is not applicable to all internal hemorrhoids, if hemorrhoids are treated mainly with ALTA therapy or surgery without incision where possible, it is suggested that all hemorrhoids can be treated with day surgery.
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Special Articles Theme II.
  • Fumihito Hirai, Toshiyuki Matsui
    2010 Volume 63 Issue 10 Pages 855-862
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Crohn's disease (CD) is a chronic inflammatory disorder characterized by a disabling and interactive course. Treatments for patients with CD have been developed and effective therapies, such as Infliximab, have been widely used in Japan. Therefore, physicians are required to choose an optimal treatment for each patient. The Japanese guideline for CD, consisting of not only evidence but also the consensus of specialists, was published in April 2010. This article introduces the treatments for CD described in the guideline and their proper use.
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  • Yasuo Suzuki
    2010 Volume 63 Issue 10 Pages 863-868
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Infliximab (IFX), which is an anti-TNF biologic, is becoming a standard medication for the treatment of Crohn's disease (CD). IFX appears to be more effective than conventional medications in inducing intestinal mucosal healing, and maintaining remission as scheduled maintenance therapy when administered at 8-week intervals, offering better long-term control of symptoms. Significantly, mucosal healing is associated with lower flare-up rates, the need for surgical intervention, and hospitalization rate. As a result, the long-term prognosis and QoL of CD patients are improved. However, there is significant concern about the long-term efficacy and safety of IFX, which needs to be addressed such as through immunomodulator therapy to minimize the loss of efficacy during maintenance IFX therapy.
    Recently, a granulocytapheresis therapy (GCAP), which is fundamentally different from drug based medication, has become available for clinical application in patients with IBD. GCAP is viewed as an alternative therapy for patients with CD, and is very effective for the treatment of IBD; it has been accepted as a standard therapy for patients with active ulcerative colitis, and its use is now extending to CD. Further investigations are required for the use of GCAP in treating patients with IBD.
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  • Tomoyuki Tsujikawa, Shigeki Bamba, Akira Andoh, Masaya Sasaki, Yasuhar ...
    2010 Volume 63 Issue 10 Pages 869-874
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Intestinal complications in Crohn's disease include stricture, internal/external fistula, and massive hemorrhage. These complications reduce the patient's quality of life because surgical procedures are usually needed. Recently, many patients with stricture have been able to avoid surgery by endoscopic balloon dilatation. Anti-TNFα antibody may heal an external fistula, but is less effective for an internal fistula due to complicated stricture. Anti-TNFα antibody should also be administered to patients with massive hemorrhage. In particular, maintenance of clinical remission may not be sufficient to prevent intestinal complications and more intensive therapy may be necessary. In order to achieve mucosal healing, effective combined therapy based on the behavior of the patient's disease should be performed.
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  • Yuji Funayama, Ken-ichi Takahashi, Kohei Fukushima, Hitoshi Ogawa, Sho ...
    2010 Volume 63 Issue 10 Pages 875-880
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    The principle of surgical management in Crohn's disease is conservative resection of the diseased intestine while retaining as much of the healthy segment as possible. Various types of stricture plasties are used for fibrous stricture, which enables the conservation of healthy intestine. Fecal diversion is indicated for cases of poor risk or with poor anorectal function. In western countries, an algorithm for the postoperative maintenance regimen has been proposed, in which 5-ASA is used in mild disease, immunomodulators are indicated for moderate disease, and infliximab is added for high risk or severe cases, with regular follow-up using endoscopy at 6- to 12-month intervals. In Japan, more careful management with a basic diet is expected to be practiced.
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  • Kitaro Futami, Daijiro Higashi, Yuji Egawa, Yukiko Ishibashi, Takashig ...
    2010 Volume 63 Issue 10 Pages 881-887
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    We studied the long-term clinical course and postoperative outcome of perianal lesions for 139 patients with CD. Of the 139 patients, 129 (92.8%) had anal lesions, and perianal fistula or abscess was the most common. During a mean follow-up period of 178.2 months, all lesions increased and exacerbated, particularly with complex fistula and anal stricture. Finally, anorectal carcinoma was complicated in 4 patients (2.9%). After conventional fistulotomy for perianal fistula with CD, recurrence was frequent with the risk of anal sphincter damage, and seton drainage effectively improved symptoms in the long term. Rectal amputation was performed for 14 patients including 4 patients with carcinoma and 10 with intractable lesions.
    It is thought that, in surgery for perianal lesions with CD, the main goal is to alleviate the symptoms and improve the quality of life. Therefore, successive careful management is important, with consideration of anal function and complicated carcinoma in the long term.
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  • Kiyokazu Nakajima, Riichiro Nezu, Junichi Hasegawa, Masaki Hirota, Tsu ...
    2010 Volume 63 Issue 10 Pages 888-892
    Published: 2010
    Released on J-STAGE: October 15, 2010
    JOURNAL FREE ACCESS
    Laparoscopic surgery has been clinically accepted for stricturing ileocecal Crohn's disease without fistula, abscess or large inflammatory mass. With the recent advancement of laparoscopic devices, this approach has been further modified to "single port surgery", which has an apparent cosmetic advantage over conventional laparoscopic surgery. Laparoscopic surgery, however, remains technically challenging for complicated cases and/or recurrent disease, resulting in a higher rate of open conversion. The surgical approach should be carefully determined for these cases, with full consideration of mini-laparotomy assistance and/or hand-assisted laparoscopic surgery (HALS). Currently, HALS is our preferred method especially for cases requiring total/subtotal colectomy for diffuse colonic disease expecting retrieval of a bulky specimen. The true advantage of these "minimally invasive" surgical approaches over conventional open surgery remains unclear, and so further studies, ideally prospective randomized trials, are necessary.
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