Pit pattern diagnosis using magnifying chromoendoscopy for colorectal tumors is useful in histologic diagnosis and invasion depth prediction. There are two kinds of chromoendoscopy: that using indigo carmine dye spraying and that using crystal violet staining. However, crystal violet staining can not be used to examine all tumors. When tumors are suspected of type V pit pattern, it is necessary to observe the tumors using crystal violet staining. Especially, the type V_N pit pattern is a useful indicator of submucosal invasion deeper than 1,000 μm. Also, narrow band imaging (NBI) is considered to be useful in differential diagnosis between neoplasia and non-neoplasia & pit pattern diagnosis (surface pattern) for regular pits without chromoendoscopy. NBI magnification is expected to be useful for the qualitative diagnosis of colorectal tumors through assessment of both microvessel structure and surface pattern on the lesion surface.

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The number of patients suffering from colorectal cancers has markedly increased, by 2.5 times in the last 20 years in Japan. Meanwhile, endoscopic diagnosis including magnifying endoscopy and treatment for early colorectal cancers has developed during the same period. The progress of endoscopic resection techniques such as polypectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) has led to changes in therapeutic strategies for early colorectal cancers. ESD is a resection method, which was first developed in Japan as a therapy for early gastric cancers. This endoscopic technique is also a very useful endoscopic procedure, making it possible to perform en bloc resection of colorectal tumors regardless of lesion size. We compared the incidence of perforation and residual/local recurrence associated with colonoscopic treatment. The incidence of perforation was 0.15% with EMR, 0.57% with EPMR, and 0.24% with ESD. This result revealed that ESD has become a very safe procedure similar to the EMR technique. The incidence of residual/local recurrence was 0.6% with EMR, 7.1% with EPMR, and 0% with ESD. Thus, although there is no significant difference in the incidence of perforation between these endoscopic procedures, the rate of residual/local recurrence of EPMR was significantly higher than that of EMR and ESD.
The possibility of completing ESD for colorectal tumor sometimes depends on the existence of fibrosis in the submucosal layer rather than the size and location. ESD was performed for 412 cases of colorectal neoplasm in 401 patients (male:female = 240:161; mean age, 66.9 years). Among these cases, 84 cases were accompanied by SM fibrosis, of which 27 cases were considered related to cancer invasion and 57 cases were unrelated. En bloc resection rate of the tumor without fibrosis was 96.7% (317/328), and the tumor was accompanied with fibrosis in 78.6% (66/84). We experienced only one case of perforation (0.2%), which was accompanied with fibrosis. From the viewpoint of safety and radicality, use of the ESD procedure is thought to be limited for this group at high risk of perforation and recurrence.
For the above reasons, we established a safe resection procedure using laparoscopic and endoscopic cooperative surgery (LECS) in order to perform en bloc resection of tumors for which it is difficult to perform ESD due to fibrosis in the submucosal layer. It is important to establish the limitations of EMR and ESD in the therapeutic strategy for treating early colorectal cancer.

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In this review, we present recent topics on the assessment of the pathological diagnosis for early colorectal carcinoma resected by endoscopy. Our conclusions were as follows: 1) handling of resected specimens is very important: fixation and sectioning, 2) depth of tumor invasion: when invasive SM colorectal carcinomas are divided into SM1 (depth of SM invasion is less than 1000μm) and SM2 (depth of SM invasion is 1000μm or more), lymph node metastasis was found in more than 30% of SM2 cases with positive budding/sprouting, 3) sessile serrated adenoma/polyp (SSA/P) with distinct molecular abnormalities: high frequency of DNA methylation at CpG islands and BRAF-mutations, rather than K-ras was a new precancerous lesion in the serrated-neoplastic pathway, 4) analysis of ER gene methylation and the DNMT-1 marker are useful for identifying individuals at increased risk of neoplasia among those with longstanding and extensive UC, but we stress the specific morphology of dysplasia, which is different from that of sporadic adenoma.

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The rate and status of lymph node metastases in patients with T1 and T2 colorectal carcinoma were examined based on our experience, a multi-institutional registry of large bowel cancer in Japan, and other reports. The rates of lymph node metastasis are about 10% in T1 colorectal carcinoma and 30% in T2. The recommendation of D2 dissection in patients with T1 colorectal carcinoma and D2 or D3 dissection for T2 in the JSCCR Guidelines 2010 for the treatment of colorectal cancer is considered appropriate. Although there was no pN3 in patients with T2 colorectal carcinoma from our data, D3 dissection should be performed in patients with T2 and moderately or poorly differentiated adenocarcinoma, because of the high rate of lymph node metastasis.

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Early colorectal cancer is surgically resected by either local excision or bowel resection. Local excision is principally a method of total biopsy for pathological examination of the lesion. If the lesion is an advanced cancer, or a submucosal cancer having risk factors of lymph node metastasis, additional bowel resection is indicated. Local excision for early colon cancer is rarely performed. Methods of local excision for early rectal cancer include transanal local excision, minimally invasive transanal surgery (MITAS), transanal endoscopic microsurgery (TEM), and transsacral local excision. Both the advantages and disadvantages of each procedure should be well evaluated when selecting the procedure for each lesion. In bowel resection, dissection of regional lymph nodes is usually carried out. For early rectal cancer, pelvic autonomic nerves should be carefully preserved. Intersphincteric resection (ISR) and rectal prolapsing are sometimes used to avoid abdominoperineal excision with permanent colostomy. Laparoscopic surgery is suitable for early colon cancer. Although laparoscopic surgery is currently not yet the standard of care for rectal cancer, its safety and usefulness are being validated by clinical trials because it provides a much better view of the pelvic cavity than conventional open surgery.

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Many surgical procedures are available for rectal prolapse, but it is still unknown which procedure is the best. Therefore, the procedure is decided depending on the conditions and request of patients as well as the experience and preference of surgeons. According to the best available evidence, abdominal rectopexy is recommended if patients are fit enough, and the laparoscopic approach is superior to open surgery if techniques are good enough. For rectopexy, lateral ligaments might as well be preserved, and a mesh does not need to be utilized. Sigmoidectomy may be added in patients with preoperative constipation, but it is not necessary in those without. Patients who are not candidates for rectopexy may be treated with perineal approaches including Delorme, Altemeier and Gant-Miwa (-Thiersch).
However, such strategy is based on the policy that the lowest recurrence rate has the highest priority. We must remember that rectal prolapse is a benign condition and its “recurrence” does not necessarily mean the end of the world. Based on this concept, perineal approaches can be chosen even if patients are fit enough. In order to substantiate these statements, this paper conducts a historical review of surgery for rectal prolapse, and discusses how to select an appropriate procedure.

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In the diagnosis of rectal prolapse, it is quite unmistakable when a typical protruded mucosa from the anus is present with sulcus in a concentric ring. It is also helpful when differentiating radial furrows are found in mucosal prolapse. Recent advances in the dynamic study of pelvic floor imaging have shown that rectal prolapse is accompanied with pelvic organ prolapse, such as cystocele, enterocele, and rectocele. Moreover, through inter-professional collaboration between urologists and gynecologists, many physicians have understood that there are overlapping pathophysiologies among these pelvic conditions. Pelvic floor disorders may also be a cause of urinary, defecatory and sexual disturbance which greatly affect the patient's quality of life. From this point of view it is not enough to demonstrate the existence or severity of rectal eversion; either anatomical or functional abnormality associated with rectal prolapse should be observed. A comprehensive evaluation includes addressing anterior and/or middle pelvic organ descent as well as their continence status. This article reviews investigations of rectal prolapse as pelvic floor disorders.

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Abdominal rectopexy for rectal prolapse is a more invasive and radical procedure than perineal procedures. Though patients with rectal prolapse are usually aged and poor risk patients, abdominal rectopexy is usually recommended if feasible because of the radicality. In recent years, laparoscopic rectopexy has become more popular and covered by insurance since April this year, therefore less invasive and more radical treatment can now be achieved.
The key points of the procedures are to mobilize the rectum, to pull it up, and to fix it fully. The detailed procedures might differ slightly according to the institute where performed, to what extent the rectum is dissected, whether the lateral ligament is divided or not, whether the rectum is fixed by mesh or sutured directly, and whether bowel resection is accompanied or not. To determine the proper detailed procedures, a prospective comparative study should be planned and treatment guidelines established.

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Altemeier's procedure for prolapse has been employed for more than 100 years. The operation consists essentially of perineal rectosigmoidectomy and levator plasty. It can be performed under a general, saddle block or even local anesthesia. Therefore, the operation is generally recognized as one of the procedures of choice for elderly debilitated patients who can tolerate the procedure well. In the past the procedure was limited to this category of patient because of the high recurrence rates reported. However, a recent detailed clinical assessment indicates excellent results including a low rate of recurrence, morbidity and improvement of bowel dysfunctions such as incontinence. Therefore, the detailed procedure should be tailored to the pathology of the individual. There are three major theories of the pathology: circumferential intussusceptions, sliding hernia and attribute to mucosal prolapse. Moreover, various other factors are concomitant with the condition, and often need to be balanced against one another. Of course, Altemeier's procedure itself may not be able to solve all the problems. However, as the procedure is so simple, we can modify it to suit the pathology. Altemeier's procedure comes closest to achieving the goals regardless of patient age and associated co-morbidities, providing excellent results and resolving problems in defecation.

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A retrospective study on the use of the Gant-Miwa procedure in conjunction with the Thiersch procedure in 31 cases of rectal prolapse was performed and completed in March 2011. We evaluated these cases after a follow-up period of more than one year. The findings revealed that: 1) the number of female cases was overwhelmingly more than that of male cases, with a male to female ratio of 16.1:83.9; 2) the mean age was 82.3±8.1 with the majority of cases being elderly; 3) the mean operative time was 41 minutes; 4) postoperative complications were observed in three cases (severe anal bleeding after defecation occurred 23 days after the operation, surgical knot appeared at the point of insertion one year later, and the surgical thread was placed on the inside of the sphincter muscle causing anal pain during defecation and difficult evacuation); and, 5) recurrence was observed in five of the cases (16.2%). The cases were then compared in terms of prolapsed bowel length of either less than 5 cm or longer. The less than 5 cm group contained 1 out of 8 cases (12.5%), and the 5 cm or longer group contained 4 out of 23 cases (17.4%).

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Rectal prolapse occurs in people of all ages, from infants to the elderly. In today's aging society, the incidence of elderly-onset rectal prolapse has been increasing. Treatment of rectal prolapse is primarily surgical. Invasiveness and radicality of the surgical procedure, and quality of life after surgery should be considered in selecting an appropriate procedure. In Western countries, Delorme's method has been widely used as a minimally invasive surgical procedure. Nowadays, in several institutions in Japan, the Gant-Miwa procedure is being replaced by Delorme's procedure in the surgical management of rectal prolapse. The outcomes of Delorme's procedure are affected by the experience and skill of the surgeon. Since Delorme's procedure is performed via a perineal approach, it is less invasive and safer than abdominal procedures. Therefore, Delorme's procedure is used as the primary surgical treatment for rectal prolapse because of its safety and less invasiveness for patients in poor general condition. This article reviews the indications, procedures, and outcomes (complications and recurrence rates) of modified Delorme's procedure (Umegae method) for patients with rectal prolapse.

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Anal encircling (Thiersch procedure) is one of the perineal procedures for rectal prolapse. It was first described in 1891 by Carl Thiersch. This procedure entails encircling and straightening the anal canal with a kind of cord. It was used for rectal prolapse in Japan in the 1960s. Although silver wire was the original material described by Thiersch, nowadays other materials are used: nylon thread, Teflon^® tape or stretchable polyester tape. These variants were conceived to prevent complications, broken wire, anal or perineal erosion, and infection. However, there are many reports of a recurrence rate of over 40% with this procedure; anal encircling combined with another method such as mucosal plication (Gant-Miwa Procedure) has proven to reduce the recurrence rate. Nevertheless, the Thiersch procedure does not require general anesthesia, so it is preferred by elderly patients and those who cannot tolerate general anesthesia.

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