This study was conducted to evaluate the prognostic factors of patients with primary tumor resection in non-resectable stage IV colorectal cancer. One hundred seventy- seven non-curative stage IV cases, who underwent primary tumor resection from 2000 to 2010, were enrolled in this study. In univariate analysis, preoperative CEA(=>5ng/ml), with H2 or 3 liver metastasis, there were more than 2 sites of remote metastasis, venous invasion, no targeted therapy and the overall survival time (OS) was significantly shorter. In multivariate analysis, with H2 or 3 liver metastasis, there were more than 2 sites of remote metastasis, no targeted therapy and there were independent poor prognostic factors in non-resectable stage IV colorectal cancer with primary tumor resection. In subgroup analysis, OS was improved in patients with H2 or 3 liver metastasis by using targeted therapy, but not improved in H0 or 1 liver metastasis. Targeted therapy may improve prognosis in patients with non-resectable stage IV colorectal cancer, in particular those who have advanced liver metastasis.

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[Purpose] To evaluate our enhanced recovery after surgery (ERAS) protocol based on data collected during the treatment of 25 patients who underwent an elective colorectal resection at our institute. [Method] The 7 components of our ERAS protocol are as follows. 1. Pre-operative: pre-operative written assessment; 2. Day prior to surgery: no mechanical bowel preparation; 3. Pain control: epidural analgesia until POD2, local anesthetics around the surgical wound closure, and oral NSAIDs from POD1; 4. Surgery: laparoscopic colectomy with no surgical drains; 5. Fluid and food: free fluid from POD1, liquid diet from POD1, and normal diet from POD2; 6. Mobilization: oral prokinetics from POD1 and walking around the ward from POD1; and 7. Assessment for discharge on POD3. [Results] The patients' mean dietary intake on POD1 was 50% (0-100%), and on POD3 it was 90% (10-100%). The mean walking distance on POD1 was 300 m (33-770m) and on POD3 it was 600 m (300-3,630m). Patients' first bowel movement occurred at a mean of 31 h (12-53h) after surgery. The postoperative complication rate was 4%. Mean postoperative hospital stay was 5 days (4-17 days). There were no readmissions due to postoperative complications. [Conclusion] Our ERAS protocol accelerates postoperative recovery without compromising patient safety.

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We retrospectively examined the validity of the early removal of the pelvic drain. Seventy-six patients, who underwent restorative total proctocolectomy for ulcerative colitis from January 2006 to December 2010, were enrolled in this study. A closed suction drain in the pelvis was planned to be removed approximately 48 hours after surgery. Forty-six patients were male and 30 were female, the median age was 40.5 years old, corticosteroid was used preoperatively in 78.9% of the series and immunosuppressive agents were also used in 25.0%. The actual period of removal was an average of 2.6 days after surgery. The total incidence of surgical site infection was 31.6% (24/76) and space/organ surgical site infections developed in 9.2% (7/76) of patients. All pelvic abscesses were treated using CT-guided drainage and they were recovered. Exogenous infection was suspected in only one case: a Staphylococcus was isolated from a pelvic abscess. Even if patients with ulcerative colitis are a high risk group regarding surgical site infections, short-term placement of the closed suction drain is safe and effective to prevent exogenous infection.

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This article reports on the results of treatment of patients with mixed hemorrhoids with a combination therapy consisting of excision of the external hemorrhoids and injection of an ALTA solution into internal hemorrhoids (EA method).
A total of 296 patients who underwent treatment of 1 or more primary hemorrhoids with the EA method between February 2011 and January 2013 were included in this study. The hemorrhoidal sites in which the EA method was not used were treated with ALTA therapy alone. In preoperative assessment, 51 subjects had Goligher Grade II, 216 had Goligher Grade III, and 29 subjects had Goligher Grade IV hemorrhoids. For external hemorrhoids, the resection line was near the dentate line and the vessels at the base of hemorrhoids were bundled with ligation in accordance with the ligation and excision (LE) method.
The EA method was used in 209 subjects with 1 hemorrhoid (group 1), in 75 with 2 (group 2), and in 12 subjects with 3 hemorrhoids (group 3). Recurrence of symptoms was found in 3 subjects (1%), all of whom were in group 1. The recurrence of hemorrhoids occurred in hemorrhoidal tissue treated with ALTA therapy alone and was caused by remnants of external hemorrhoids.
The EA method is considered to be a promising and safer hemorrhoidectomy technique to replace the LE method. Treatment with the EA method not only overcomes the drawbacks of current ALTA therapy for external hemorrhoids, but also avoids late bleeding from the base of hemorrhoids, one of the postoperative complications associated with the LE method.

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Intractable constipation could easily ruin patients' QOL. We reviewed referral patients who received surgical treatment under the diagnosis of severe constipation. Between January 2002 and May 2012, 47 patients were referred to our department. Eleven were male and 36 were female, the mean age was 47.5 years. Five patients underwent surgical treatment. All female, the mean age was 42.0 years. Case 1: 27-year-old female. Since a manometric and transit study showed an outlet obstruction, an anorectal myectomy was performed. Case 2: 63-year-old female. A transit study showed slow transit constipation and a subtotal colectomy was performed. Case 3: 32-year-old female. She was diagnosed with slow transit constipation and a laparoscopic subtotal colectomy was performed. Case 4: 32-year-old female. She had been treated in other hospitals for mental disorder and hypothyroidism. She was referred to our department for constipation. A temporary ileostomy was performed. Case 5: 43-year-old female. She was referred to our department for eating disorders. A temporary ileostomy was performed. Functional results were satisfactory in all patients.

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A 78-year-old woman underwent right hemicolectomy with D3 lymph node dissection for ascending colon carcinoma in July 2005.
The histological findings indicated moderately-differentiated-type adenocarcinoma with mucinous and poorly differentiated-type adenocarcinoma, Type 2, SS, N0, Stage II. Four years after resection of the colon carcinoma, she underwent right mastectomy for primary breast carcinoma. Histological findings indicated T1b, N0, M0, Stage I. Five years after curative resection of the colon carcinoma, follow-up of the colon carcinoma was ceased because there was no recurrence.
During follow-up for the breast carcinoma, serum CEA was found to be 86.0 ng/ml, and it was increased to 234.8 ng/ml within the next month. A CT scan showed inferior vena cava tumor thrombosis, which was diagnosed as the recurrence of colon carcinoma. It was impossible to resect the tumor thrombosis because it extended to the hepatic vein.
After four courses of chemotherapy (mFOLFOX6), the patient died due to progression of the colon carcinoma in July 2011. A pathological autopsy indicated that the mucinous adenocarcinoma had metastasized to the right kidney and adrenal gland, and had invaded to the inferior vena cava, right atrium, right pulmonary artery, and the hepatic and bilateral renal veins.
The cause of death was multiple organ failure due to tumor thrombosis of the hepatic and renal veins, adrenal gland metastasis, and invasion to the inferior vena cava.

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We report two patients with gastrointestinal stromal tumors (GIST) arising from the anal canal sphincter and with a gluteal mass. Patient 1 was a woman in her fifties with a tumor in the 3- to 6-o'clock position of the anal area. After a thorough examination, the tumor was resected percutaneously without rupturing the rectal mucosa or pseudocapsule. Histopathological examination showed the proliferation of spindle-shaped tumor cells arranged in irregular bundles, with 7 to 8 mitotic figures per 50 high-power fields. On immunohistochemical staining, the tumor cells were positive for CD34 and C-Kit, and negative for α-SMA and S-100, with an MIB-1 labeling index of 3-4%. Patient 2 was a man in his seventies with a tumor in the 3- to 6-o'clock position of the anal area. As in Patient 1, the tumor was resected. Approximately 60-70 mitotic figures per 50 high-power fields were observed. Immunohistochemical staining was positive for CD34 and C-Kit, and the MIB-1 labeling index was 17-18%. These patients were high-risk patients, took 400 mg/day of Gleevec, have shown no signs of recurrence for more than about 18 months, and are being followed-up in the outpatient clinic.

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Here, we report a case wherein a rectovaginal fistula (RVF), which developed following low anterior resection for rectal cancer, was treated with surgical repair using a gracilis muscle flap. An 82-year-old Japanese woman underwent low anterior resection for rectal cancer. Intestinal anastomosis was performed in a side-to-end fashion using the double stapling technique. An RVF developed 1 month after the resection. We confirmed the presence of an RVF, 2 cm in diameter, at the rectal anastomosis site. We decided to perform surgical repair by the perineal approach. The fistula was resected through an incision of the posterior wall of the vagina. The defect on the rectal wall was closed, and a gracilis muscle flap was fixed to the anterior rectal wall. The posterior wall of the vagina was closed, and a diverting colostomy was performed. She had an uneventful course and underwent colostomy closure after 6 months. She did not exhibit any signs of RVF recurrence or dysfunction in the lower extremities. Thus, we believe that surgical repair of RVF using a gracilis muscle flap is safe and effective.

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