In Japan, patients with long-standing Crohn's disease (CD) are at increased risk of colorectal cancer, especially anorectal cancer. We performed a questionnaire survey about anorectal cancer surveillance in patients with CD. Eighteen major hospitals in Japan that treat inflammatory bowel disease surgically participated in this study. Most hospitals started anorectal cancer screening of CD patients who had had perianal disease for more than ten years. Ten hospitals had experienced a case in whom anorectal cancer had been detected by anorectal cancer screening test. There is a pressing need to develop strategies for the early detection of anorectal cancer.
A 75-year-old man underwent radical retropubic prostatectomy for prostate cancer. During this operation, a full-layer rectal injury of about 15 mm in diameter was observed in the anterior wall of the lower rectum. The damaged part was repaired and ileostomy was constructed. After surgery, a rectourethral fistula of about 10 mm occurred. We performed transanal repair, but he did not recover completely. We constructed a bladder fistula. After six months of observation, the diameter of the fistula reduced to about 3 mm, so we again closed the transanal fistula, and the urination from the anus disappeared. There has been no recurrence of the rectourethral fistula since ileostomy closure. The incidence of rectal injury, which is one of the complications of radical retropubic prostatectomy, is rare, but some migrate to a rectourethral fistula, which is a serious complication, as in this case. Once a rectourethral fistula is formed, it is often refractory. We experienced a case of a rectourethral fistula after radical retropubic prostatectomy in which construction of a bladder fistula contributed to the healing. We report this case and review the literature.
An 81-year-old Japanese woman who had been followed for elevated serum level of carcinoembryonic antigen (CEA) and right ovarian cyst for 7 years, was admitted due to abdominal pain. Although gynecologists conducted cytology, some imaging series, and gastrointestinal endoscopy, no malignant lesion had been detected for 7 years. On admission, blood test and serum examination revealed respectively WBC: 12150 /μL, CRP: 18.1 mg/dL, and CEA: 13.8 ng/mL. Imaging series demonstrated a hypertrophic appendix penetrating the ovarian cyst with peripheral inflammatory reaction. We preoperatively diagnosed appendicitis penetrating the ovarian cyst, and performed laparotomic appendectomy and right oophorectomy. Postoperative pathological examination revealed well-differentiated tubular adenocarcinoma in situ of the appendix penetrating the ovary without dissemination. The patient is well with no recurrence, and the serum level of CEA is normal at 2 years after the surgical treatment. We believe that this is a rare case, and interesting in that the appendiceal cancer was obscured by the ovarian cyst with long-standing high serum level of CEA, and unexpected penetration of appendiceal cancer to the ovary evading intraabdominal dissemination of cancer cells.
Systemic chemotherapy based on 5-fluorouracil (5-FU) is a standard treatment for unresectable or recurrent colorectal cancer. However, there have been few reports of hyperammonemia and coma as adverse events of the therapy. We have experienced a case of sigmoid colon cancer with metastases in which the patient developed hyperammonemia and coma after the introduction of FOLFIRI therapy. In our case, blood tests showed hyperammonemia (343 μg/dl) and the patient was treated with rehydration resulting in gradual improvement of the symptoms. We should be aware that 5-FU may cause hyperammonemia and resultant disturbance of consciousness during 5-FU therapy.
A 79-year-old woman who had undergone total hysterectomy for a uterine leiomyoma 40 years earlier visited our hospital. Perianal pain and fever were observed, and symptoms were relieved by treatment such as antibiotic administration, but the leakage of stool from the vagina appeared. Upon vaginaloscopy examination, a fistula was observed on the right side of the vaginal cut end, which was diagnosed as colovaginal fistula. Digital examination and anoscopic examination showed no obvious abnormality, but sigmoid colon was observed by contrast examination from the vagina. A diagnosis of sigmoid colovaginal fistula was made and surgical operation was performed. The sigmoid colon showed remarkable wall thickening and the fistula communicated with the abscess cavity. Closure of the vaginal stump and sigmoidectomy were performed and ileostomy construction was performed. An ileostomy closure was done 4 months after surgery, after which recurrence was not recognized. In this case it was considered that the pelvic abscess caused by sigmoid colon diverticulitis drained into the vaginal cavity from the fragile vaginal stump and then formed the sigmoid colovaginal fistula.