Laparoscopic surgery for inflammatory bowel disease (IBD) such as ulcerative colitis (UC) and Crohn's disease (CD) has been increasing in recent years with the development of laparoscopic surgery for colorectal cancer. Laparoscopic surgery for UC requires specific procedures and is difficult, and the longer operation time is a major problem. In the future, it will be necessary to standardize procedures and evaluate their indications and safety.

According to the guidelines of the Endoscopic Surgical Society, laparoscopic surgery for CD is described as a good indication for the first surgery for non-perforated ileocecal localized lesions. Examination of the indications and safety in cases of fistula, abscess formation and reoperation is a future subject.

Laparoscopic surgery for IBD is a very useful surgical procedure provided the cases are carefully selected.

Although endoscopic surgery has definitely entered the field of colorectal cancer surgery, endoscopic surgery for rectal cancer is still technically demanding, and certain concerns about curability have been suggested. Recently, transanal total mesorectal excision (TaTME) has been gaining attention along with robotic surgery, aiming to solve such technical problems, and is recognized worldwide.

TaTME may outperform conventional rectal cancer surgery in both oncological and functional preservation. In particular, there is the great merit that the dissection layer can be selected visually under endoscopy from the anus. Currently, randomized controlled trials of laparoscopic TME and TaTME are planned in the US and Europe, and the usefulness of TaTME is expected to be verified. However, characteristic anatomical recognition and learning curves are raised as issues, and there is an urgent need to develop a training system to ensure safe enforcement.

Background: Laparoscopic colorectal surgery has become widely accepted and the scope of surgical indications has expanded beyond total mesorectal excision. We describe our single-center experience of 15 cases of laparoscopic total pelvic exenteration (TPE).

Methods: Between April 2017 and June 2019, 5 patients with locally advanced rectal cancer and 10 patients with recurrent rectal cancer underwent laparoscopic TPE with or without pelvic bone resection. The aim of this study was to assess the safety, feasibility, and short-term outcome of laparoscopic TPE.

Key points for surgical intervention:

1) Surgical indication on the basis of preoperative imaging

2) Multimodal therapy such as preoperative chemoradiotherapy

3) Sufficient knowledge of the pelvic anatomy based on magnified images and decrease of blood loss by laparoscopy

4) Use of appropriate devices

Results: Five patients underwent TPE, 9 patients sacrectomy, and one patient ischiopubic rami resection. No open conversion was required. Margin-negative resection was achieved in 93.3% of cases.

The median operating time was 979 (range, 691-1,277) minutes, median blood loss was 400 (range, 80-4,350) mL, and post-operative hospitalization was 45 (range, 21-99) days. Severe postoperative complications were found in 33.3% of cases.

Conclusions: Our data suggested that laparoscopic TPE is feasible and safe in selected patients.

Robotic-assisted laparoscopic surgery (RALS) has been introduced as a recent advance in minimally invasive surgery.

RALS has the potential to provide better clinical outcomes in rectal cancer surgery, allowing for precise dissection in the narrow pelvic space. Because the public health insurance systems in Japan have covered the cost of RALS for rectal cancer since April 2018, RALS has been attracting increasing attention. Although no overall robust evidence has yet shown that RALS is superior to laparoscopic or open surgery, current evidence supports the notion that technically demanding subgroups may benefit from RALS. Technological innovation is a constantly evolving field. Several companies have been developing new robotic systems that incorporate new technology. This competition among companies to develop such systems is anticipated to lead to further improvements in patient outcomes as well as drive down the cost of RALS, which is one main concern of this new technique.

Robotic-assisted rectal surgery (RARS) has been covered by national health insurance (NHI) in Japan since April 2018, and the number of cases has increased. However, in order for RARS to be covered by NHI, the requirements listed in the “Guidelines for introduction of robotic-assisted surgery” of the Japan Society for Endoscopic Surgery (JSES) must be met. First of all, the hospital must meet the facility standards. Second, surgery must be performed by a full-time surgeon who has passed the Endoscopic Surgical Skill Qualification System in Japan, and has completed the training course for robotic surgery. In addition, the hospital must obtain institutional certification to prove that it has at least one surgeon who has performed ten or more RARSs. Since February 2017, we have invited a proctor to our hospital to observe more than 10 RARS cases to ensure that RARS was done correctly. This article describes the progress of introduction at our hospital, which we hope will be helpful for facilities intending to introduce RARS in the future.

Constipation is defined as a “chronic condition, in which a certain amount of stool that ought to be defecated cannot be evacuated sufficiently and comfortably” in the Japanese Guideline for the Management of Chronic Constipation published in 2017. Chronic constipation is classified into infrequent bowel motion type (IBM) and evacuation difficulty type (ED) depending on its symptoms, and is further classified into slow transit constipation, normal transit constipation and defecation disorder depending on its pathophysiology. There are many causes of chronic constipation and so it should be adequately treated based on a proper diagnosis of its causes. The initial management of patients with chronic constipation includes differential diagnosis of IBM and ED based on their symptoms and physical findings, followed by modification of diet, lifestyle and bowel habits and medical therapy with drugs. If the initial therapy for chronic constipation fails, its pathophysiology should be diagnosed with a colonic transit study and defecography at specialized institutions, where centrally mediated abdominal pain syndrome, functional abdominal bloating/distension and obsessive-compulsive disorder of defecation should be excluded from true chronic constipation. Specialized therapies include biofeedback therapy, transanal irrigation, rectocele repair, ventral rectopexy, and total colectomy with ileorectal anastomosis.

New pharmacological therapeutics are needed to achieve substantial relief of constipation symptoms and normalization of gastrointestinal motility. In recent years, several new agents with novel mechanisms of action that are both efficacious and safe have been approved in Japan for the treatment of chronic constipation.

Osmotic laxatives, such as polyethylene glycol (PEG) and lactulose, contain poorly absorbed molecules that draw water into the intestinal lumen, thus softening stool and increasing intestinal transit. A systematic review found that PEG was superior to both placebo and lactulose in adults and children. The most common adverse events for PEG include distension and diarrhea, whereas lactulose commonly causes dose-dependent abdominal cramping and bloating.

Lubiprostone stimulates chloride secretion through activation of type-2 chloride channels, increasing intestinal secretion and transit, and its use has been associated with improvements in bowel habit and symptoms of constipation. Nausea and diarrhea are the most commonly reported adverse events. Linaclotide is a minimally absorbed agonist of guanylate cyclase-C that reduces symptoms associated with irritable bowel syndrome with constipation. Elobixibat exerts its novel mechanism of action by blocking the ileal absorption of bile acids, which ultimately increases the flow of bile into the colon, causing increased intestinal secretions and transit.

Constipation is a common symptom in routine care and is a disease with a high prevalence in Japan. The mechanism and treatment of chronic constipation have been studied from the viewpoint of intestinal function. With the advent of next-generation sequencing in recent years and its improved accuracy, comprehensive analysis of the intestinal microbiota has become possible, and the relationship between various diseases and gut microbiota has been discussed. Chronic constipation is also considered to be caused by gut microbiota and their metabolites, and clinical application is being attempted. The efficacy of probiotics and prebiotics has been noted as a method to improve dysbiosis of the gut microbiota in patients with chronic constipation. Recently, the clinical application of fecal transplants for administering rich intestinal bacteria has been attempted.

As a therapeutic strategy for chronic constipation, Japanese traditional medicine (Kampo) is a unique and non-negligible medicine for patients with chronic constipation in Japan. Chronic constipation is divided into three subgroups (slow transit group, normal transit group, pelvic group) in terms of the pathological condition. The most suitable Kampo medicine for each subgroup is selected according to basic and clinical evidence. Daikenchuto is selected for the slow transit group and the pelvic group, whereas mashiningan, daiokanzoto, and junchoto are selected for the normal transit group.

It is important to consider the type of chronic constipation such as slow transit type constipation or outlet obstruction. Diet and exercise therapies are the first choices for slow transit constipation. A high-fiber diet, lactic acid bacterium products and fermented foods are recommended. Aerobic exercise is known to reduce the symptoms of constipation. On the other hand, physical therapies such as biofeedback and inner muscle training are effective for outlet obstruction. There are reports that show the efficacy of biofeedback therapies with balloon, electromyogram and manometry. Also, defecating position is important for fecal evacuation.

Surgery may be performed in patients with obstructed defecation due to structural abnormality (ODSA) and slow transit constipation (STC). Rectal intussusception and rectocele are frequently seen among cases of ODSA. The surgical approach can be transanal, transvaginal or transabdominal, which should be selected individually according to anatomical abnormality, sexual function, anal function and fecal continence status. Laparoscopic ventral rectopexy can correct rectal intussusception associated with rectocele or these abnormalities combined with enterocele simultaneously, and has been recognized as an effective and safe procedure in the treatment of ODSA. The most frequently performed procedure in the treatment of STC has been total colectomy with ileorectal anastomosis. This procedure may be associated with severe postoperative complications; thus, the indication should be strictly determined. Antegrade continent enema is an alternative to colon resection or stoma, and is hardly associated with severe complications, but there is insufficient evidence.

Generally, there is not enough evidence of the indications, selection of approach, and outcome of surgical treatment of chronic constipation. High-quality articles published in Japan are expected.