Endoscopic evaluation is considered as the gold standard for the assessment of disease activity in ulcerative colitis. However, it is invasive and costly, and there is increasing demand for the development of reliable and non-invasive biomarkers. Here, we review the usefulness and limitations of biomarkers that can be used in the daily practice of UC, such as fecal calprotectin, fecal immunochemical test, C-reactive protein, erythrocyte sedimentation rate, leucine-rich alpha-2 glycoprotein and prostaglandin E-major urinary metabolite. In addition, novel diagnostic biomarkers, such as serum IgG anti-integrin αvβ6 autoantibody and anti-EPCR antibody, have been recently found. It is important to develop diagnostic and therapeutic algorithms that adequately incorporate biomarkers to improve the medical management of UC.

The number of subjects for surveillance colonoscopy among patients with long-standing ulcerative colitis is increasing, but the incidence is decreasing due to the development of drug treatments in Japan. Therefore, highly accurate and efficient surveillance colonoscopy is needed. The development of endoscopic equipment and treat-to-target strategy for endoscopic healing is essential to improve the quality of surveillance colonoscopy, which should be performed at the time of assessing the endoscopic efficacy of drug treatment in daily clinical practice. The initial detection is the most important step of surveillance colonoscopy. Accordingly, narrow band imaging (NBI) or chromoendoscopy with magnifying observation should be used to improve the accuracy by the increased contrast between a neoplastic lesion and non-neoplastic background mucosa. Artificial intelligence and molecular imaging are expected to improve the quality of surveillance colonoscopy.

Developments in endoscopy have made it possible to detect early ulcerative colitis associated neoplasia. SCENIC was adopted in 2015, indicating the feasibility of endoscopic resection for early-stage lesions. The SCENIC statement is, however, based on studies of EMR or polypectomy; ESD is considered one of the effective treatments for UC-associated neoplasia with a higher en-bloc resection ratio and R0 resection ratio. Low-grade dysplasia with high-confidence endoscopic diagnosis, without inflammation surrounding the lesion, could be a good indication for ESD. UC-associated neoplasia is technically challenging for ESD due to fibrosis and inflammation. Careful treatment by a skilled endoscopist using devices such as traction and IT knife nano is recommended. Surveillance colonoscopy is mandatory, taking into account metachronous lesions. It is important to accumulate further evidence for endoscopic treatment.

Ulcerative colitis is an inflammatory bowel disease that is intractable and causes chronic inflammation in the colon and rectum. Although the cause is unknown, an excessive immune response associated with disruption of intestinal immune homeostasis is involved in the pathology. 5-ASA preparations, corticosteroids, and thiopurines have been used as drug treatments for ulcerative colitis. With the development of excellent therapeutic drugs and biomarkers such as fecal calprotectin, a treat-to-target strategy has been proposed for the treatment of ulcerative colitis with the aim of improving the long-term prognosis, and endoscopic remission is set as the treatment goal.

The prevalence of elderly-onset ulcerative colitis (UC) is increasing worldwide. Elderly onset-UC presents a more severe disease course, a wider disease distribution and a higher incidence of hospitalization and surgery. Patients with multiple comorbidities are more often observed in elderly UC than younger UC. Management of elderly UC requires estimation of frailty, nutrition status, comorbidities, immunosenescence and IBD-related complications. A balance between the efficacy and safety of current therapies is an important factor when deciding treatment strategies. The treatment goal of acquiring better outcomes in elderly UC is not always the same as in non-elderly UC. In this review, we discuss the epidemiology and medical management of elderly UC.

Although the number of elderly patients with ulcerative colitis (UC) is increasing, the definition of elderly UC patients differs depending on the report, and the reference age ranges widely from 40 to 75 years. When reading reports of elderly UC patients, it is necessary to check the reference age. The surgical method should not be decided unconditionally based on age. The disease to be operated on, physical strength, anal sphincter muscle, and defecation function should be taken into consideration when deciding whether to perform anal preservation surgery or permanent colostomy surgery. Old age affects postoperative defecation function. Elderly UC patients have low reserve capacity, many comorbidities, and many postoperative complications. Since the mortality rate of emergency surgery in elderly patients is particularly high, it is important to decide on surgery at an earlier stage than in young patients. In reality, elderly UC patients have few subjective symptoms even if they are in a severe or fulminant condition, and it is difficult to judge the suitability for surgery in elderly UC patients. The life and postoperative QOL of elderly UC patients depend on the surgeon who decides on the operation.

Robotic surgery for colorectal cancer has been covered by the medical insurance system in Japan since April 2018 for rectal cancer and since April 2022 for colon cancer, and is rapidly becoming popular nationwide. The number of cases of rectal/colon surgery performed in Japan by organ differs greatly due to differences in the timing of insurance coverage. The number of rectal cancer surgeries performed worldwide is higher than that of colon surgeries. Robotic surgery is classified as a minimally invasive procedure similar to conventional laparoscopy, but it is more expensive than laparoscopic surgery, so superiority must be demonstrated. However, robotic surgery is a relatively new procedure with insufficient evidence worldwide. In recent years, the results of clinical trials with large numbers of patients designed during the period of widespread use of robot-assisted surgery have been reported. However, reports on short-term outcomes are still the main focus; reports on long-term outcomes are scarce. This article describes the current evidence comparing robot-assisted surgery and conventional laparoscopic surgery.

From 2022, robot-assisted resection of malignant colon tumors will be covered by insurance. Based on our experience gained through trial and error in introducing this procedure, we describe the surgical technique, focusing on port placement in robot-assisted right-sided colon cancer surgery, which is currently the standard procedure at our hospital. The first port is selected from three patterns: (1) umbilical incision, (2) Pfannenstiel incision, and (3) 4th arm (R4) position in the left upper abdomen, depending on whether the anastomosis is external or intracorporeal. Robotic-assisted surgery is considered to be compatible with intracorporeal anastomosis because of the ease of operation of instruments and staplers and suture ligation, and an increasing number of institutions are actively adopting intracorporeal anastomosis. However, the choice should be made after fully understanding the advantages and disadvantages of intracorporeal anastomosis; at our hospital, intracorporeal anastomosis is basically performed by the overlap method. The differences in insertion procedures between the da Vinci stapler and the laparoscopic stapler are explained.

Robotic surgery for colorectal cancer is rapidly gaining popularity since it was covered by insurance in 2022. Robotic surgery enables more precise surgery because the forceps have a higher degree of freedom and can be operated intuitively. On the other hand, robotic surgery has the disadvantage of a narrow surgical field. It is important to ensure the correct setting and port placement to overcome the limitations of forceps manipulation and the restricted surgical field. Surgery for left-sided colon cancer requires transfer of the splenic flexure in most cases. The pancreas, spleen, and colon are adjacent to the splenic flexure, and the complex adhesions between them vary widely from patient to patient. In this paper, we describe the standardized robotic surgical setup and the surgical technique for robotic left-sided colon resection performed at our institution.

In Japan, robot-assisted surgery for rectal cancer became covered by insurance in April 2018 for rectal resection and amputation, and the number of surgeries has increased significantly. Robot-assisted surgery is expected to be useful for clinical, oncological, and functional preservation, as it overcomes the motion limitations of laparoscopic surgery and enables more delicate total mesorectal excision and lateral dissection. This article describes the actual surgical techniques for robot-assisted low anterior resection and lateral dissection, ranging from the port position and arm settings to the actual surgical technique.

Introduction: With the spread of robot-assisted surgery, many young surgeons are expected to become robotic surgeons without sufficient experience in open or laparoscopic surgery. However, educational methods have not been established and need to be discussed.

Purpose: The purpose of this article is to introduce the education of young robotic surgeons, and to provide an overview of the latest surgical robots and their future prospects.

Methods: We present our criteria for robotic surgeons and their actual education based on the guidelines proposed by the Japanese Society of Endoscopic Surgery. In addition, we present the results of a questionnaire survey of young surgeons and evaluate the current educational system with a review of the literatures.

Results: Robotic surgery is being performed safely and effectively by young surgeons. New surgical robots are being developed and improved to solve issues related to the lack of tactile sensation and the realization of remote surgery.

Conclusion: The resolution of both issues will help maintain the motivation of young surgeons and further improve robot-assisted surgery.