Purpose: We report on our experience of using Sokeikakketsuto for patients with chronic functional rectal pain (“anal pain”). A total of 57 patients were included. Criteria for judging therapeutic effect were “extremely effective” when the pain disappeared completely, “effective” when the pain was alleviated, and “ineffective” when the pain remained unchanged.

Results: Symptom improvement was observed in 19 excellent cases and 25 effective cases, showing efficacy within 4 weeks of oral administration. Except for 2 patients who discontinued due to side effects, we compared 44 “effective” cases and 11 “ineffective” cases. Average age was 62.1 and 55.1 for effective and ineffective cases, and number of males and females was 17/27 and 8/3, respectively, showing greater effect in females (significant difference). There was no significant difference when the disease duration was compared between less than 1 year and 1 year or more. There was no significant difference in the presence or absence of a history of surgery for anal disease and the presence or absence of spinal disease during treatment. The number of cases with or without psychiatric disorders during treatment was 6/38 and 7/4, thus, many effects were observed in patients without psychiatric disorders (significant difference).

Conclusion: For anal pain, 77.2% of patients reported improvement in symptoms with Sokeikatsuketsuto. The efficacy rate was particularly high in women and in patients without psychiatric disorders.

A 60-year-old woman underwent total prophylactic colectomy with ileorectal anastomosis (IRA) due to familial adenomatous polyposis (FAP) at the age of 25. However, after surgery, multiple adenomas developed in the residual rectum. At age 33, she underwent residual rectum resection and ileal pouch-anal canal anastomosis (IACA). However, one year after surgery, the adenoma reappeared in the residual rectum. In the long-term course, she underwent endoscopic tumor resection and transanal resection for the recurring adenomas. Finally, at age 60, she underwent abdominoperineal resection of the rectum for multiple residual rectal adenomas. When considering the technique for resecting the residual rectum after IRA for FAP, it is crucial to note that in some cases, the choice of IACA makes it difficult to resect multiple adenomas, necessitating a third bowel resection. Therefore, we suggest that resection of the residual rectum after IRA should include the mucosa of the anal canal, such as total proctocolectomy with ileoanal anastomosis.

Pilonidal disease often occurs in men with a lot of hair in the midline of the sacrum, and complete resection of the sinus is necessary for radical surgery. However, simple excision sutures often open the wound because of the tension. Rhomboid flap plasty is a useful reconstruction method that allows the wound to be sutured without tension. The patient was a 34-year-old man. Swelling and pain had appeared in the sacral region 3 weeks previously. A ridge with a diameter of 3 cm was observed in the midline of the sacrum, and mild tenderness was observed. He was diagnosed with pilonidal sinus and was operated under spinal anesthesia. The skin incision was a rhombus shape including the lesion, and the lesion was completely resected so as not to damage it. A rhomboid flap was created on the left side of the excised site, dislocated to the defect site to avoid tension on the wound. Six months after the operation, the wound healing was good.

A 91-year-old woman was admitted to the hospital with a complaint of abdominal pain and vomiting. Abdominal CT showed perforation of the descending colon, and emergency surgery was performed. Intraoperative findings revealed perforation in the descending colon, and Hartmann's procedure was performed by resecting the descending colon including the perforation area from the left transverse colon. Pathological findings showed ischemic changes in the mucosa around the perforation. On the 9th postoperative day, the inflammatory response increased again, and CT showed perforation in the ascending colon near the stoma. Subtotal colorectomy was performed and an ileum stoma was constructed. Pathological findings showed no ischemic changes in the mucosa and a steep rupture of the mucosal muscle layer, and we diagnosed idiopathic colon perforation. Postoperatively, cerebral infarction and aspiration pneumonia were complicated, but she was discharged on the 51st day of illness. Stercoral colon perforation and idiopathic colon perforation have similar sites, symptoms, and pathological findings, so it is difficult to differentiate them. Idiopathic colon perforation is rare in Japan, with only 7 cases reported. We report a case of two idiopathic colon perforations in a short period of time by different mechanisms.

We herein report a case of medullary carcinoma of the ascending colon. An 82-year-old female was hospitalized at our hospital with complaints of nausea and dizziness. Colonoscopy demonstrated an infiltrative ulcerated tumor in the ascending colon. A contrast-enhanced computed tomography scan showed regional lymph node swelling but no distant metastasis. Under the preoperative diagnosis of ascending colon cancer (stage IIIb), laparoscopic ileocecal resection with regional lymph node dissection was performed. The resected specimen revealed medullary carcinoma with no regional lymph node metastasis. Although the tumor partially invaded the abdominal wall, adjuvant chemotherapy was not administered because of her age. Postoperative recurrence in the left adrenal gland and para-aorta and right external iliac lymph nodes was recognized seven months after surgery. Genetic examination revealed microsatellite instability (MSI)-high and BRAF V600E mutation in this tumor. Progression was observed despite first-line therapy of four cycles of capecitabine and bevacizumab, but second-line therapy of nivolumab reduced the size of the recurrent lesion during 33 months after surgery. Programmed death-1 blockade therapy may be feasible for recurrent medullary carcinoma with MSI-high.

An 84-year-old man presented with abdominal pain and underwent laparoscopic appendectomy with a diagnosis of acute appendicitis. Intraoperative findings showed abscess formation and perforation of the appendiceal wall. Histopathological findings revealed appendiceal cancer, tub2, PM1. Later, laparoscopic ileocecal resection (D3) was performed for the purpose of additional resection. The final diagnosis was pT3, pN0, pM0, pStageIIa. One year after the operation, a 23 mm-sized mass was found by CT scan, and FDG-PET/CT showed abnormal accumulation. Local recurrence of appendiceal cancer could not be ruled out, so mesenteric tumor resection and partial ileocolonic resection were performed. Histopathological findings revealed a foreign body reaction to silk thread and abscess formation, and the diagnosis was suture abscess. The silk thread used for ligation was considered to be the cause of the suture abscess. It should be noted that suture abscesses are often difficult to distinguish from local recurrence.

An 88-year-old woman was diagnosed with rectosigmoid type 1 colon cancer and scheduled for surgery. Nine days before surgery, she presented to our hospital with abdominal pain. Physical and abdominal X-ray examination findings were unremarkable, and laboratory examinations did not reveal an inflammatory response. After 9 days of hospitalization and ingestion of a liquid diet, surgical treatment of the colon cancer was performed. The operative findings confirmed an intussusception at the peritoneal reflection, and manual reduction was impossible. We exfoliated the rectal mesentery around the intussusception from the peritoneal reflection to its anal side to ensure mobility of the rectum, and manual reduction was performed by Hutchinson's maneuver. The resected specimens exhibited segmental mucosal necrosis 6 cm in length on the anal side of the tumor; therefore, Hartmann's procedure was performed. It has been reported that intussusception is likely to occur in type 1 or villous tumors with a large tumor diameter. Our patient may have developed the intussusception at the onset of abdominal pain. In summary, we herein report a case of incarcerated intussusception of rectosigmoid colon carcinoma with difficulty of manual reduction.

A 73-year-old man underwent colonoscopy for an examination of anemia, which revealed a type 2 lesion on the anterior wall of rectum Ra-Rb. It was diagnosed as adenocarcinoma on biopsy. He had no history of parasitic disease, although he had lived in an area where Schistosoma japonicum used to be epidemic. Preoperative examination revealed no evidence of schistosomiasis, and laparoscopic-assisted abdominal perineal rectal amputation was performed. The pathological diagnosis was T3N0M0 Stage II. However, Schistosoma japonicum eggs were found in the submucosa of the surrounding normal area. Schistosoma japonicum is a parasitic disease caused by Oncomelania hupensis nosophora with dermatitis, gastrointestinal symptoms, and cirrhosis in severe cases. Thanks to the eradication of Oncomelania hupensis nosophora, there have been no cases of infection in Japan since 1978. However, there have been several case reports in which Schistosoma japonicum eggs were found in pathological specimens of colorectal cancers since then. In the present case, Schistosoma japonicum eggs happened to be found in a resected rectal cancer specimen. We report the case, with a review of the literature.