Objective: To clarify the short-term outcome of combined resection of adjacent organs and pelvic exenteration (PE) for locally advanced primary rectal cancer.

Methods: In our retrospective cohort study, we enrolled patients who underwent robotic surgery for rectal cancer with combined resection of adjacent organs between 2017 and 2023, and evaluated the short outcome.

Results: Of a total of 34 eligible patients, 26 patients (76.5%) were male, low rectal cancer was observed in 20 patients (58.8%), and 25 patients (73.5%) were cStage III. Sixteen patients underwent abdominoperineal resection, 8 underwent low anterior resection, and 5 underwent PE. Operating time was 334 (min) in cases undergoing combined resection except PE, and 617 (min) in PE. Total blood loss was 40/367 (mL), and postoperative hospital stay was 7/14 (days), respectively. The frequency of complications (Clavien-Dindo Grade II or higher) was 20% in total. The radial margin was positive in 7% except for PE cases, and 0% within PE cases.

Conclusion: The short-term outcomes of combined resection of adjacent organs and pelvic exenteration (PE) for rectal cancer were acceptable.

Aim: Identification of characteristic clinical findings for early diagnosis of carcinoma associated with anal fistula.

Methods: From the perspective of early diagnosis, we compared the clinical characteristics of 13 cases of carcinoma associated with anal fistula with 5 clinical diagnostic criteria defined by Sumikoshi et al.

Results: Pain and induration, absence of primary cancer at other sites, and presence of the fistula opening were observed in all cases, while mucinous secretion was observed in 8 cases and duration of anal fistula for more than 10 years in only 5 cases. Pain not relieved by drainage and marked induration without elasticity are differential points from abscesses. MRI showed hyperintense heterogeneous multifocal cystic lesions in 86% of cases, and endoanal ultrasonography (EAUS) showed lattice structures with septations of various sizes and isoechoic solid components in 83% of cases, all of which were useful for early diagnosis.

Conclusions: The following four findings were useful for early diagnosis: 1) extensive severe induration, 2) pain not relieved by drainage, 3) mucinous secretion, and 4) characteristic MRI/EAUS findings. If even one of these is present, carcinoma associated with anal fistula should be strongly suspected and aggressive biopsy should be performed.

Aim: Five hundred twenty-five patients undergoing defecography (297 females), with a median age of 68 (range, 17 - 93), were enrolled in this study.

Results: The findings of each of (overlapping) rectocele, wide rectum, intussusception, sigmoidcele, paradoxical puborectalis contraction, puborectalis insufficiency of relaxation, stuck pelvic floor, poor anal canal opening, perineal descent, and serrated rectum were investigated. Regarding gender differences (female vs. male), females were more likely to have rectocele (p < 0.0001), wide rectum (p = 0.0309) and perineal descent (p < 0.0001). Meanwhile, males were more likely to have puborectalis insufficiency of relaxation (p < 0.0001) and stuck pelvic floor (p < 0.0001). In addition, when investigated separately for structural defecation disorder and functional defecation disorder, structural was more common in females (p < 0.0001), functional was more in males (p < 0.0001), and both of them were observed more commonly in females (p = 0.0006).

Conclusion: It is considered that defecation disorder can be diagnosed only by defecography in females but in males, additional tests such as anorectal manometry are more needed.

A 67-year-old woman with obstructive rectal cancer underwent laparoscopic low anterior resection 2 years prior and total hysterectomy and bilateral adnexectomy for uterine cancer at another hospital 20 years earlier, which led to the diagnosis of Lynch syndrome. During the postoperative follow-up, chronic anemia was noted. Upper and lower gastrointestinal endoscopy and contrast-enhanced abdominal computed tomography were performed to evaluate the etiology of the anemia; however, the findings were unremarkable. Small bowel endoscopy was performed and a full circumferential type 2 lesion was found in the jejunum. Biopsy confirmed a moderately differentiated adenocarcinoma. Thus, laparoscopic partial resection of the small bowel was performed, and the patient was discharged on the 11th hospital day with an uneventful postoperative course. Although a preoperative diagnosis of small bowel cancer is difficult to establish, this was considered due to Lynch syndrome, and the preoperative diagnosis was confirmed via small bowel endoscopy.

A 46-year-old man who had sigmoid colon cancer with bladder invasion underwent diverting colostomy. After 5 courses of chemotherapy with FOLFIRI+BEV regimen, sigmoid colectomy with partial resection of the bladder was performed. About 6 months after the radical surgery, recurrent tumors developed in the bladder and transurethral resection of the tumor was performed. After closing the stoma, a left internal iliac lymph node metastasis was suspected by PET-CT scan, which was successfully treated with carbon ion radiotherapy. Three months after the radiotherapy, a new right external iliac lymph node metastasis was detected. Second carbon ion radiotherapy was performed, which resulted in the disappearance of the metastasis. He remains alive without recurrence 4.5 years after the final radiotherapy. These recurrences could be considered as lateral regional lymph nodes metastases from the urinary bladder invaded by sigmoid colon cancer. Partial resection and transurethral resection of the bladder tumor avoided total cystectomy. The efficacy of carbon ion radiotherapy for oligo-recurrence has been reported, and this case was successfully treated with radiotherapy, avoiding adverse complications of surgery.

We experienced a case of locally advanced sigmoid colon cancer with obstructive symptom, that could be resected after chemotherapy under colonic stent placement. A 61-year-old male came to our hospital suffering from anal bleeding. After some examinations a diagnosis of colonic obstruction due to sigmoid colon cancer (CROSS1) was made. At first, a colon stent was inserted. Then, the patient was administered four courses of SOX (S-1+Oxaliplatin) therapy. No significant adverse effects were observed during chemotherapy. Subsequently, laparoscopic assisted sigmoid colon resection was performed. R0 excision was achieved. The effect of chemotherapy was Grade 3. It is controversial whether chemotherapy for advanced colorectal cancer cases can be performed under stent placement. However, for the treatment of locally advanced cancers with obstruction, we considered that systemic chemotherapy under stent placement can be a treatment option if there is a possibility that the tumor can be reduced by systemic chemotherapy, after obtaining sufficient informed consent. Nevertheless, further investigation of these cases should be performed.

A 44-year-old man with no previous history of laparotomy was referred to our hospital with chief complaints of left upper quadrant pain and fever. Blood tests revealed an elevated inflammatory response and abdominal CT scan showed the small intestine mainly in the right abdominal cavity and the colon in the left abdominal cavity, suggesting intestinal malrotation. He was diagnosed with diverticulitis and treated conservatively. However, the treatment was unsuccessful and laparoscopic surgery was performed. Intraoperative findings revealed no formation of the Treitz ligament, and showed that the cecum and ascending colon were not fixed to the abdominal wall. We performed laparoscopic right hemicolectomy including the ascending colon with strong inflammatory changes. The resected specimen showed diverticulum on the membrane side of the ascending colon and abscess formation. We describe here a rare case of penetration of diverticulum of the colon accompanied with intestinal malrotation in an adult, with a review of the literature.

Although preoperative chemoradiotherapy (CRT) for advanced lower rectal cancer is standard treatment in western countries, there are few reports about the utility of CRT for advanced lower rectal cancer in patients with familial adenomatous polyposis (FAP). We report here the long-term oncological and functional outcomes after CRT followed by proctocolectomy for advanced rectal cancer in patients with FAP. The patients were two males and a female in their 50s to 60s, and all had stage II, T3N0M0 rectal cancer. They underwent CRT followed by proctocolectomy with ileal-pouch anal anastomosis (n = 1) and permanent ileostomy (n = 2). In all cases, preventive lateral lymph node dissection was not performed, and the histological effects of preoperative CRT were grade 1a, grade 2, and grade 3, respectively. All patients have been followed up for more than 6 years, with no recurrence observed.