勝野 秀稔

We report a case of gigantic cystic lymphangioma of the ascending colon excised through an open laparotomy. A 34-year-old woman consulted a gynecologist for treatment of infertility. Transvaginal ultrasonography revealed a cystic mass in the pelvis, and she was transferred to our hospital for further investigation. Abdominal enhanced computed tomography (CT) showed a bulky cystic mass, 25 cm or larger, in the abdominal and pelvic cavity. Colonoscopy revealed a cystic submucosal tumor with a cushion sign. Cystic lymphangioma was diagnosed and excised via open surgery as we could not exclude its malignant potential. Pathological examination confirmed lymphangioma. To our knowledge, this is the most gigantic lymphangioma of the colon documented in the literature. About 3 months after surgery, the patient discovered that she was pregnant and her first baby was delivered at term, uneventfully.

Objective: This exploratory trial was performed to determine whether Daikenchuto accelerates recovery of gastrointestinal function in patients undergoing open colectomy for colon cancer. Methods: A total of 386 patients undergoing colectomy at 1 of the 51 clinical trial sites in Japan from January 2009 to June 2011 were registered for the study (JFMC39-0902). Patients received either placebo or Daikenchuto (15.0 g/day, t.i.d) between post-operative day 2 and post-operative day 8. Primary end-points included time to first bowel movement, frequency of bowel movement and stool form. The incidence of intestinal obstruction was evaluated post-operatively. The safety profile of Daikenchuto until post-operative day 8 was also evaluated. Results: The results for 336 patients (Daikenchuto, n = 174; placebo, n = 162) were available for statistical analysis. The time to first bowel movement did not differ significantly between the two groups. All patients reported having diarrhea or soft stools immediately after surgery, and the time until stool normalization (50th percentile) in the Daikenchuto and placebo groups was 6 days and 7 days, respectively. The placebo group had a significantly greater number of hard stools at post-operative day 8 (P = 0.016), and bowel movement frequency continued to increase until post-operative day 8 aswell. In contrast, bowel movement frequency in the Daikenchuto group increased until post-operative day 6, however decreased from post-operative day 7 and was significantly lower at post-operative day 8 compared with the placebo group (P = 0.024). Conclusion: The moderate effects of Daikenchuto were observed similar to 1 week after the operation. Although Daikenchuto had an effect on gastrointestinal function after open surgery in patients with colon cancer, this study did not show its clinical benefits adequately.

＜ポイント＞手技のポイントは以下の3点である.助手に直腸を展開させ,岬角より切開し,腹膜を多く切除しない.肛門挙筋までしっかり剥離する.下腹神経前筋膜と直腸固有筋膜との間の疎性結合織を切離し,下腹神経,骨盤内臓神経,骨盤神経叢を温存する.直腸を牽引した状態でメッシュを腸管へ固定する.さらに腹膜を修復し,ダグラス窩の挙上再建をする.(著者抄録)

Introduction: Anastomotic surgical recurrence after bowel resection is a major problem in patients with Crohn's disease. The aim of this prospective observational study was to evaluate the efficacy of a novel technique for restoring bowel continuity after resection involving either the small or the large intestine. Methods: The first case was instructed by Dr. Kono at Fujita Health University. The involved bowel segment was divided transversely with a linear stapler. The edges of two stapled lines are then connected to create a supporting column, which prevented surgical recurrence from anastomotic distortion due to mesenteric longitudinal ulcers. Thereafter, an antimesenteric longitudinal enterotomy was performed on each side to create a large-sized hand-sewn end-to-end anastornosis. Results: Thirty consecutive patients underwent Kono-S anastomoses from December 2009 to August 2013. Neither anastomotic leakage nor surgical recurrence was observed during a median follow-up period of 35 months. Endoscopic surveillance was performed in 18 cases (69.2%) undergoing ileo-colonic or ileo-rectal anastonnosis with an average Rutgeert's score of 0.78 (0-3) at a mean of 14.5 months postoperatively. Conclusion: The Kono-S anastomosis for Crohn's disease has been a safe and feasible technique. Long-term outcomes are required to confirm its advantage in preventing surgical recurrence at the anastomosis. (C) 2015 S. Karger AG, Basel

Local excision is increasingly performed for "early stage'' rectal cancer in the US; however, local recurrence after local excision has become a controversial issue in Western countries. Local recurrence is considered to originate based on the type of tumor and procedure performed, and in surgical margin-positive cases. This review focuses on the inclusion criteria of "early" rectal cancers for local excision from the Western and Japanese points of view. "Early" rectal cancer is defined as T1 cancer in the rectum. Only the tumor grade and depth of invasion are the "high risk" factors which can be evaluated before treatment. T1 cancers with sm1 or submucosal invasion <1,000 mu m are considered to be "low risk" tumors with less than 3.2 % nodal involvement, and are considered to be candidates for local excision as the sole curative surgery. Tumors with a poor tumor grade should be excluded from local excision. Digital examination, endoscopy or proctoscopy with biopsy, a barium enema study and endorectal ultrasonography are useful for identifying "low risk" or excluding "high risk" factors pre-operatively for a comprehensive diagnosis. The selection of an initial local treatment modality is also considered to be important according to the analysis of the nodal involvement rate after initial local treatment and after radical surgery.

超高齢者大腸癌の頻度は増加しているが,患者は種々の臓器の機能低下や合併症,手術既往,認知症などを有していることが多い.超高齢者大腸癌でも根治切除が可能ならば,非高齢者とほぼ同等の予後が得られることも報告されている.術前に十分なリスク評価と機能改善の対応ならびに治療を行い,可能ならばより低侵襲で根治的な治療を施行する.術後にはせん妄や種々の機能低下に注意して術後管理を行う必要がある.(著者抄録)

To establish the efficiency of bowel ligatures in colon cancer surgery, focusing on the extent to which exfoliated cancer cells are shed in the colonic lumen during sigmoidectomy. Twenty consecutive patients who underwent sigmoidectomy for sigmoid colon cancer were prospectively randomized into two groups: the "ligatures group", in which bowel ligatures were placed, 3, 5, 10 cm from the tumor proximally and distally before dissection; and the "no ligatures group", in which the corresponding sites were ligated only immediately before taking the specimen out. Each colonic segment ligated was irrigated with saline and samples were sent for blind cytological examination. Cancer cells were found in the colonic segment where the tumor was located, in 18 of 20 samples. The frequency of free cancer cells decreased from 50 to 0 % (p < 0.04) in the distal 3-5 cm colonic segment and from 80 to 20 % (p < 0.03) in the proximal colonic segment after performing bowel ligatures. Free cancer cells were confirmed in 1 of 10 samples at both colonic segments 5-10 cm from the tumor, even after bowel ligatures. Intraluminal exfoliated cancer cells could be eliminated by placing bowel ligatures during sigmoidectomy. Measures should be considered to eliminate exfoliated cancer cells during colectomy, even after placing bowel ligatures.