maeda kotaro

To evaluate a change of defecatory function after resection of sacral tumor, clinical assessment and manometric studies were performed. Four cases with sacral tumor (two cases of neurinoma and two cases of chordoma) were studied in anorectal manometry and questionnaires pre-and postoperatively. Male to female ratio was 1:1 (two cases each), and the mean age was 40 years. Radicular resection was done in three cases, and the sacral nerve roots were preserved in one case. One case underwent bilateral radicular resection under L5, another case bilateral resection of S2, 3, and 4, and the last case unilateral resection of S2 and 3. HPZ, MRP, RW, MSP, RAR, FS and MTV were measured by anorectal manometry using a micro-tip transducer by a station pull-through technique. The condition of defecation was assessed by questionnaire. Frequency of defecation per day, consistency of stool, defecation sensation, discrimination between feces and gas, state of continence and urgency were evaluated.<BR>Defecatony function was destroyed in one case that underwent bilateral radicular resection. However, defecation was maintained by controlling fecal consistency in spite of some changes in manometric studies in cases with unilateral radicular resection and radicular preservation.

Endocrine cell carcinoma of the colon is highly malignant, matastasizes to other organs early, is often detected in an advanced stage, and consequently has a very poor prognosis. A rare case of endocrine cell carcinoma coexisted with adenocarcinoma in the ascending colon following a resection of early cancer of the tranverse colon is reported. A 69-year-old woman was admitted to the hospital because two independent tumors were found in the ascending colon. There was a history of undergoing a resection of an early stage of colon cancer one and half years before admission. Bariun enema study and colonoscopy revealed an early stage carcinoma of IIa type and a yellowish submucosal tumor with central indentation in the ascending colon. Ileocecal resection was performed for these tumors. The submucosal tumor, 13×8×10mm in size, penetrated into the musuclaris propria. The tumor was consisted of large atypical polygonal cells which were positive for chromogranin and synaptophysin stainings. Electron micrograph showed an inclusing of neuroendocrine granules of the neoplastic cells in the cytoplasm. Histology of the submucosal tumor revealed endocrine cell carcinoma. Neuroendocrine cell carcinoma of the colon is a rare condition, and only 42 cases have been reported in the Japanese literature. This is the first case of the endocrine cell carcinoma with synchronous adenocarcinoma in the colon after metachronous adenocarcinoma of the colon. The patient has survived 2 years and 6 months after the surgery with no signs of recurrence.

Lateral node metastasis, recurrence, and outcome were investigated in rectal cancer with and without autonomic nerve-preserving operation to clarify the effect of autonomic nerve-preserving operation on lateral node dissection. All patients undergoing curative surgery for middle and lower rectal cancer were classified into the following three groups : a group that underwent autonomic nerve non-preserving operation from 1980 and 1987 (group A, n=109), a group that underwent the nerve-preserving operation between 1988 and 1993 (group B, n=71), and a group that underwent non-preserving operation between 1988 and 1993 (group C, n=12). Our indications for nerve preservation since 1988 have been the absence of evidence of direct invasion of the autonomic nerve macroscopically in frozen sections during surgery. The 5-year survival rate of all cases with and without node metastasis was 33.8% and 76.8% respectively. There were no statistically significant differences in the 5-year survival rate between groups A and B according to Duke's staging, staging by the General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus, and recurrence rate. However, the cumulative 5-year survival rate in group B was significantly better than in group A (P<0.05) in the lower rectum. There were no significant differences between group A and groups B and C in the 5-year survival rate. The 5-year survival rate in group B was significantly better than in group C (P<0.05). The autonomic nerve-preserving operation with lateral node dissection was concluded to provide as good an outcome as non-preserving operations with lateral node dissection within our indications.

従来の経肛門的局所切除術 (PAE) と新しく開発したE式およびF式開肛器と自動縫合器を用いた経肛門的局所切除術 (MITAS) について臨床的に比較検討した。対象は経肛門的局所切除術が施行された直腸腫瘍61例 (62病変) で, 術式はMITAS43例 (44病変), PAE18例であった。肛門縁から病変までの距離はPAEの4.9cmに比べてMITASでは9.3cmと有意に高位で, 腹膜反転部以上に局在する症例が有意に多かった。手術時間はMITASでは平均24.7分, PAEは40.9分で, 出血量はMITASでは平均19.6g, PAEは50.0gであった。術後経口摂取開始までの日数はPAEに比べてMITASは有意に短縮していた。MITASでは86.4%の病変で筋層以上の切除がなされていた。合併症はPAEで縫合不全を2例, MITASで後出血を1例に認めた。MITASはすべての部位の早期直腸癌の根治術として, また根治性確認の手段として有用なminimally invasiveな術式と考えられた。

A clinicopathological features of suture line recurrence were studied in 337 patients who underwent curative resection for primary colonic cancer at the department between 1974 and 1996. Two patients had a suture line recurrence (0.6%) 3 and 16 months after the initial operation respectively. They were both female and 42 and 53 years old at the initial operation. Both primary tumors were located in the sigmoid colon. Surgical margin was 6 to 10cm in both cases. The primary cancer invaded beyond the colonic wall with positive nodes, slight to moderate lymphatic invation and no vessel invasion in each case. These cases were curatively resected at the initial operation. The local recurrence was considered to be originated from implantation metastasis of exfoliated cancer cells.

The clinicopathological features of 21 cases of poorly differentiated adenocarcinoma of the colon and rectum resected in our department from 1988 to 1996 were compared with those of 472cases of well and 162cases of moderately differentiated adenocarcinoma. Poorly differentiated adenocarcinomas were more frequently found in the right side of the colon. Eighty five point seven percent of poorly differentiated adenocarcinomas invaded beyond serosal and adventitical layer, and 28.6% of them had high grade lymph node metastasis. Sixty six point seven percent of poorly differentiated adenocarcinomas were Dukes C and D, and 57.1% were over 3b. Poorly differentiated adenocarcinomas were more advanced than well differentiated adenocarcinomas with significant difference. No differences were observed between poorly differentiated adenocarcinomas and well and moderately differentiated adenocarcinomas in frequency of liver and lung metastasis. However, the incidence of peritoneal dissemination was higher in poorly differentiated adenocarcinomas than in well and moderately differentiated adenocarcinomas at the time of primary surgery and recurrence. The curative A resection was done in 71.4% of poorly differentiated cases, and the five-year survival rate was 77.8% in cases with curative A resection. There was no significant difference in the five-year survival rate between poorly differentiated and well and moderately differentiated adenocarcinomas in case of curative A resection. Advanced disease was more often discovered in patients with poorly differeniated adenocarcinoma, however, the prognosis may be improved by early detection and sufficient lymphadenectomy.

Two cases of endocrine cell carcinoma of the large bowel are reported, with a review of 42cases of the disease reported in the Japanese literature. Case 1: A 53-year-old woman was seen at the hospital because of diarrhea. A cancer of the ascending colon with peritoneal dissemination was detected by barium enema study, colonoscopy and abdominal computed tomography (CT). Right hemicolectomy was performed for the primary cancer. The patient is so far doing well without any symptoms 13months after the surgery. Case 2: A 66-year-old woman was seen at the hospital because of bloody stool. A low rectal cancer with multiple liver metastases was discovered by colonoscope and CT. Abdominoperineal resection with combined resection of posterior vagina wall was performed. The patient died of liver meastasis 59 days after the surgery. Histological examination of resected materials from both patients showed that each tumor consisted of polygonal-shaped cells and grew in solid pattern without gland formation. Microscopically the tumors were poorly differentiated adenocarcinoma. On immunohistochemical study, both tumors were positive for chromogranine A. Therefore, the definite diagnosis of endocrine cell carcinoma was made in each case. In a review of the Japanese literature, endocrine cell tumors often occurred in the rectum, had more malignant potential in lymphatic, vascular and liver metastases, and the prognosis was so poor that 17 out of 42patients died within one year.

これまでの骨盤直腸窩痔瘻の治療の問題は, 術後の創治癒の遅延, 肛門機能の低下, 肛門や創の変形, 再発などであった。これらの問題を解決するために瘻孔造影で術前に瘻管の走行を確認し, 経仙骨的アプローチで全瘻管を確実に処理し, 半閉鎖する手術を施行した。症例は40歳の男性で, 肛門周囲痛で来院し, 肛門周囲膿瘍の切開排膿後痔瘻に移行した。肛門会陰部には10時の2次口と2次口周囲の皮膚の発赤, 直腸右壁の硬化を認めた。直腸肛門管造影を併用した瘻孔造影で骨盤+坐骨直腸窩痔瘻と診断し手術を施行した。2次口と皮下膿瘍を切除し瘻管をcoring out後, 経仙骨盤直腸窩の瘻管, 膿瘍を全て切除, 掻爬した。次に, 1次口の切除, coring outを行い1次口は半閉鎖した。2次口と仙骨切開創はドレーンを留置し閉鎖した。術後経過は良好で, 術後23日目に退院し, 術後6カ月現在再発もない。