[A Case of Sigmoid Colon Cancer with Liver Metastasis and Gastric Infiltration for Which Ileus Surgery Was the Impetus for Surgery].

The case is a woman in her 60s. Sigmoid colon cancer surgery, liver metastasis surgery, and adjuvant chemotherapy were performed at another hospital 2 years ago. Later, she developed a metastasis in her liver and was recommended surgery, but she refused treatment and was transferred. Her liver metastasis had invaded the stomach and formed a giant gastric ulcer. This time she had an adhesive ileus and underwent laparoscopic surgery at our hospital. At that time, we observed the state of liver metastasis and gastric infiltration by laparoscopy, so we thought that palliative surgery was possible and recommended it. Although she initially refused treatment, the relative ease with which her ileus surgery was performed encouraged her to undergo palliative surgery. Laparoscopic-assisted gastrectomy and partial hepatectomy were performed, and she was discharged on hospital day 13 after surgery. She subsequently developed liver metastases and died 8 months after palliative surgery, although she was able to eat and maintain her ADL until the end of life. By staying close to the patient, we were able to lead the patient from refusal of surgery to palliative surgery, and we felt that we were able to make the patient reach a favorable end.

Acute intestinal necrosis due to multiple thrombosis in COVID-19 patient. Report of a case.

BACKGROUND: While thrombosis is a well-known complication of coronavirus disease 2019 (COVID-19) infection, reports on intestinal necrosis due to intestinal ischemia caused by thrombosis are extremely rare. We herein report a case of intestinal necrosis due to multiple thrombosis in a COVID-19 patient. CASE PRESENTATION: The patient was a 64-year-old man. He was admitted to hospital after being diagnosed with COVID-19, the severity was classified as moderate II. Nasal High Flow™ management was conducted along with treatment with tocilizumab, remdesivir, and dexamethasone. Heparin was also administered due to high D-dimer values. As abdominal pain appeared from the 6th day of hospitalization, contrast-enhanced CT was performed, which confirmed multiple thrombosis in the aorta. However, no obvious intestinal ischemia was found. On the 10th day of hospitalization, the patient's abdominal pain was exacerbated. Upon re-evaluation by CT, he was diagnosed with perforative peritonitis due to ileal ischemic necrosis and emergency surgery was performed. Intraoperative examination revealed perforation due to necrosis at multiple sites in the ileum; thus, partial ileectomy was carried out. Pathological findings also revealed discontinuous multiple intestinal necrosis due to the frequent occurrence of thrombosis. Following surgery, the patient recuperated and was discharged after ventilator management and multimodal therapy at the ICU. CONCLUSIONS: Thrombosis due to COVID-19 complications is rare in the intestinal tract, but also occur. Its initial symptoms might not be captured by CT images, therefore caution is required.

A case of simultaneous abdominal wall metastasis of hepatocellular carcinoma with long-term relapse-free survival after laparoscopic resection.

We report our experience of an extremely rare case of a simultaneous extrahepatic metastasis of hepatocellular carcinoma (HCC) with long-term relapse-free survival, treated by laparoscopic resection of an abdominal wall tumor and subsequent radiofrequency ablation (RFA) of an intrahepatic lesion. A 76-year-old man visited a local clinic for right lower abdominal pain. He was treated with antibiotics and the symptom resolved. However, a mass was detected in the same region and he was referred to our hospital for further evaluation. Computed tomography (CT) of the abdomen showed a mass 5 cm in diameter, raising suspicions of an intra-abdominal tumor. Laparoscopic surgery was performed, and the tumor was found in the abdominal wall and completely resected. Histopathological examination yielded a diagnosis of extrahepatic HCC. Post-operative positron emission tomography (PET)-CT showed increased uptake of fluorodeoxyglucose in segment 3 (S3) of the liver. On performing a liver biopsy, HCC was diagnosed. Subsequently, the S3 lesion was treated with radiofrequency ablation. The patient has remained relapse-free for 6 years without further treatments.

Impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer: A multicenter retrospective cohort study.

AIMS: Primary tumor resection for patients with incurable stage IV colorectal cancer can prevent tumor-related complications but may cause postoperative complications. Postoperative complications delay the administration of chemotherapy and can lead to the spread of malignancy. However, the impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer remains unclear. Therefore, this study aimed to investigate how postoperative complications after primary tumor resection affect survival in this patient group. METHODS: We reviewed data on 966 patients with stage IV colorectal cancer who underwent palliative primary tumor resection between January 2006 and December 2007. We examined the association between major complications (National Cancer Institute Common Terminology Criteria for Adverse Events v3.0 grade 3 or more) and overall survival using Cox proportional hazard model and explored risk factors associated with major complications using multivariable logistic regression analysis. RESULTS: Ninety-three patients (9.6%) had major complications. The 2-year overall survival rate was 32.7% in the group with major complications and 50.3% in the group with no major complications. Patients with major complications had a significantly poorer prognosis than those without major complications (hazard ratio: 1.62; 95% confidence interval: 1.21-2.18; P < .01). Male, rectal tumor, and open surgery were identified to be risk factors for major complications. CONCLUSIONS: Postoperative complications after primary tumor resection was associated with decreased long-term survival in patients with incurable stage IV colorectal cancer.

A case of endosalpingiosis in the lymph nodes of the mesocolon.

BACKGROUND: Endosalpingiosis in the lymph nodes of the mesocolon is very rare. We reported a case with appendiceal endometriosis who had endosalpingiosis in the lymph nodes of the mesocolon that was found during laparoscopic ileocecal resection. CASE PRESENTATION: The patient was a 44-year-old woman who had visited a physician for fever, bloody stool, and abdominal pain 1 year earlier. She was diagnosed with ulcerative colitis on colonoscopy, and symptoms improved with oral treatment. A colonoscopy performed 2 months after diagnosis detected a hard, 20-mm submucosal tumor (SMT) in the cecum. On abdominal contrast CT, an intensely stained mass, including a low-density region, was observed in the cecum. A boring biopsy was performed after mucosal resection of the cecal SMT at our hospital, but diagnosis could not be made. Since the possibility of a malignant lesion could not be ruled out, laparoscopic ileocecal resection was performed. In the resected specimen, a 29 × 27 × 21-mm mass was present in the appendicular root. On histopathological examination, appendiceal endometriosis and endosalpingiosis in the lymph nodes around the ileocolic artery were observed. The postoperative course was favorable, and the patient was discharged 7 days after surgery. CONCLUSION: Differentiation of endosalpingiosis in lymph nodes in the mesocolon from lymph node metastasis of adenocarcinoma is important in patients with an abdominal mass.

A case of ileus surgery using the water pressure method against ileus caused by incarceration into the inverted bladder diverticulum.

BACKGROUND: Ileus is quite a common disease, but is associated with various causes. As far as we know, there have only been one case of ileus due to inverted bladder diverticulum, which is extremely rare. CASE PRESENTATION: The patient was a 53-year-old male. He made an emergency visit to our hospital with a chief complaint of left lower quadrant pain. He underwent right inguinal hernia surgery at 2 years of age with no history of laparotomy. An abdominal enhanced CT revealed inversion of the bladder left side wall where part of enlarged small intestine was found. Ascites were also found between the incarcerated small intestine and the bladder, leading to a diagnosis of strangulation ileus due to internal hernia and subsequent emergency surgery. A laparotomy revealed incarceration of the small intestine in the bladder left wall as a Richter type. The incarceration was rigid. We believed it would be difficult to pull out by extraction. Therefore, we inserted a Nelaton catheter between the incarcerated small intestine and the bladder and carried out the water pressure method to release the ileus. We did not perform an enterectomy since no manifest necrosis or perforation of the small intestine was found. The inverted bladder wall was a partial depression. We interpreted it to be a bladder diverticulum. We made a suture for occlusion with the bladder diverticulum inverted. Ileus arising from inverted bladder diverticulum is a very rare disease state. We hereinafter report on this case along with bibliographical considerations. CONCLUSIONS: We experienced a case of small intestine ileus due to inverted bladder diverticulum, which is very rare. In terms of preservation of the bowel, we believed the water pressure method to release the ileus was useful.

Metastatic seeding of human colon cancer cell clusters expressing the hybrid epithelial/mesenchymal state.

Emerging evidence supports the theory that tumor cell clusters efficiently metastasize to distant organs. However, the roles of epithelial-to-mesenchymal transition (EMT) in metastasizing tumor cell clusters have not yet been fully elucidated. To investigate this issue, tumor fragments were dissected from 40 colorectal cancer (CRC) patients and implanted subcutaneously into immunodeficient mice. We observed that tumors developed from the tumor fragments obtained from 28 of the 40 CRC patients. The tumors were then dissociated into cell suspensions to be orthotopically injected into secondary mice. The tumors from 13 of the 28 patients progressed. Furthermore, metastases formed spontaneously in the liver and lungs from the tumor fragments obtained from 8 of these 13 patients. Moreover, employing a mathematical analysis, we showed that tumor cell clusters seeded these metastases significantly more often than did single tumor cells. Membrane E-cadherin- and nuclear ZEB1-positive tumor cells indicating the hybrid epithelial/mesenchymal state were also detected in primary tumors of various CRC patients, and in the corresponding patient-derived xenografts (PDXs) and circulating tumor cell clusters in the bloodstreams of mice. In contrast, ZEB1 staining was barely detectable in the patient-matched liver metastases presumably developing through mesenchymal-to-epithelial transition. Inhibition of E-cadherin or ZEB1 expression by shRNA notably prevented the PDX-derived tumor organoids from colonizing the liver, when injected intrasplenically into mice, indicating E-cadherin and ZEB1 expressions to be required for their metastatic colonization. Taken together, these findings suggest that the epithelial/mesenchymal state mediates metastatic seeding of human CRC cell clusters into distant organs.

Current status of venous thromboembolism development during the perioperative period for colorectal cancer, its prevention with enoxaparin, and monitoring methods.

Background: There is a high incidence of venous thromboembolism (VTE) during the perioperative period for cancer. Therefore, there is an urgent need to elucidate the perioperative onset and appropriate prophylaxis for VTE. Purpose: VTE during the perioperative period for colorectal cancer was evaluated by lower limb venous ultrasonic examinations (lower limb echo) under enoxaparin prophylaxis. We also examined the relationship between hemorrhagic adverse events and anti-Xa factor activity. Patients and methods: Eighty-three subjects who underwent lower limb echo during the perioperative period for colorectal cancer were prospectively included. Enoxaparin was administered for 5 days, from day 1 to day 5 after surgery. Lower limb echo was performed before surgery and on day 5 after surgery. The activated partial thromboplastin time, D-dimer levels, and anti-Xa factor activity were measured before surgery and on days 1, 3, 5, 7, and 9 after surgery. Results: VTEs before surgery were observed on lower limb echo for 16 patients (19.2%). Three patients (3.6%) had a new thrombus during the perioperative period. The preoperative D-dimer level was an independent prognostic factor for newly formed postoperative VTEs (p=0.0036; odds ratio, 19.37). Three patients (3.6%) had hemorrhagic events; however, there was no significant trend for anti-Xa factor activity. Conclusion: VTE prevention using enoxaparin was relatively safe, and D-dimer measurements before surgery were useful for predicting perioperative VTE.

High-sensitivity Detection of Micrometastases Generated by GFP Lentivirus-transduced Organoids Cultured from a Patient-derived Colon Tumor.

Despite current advances in human colorectal cancer (CRC) treatment, few radical therapies are effective for the late stages of CRC. To overcome this clinical challenge, tumor xenograft mouse models using long-established human carcinoma cell lines and many transgenic mouse models with tumors have been developed as preclinical models. They partially mimic the features of human carcinomas, but often fail to recapitulate the key aspects of human malignancies including invasion and metastasis. Thus, alternative models that better represent the malignant progression in human CRC have long been awaited. We herein show generation of patient-derived tumor xenografts (PDXs) by subcutaneous implantation of small CRC fragments surgically dissected from a patient. The colon PDXs develop and histopathologically resemble the CRC in the patient. However, few spontaneous micrometastases are detectable in conventional cross-sections of affected distant organs in the PDX model. To facilitate the detection of metastatic dissemination into distant organs, we extracted the tumor organoid cells from the colon PDXs in culture and infected them with GFP lentivirus prior to injection into highly immunodeficient NOD/Shi-scid IL2Rγnull (NOG) mice. Orthotopically injected PDX-derived CRC organoid cells consistently form primary tumors positive for GFP in recipient mice. Moreover, spontaneously developing micrometastatic colonies expressing GFP are notably detected in the lungs of these mice by fluorescence microscopy. Moreover, intrasplenic injection of CRC organoids frequently produces hepatic colonization. Taken together, these findings indicate GFP-labelled PDX-derived CRC organoid cells to be visually detectable during a multistep process termed the invasion-metastasis cascade. The described protocols include the establishment of PDXs of human CRC and 3D culture of the corresponding CRC organoid cells transduced by GFP lentiviral particles.

Survival benefit of lymph node dissection in surgery for colon cancer in elderly patients: A multicenter propensity score-matched study in Japan.

INTRODUCTION: In surgery for elderly patients with colorectal cancer, it is unclear whether radical lymph node (LN) dissection safely offers a survival benefit. The aim of the study was to evaluate the impact of the LN yield in elderly patients undergoing surgery for colorectal cancer. METHODS: The subjects were selected from a surgical database of 2065 patients aged ≥80 years old who underwent surgery for colorectal cancer at 41 hospitals in Japan between 2003 and 2007. The patients were divided into groups according to the number LN harvested: <12 and ≥12. Propensity scores were subsequently matched to balance the baseline characteristics. RESULTS: Of the 954 patients initially selected, 331 were in the <12 LN and 623 were in the ≥12 LN group. After cases were matched, 293 patients were allocated to each group, and all covariates were balanced. For short-term outcomes, the time for surgery was longer in the ≥12 LN group, but there was no significant difference in morbidity between the groups. Overall, relapse-free and cancer-specific survival rates were higher in the ≥12 LN group (P = 0.004, 0.001, and 0.02). CONCLUSIONS: In patients aged ≥80 years old with stage II-III colon cancer, harvesting ≥12 LN provides a survival benefit, and therefore, limited LN dissection is not recommended in these patients.

Retrocecal hernia preoperatively diagnosed by computed tomography: A case report.

INTRODUCTION: Retrocecal hernia is a rare type of pericecal hernia. Because it is difficult to diagnose preoperatively, it is often treated with emergency operation. CASE PRESENTATION: An 83-year-old male patient experienced sudden abdominal pain. Marked small bowel dilatation and intestinal obstruction were detected by abdominal computed tomography (CT). An enhanced CT scan also revealed a trapped cluster of small bowel loops behind the cecum and ascending colon. We preoperatively diagnosed small bowel ileus as a result of retrocecal hernia. After conservative therapy with a long intestinal tube, an emergency operation was performed. During the surgery, a portion of the ileum was found to be incarcerated in the retrocecal fossa. Intestinal resection was not necessary because the incarcerated ileum appeared viable, and the orifice to the hernia was opened. The patient was discharged without postoperative complications. DISCUSSION: The diagnosis of retrocecal hernia can often be confirmed intraoperatively. This disease is identified based on a minimal error in rotation with incarceration behind the cecum during the final phase of descent and fixation of the right colon or failure of cecal and retroperitoneal fixation. Early preoperative diagnosis is important to prevent intestinal ischemia, necrosis, and perforation and to reduce resection rates. CONCLUSION: Early preoperative diagnosis is important to avoid resection of the small intestine. CT scans are useful for preoperative diagnosis in case of retrocecal hernia.

Defunctioning loop ileostomy with restorative proctocolectomy for rectal cancer: Friend or foe?

OBJECTIVES: Temporary ileostomy is used to decrease morbidity from anastomotic leakages (ALs). However, ileostomies are associated with complications (i.e., stoma-related complications; SRCs), ileus due to stenosis, dehydration, and the need for a second operation. Here we retrospectively evaluated the impact of SRCs on the treatment of rectal cancer. METHODS: We identified 180 consecutive patients who underwent curative resection for rectal cancer at Juntendo University Hospital between January 2006 and December 2014. We divided the patients into groups with and without defunctioning stoma (DS), and we compared the patient age and gender, tumor location, approach (laparotomy/laparoscopy), surgical procedure, distance of the tumor from the margin of the anus, T factor, stage, duration of postoperative hospital stay, and postoperative complications between these groups. Univariate and multivariate analyses were performed to determine the risk factors for postoperative hospital stay. RESULTS: The symptomatic leakage rate in the DS group (n = 92) was not significantly different from that of the non-DS group (n = 88; p = 0.29). However, Grade ≥ 4 AL occurred significantly less frequently in the DS group (0%) than in the non-DS group (5.7%; p = 0.02). SRCs occurred in 14 DS-group patients (15.2%). The multivariate analysis demonstrated that both AL (odds ratio [OR] 9.24; confidence interval [CI] 4.91-19.4) and SRC (OR 1.84; CI 1.03-3.54) were independently predictive of short-term outcomes. CONCLUSIONS: The benefit of a DS is balanced against the risk of leakage and SRCs at rectal resection. Surgeons should focus on not only the consequences of AL, but also SRC risk.

Two Cases of Rectal Neuroendocrine Tumor Resection Combined with Dissection of the Circular Muscle Layer Using the Endoscopic Submucosal Dissection Technique.

Generally, lesions of rectal neuroendocrine tumors (NETs) 10 mm or smaller are less malignant and are indicated for endoscopic therapy. However, the vertical margin may remain positive after conventional endoscopic mucosal resection (EMR) because NETs develop in a way similar to submucosal tumors (SMTs). The usefulness of EMR with a ligation device, which is modified EMR, and endoscopic submucosal dissection (ESD) was reported, but no standard treatment has been established. We encountered 2 patients in whom rectal NETs were completely resected by combined dissection and resection of the circular muscle layer using the ESD technique. Case 1 was an 8-mm NET of the lower rectum. Case 2 was NET of the lower rectum treated with additional resection for a positive vertical margin after EMR. In both cases, the circular muscle layer was dissected applying the conventional ESD technique, followed by en bloc resection while conserving the longitudinal muscle layer. No problems occurred in the postoperative course in either case. Rectal NETs are observed in the lower rectum in many cases, and it is less likely that intestinal perforation by endoscopic therapy causes peritonitis. The method employed in these cases, namely combined dissection and resection of the circular muscle layer using the ESD technique, can be performed relatively safely, and it is possible to ensure negativity of the vertical margin. In addition, it may also be useful for additional treatment of cases with a positive vertical margin after EMR.

Ascending Colon Cancer Associated with Dermatomyositis Which Was Cured after Colon Resection.

A 76-year-old woman with muscle ache, weakness of the extremities, and skin rash was diagnosed with dermatomyositis (DM). Upon the diagnosis of DM, a systemic survey of malignancy revealed an advanced carcinoma of the ascending colon. The patient underwent right hemicolectomy approximately 2 months after the onset of DM. The symptoms and signs of DM disappeared after the surgery without additional therapy. DM is an idiopathic systemic inflammatory disease characterized by muscle ache, muscle weakness, and skin rash. In some cases, DM develops as paraneoplastic syndrome, and it is assumed that 30% of DM patients have cancer. Symptoms and signs of DM can be attenuated by treatment of the malignancy, and they reappear if the malignancy recurs. It is essential to perform a systemic survey of malignancy in DM patients, and treatment of the malignancy has to precede treatment of DM.

Accessory liver lobe attached to the gallbladder wall preoperatively detected by ultrasonography: A case report.

INTRODUCTION: An accessory liver lobe is a rare developmental abnormality, which is often not diagnosed preoperatively, and is usually detected incidentally during abdominal surgery. This condition is often asymptomatic; here, we report on a case where the accessory liver lobe was diagnosed preoperatively using ultrasonography. CASE PRESENTATION: A 59-year-old woman presented to our hospital with right upper abdominal pain. An abdominal ultrasonography indicated the presence of gallbladder debris and an accessory liver lobe. She underwent laparoscopic cholecystectomy and resection of the accessory liver lobe without any complications. DISCUSSION: An accessory liver lobe is a rare anomaly of the liver. It is typically asymptomatic and is detected incidentally during surgery or autopsy in most cases. However, we diagnosed the accessory liver lobe using ultrasonography. An accessory liver lobe can occasionally result in complications, such as bleeding, portal vein obstruction, or malignant transformation to hepatocellular carcinoma. CONCLUSION: An accessory liver lobe should be resected to prevent complications and malignant transformation. Ultrasonography is useful for preoperative diagnosis in cases with an accessory liver lobe.

Unusual False-Positive Mesenteric Lymph Nodes Detected by PET/CT in a Metastatic Survey of Lung Cancer.

Positron emission tomography/computed tomography (PET/CT) is a credible diagnostic modality for detecting primary and metastatic malignancy. PET/CT sometimes shows false positives and negatives, which make clinical diagnosis difficult. A 42-year-old man who had undergone right upper lobectomy for lung cancer 1 year previously had PET/CT for a metastatic survey of the lung. The lung cancer was stage IB (pT2N0M0) bronchioloalveolar carcinoma. PET/CT showed massive (18)F-fluorodeoxyglucose (FDG) uptake in the mesenteric lymph nodes. Because the mesentery is an unusual site of metastasis, the patient was under watchful observation. Another PET/CT after 6 months still showed FDG uptake in the same location, with a slightly increased standard uptake value. A systemic survey was performed, but it did not reveal any malignancies or inflammatory diseases. Eventually, the patient underwent probing laparoscopic surgery. For complete resection of the lymph nodes, laparoscopic ileocecal resection was performed. Histologically, the resected lymph nodes showed reactive lymphadenitis. Glucose transporter 1 immunostainings of the lung cancer and the lymph node were positive and partially positive, respectively. Although PET/CT is a powerful diagnostic modality, clinical interpretation of unusual results is difficult.

Combined laparoscopic abdominoperineal resection and robotic-assisted prostatectomy for synchronous double cancer of the rectum and the prostate.

Here we report a combined laparoscopic abdominoperineal resection and robotic-assisted prostatectomy. A 74-year-old man was diagnosed with T4b low rectal and prostate cancer. The operation was performed after neoadjuvant chemotherapy for the rectal cancer. The procedure used eight ports in total, five for laparoscopic abdominoperineal resection and six for robotic-assisted prostatectomy. First, laparoscopic total mesorectal excision including division of the inferior mesenteric artery was performed, and then, robotic dissection of the prostate was performed. The en bloc specimen was removed through the perineal wound. Then, robotic urethrovesical anastomosis was performed. An extraperitoneal end colostomy was created to finish the operation. The operating time was 545 min, and blood loss was 170 mL. The postoperative course was uneventful, and the patient discharged on postoperative day 17. The combined laparoscopic abdominoperineal resection and robotic-assisted prostatectomy were performed safely without any additional technical difficulty, as both procedures shared port settings and patient positions.

Impact of chromosome 17q deletion in the primary lesion of colorectal cancer on liver metastasis.

Colorectal cancer is a prevalent malignancy worldwide, and investigations are required to elucidate the underlying carcinogenic mechanisms. Amongst these mechanisms, de novo carcinogenesis and the adenoma to carcinoma sequence, are the most understood. Metastasis of colorectal cancer to the liver often results in fatality, therefore, it is important for any associated risk factors to be identified. Regarding the treatment of the disease, it is important to manage not only the primary colorectal tumor, but also the liver metastases. Previously, through gene variation analysis, chromosomal loss has been indicated to serve an important role in liver metastasis. Such analysis may aid in the prediction of liver metastasis risk, alongside individual responses to treatment, thus improving the management of colorectal cancer. In the present study, we aimed to clarify a cause of the liver metastasis of colorectal cancer using comparative genomic hybridization analysis. A total of 116 frozen samples were analyzed from patients with advanced colorectal cancer that underwent surgery from 2004 to 2011. The present study analyzed mutations within tumor suppressor genes non-metastatic gene 23 (NM23), deleted in colorectal carcinoma (DCC) and deleted in pancreatic carcinoma, locus 4 (DPC4), which are located on chromosomes 17 and 18 and have all been reported to affect liver metastasis of colorectal cancer. The association between chromosomal abnormalities (duplication and deletion) and liver metastasis of colorectal cancer was evaluated using comparative genomic hybridization. Cluster analysis indicated that the group of patients lacking the long arm of chromosome 17 demonstrated the highest rate of liver metastasis. No significant association was observed between the frequency of liver metastases for synchronous and heterochronous colorectal cancer cases and gene variation (P=0.206). However, when these liver metastasis cases were divided into the synchronous and heterochronous types, the ratio of each was significantly different between gene variation groups, classified by the existence of the 17q deletion (P=0.023). These results indicate that the deletion of 17q may act as a predictive marker of liver metastasis in postoperative states.

Treatment of Internal Hemorrhoids by Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid.

Objective. A new sclerosing agent for hemorrhoids, aluminum potassium sulfate and tannic acid (ALTA), is attracting attention as a curative treatment for internal hemorrhoids without resection. The outcome and safety of ALTA sclerotherapy using an endoscope were investigated in the present study. Materials and Methods. Subjects comprised 83 internal hemorrhoid patients (61 males and 22 females). An endoscope was inserted and retroflexed in the rectum, and a 1st-step injection was applied to the upper parts of the hemorrhoids. The retroflexed scope was returned to the normal position, and 2nd-4th-step injections were applied to the middle and lower parts of the hemorrhoids under direct vision. The effects of endoscopic ALTA sclerotherapy were determined by evaluating the condition of the hemorrhoids using an anoscope and interviewing the patient 28 days after the treatment. Results. A cure, improvement, and failure were observed in 54 (65.1%), 27 (32.5%), and 2 (2.4%) patients, respectively, treated with ALTA. Complications developed in 4 patients (mild fever in 3 and hematuria in 1). Recurrence occurred in 9.6%. Conclusions. The results of the present study suggest that endoscopic ALTA has the potential to become a useful and minimally invasive approach for ALTA sclerotherapy.

A case of metastatic carcinoma of anal fistula caused by implantation from rectal cancer.

This case involved an 80-year-old man who was seen for melena. Further testing revealed a tubular adenocarcinoma 50 mm in size in the rectum. In addition, an anal fistula was noted behind the anus along with induration. A biopsy of tissue from the external (secondary) opening of the fistula also revealed adenocarcinoma. Nodules suspected of being metastases were noted in both lung fields. The patient was diagnosed with rectal cancer, a cancer arising from an anal fistula, and a metastatic pulmonary tumor, and neoadjuvant chemotherapy was begun. A laparoscopic abdominoperineal resection was performed 34 days after 6 cycles of mFOLFOX-6 therapy. Based on pathology, the rectal cancer was diagnosed as moderately differentiated adenocarcinoma, and this adenocarcinoma had lymph node metastasis (yp T3N2aM1b). There was no communication between the rectal lesion and the anal fistula, and a moderately differentiated tubular adenocarcinoma resembling the rectal lesion was noted in the anal fistula. Immunohistochemical staining indicated that both the rectal lesion and anal fistula were cytokeratin 7 (CK7) (-) and cytokeratin 20 (CK20) (+), and the patient's condition was diagnosed as implantation of rectal cancer in an anal fistula.In instances where an anal fistula develops in colon cancer, cancer implantation in that fistula must also be taken into account, and further testing should be performed prior to surgery.