Long-term assessment of anorectal function after extensive resection of the internal anal sphincter for treatment of low-lying rectal cancer near the anus.

OBJECTIVES: Intersphincteric resection (ISR) for low-lying rectal cancer (LRC) may induce major problems associated with anorectal function. In this study, we assessed the severity of ISR-induced impairment in anorectal function. METHODS: In total, 45 patients followed up regularly ≥2 years after diverting ileostoma closure were eligible. The patients underwent ISR (n=35) or conventional coloanal anastomosis without resection of the internal anal sphincter (IAS) (n=10) for treatment of LRC from January 2000 to December 2011. We retrospectively compared anorectal function [stool frequency, urgency, Wexner incontinence scale (WIS) score, and patient satisfaction with bowel movement habits on a visual analog scale (VAS) score] for ≥2 years after stoma closure between the two groups. RESULTS: The median follow-up period was 4.0 years (range, 2.0-6.5 years). Of the total, 17 (48.6%) patients who underwent ISR had poor anorectal function, including two with complete incontinence. Significant differences were found between the groups in the incidence of urgency (p=0.042), WIS score (p=0.024), and defecation disorder with a WIS score of ≥10 (p=0.034) but not in stool frequency. Based on the VAS score, 45.7% of patients who underwent ISR were dissatisfied with their bowel movement habits (p=0.041). CONCLUSIONS: Extensive resection of the IAS has negative short- and long-term effects on anorectal function.

Clinical outcome of laparoscopic intersphincteric resection combined with transanal rectal dissection for t3 low rectal cancer in patients with a narrow pelvis.

Purpose. The purpose of this study was to analyze the safety and feasibility of laparoscopic intersphincteric resection (ISR) combined with transanal rectal dissection (TARD) for T3 low rectal cancer in a narrow pelvis. Methods. We studied 20 patients with a narrow pelvis of median body mass index 25.3 (16.9-31.2). Median observation period was 23.6 months (range 12.2-56.7). Results. Partial, subtotal, and total ISR was performed in 15, 1, and 4 patients, respectively. Median duration of TARD was 83 min (range 43-135). There were no major complications perioperatively or postoperatively. Surgical margins were histologically free of tumor cells in all patients, and there was no local recurrence. Excluding urgency, frequency of bowel movements, and incontinence status improved gradually after stoma closure. Conclusion. Laparoscopic ISR combined with TARD is technically feasible for selective T3 low rectal cancer in patients with a narrow pelvis.

Characteristics of recurrence after curative resection for T1 colorectal cancer: Japanese multicenter study.

BACKGROUND: Because the rate of recurrence after curative resection for T1 colorectal cancer is low, the characteristics of recurrence remain obscure. This multicenter study attempted to clarify the characteristics of recurrence after curative resection for T1 colorectal cancer. METHODS: We analyzed the associations between recurrence and various clinicopathological features in 798 patients who had undergone curative resection alone for T1 colorectal cancer at 14 hospitals between 1991 and 1996. RESULTS: The rate of lymph node metastasis (LNM) in patients with T1 colorectal cancer was 10.5% (84/798), and 18 (2.3%) of the 798 patients developed recurrence during the median follow-up of 7.8 years. The recurrence rates in patients with colon cancer with and without LNM were 3.6 and 1.3%, respectively (p = 0.19). These rates in patients with cancer of the rectum were 25.0 and 1.1% (p < 0.0001). Among various parameters, histological grade (p < 0.0001), location (p = 0.025), LNM (p < 0.0001), and venous invasion (p = 0.0013) were risk factors for recurrence. Among them, LNM (p = 0.0008) and histological grade (p = 0.041) were independent risk factors for recurrence after curative resection for T1 colorectal cancer. Time to recurrence was more likely to be shorter for patients with, than without nodal involvement. In patients with an unfavorable histological grade, all recurrences developed within 1 year. CONCLUSIONS: The recurrence rate after curative resection for node-negative T1 colorectal cancer was very low. The effectiveness of surveillance to detect recurrence after curative resection for T1 colorectal cancer should be validated in further studies.

Development and validation of a modified fecal incontinence quality of life scale for Japanese patients after intersphincteric resection for very low rectal cancer.

PURPOSE: Fecal incontinence is a frequently observed symptom after lower rectal surgery with sphincter manipulation. The aim of this study was to evaluate a proposed modification to the fecal incontinence quality of life (FIQL) scale for the assessment of the quality of life among patients with very low rectal cancer who have undergone intersphincteric resection. METHODS: A single 14-item composite scale was prepared that was derived from items in the "Lifestyle" and "Coping" subscales of the original FIQL. The scale was tested with a convenience sample of 152 postoperative patients. In addition to classic psychometric evaluation, newer statistical techniques, such as a multiple correspondence analysis and partial credit model, were performed to evaluate the item response patterns. RESULTS: The proposed scale exhibited an item-rest correlation of 0.66-0.84 and a Cronbach's alpha of 0.96, and was correlated with concurrently measured Social Functioning subscale of the Medical Outcomes Study Short Form 36 (-0.70), physical role limitation (-0.61), and Wexner continence grading scale (-0.61). Multiple correspondence analysis supported a uni-dimensional construct, and the partial credit model showed a varying yet overlapping range of item response thresholds across items. Several items, such as "Locating bathroom whenever going out", reflected more a serious condition than items such as "Avoiding eating-out." Weighted item scores based on estimated thresholds provided results comparable with those based on non-weighted scores. CONCLUSIONS: The proposed modification to the FIQL scale exhibited high internal consistency and satisfactory concurrent and convergence validity. The modified scale is practical to administer and is sensitive to a range of functional problems associated with fecal incontinence among patients who have undergone intersphincteric resection.

Timing of relapse and outcome after curative resection for colorectal cancer: a Japanese multicenter study.

BACKGROUND: The aim of this multicenter study was to clarify the influence of timing of relapse after curative resection for colorectal cancer on prognosis. METHODS: We enrolled 5,230 consecutive patients who underwent curative resection for colorectal cancer at 14 hospitals from 1991 to 1996. All patients were intensively followed up. Time to relapse (TR) was classified into three groups as follows: group A, TR < or =1 year; group B, TR >1 year and < or =3 years, and group C, TR >3 years. The prognoses after relapse were compared among the three groups. RESULTS: Of the 5,230 patients, 906 experienced relapse (17.3%). The curative resection rates for recurrent tumors were 35.2% in group A, 46.6% in group B, and 45.1% in group C (p = 0.0045). There were significant differences in the prognoses after relapse among the three TR groups in patients with relapse to the liver (p = 0.0175) and in those with local relapses (p = 0.0021), but not in those with pulmonary or anastomotic recurrence. There were no differences in prognoses after relapse in any recurrence site among the three groups in patients who underwent curative resection for relapse. CONCLUSION: If patients can undergo curative resection for relapse, they receive a survival benefit regardless of the timing of relapse.

Transanal rectal dissection: a procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis.

BACKGROUND: Laparoscopic approaches for colorectal surgery have been improved recently; however, it is often difficult to achieve total mesorectal excision (TME) for lower rectal cancer laparoscopically because of a narrow pelvis and a thickened mesentery. METHODS: TME was successfully performed in 6 patients (4 men, 2 women) with dissection of the rectum transanally from the anal side of the tumor. The preoperative stage was T3N1M0 in 1 patient and T3N0M0 in 5 patients. The mean body mass index was 29.8 kg/m(2) (range, 28.7-31.2 kg/m(2)), and the mean tumor size was 46.5 mm (range, 30-60 mm). RESULTS: The mean duration of the anal portion of the operation was 64 minutes (56 minutes in women, 79 minutes in men). No complications occurred during surgery or postoperatively. CONCLUSION: This technique is a simple and effective procedure for successfully performing laparoscopic TME of lower rectal cancer in patients with bulky tumors, narrow pelvises, and thickened mesenteries.

Expression profiling of fecal colonocytes for RNA-based screening of colorectal cancer.

The early detection of colorectal cancer originating from any part of the colorectum is desirable because this cancer can be cured surgically if diagnosed early. We searched for marker genes for a fecal RNA-based colorectal cancer screening method by comparison of genome-wide expression profiles among cancerous and non-cancerous tissues, and healthy volunteer- and cancer patient-derived colonocytes from the feces, and the peripheral blood. Of 14,564 genes, only 3 (PAP, REG1A, and DPEP1) were selectable as final candidates which were expressed frequently at any stage of this cancer and were suppressed in non-cancerous tissues and also in the peripheral blood and colonocytes of healthy volunteers. Next, we directly compared fecal RNA-expression profiles between colorectal cancer patients and healthy volunteers, and found that most of the genes (92%) expressed in the colonocytes of the cancer patients were not expressed in those of the healthy volunteers. Six genes (SEPP1, RPL27A, ATP1B1, EEF1A1, SFN, and RPS11) selected randomly from 85 cancer patient-derived colonocyte-specific genes were evaluated. In total, reverse transcription-polymerase chain reaction or focused microarray of all those 9 genes detected 18 (78%) of 23 curable colorectal cancers (Dukes stages A-C), 9 or 10 (64% or 71%) of 14 early cancers with no lymph node metastasis (Dukes stage A or B) and 4 (80%) of 5 right-sided cancers. Our extensive gene list provides other markers for fecal RNA-based colorectal cancer screening.

A rare case of repeated anastomotic recurrence due to tumor implantation after curative surgery for sigmoid colon cancer.

BACKGROUND: Anastomotic recurrence is often experienced at colocolic or colorectal anastomoses. Tumor cell implantation has been reported as the mechanism of anastomotic recurrence. However, anastomotic recurrence occurring repeatedly after curative surgery is rare. We herein report a rare case of repeated anastomotic recurrence after curative surgery for sigmoid colon cancer. CASE PRESENTATION: A 51-year-old man underwent radical surgery for sigmoid colon cancer. However, anastomotic recurrence developed three times during three years and six months after the initial operation in spite of irrigation with 5% povidone-iodine before anastomosis. The serum carcinoembryonic antigen (CEA) level had been within normal limits after sigmoidectomy. Finally, the patient underwent abdominoperineal resection. The clinico-pathological findings revealed that possible tumor cell implantation caused these anastomotic recurrences. The patients survived without recurrence during the follow-up period of seven years and nine months. CONCLUSION: We experienced a rare case of repeated anastomotic recurrence due to possible tumor implantation after curative surgery for sigmoid colon cancer; however the prognosis was ultimately very good. CEA monitoring was insensitive for detection of anastomotic recurrence in this case.

A single nucleotide substitution (-107C-->G) in the hMLH1 promoter found in colorectal cancer population reduces transcriptional activity.

Inactivation of the DNA mismatch repair gene hMLH1 predisposes one to colorectal cancer. We have identified a C to G nucleotide substitution at position -107 relative to the hMLH1 gene translation initiation site in three of 163 colorectal cancer patients with an allele frequency of 0.0092 (3/326). One of the three -107G alleles occurred in one patient out of five with reduced hMLH1 expression in the tumor tissue. The -107G was not found in 63 healthy individuals. This substitution reduced transcriptional activity by 51% compared with -107C (P<0.01) and impeded the promoter-binding capacity of nuclear proteins. Although the small number of identified -107G alleles is insufficient to evaluate the contribution to the carcinogenesis and clinicopathological properties of the tumors, the effects of -107G on hMLH1 gene transcription and nuclear protein binding to the promoter sequence implicate the site, including -107C, as a crucial element interacting with the activator that maintains hMLH1 gene expression.

Use of an opened umbilical vein patch for the reconstruction of the injured biliary tract.

BACKGROUND/PURPOSE: When iatrogenic biliary tract injury occurs, there is the risk of complications such as bile leak and biliary stricture, and hepaticojejunostomy is the conventional procedure used for injury repair. However, this procedure can be complicated by retrograde biliary tract infection and the procedure can destroy the normal anatomical structure. METHODS: We report here a method of end-to-end biliary tract reconstruction that uses an opened umbilical vein (OUV) patch and two stents to reduce bile leakage and biliary stricture formation following injury to the common bile duct or right main bile duct. The postoperative courses of four patients are reviewed. RESULTS: In two of the patients, there was a small amount of postoperative bile drainage (for 3 days in the first patient and 2 days in the second patient). Of the two stents, the first stent was removed 1 month postoperatively, and the second stent at 2 to 3 months postoperatively. Three patients have returned to normal activity without symptoms after 44, 62, and 93 months, respectively. One patient died of a liver tumor recurrence in the fifth postoperative month, without a biliary problem. CONCLUSIONS: An OUV patch for end-to-end biliary reconstruction reduced the volume and duration of bile leakage. Further research is needed to accurately evaluate the stenting period so as to reduce its duration.

Characteristics of recurrence and surveillance tools after curative resection for colorectal cancer: a multicenter study.

BACKGROUND: The aim of this study was to clarify the characteristics of recurrence and the effectiveness of surveillance tools after curative resection for colorectal cancer. METHODS: We enrolled 5230 consecutive patients (stage I, 1367; stage II, 1912; stage III, 1951) who underwent curative resection at 14 hospitals from 1991 to 1996. All patients were followed up intensively, and their outcomes were investigated retrospectively. RESULTS: Of the 5230 patients, 906 developed recurrence. The recurrence rates of stage I, II, and III cancers were 3.7%, 13.3%, and 30.8%, respectively (P < .0001). The curves of the cumulative appearance rate of recurrence in stage II and III patients showed a rapid increase for the first 3 years. Recurrence after 5 years was less than 1% in each stage. Clinical visits combined with measurements of tumor markers detected the majority of recurrences except in the case of lung metastasis. In contrast, 43.4% of hepatic recurrences were detected by liver imaging, and 48.4% of pulmonary recurrences were noted by chest x-ray. The 5-year survival rates after primary colorectal surgery in patients who underwent resection for recurrence were better than in those without resection: 55% vs 11% in hepatic recurrence, 68% vs 13% in pulmonary recurrence, and 48% vs 22% in local recurrence (all P < .001). CONCLUSION: It is useful to take these characteristics of recurrence into account in the management of patients after curative resection for colorectal cancer and in the setting of clinical trial for follow-up after curative resection for colorectal cancer.

[Transarterial chemoembolization with irinotecan (CPT-11) and degradable starch microspheres (DSM) in patients with liver metastases from colorectal cancer].

We report 27 cases of liver metastases treated with transarterial chemoembolization (TACE) with CPT-11, DSM, and mitomycin C (CPT-DSM therapy). In the 27 patients with liver metastases from colorectal cancer, CPT-DSM therapy was performed 47 times. All of these patients were a contra indication of hepatectomy. We compared a tumor marker before and after the treatment, and measured a serum level of SN-38, which is an active substance of CPT-11 and resolved from CPT-11. Although the level of CPT-11 was wearing off after CPT-DSM therapy, the peak of SN-38 level delayed 1 hour after the infusion. The CEA and CA19-9 levels were decreased to 54.2% and to 45.1% of the level before the treatment, respectively. Nine of the partial response and stable disease patients underwent surgery. The response rate was 59%. A 3-year survival rate was 20%. These results suggest that CPT-DSM therapy is one of the most effective anticancer agents. This TACE can be a feasible therapy for colorectal liver metastases as the first-line therapy.

[A case of gastric cancer with synchronous hepatic metastases which enforced the intra hepatic arterial chemotherapy showed a reduction of both tumors].

This is a case report of the intrahepatic arterial chemotherapy showing an effective reduction of tumors without an operation. The patient was a 68-year-old female. Instead of having an operation to gastric cancer with synchronous hepatic metastases, an intrahepatic arterial embolization of MMC and CPT-11 with DSM was enforced in the right-and-left hepatic arteries, and intrahepatic arterial infusions of 5-FU and CDDP were enforced after that. After intrahepatic infusion, the tumor size and marker of the gastric cancer and synchronous hepatic metastases decreased, and it was diagnosed as partial response (PR). Since the tumor marker showed an increase after thirteen times of the intrahepatic arterial infusions of 5-FU and CDDP, intrahepatic arterial embolization of CPT-11 and MMC with DSM was performed again and the intrahepatic arterial infusions of 5-FU and CDDP were enforced fourteen times after that. Although the tumor marker showed a small range of fluctuation, PR was kept observed and the patient has been stable for fifteen months since the chemotherapy began. She continuously received the combination chemotherapy as an outpatient.