記述言語：英語   出版者・発行元：Surgery Today  

Purpose: To clarify the influence of additional internal iliac artery (IIA) resection on the loss of the gluteus muscle volume after pelvic exenteration (PE). Methods: The subjects of this retrospective analysis were 78 patients who underwent PE with or without IIA resection (n = 44 and n = 34, respectively) between 2006 and 2018. The areas of gluteal muscles (GMs) and psoas muscles (PSMs) were calculated using CT images before and 6 months after PE, and the difference was compared. Results: The volumes of the GMs and PSMs were significantly reduced after PE (P < 0.001 and P = 0.005, respectively). In the IIA resection group, the GMs were significantly reduced after surgery, but the PSMs were not. The maximum GM (Gmax) was the most atrophied among the GMs. Multivariable analysis revealed that complete IIA resection was an independent promotor of the loss of volume of the Gmax (P = 0.044). In 18 patients with unilateral IIA resection, the downsizing rate of the Gmax was significantly greater on the resected side than on the non-resected side (P = 0.008). Conclusions: The GMs and PSMs were significantly smaller after PE. Complete IIA resection reduced the Gmax area remarkably. Preservation of the superior gluteus artery is likely to help maintain Gmax size, suggesting a potential preventative measure against secondary sarcopenia.

DOI： 10.1007/s00595-022-02635-z

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出版者・発行元：株式会社医学書院  

DOI： 10.11477/mf.1407214143

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出版者・発行元：金原出版  

DOI： 10.18888/op.0000003383

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出版者・発行元：南江堂  

DOI： 10.15106/j_geka85_536

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記述言語：日本語   出版者・発行元：一般社団法人 日本消化器外科学会  

<p>近年，高頻度マイクロサテライト不安定性（microsatellite instability-high；以下，MSI-Hと略記）切除不能大腸癌に対し，免疫チェックポイント阻害薬（immune checkpoint inhibitors；以下，ICIと略記）使用が推奨されている．今回，ICI投与後に根治切除を行ったborderline resectableの1例を経験したため報告する．S状結腸癌術後1年，前医で左下腹壁に浸潤する限局性腹壁再発を指摘された．RAS/BRAF野生型であり，一次治療としてFOLFIRI+panitumumabを施行し，縮小を認めたため切除の可能性を求めて当科を受診した．MSI-Hを呈しており，さらなる病勢制御のためにipilimumab+nivolumab併用療法を導入した．中間画像評価では5%の増大を示したため，3コースで終了し根治手術（腹壁腫瘍切除+リンパ節郭清+大腿筋膜腹壁再建）を施行した．病理結果は完全奏効で，術後補助療法は施行せず，無再発経過観察中である．</p>

DOI： 10.5833/jjgs.2022.0056

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記述言語：英語   出版者・発行元：Digestive Endoscopy  

Transanal total mesorectal excision (taTME) has been rapidly accepted as a promising surgical approach to the distal rectum. The benefits include ease of access to the bottom of the deep pelvis linearly over a short distance in order to easily visualize the important anatomy. Furthermore, the distal resection margins can be secured under direct vision. Additionally, a two-team approach combining taTME with a transabdominal approach could decrease the operative time and conversion rate. Although taTME was expected to become more rapidly popularized worldwide, enthusiasm for it has stalled due to unfamiliar intraoperative complications, a lack of oncologic evidence from randomized trials, and the widespread use of robotic surgery. While international registries have reported favorable short- and medium-term outcomes from taTME, a Norwegian national study reported a high local recurrence rate of 9.5%. The characteristics of the recurrences included rapid, multifocal growth in the pelvis, which was quite different from recurrences following traditional transabdominal TME; thus, the Norwegian Colorectal Cancer Group reached a consensus for a temporary moratorium on the performance of taTME. To ensure acceptable baseline quality and patient safety, taTME should be performed by well-trained colorectal surgeons. Although the appropriate indications for taTME remain controversial, the transanal approach is extremely important as a means of goal setting in difficult TME cases and as an aid to the transabdominal approach in various types of extended pelvic surgeries. The benefits in transanal lateral lymph node dissection and pelvic exenteration are presented herein.

DOI： 10.1111/den.14464

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記述言語：日本語   出版者・発行元：日本大腸肛門病学会  

<p>症例は75歳女性で，倦怠感を主訴に精査し，盲腸癌，切除不能多発肝転移，腹膜播種と診断された．コンパニオン遺伝子検査結果ではRAS変異型（KRAS G12V），BRAF V600E野生型，microsatellite stableで，FOLFOX+bevacizumab療法を導入した．がん遺伝子パネル検査を行ったところ，生殖細胞系列に<i>BRCA1</i>病的バリアントが検出され，遺伝性乳癌卵巣癌症候群と診断され，本人および家族に対して遺伝カウンセリングを行った．がん遺伝子パネル検査の普及により，期せずして生殖細胞系列に二次的所見が得られ，遺伝性疾患の診断に繋がる機会は増えると予測される．このことは説明同意文書には必ず記載があるものの，患者側のみならず医療者側も認識に乏しい場合は少なくなく，今一度，患者への十分な説明を肝に銘じ，遺伝カウンセリングの体制を整えることが極めて重要である．</p>

DOI： 10.3862/jcoloproctology.76.443

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記述言語：英語   出版者・発行元：European Journal of Surgical Oncology  

Purpose: The aim of this study was to clarify the suitable radial margin (RM) for favourable outcomes after pelvic exenteration (PE), focusing on the discrepancy between the concepts of circumferential resection margin (CRM) and traditional R status. Methods: Seventy-three patients with locally advanced (LARC, n = 24) or locally recurrent rectal cancer (LRRC, n = 49) who underwent PE between 2006 and 2018 were retrospectively analysed. Patients were histologically classified into the following 3 groups; wide RM (≥1 mm, n = 45), narrow RM (0–1 mm, n = 10), and exposed RM (n = 18). The analysis was performed not only in the entire cohort but also in each disease group separately. Results: The rates of traditional R0 (RM > 0 mm) and wide RM were 75.3% and 61.6%, respectively, resulting in the discrepancy rate of 13.7% between the two concepts. Preoperative radiotherapy was given in 12.3%. In the entire cohort, the local recurrence and overall survival (OS) rates for narrow RMs were significantly worse than those for wide RMs (p < 0.001 and p = 0.002), but were similar to those for exposed RMs. In both LARC and LRRC, RM < 1 mm resulted in significantly worse local recurrence and OS rates compared to the wide RMs. Multivariate analysis showed that RM < 1 mm was an independent risk factor for local recurrence in both LARC (HR 15.850, p = 0.015) and LRRC (HR 4.874, p = 0.005). Conclusions: Narrow and exposed RMs had an almost equal impact on local recurrence and poor OS after PE. Preoperative radiotherapy might have a key role to ensure a wide RM.

DOI： 10.1016/j.ejso.2022.06.015

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記述言語：日本語   出版者・発行元：一般社団法人 日本消化器外科学会  

<p><b>目的：</b>BRAF V600E変異陽性進行再発大腸癌は薬物療法の効果が乏しく極めて予後不良で，転移巣が切除可能でも切除すべきか否かの判断が難しい．BRAF変異大腸癌の治療成績から切除可能転移巣の手術適応について後ろ向きに検討した．<b>方法：</b>2016年から2020年に治療を開始したBRAF変異大腸癌14例を対象とした．一次治療の初回画像効果判定で，腫瘍がベースラインより縮小または不変の症例をcontrolled disease（以下，CDと略記）群（<i>n</i>=8），増大した症例をuncontrolled disease（以下，UDと略記）群（<i>n</i>=6）に分類し比較検討した．<b>結果：</b>経過観察期間中央値は39.7か月であった．全体の2年全生存率は35.7%で，CD群およびUD群ではそれぞれ50.0%および16.7%であった（<i>P</i>=0.051）．転移巣根治切除を6例（42.9%）に施行し，4例で再発を来したが，1例は再転移巣切除を施行した．CD群では転移巣切除を行った3例中2例が無担癌生存中であるが，UD群の3例は全例で術後再発を来し，2例が術後3か月以内の早期再発であった．<b>結語：</b>BRAF変異大腸癌の予後予測因子として一次治療での初回病勢コントロール評価が有用である可能性が示唆された．たとえ切除可能であっても，一次治療での病勢コントロール不良例に対する転移巣切除の適応は慎重に考慮すべきである．</p>

DOI： 10.5833/jjgs.2021.0129

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記述言語：英語  

DOI： 10.1093/jjco/hyac045

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PubMed

記述言語：英語   出版者・発行元：Surgery Today  

Purpose: Parastomal hernia (PH) develops more frequently than incisional hernia (IH) after colorectal surgery with stoma. This study evaluated our hypothesis that inward traction of the fascia when closing a midline incision widens the stoma hole and increases the incidence of PH. Methods: A total of 795 patients who underwent colorectal resection between 2006 and 2016 were retrospectively analyzed. The risk classification was constructed from IH risk factors extracted from the non-stoma group. Then, the classification was extrapolated to the stoma group for predicting midline IH and PH. Results: The incidence of IH was 5.3% in the stoma group and 12.5% in the non-stoma group (p = 0.005). PH developed in 19.6% of 97 patients with permanent stoma. The risk classification was able to predict PH without a significant difference but was well balanced in patients with permanent stoma; however, it failed to predict IH in the stoma group. Conclusion: The risk classification constructed from the non-stoma group was useful for predicting not midline IH but PH, suggesting that the stoma site was the most vulnerable for herniation. The “fighting over the fascia” theory between the midline incision and stoma hole may explain the causal relationship between the midline IH and PH.

DOI： 10.1007/s00595-021-02434-y

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出版者・発行元：株式会社医学書院  

DOI： 10.11477/mf.1407213704

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出版者・発行元：南江堂  

DOI： 10.15106/j_geka84_484

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記述言語：日本語   出版者・発行元：日本大腸肛門病学会  

<p>再発大腸癌に対する完全切除は治癒や長期予後を得るために重要な治療法である．今回，解剖学的知識に疎い大腿骨頭周囲への稀な再発を，整形外科と合同で積極的に切除した経験を報告する．</p><p>症例は69歳の女性．前医で右大腿まで広範囲に膿瘍形成を伴う盲腸癌の後腹膜穿通と診断された．全身化学療法により腫瘍は著明に縮小し，2年半前に回盲部切除術，腸腰筋および右付属器合併切除が施行された．今回，大腿骨頭腹側の腫瘤を指摘され，当院での切開生検で盲腸癌再発と診断された．孤発性転移であり，整形外科と合同で関節包および大腿神経合併切除を伴う腫瘍切除を施行した．寛骨臼との剥離面に術中放射線照射を追加した．同部は病理学的検査でR1と診断された．術後難治性リンパ漏に対し，形成外科と合同で腹直筋皮弁充填術を施行した．術後1年7ヵ月の現在，脳髄膜播種再発は認めるものの局所制御は良好で，良好なQOLを保ちつつ，全身化学療法を継続中である．</p>

DOI： 10.3862/jcoloproctology.75.44

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記述言語：日本語   出版者・発行元：日本大腸肛門病学会  

<p>症例は75歳，男性．1年前に前医で，痔瘻癌に対する腹会陰式直腸切断術および右腹直筋皮弁による会陰再建が施行された．病理組織診断は粘液癌，pT4N0M0で，R1切除であった．今回，術後局所再発を指摘され当科を受診した．CT検査では，前立腺の右側で腹直筋皮弁の腹側に30mm大の嚢胞性腫瘤が存在し，穿刺生検で印環細胞癌を認めた．筋皮弁の主栄養血管である右下腹壁動静脈への浸潤はないと判断し，腹直筋皮弁温存の骨盤内臓全摘術を施行し，R0切除が得られた．</p><p>会陰部へ広範に進展する直腸癌や痔瘻癌では切除後に腹直筋皮弁による会陰再建が行われることは少なくない．しかし，術後に局所再発をきたせば，再手術時に筋皮弁の取扱いに苦慮することは想像に難くない．栄養血管の温存は技術的難易度が高く，時として癌に近付き根治性を損ないかねないため，適応は慎重に考慮すべきであるが，筋皮弁切除を回避できたメリットは大きかった．</p>

DOI： 10.3862/jcoloproctology.75.15

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出版者・発行元：株式会社医学書院  

DOI： 10.11477/mf.1407213500

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記述言語：英語   出版者・発行元：International Journal of Clinical Oncology  

Background: The carcinoembryonic antigen (CEA) “value” itself is often useless in patients with a normal CEA level at initial presentation and those with tumor-irrelevant elevated CEA. Although the unified marker using CEA has been desirable for recurrent tumor staging as well as for primary tumor staging, little is known concerning its relationship with the survival of patients with recurrent colorectal cancer in particular. Methods: This retrospective historical study included patients who experienced disease relapse after curative surgery for stage I–III colorectal cancer between 2006 and 2018. A total of 129 patients with recurrent disease after curative surgery for colorectal cancer were included. We focused on the CEA “ratio” (CEA-R: the ratio of the CEA level at the time of recurrence to that measured 3 months before recurrence) and aimed to evaluate the correlation between CEA-R and survival in recurrent colorectal cancer. Results: Patients with a high CEA-R (≥ 2) exhibited significantly worse 2 year survival than those with a low CEA-R (< 2) (88.1% vs. 44.9%, P < 0.001), irrespective of the CEA value before primary resection. Multivariate analyses demonstrated that the CEA-R (HR; 3.270, 95% CI 1.646–6.497, P = 0.001) was a significant prognostic factor. Conclusion: The CEA-R is a potential marker stratifying the survival of patients with disease relapse who exhibit aggressive biology at recurrent disease foci. As a novel marker, the CEA-R would serve as a clinical guide for tailoring treatment strategies at the time of disease relapse in patients with colorectal cancer.

DOI： 10.1007/s10147-021-01919-7

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出版者・発行元：株式会社医学書院  

DOI： 10.11477/mf.1407213349

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記述言語：英語   出版者・発行元：European Journal of Surgical Oncology  

Introduction: The oncological benefit of neoadjuvant chemotherapy (NAC) alone for locally advanced rectal cancer (LARC) remains controversial. The aim of this study was to clarify the clinical risk factors for poor prognosis before and after NAC for decision making regarding additional treatment in patients with LARC. Materials and methods: We examined a total of 96 patients with MRI-defined poor-risk locally advanced mid-low rectal cancer treated by NAC alone between 2006 and 2018. Survival outcomes and clinical risk factors for poor prognosis before and after NAC were analyzed. Results: In the median follow-up duration after surgery of 60 months (3–120), the rates of 5-year overall survival (OS), relapse-free survival (RFS), and local recurrence (LR) were 83.6%, 78.4%, and 8.2%, respectively. In the multivariate analyses, patients with cT4 disease had a significantly higher risk of poor OS (HR; 6.10, 95% CI; 1.32–28.15, P = 0.021) than those with cT3 disease. After NAC, ycN+ was significantly associated with a higher risk of poor OS (HR; 5.92, 95% CI; 1.27–27.62, P = 0.024) and RFS (HR; 2.55, 95% CI; 1.01–6.48, P = 0.048) than ycN-. In addition, patients with CEA after NAC (post-CEA) ≥ 5 ng/ml had a significantly higher risk LR (HR; 5.63, 95% CI; 1.06–29.93, P = 0.043). Conclusion: NAC alone had an insufficient survival effect on patients with cT4 disease, ycN+, or an elevated post-CEA level. In contrast, NAC alone is a potential treatment for other patients with LARC.

DOI： 10.1016/j.ejso.2020.10.038

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出版者・発行元：南江堂  

DOI： 10.15106/j_geka83_506

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記述言語：日本語   出版者・発行元：一般社団法人 日本消化器外科学会  

<p>今日，進行再発大腸癌治療において遺伝子検査は必要不可欠なものとなっている．中でもBRAF V600E変異症例の予後は極めて不良と報告され，その治療選択に悩むことは少なくない．今回，オキサリプラチンベースの術後補助化学療法が終了した直後の術後9か月の早期に，頸部リンパ節再発を来し，BRAF V600E変異型で予後不良が予測された症例に対し，二次治療としてのFOLFIRI+aflibercept療法が著効し，切除により病理学的完全奏効を確認した1例を経験した．術後経過観察期間は9か月とまだ短いが，外来で無再発，無治療で経過観察中である．予後不良とされるBRAF V600E変異型であっても野生型と同様に一定の全身コントロールが可能であれば，転移巣切除を考慮する意義はあると考えられた．</p>

DOI： 10.5833/jjgs.2020.0057

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