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Purpose: The purpose of this study was to evaluate the clinicopathological features of mucinous adenocarcinoma associated with perianal fistulas (MAF), to assess the importance of preoperative MRI analysis, and to determine the optimal surgery., Methods: We performed a retrospective analysis of the data from seven patients with MAF treated at our hospital between 2000 and 2013, and herein discuss the importance of preoperative magnetic resonance imaging (MRI) and of radical surgery., Results: The male to female ratio was 5:2, and the mean age of the patients was 63 years old (28-70). The median duration of chronic fistulation was 16 years (5-40). The tumor extension was classified as II+III+IV in five patients and as II+III in 2 patients according to the Sumikoshi classification, as determned by pelvic MRI. The performed surgeries were 3 abdominoperineal resections with sacral resection and 4 pelvic exenterations with sacral resection. Two local recurrences developed in patients with R1 resection, and 1 distant metastasis occurred in 1 patient with R0 resection., Conclusion: For patients with MAF, a curative surgical resection is the only definitive treatment that can be expected to provide a good prognosis. The application of the Sumikoshi classification using MRI may provide a precise assessment of the extension of MAF, which can allow the appropriate surgery to be selected for the patients with MAF.

Objective: To introduce the prophylactic laparoscopic lateral pelvic lymph node dissection performing by remarking the vesicohypogastric fascia following total mesorectal excision for patients with advanced lower rectal cancer without radiological evidence of lymph node involvement., Surgical Method: We set 5 ports for conventional laparoscopic rectal surgery. During the prophylactic laparoscopic lateral pelvic lymph node dissection, we retrieved the lymph nodes from the internal iliac area and obturator area. We recognized the pelvic nerve plexus, vesicohypogastric fascia (including internal iliac vessels), and parietal fascia (psoas muscle fascia, pubic bone and internal obturator muscle fascia) as the dissection borders from internal to external. Of note, the vesicohypogastric fascia can be recognized under magnified clear vision, and can be preserved by precise dissection, resulting in reduced hemorrhage from the internal iliac vessels and complications such as urinary dysfunction., Conclusion: Prophylactic laparoscopic lateral pelvic lymph node dissection after remarking on the vesicohypogastric fascia may contribute to a less invasive surgery compared with conventional laparoscopic lateral pelvic lymph node dissection.

Endoscopic submucosal dissection involves dissecting manipulation performed with tumors in an exposed condition for a long period of time. Thus, there is a risk for implantation of tumor cells. The objectives of this study were to examine exfoliated tumor cells after colorectal endoscopic submucosal dissection and to elucidate the effectiveness of intraluminal lavage to remove these cells. The subjects were 8 patients who had undergone colorectal endoscopic submucosal dissection at our hospital between September and December 2012. A retrospective study was conducted on the cytological findings of intraluminal lavage samples in these patients. Seven of the 8 patients (88%) had exfoliated tumor cells in the lavage samples at the beginning of lavage. Only 3 patients (3 8%) had exfoliated tumor cells after lavage with 300 ml of water. A large number of tumor cells were thought to have exfoliated into the intestinal lumen after endoscopic submucosal dissection. Sufficient intraluminal lavage after colorectal endoscopic submucosal dissection is necessary to remove exfoliated tumor cells.

Radical surgery is often necessary in patients with local recurrence of rectal cancer or in those with carcinoma associated with an anal fistula. The surgery may include extended excision of the perineal area and can create a large dead space in the pelvis and a large skin defect, often necessitating reconstruction of the pelvic floor using rectus abdominis musculocutaneous (RAM) flap transposition. Wound dehiscence and incisional hernia are common complications of RAM flap transposition. We report herein our encounter with 3 patients in whom we used a "sliding door" technique for reconstruction of the abdominal wall after the creation of a RAM flap. One patient underwent abdominoperineal resection with sacrectomy and RAM flap transposition; he experienced a postoperative surgical site infection and wound dehiscence, which we urgently repaired by reconstructing the abdominal wall using the sliding door technique. Two other patients underwent posterior pelvic exenteration with sacrectomy and RAM flap transposition. These patients underwent simultaneous abdominal wall reconstruction using the sliding door technique. No patient experienced postoperative pelvic sepsis, wound dehiscence, or incisional hernia. The sliding door technique might be useful for preventing wound dehiscence and incisional hernia in patients undergoing RAM flap transposition.

Objective: The aim of this study was to evaluate the outcomes of patients who underwent extensive pelvic surgery for locally advanced primary or recurrent non-colorectal pelvic malignancies., Patients and Methods: We performed a retrospective review of the medical records of 19 patients with non-colorectal pelvic malignancies who underwent extensive surgery at our institution between January 2005 and May 2013. Overall survival and progression-free survival were estimated using the Kaplan-Meier method and compared using the logrank test., Results: With regard to tumor histology, 6 patients (31.6%) had gynecological tumors, 8( 42.1%) had urological tumors, 2( 10.5%) had sarcomas, and 3( 15.8%) had other malignancies. Total pelvic exenteration was performed in 13 patients (68.4%), and other procedures were performed in 6 patients( 31.6%). For all patients, the median operation time and blood loss were 699 min and 2,930 mL, respectively. Complete tumor resection( R0) was achieved in 13 patients( 68.4%), and 16 patients had complications( 84.2%). The median overall survival was 18.5 months for patients who underwent R0 resection, compared with 7.3 months for those who underwent R1/R2 surgery (p=0.113), and the median progression-free survival was 7.3 months for cases of R0 resection, compared with 2.0 months for cases of R1/R2 surgery (p=0.035)., Conclusion: Our findings indicate that extensive pelvic surgery may be an optimal treatment for some patients with locally advanced primary or recurrent non-colorectal pelvic malignancies. Careful patient selection according to oncological, anatomical, and patient-related factors may improve the outcomes of patients undergoing this extensive, aggressive pelvic surgical procedure.

Aim: To evaluate the technical feasibility of laparoscopic lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) as prophylaxis for patients with advanced lower rectal cancer but no radiologic evidence of lymph node involvement., Patients and Methods: TME was performed on 30 patients with cT3N1-2M0 lower rectal cancer. LPLD was performed by laparoscopic surgery in 12 patients (LAP group),and open surgery in 18 patients (Open group). Statistical analysis was used to compare the number of harvested lymph nodes, operative time, operative blood loss, transfusion rate, and volume of transfusion between the groups., Results: No significant difference was observed in the number of harvested lymph nodes. Operative time was significantly longer in the LAP group; however, operative blood loss, transfusion rate, and volume of transfusion were significantly lower in the LAP group., Conclusion: Laparoscopic LPLD, when performed by a well-trained laparoscopic team, is safe and feasible in some selected lower rectal cancer patients. This approach has the potential to achieve oncologic lymph node clearance equivalent to open surgical LPLD, and to overcome the cited disadvantages of LPLD, which include greater operative blood loss and urinary dysfunction.