The inguinal lymph nodes as regional lymph nodes in anal canal adenocarcinomas: a nationwide database analysis in Japan.

PURPOSE: To establish if it is appropriate to treat the inguinal lymph node (LN) of anal canal adenocarcinoma (ACA) as the intermediate LN according to the Japanese classification. METHODS: The characteristics of 346 ACA patients were examined from the nationwide registry. The effect of LN dissection was evaluated using the therapeutic value index (TVI). Furthermore, the prognostic classification ability of N factors and stage was evaluated using Akaike's information criterion (AIC), the concordance index (C-index), and the 5-year overall survival (OS) rate. RESULTS: The rate of metastasis of the inguinal LN was 7.5% and the TVI was 3.05. Evaluation using AIC and the C-index showed better results when the inguinal LN was treated as the intermediate LN. The 5-year OS rate for 66 patients with perirectal or intermediate LN metastasis, 7 with inguinal LN metastasis, and 13 with inguinal and perirectal or intermediate LN metastasis were 49.2%, 68.6%, and 47.6%, respectively. When inguinal LN metastases were treated as N3, the 5-year OS rates were 66.7% for those with T1N3 and T2N3 disease, and 49.2% for those with T3N3 disease. CONCLUSIONS: The inguinal LN of ACA was evaluated and staged as the intermediate LN to devise an appropriate treatment strategy.

Characteristics of anal canal squamous cell carcinoma as an HPV-associated cancer in Japan.

The definition of the anal canal was revised in the TNM classification (8th edition). The Japanese Society for Cancer of the Colon and Rectum (JSCCR) conducted a retrospective multi-institutional study to clarify the characteristics of anal canal cancer (ACC) in Japan. The diagnoses of 1781 patients treated for ACC were squamous cell carcimoma (SCC; n = 428; 24.0%), adenosquamous cell carcinoma (n = 7; 0.4%), and adenocarcinoma (n = 1260; 70.7%). Anal carcinoma is associated with human papillomavirus (HPV) infection and is risk factor for anal SCC. Among 40 cases analyzed at Takano Hospital and 47 cases analyzed at National Cancer Center Hospital, 34 cases (85.0%) and 40 cases (85.1%), respectively were infected with HPV; HPV-16 was the most common genotype (79.4% and 82.5%). In the JSCCR retrospective multi-institutional study, the prognosis analysis by stage was performed for anal SCC cases (202 cases treated by CRT and 91 cases treated by surgery). The 5-year overall survival (OS) rates by stage did not differ between the two treatment groups to a statistically significant extent. Regarding the results of cancer treatment of patients who underwent HPV infection tests, although the 5-year OS rates by stage did not differ to a statistically significant extent due to the small number of cases, HPV-positive patients had better survival. While an HPV vaccine for anal canal SCC has already been approved internationally, HPV vaccination has already been implemented in Japan as a national immunization program for young women but not for men at present. An HPV vaccination for men is urgently needed.

Correction to: Long-term results of intersphincteric resection for low rectal cancer in Japan.

In the original publication Fig. 2 and Table 4 were incorrectly published. The corrected figure and table are given in this Correction.

Long-term results of intersphincteric resection for low rectal cancer in Japan.

Intersphincteric resection (ISR) is the ultimate sphincter-preserving procedure for low rectal cancer. A questionnaire about the standardization of ISR was given to 2125 patients who underwent curative ISR for low rectal cancer between 2005 and 2012 at 127 affiliated institutions of the Japanese Society for Cancer of the Colon and Rectum (JSCCR), and the results were compared with the results of a systematic review. The findings revealed that although mortality and morbidity were relatively low and the survival rate after ISR was good, the rates of local recurrence and postoperative fecal incontinence were relatively high. The radicality of ISR was compared with that of abdominoperineal resection and low anterior resection using the propensity score matching prognosis analysis of patients in the JSCCR nationwide registry. The local recurrence rate was significantly higher after ISR, and especially high in patients with T3 (invasion into the external anal sphincter) and T4 disease. These results provide evidence about the factors related to fecal incontinence after ISR. As measures for the standardization of ISR, it is important to reconfirm that ISR is not indicated for patients with cT3 and cT4 disease and those with poor preoperative defecatory function, based on the ISR indication criteria.

A Retrospective Critique of the Various Sphincter-preserving Surgical Procedures for Ischiorectal Fistula.

In the 1950s, the cause of anal fistulas was identified as an infection of the anal gland (cryptoglandular infection theory). Thereafter, treatment for this disorder began in the 1960s with the lay-open procedure, which involved incising the sphincter and the fistula tract. However, it was found that too much invasion into the sphincter could result in postoperative fecal incontinence. Thus, to reduce such risk, sphincter-preserving surgery was applied for superficial anal fistula in 1961 and for deep anal fistula (ischiorectal fistula) in 1965. Over the years, more effective sphincter-preserving procedures for ischiorectal fistula have been developed to improve the quality of life of the patient. In this review article, we aim to first introduce the basic surgical techniques for ischiorectal fistula. We will discuss the anatomy of the anus and the pathogenesis of ischiorectal fistula and will provide some diagnostic methods. Representative sphincter-preserving procedures that have been performed for ischiorectal fistula since 1965 will also be categorized and outlined chronologically. The discussion will look at the following techniques for ischiorectal fistula and outline the advantages and disadvantages of each procedure so that they can be used as a reference for ischiorectal fistula surgery in the future: the lay-open procedure (fistulotomy and fistulectomy), the Hanley procedure (first partial sphincter-preserving procedure), the muscle-filling procedure, the Moriya method and Ui method (modified partial sphincter-preserving procedure), the Takano method and the sphincter-preserving lateral procedure (complete sphincter-preserving procedure), the seton method (a cross between the lay-open procedure and sphincter-preserving procedure), and the overseas sphincter-preserving procedure.

Herbivorous damselfishes expand their territories after causing white scars on Porites corals.

Turf algae become the most abundant benthic group on coral reefs after mass coral bleaching. By defending feeding territories, damselfishes enhance the growth of turf algae in so-called algal farms and affect coral communities both directly and indirectly. We found several white scars (i.e., bite lesions) on massive Porites colonies around feeding territories. In this study, we examined the occurrence of white scars on corals and their function in coral-algal competition at the boundaries between algal farms of two damselfish species-the intensive farmer Stegastes nigricans, and the intermediate farmer S. lividus-and adjacent Porites corals for 3 years around Okinawa Island, Japan. White scars occurred on Porites colonies only adjacent to the territories of both damselfish species. Of the white scars on corals around S. nigricans territories, 73% of the area was covered by algae within 2 weeks, while the remaining was re-covered by Porites tissues. The coral-algal boundaries encroached further into areas of coral when the area of white scars were larger. These results suggest that both intensive and intermediate farmers bite adjacent Porites colonies causing white scars on corals, and expand their territories onto corals using algae-covered white scars as stepping stones.

Propiverine Hydrochloride as a Treatment for Fecal Incontinence.

PURPOSE: Propiverine hydrochloride (PH) is widely used for the treatment of urinary incontinence (UI) due to bladder overactivity. Moreover, the comorbidity of UI with fecal incontinence (FI) is known to be due to the relationship of both to nervous system disorders and dysfunction or weakening of the pelvic floor muscles. The aim of this single-arm prospective study was to evaluate the therapeutic value of PH for FI. METHODS: Patients (n = 24) who were diagnosed as having both FI and UI from April 2015 to November 2016 were included in the study and administered a dosage of 10-20 mg PH every day for 1 month. The primary endpoint was to create a reduction in the frequency of FI per week. An evaluation criterion of ≥50% reduction in frequency was determined as effective. The percentage of the patients who achieved the ≥50% endpoint (responders) was also calculated. RESULTS: The frequency of FI per week was 6.0 ± 8.2 (0.25-30) at baseline and reduced to 1.6 ± 2.1 (0-7) at the posttherapeutic state (P = 0.005). A reduction of ≥50% was seen in 14 of the patients (58.3%). CONCLUSION: PH reduced the frequency of FI in patients with both FI and UI. This study introduces a possible therapeutic option for the pharmacological treatment of FI.

Pioglitazone, a ligand for peroxisome proliferator-activated receptor-gamma acts as an inhibitor of colon cancer liver metastasis.

BACKGROUND: Peroxisome proliferator-activated receptor-gamma (PPARgamma) is a member of the steroid receptor superfamily. Liganded PPARgamma can inhibit cancer cell proliferation. The in vitro and in vivo inhibitory effect of the synthetic ligands, ciglitazone (CGZ) and pioglitazone (PGZ), on human colon cancer was investigated. MATERIALS AND METHODS: Cell proliferation and the expression of PPARgamma, cyclooxygenase (COX)-2 and cyclin D1 were assessed in colon cancer cells treated with CGZ or PGZ. After subcutaneous or splenic inoculation of severe combined immunodeficient (SCID) mice using colon cancer HT-29 and SW480 cells, PGZ was administered orally and tumor growth inhibition was assessed by xenograft volume. The COX-2, cyclin D1 and PPARgamma expression in the HT-29 cells was evaluated. RESULTS: Cultured HT-29 and SW480 cells expressed PPARgamma and proliferation was inhibited by CGZ and PGZ. Oral PGZ inhibited xenograft tumor growth and liver metastases in the SCID mouse and suppressed expression of COX-2 and cyclin D1 in HT-29 cells. CONCLUSION: PGZ down-regulates COX-2 and cyclin D1 and inhibits colon cancer proliferation and liver metastasis, making PPARgamma a candidate target for the treatment/prevention of colon cancer metastasis.

Efficacy of Bilateral Transcutaneous Posterior Tibial Nerve Stimulation for Fecal Incontinence.

CONTEXT: Posterior tibial nerve stimulation is a new second-line treatment for refractory fecal incontinence. OBJECTIVE: To assess the efficacy of bilateral transcutaneous posterior tibial nerve stimulation (BTPTNS) for treatment of fecal incontinence in Japanese patients and its impact on quality of life. DESIGN: A prospective observational-interventional study was conducted from May 2015 to June 2017 in patients with fecal incontinence in whom conservative treatment had failed. All patients received a 30-minute session of stimulation twice weekly for 6 consecutive weeks. Evaluation at baseline and at 6 weeks involved the Wexner score, Fecal Incontinence Quality of Life (FIQL) questionnaire, and anal manometry. Patients recorded episodes of incontinence in a weekly diary. MAIN OUTCOME MEASURES: Reduction of 50% or greater in incontinence episodes, decreased Wexner score, and improved FIQL scores. RESULTS: Twenty-two patients with a median age of 64.1 years (range, 26-81 years) and men:women ratio of 9:13 completed BTPTNS. Mean episodes of fecal incontinence were significantly reduced from 4.7 to 1.5 (p < 0.05). An improvement of 50% or better in episodes of fecal incontinence was achieved in 77.2% of patients. The median Wexner score significantly decreased from 10.2 to 6.9 (p < 0.05). The median FIQL score improved from 2.7 to 3.1 (p = 0.06), and significant improvement was seen in the embarrassment domain (2.2 vs 2.8, p < 0.05). Resting and squeezing anal pressures revealed no significant changes. CONCLUSION: Our findings suggest that BTPTNS is safe and well tolerated and may improve symptoms of fecal incontinence. This technique offers an additional noninvasive, less expensive form of treatment.

Clinical efficacy of adalimumab versus infliximab and the factors associated with recurrence or aggravation during treatment of anal fistulas in Crohn's disease.

BACKGROUND/AIMS: Infliximab has proven to be effective in the treatment of perianal fistulas in Crohn's disease (CD) but the efficacy of adalimumab is still unclear. The aim of this study is to assess the clinical efficacy of adalimumab and compare the results with those for infliximab. METHODS: Forty-seven CD patients treated for perianal fistulas with infliximab from September 2005 to December 2010 (n=31), or with adalimumab from November 2010 to May 2012 (n=16), were enrolled in this retrospective study. The following patient characteristics were analyzed; intestinal lesion site, fistula classification, seton placement, index of inflammatory bowel disease, C-reactive protein level, follow-up period, and the cumulative rate of nonrecurrence or aggravation of fistula. RESULTS: There were no significant differences in the intestinal lesion site, fistula classification, inflammatory bowel disease index, C-reactive protein level, and the frequency of injection between the infliximab group and the adalimumab group. The cumulative rate of nonrecurrence or aggravation of fistula was 62.5% in the adalimumab group and 83.9% in the infliximab group at 24 months after treatment (P=0.09). The risk factors for recurrence or aggravation may be related to seton placement (P=0.02), gender (P=0.06), and fistula classification (P=0.07). CONCLUSIONS: There was no significant difference in the clinical efficacy of adalimumab and infliximab in the treatment of perianal fistulas in CD. However, fistula classification may be an important risk factor for recurrence or aggravation. The preliminary findings in this study show that further research is warranted.

Surgical outcomes and their relation to the number of prior episodes of diverticulitis.

PURPOSE: We aimed to investigate the relationship between the number of prior episodes of diverticulitis and outcomes of sigmoid colectomy. METHODS: After institutional review board approval, a retrospective review was undertaken based on records of patients who underwent sigmoid resection with anastomosis for diverticulitis between 4 May 2007 and 29 February 2012. Patients were divided into two groups: 0-3 attacks (group 1) and ≥4 attacks (group 2). Statistical analyses were performed to determine whether the groups differed on demographic, intra-operative and postoperative variables. RESULTS: We identified 247 patients who underwent sigmoid colectomy for diverticulitis (45 open, 202 laparoscopic). The two groups did not differ significantly in age, gender, American Society of Anesthesiologists score, past surgical history, body mass index, length of stay, use of a stoma or number of prior hospitalizations for diverticulitis. Group 1 had a higher rate of abscesses (30.6 vs 6.8%, P < 0.001) and fistulas (19.4 vs 0.9%, P < 0.001); a longer operative time (190.1 vs 166.3 min, P = 0.0024); and higher rates of postoperative complications (45.8 vs 23.3%, P < 0.001) and conversion (17.1 vs 4.4%, P = 0.0091). The most common surgical complications in groups 1 and 2 were wound infection (35 vs 10) and ileus (20 vs 8). Based on multivariate regression analysis, ≥4 attacks were independently correlated with a lower complication rate (odds ratio = 0.512, 95% confidence interval = 0.266-0.987, P = 0.046). CONCLUSIONS: Patients who had ≥4 previous attacks of diverticulitis had fewer postoperative complications.