Anal canal cancer (ACC) has been reported to be an uncommon cancer in Japan, as in the USA, Europe, and Australia. This retrospective multi‐institutional study was conducted to clarify the characteristics of ACC in Japan. First, the histological ACC type cases treated between 1991 and 2015 were collected. A detailed analysis of the characteristics of anal canal squamous cell carcinoma (SCC) cases was then conducted. The results of the histological types revealed that of the 1781 ACC cases, 435 cases (24.4%) including seven cases of adenosquamous cell carcinomas were SCC and 1260 cases (70.7%) were adenocarcinoma. However, the most common histological type reported in the USA, Europe, and Australia is SCC. Most ACC cases are adenocarcinomas and there is a low incidence of SCC in Japan which is different from the above‐mentioned countries. Moreover, we reclassified T4 into the following two groups based on tumor size: T4a (tumor diameter of 5 cm or less) and T4b (tumor diameter of more than 5 cm). The results of the TNM classification of SCC revealed that the hazard ratio (HR) to T1 of T2, T3, T4a, and T4b was 2.45, 2.28, 2.89, and 4.97, respectively. As T4b cases had a worse prognosis than T4a cases, we propose that T4 for anal canal SCC in Japan be subclassified into T4a and T4b.

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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.

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Purpose: Anal canal adenocarcinoma (AC) is rare and its surgical outcomes and prognostic factors (PFs) are not well understood. The aim of this retrospective study was to identify the characteristics and PFs of AC, using population-based data in Japan. Methods: Patients with AC (n = 390) or lower rectal adenocarcinoma (LR) (n = 12,477) diagnosed between1991 and 2006 were enrolled in this study. We compared the clinical- and patient-related factors of the two diseases and then examined propensity score matching, overall survival (OS), and PFs. Results: AC tended to develop more often in women and in patients of advanced age. Macroscopically, AC was of an unclassified type and microscopically, it was of high-grade histological types such as mucinous adenocarcinoma, poorly differentiated adenocarcinoma (por), or signet-ring cell carcinoma (sig), with a high frequency of inguinal node metastasis (P < 0.05). The 5 year OS rates were 56.9% for AC and 67.9% for LR (P = 0.002). The PFs of AC were a high-grade histological type (por/sig), T, N, and M. Conclusions: AC has a significantly worse prognosis than LR. Moreover, the AC lymph node metastatic sites for AC, especially the inguinal nodes, are different from those for LR. Keywords: Anal canal adenocarcinoma; Inguinal node; Lower rectal adenocarcinoma; Overall survival; Propensity score matching.

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機能性便排出障害に対してバイオフィードバック療法をはじめとした保存的治療は有用とされる一方 で手術適応については明確でない．われわれは，保存的治療無効な機能性便排出障害で著しく QOL 低下 をきたしたために外科的腸管切除を施行した症例を経験したので報告する． 症例は 71 歳女性．10 年前から便排出困難，著明な腹部膨満認め下剤使用も改善なく精査加療目的入院 となる．排便造影検査にて便排出を認めず，大腸通過時間検査にて 24 時間後に不透過マーカーが直腸ま で到達していることを確認．保存的治療を 3 ヵ月間施行も症状改善認めず，横行結腸双孔式人工肛門造設 施行．腹部膨満改善するも人工肛門脱出を認めたため，腹腔鏡下左側結腸切除，直腸切除，横行結腸単孔 式人工肛門造設術施行した．ストーマからの便排出良好で患者およびご家族の満足度も高い．患者 QOL の向上への貢献を第一に考え，個々の症例に応じた手術術式を選択すべきであると考える．
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欧米では様々な薬剤が用いられ保存療法が主流となっているが，本邦では使用できる薬剤が限られてい るため手術療法も選択肢となる．保存治療に抵抗性の場合や周囲組織が硬化した慢性裂肛では手術適応と なる．術式選択にあたっては裂肛の成因を踏まえた検討が重要となる．裂肛の手術療法は術後の肛門機能 障害が問題となる．肛門拡張術はこれまで否定的な見解が多かったが，近年バルーンを用いた標準化され た方法が報告されている．高齢者，糖尿病，経産婦，再発症例など肛門静止圧が低く便失禁のリスクがあ る患者には LIS は避け，肛門形成術が推奨される．近年では LIS 後の便失禁リスクを下げるため超音波 検査を用いた方法が報告されている．この項でそれぞれの術式の詳細とその成績を述べる．
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Purpose: There is currently no adequate biomarker for predicting colorectal cancer (CRC) recurrence. Chemokine (C-C motif) ligand 2 (CCL2) induces macrophages and fibroblasts to occupy metastatic niches in distant organs. The purpose of this study was to examine CCL2 as a potential predictive biomarker for CRC recurrence. Methods: Plasma samples (n = 402) were collected from 80 stage II/III/IV CRC cases and the relationship between CCL2 profiles and recurrence was investigated. The tumor immune response genes associated with CCL2 mRNA expression in a subgroup of 8 stage I/II CRC cases with 12 recurrent sites and The Cancer Genome Atlas database were also analyzed retrospectively. Results: Sixteen stage II/III/IV postoperative recurrent CRC cases experienced a significant increase in plasma CCL2 levels 6 months after surgery and continuously increased even after R0-1 resection. The 6-month postoperative CCL2 levels in recurrent cases of ≥ 1 year were significantly higher than in non-recurrent cases and recurrent cases of < 1 year. The CCL2 level in the primary tumor cases significantly correlated with the cytolytic activity, thus indicating a tumor immune response from the CD163-expressing macrophages. Conclusion: Plasma CCL2 was found to be a predictive biomarker of postoperative CRC recurrence. CCL2 in metastatic sites derives from metastatic niches that surpass the host immune response.
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【目的】　括約筋間直腸切除術（ISR）後の一時的ストーマ閉鎖後に、便失禁や頻回便のために 肛門周囲皮膚障害を起こすことが多い。本研究の目的は、この便失禁関連皮膚炎（IAD）に対 して、ストーマ閉鎖前から肛門周囲に保湿剤を塗布指導する予防的スキンケアの有用性を検討 することである。 【方法】 ISR後に一時的ストーマ閉鎖を行った患者を対象に、2016～2018年に術前から肛門周 囲に保湿剤を塗布する予防的スキンケアを実施した患者（介入群）と2013～2014年に予防的ス キンケアをしなかった患者（非介入群）の間で、術後7日目と1ヵ月目の便失禁関連皮膚障害の 有無と程度を後方視的に比較検討した。 【結果】　介入群は16名で、非介入群は11名であった。介入群と非介入群のIAD発生率は各々、 術後7日目は12.5％と63.6％（P＝0.012）、1ヵ月目は0％と54.5％（P＝0.002）であり、術後7日 目も1ヵ月目も介入群で有意に低かった。 【結論】 ISR後のIADに対する予防的スキンケアは有用と考えられる。
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今回，われわれは便失禁診療における肛門管超音波検査（EAUS）の有用性を検証するため，女性 196 人 を対象にEAUS を用いて下部肛門管での内・外肛門括約筋，連合縦走筋（IAS，EAS，LM）の厚み，括約筋断裂の有無を確認し，肛門内圧検査や CCFIS との関係性や加齢性変化について後方視的に検証した． IAS 厚みと最大静止圧（MRP）に相関関係を認めなかったが，IAS 断裂群は IAS 断裂無し群に比べ MRP が有意に低値，便失禁回数は有意に多く CCFIS は有意に高かった．加齢性変化については，非失禁群 94 人において 65 歳以上群は 65 歳未満群に比べ，IAS が有意に厚く年齢と IAS 厚みに正の相関関係を認め た．便失禁診療において，EAUS 括約筋の厚みは症状や MRP と関連しない一方で，括約筋断裂の形態異 常および加齢性変化の特徴は便失禁の臨床的評価およびその後の治療方針を定める一助になると考えら れる．
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Background: Gastrointestinal lymphomas like diffuse large B-cell lymphoma (DLBCL) are rare complications of ulcerative colitis (UC), and only a few studies have reported intestinal ulcers caused by DLBCL, which got perforated during the treatment of UC. Case presentation: A 43-year-old man with severe lower abdominal pain and an 8-year history of UC was admitted in our hospital. He was diagnosed UC since 8 years and received a maintenance oral dose of 5-aminosalicylic acid, and no other immunosuppressive drugs. A deep rectal ulcer was endoscopically diagnosed 10 months before admission, no malignancy or cytomegalovirus infection was detected on biopsy. After 7 months a further endoscopy with biopsies confirmed the finding and the absence of malignancy. Three months later the patient developed sudden abdominal pain and was admitted in our hospital. Rectal perforation was suspected on X-ray and computed tomography imaging, and an emergency surgery was performed. Surgical exploration revealed a perforation on the anterior wall of the rectum. A subtotal colectomy with temporary ileostomy was performed. Pathology examinations showed lymphocyte infiltration of all of the layers of the perforated site and an immunohistochemical evaluation revealed DLBCL. Clinical staging was stage IV, and the patient received a 6-months regimen of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy. Positron emission tomography restaging revealed disappearance of distant uptake and a slight uptake in the residual rectum, and completion proctectomy with ileal pouch-anal anastomosis was performed. No residual tumor in the specimen was found, and the patient was disease-free at 2 years follow-up. Conclusions: DLBCL may increase the frequency of perforation and is a poor prognostic risk factor for patients with UC. This case study emphasizes the importance of careful medical surveillance and repeated endoscopic biopsies during the treatment of UC.
Keywords: Diffuse large B-cell lymphoma; Intestinal perforation; Ulcerative colitis.
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抄録：直腸肛門の機能性障害は心療内科分野でもあまり検討されていない領域である．主な症 状としては括約不全，肛門痛，排便困難であるが，これらの症状は高い確率で合併する．当院で はこれらの疾患に対して直腸肛門機能検査を行い，病態を把握したうえで肛門機能検査を治療 に応用している．具体的には肛門内圧をモニターに表示し，患者に見せながら括約筋の収縮弛緩 訓練を行う肛門内圧バイオフィードバック（BF）療法，シリコンバルーンを排出する排出訓練， 直腸内に留置したバルーンを用いて直腸最大耐用量の増加を図る直腸感覚訓練である．特に機 能性直腸肛門痛においてはこれら単独では不十分で心身医学的治療を含む集学的治療を要する． その治療成績の概要を示し，症例を提示しその実際を述べる．また自己臭症に BF 治療を試み た．肛門痛，自己臭に対する直腸肛門機能検査・治療および心身医学的治療の併用が有用であっ た．
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