本邦の坐骨直腸窩痔瘻に対する括約筋温存術は、浅外括約筋間の肛門後方から始まる方法（後方法）と浅外括約筋外から始める方法（側方法）等がある。そこで今回、坐骨直腸窩痔瘻に対する2つの手術法をいろいろな項目から比較検討した。結果は手術の安易性（時間）、治癒期間、再発率の比較では有意差を認めず、術後の肛門機能（肛門内圧検査とWexner's score）では有意差を認め、側方法は後方法より肛門機能への侵襲が少ないと結論付けられた。

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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