Colorectal (Pelvic) Surgery

Introduction
The clinical activities of pelvic surgery launched three years ago by a fusion of colorectal surgery and urology. The main purpose is to clear the new horizon of rational surgery for pelvic malignancies considering the organic functions. Our co-operation between surgeon and urologist has been well done year by year not in technical aspects of surgery but in making oncological consensus of pelvic malignancies. Our group consists of 5 consultant surgeons (4 are surgeons, 1 is an urologist) with 2 to 3 residents, and carries out 7 to 8 operations a week under general anesthesia.

Routine Activities　
The outpatient clinic of colorectal surgery is open everyday and accepted approximately 350 patients of newcomers in 2001. All outpatients, who underwent curative operation, are closely followed up in the clinics using various diagnostic modalities to detect their recurrence more early. Also, the outpatient clinic of urology is open on Tuesday and Thursday, mainly for the consultation of urological malignancies referred to the center and clinical management of inpatients having urological disorders.
We have 3 conferences a week as for GI-malig-nancies; an image diagnosis conference with radiologists and endoscopists on Monday, a case-conference on Friday, and an integral clinical conference of the gastroenterology group on Wednesday, where we make therapeutic decisions on all the new ceases with GI malignancies through discussion with medical oncologists, endoscopists and surgeons. A surgical pathology conference is held monthly with attending surgeons and pathologists. Concerning the treatment of intrapelvic
malignancy, we are consulting with urologist every time.

Research Activities
In order to make pelvic surgery more advanced, adequate assessment of clinical outcomes is indispensable. On going clinical trials which we are conducting are as follows;
Extended surgery by Lap-Op
A prospective study for extending the indication of Lap-Op has been carried out, according to the following including criteria; 1) less than 5 cm in diameter in tumor size, 2) no mass lesions over 7 mm in diameter around the main tumor in CT image diagnosis, 3) not having histological diagnosis of poorly differentiated adenocarcinoma. The above criteria were conducted by retrospective analyses of pre-operative findings in the past-resected cases. According to the analyses, about 40% of operable colon cancer patients could be treated with extended Lap-op due to the limited lymph node metastasis. In addition, we are now planning to indicate the extended Lap-op to the patients with rectal cancer situated at the peritoneal reflection or those with dvanced colon cancer considered to be necessary to perform D3 lymph nodes dissections, because of our recent rogress in the skill of laparoscopic surgery.
Natural anus preserving operation for rectal cancers
In this trial we treat the patients with resection of internal sphincter muscle technique or local excision oftumor combined with postoperative chemoradio-therapy. The trial is on going with written informed consent in very patient. The purpose is to establish the new therapeutic approach other than rectal amputation for the atients with cancer situated at extremely lower rectum.
Functional assessment of pelvic organs
The pelvic dysfunction after surgery due to intrapelvic autonomic nerve injury is inevitable but provides erious problems for patients with intrapelvic malignancies. Although quite a few methodologies have been eported in the literature, stable and reliable data are not available. To evaluate the meanings and efficacy of bjective measurement for urinary or sexual function, we started to accumulate the objective and subjective atientsi data prospectively.

New Developments
For the treatment of early colorectal cancer cases, various modalities such as endoscopic resection or TEM transanal endoscopic microsurgery) are available, particularly for those with mucosal cancer. The other odality of laparoscopy-assisted operation (Lap-Op) was introduced in the NCCHE in 1994 and has been ssessed as useful to make minimally invasive surgery. Initially, it was indicated only for the patients with early ancer of which submucosal invasion was histologically revealed after endoscopic resection, or those who had nresectable metastatic lesions to make palliation surgery. Since January 1998, however, the indication of Lapop as been extended because we acquired the technique of wider lymph nodes dissection up to more than D2 see research activities).
ISR (internal sphincteric resection) is a new operative modality developed in the western countries, though t is unpopular in Japan. We have already performed ISR for 25 cases up to the present since the first case was one in this year of 2001. The candidates of this modality are those with rectal cancer situated less than 3 cm rom dentate line. With our introduction of this new surgical modality, the number of patients with lower rectal ancers treated by Miles operation has extremely decreased in the NCCH (only 3 cases in 2001).

M. ONO

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