Colorectal (Pelvic) Surgery

Introduction
Our clinical activities as general pelvic oncology was launched four years ago. Our main purpose in setting up this unit was to challenge conventional treating systems where pelvic surgeons were usually divided into two divisions. Cooperation between urologist and general surgeons was achieved more smoothly not in operative technique but in reaching oncological consensus concerning management of pelvic malignancies.
The number of patients with urological malignancies has been increasing year by year, and a main ward and system for training co-medical staff in treating these patients has also been developed gradually.
But last April our urologist was transferred to NCCH suddenly. We currently do not have full-time urological staff. We need to work up a new strategy for pelvic surgery only by general surgeons.

Routine Activities 
Outpatient activities: The Outpatient clinic is open 5 days a week and about 300 new patients were accepted last year. All outpatients who have undergone curative colorectal surgery are followed closely by their own doctors using various diagnostic modalities to detect early recurrence. Urological out patient clinic is still open by part-time staff on Tuesday only for consulting about inpatients of NCCHE.
Treatment system: Our pelvic oncology group consists of 4 consultants (they are all general surgeons) and two to three residents, and carries out seven to eight operations a week under general anesthesia. We have two conferences a week as for GI Malignancies; (l) image diagnosis conference with radiologists and endoscopists on Monday, (2) case conference on Friday where we make therapeutic decisions on all new ceases with GI malignancies through discussion with medical oncologists, endoscopists and surgeons. The surgical pathology conference is held monthly with attending surgeons and pathologists. Concerning intrapelvic malignancies, we are consulting with our part-time urologist for each case.
Treatment modalities: In early cancer cases, many modalities have been introduced such as endoscopic resection or TEM(transanal endoscopic micro-surgery). In addition, the laparoscopy assisted operation (Lap-Op) was introduced in 1994 and has since been used as a minimally invasive surgical technique. Patients with early cancer with submucosal invasion diagnosed histologically after endoscopic resection or those who have unresectable metastatic lesions were indicated for Lap-Op. in our hospital till December 1997. Since January 1998 we have acquired the technique of wider lymphnodes dissection up to more than D2, so the indication of Lap-op has been extending (see research activities).
ISR (internal sphincteric resection) is a new operative modality in Japan. We have already experienced 40 cases up to now since the first case was done 2 years ago. Candidates for this treatment modality are patients with rectal cancer situated less than 3cm from dentate line. The rate of Miles operation in patients with lower rectal cancers were extremely decreased in our hospital as a result (from 35% to 8% ).

Research Activities
The extension of indication for Lap-op. : Prospective trial for the extension of indication for Lap-op. is on going according to these criteria 1. Within 5cm in diameter of tumor size, 2. There is no mass over 7mm in diameter around the main tumor in CT image diagnosis, 3. Without poorly differentiated adenocarcinoma. These criteria were developed by analyzing past operated cases focusing only on preoperative information. About 40% of operable colon cancer patients were possible to be resected by this method these years. Furthermore we have been planning to extend the indication of Lap-op to patients with rectal cancer situated above the peritoneal reflection and with advanced colon cancer where D3 lymphnode dissections were considered necessary by using our recent technical improvement. From January 2001 the criteria for LAP-op was extended to almost all patients with colonic cancers except for those with direct invasion to other organs.
The extension of indication of natural anus preservation op. for extremely lower suited rectal cancer: this trial is started using resection of internal sphincter muscle technique or local excision of tumor combined with postoperative chemo-radiotherapy. This trial is on going with informed consent from each patient. The purpose of this trial is to design and establish an alternative treatment strategy to rectal amputation for patients with extremely low rectal cancers.
Concerning pelvic oncology: The dysfunction after surgery of patients with intrapelvic malignancies is an inevitable problem. But the objective evaluation for damage of functions caused by intrapelvic autonomic nerve injury after operations is difficult. There are many methods for it, but stable data has not been available. To evaluate the efficacy of objective measurement for urinary or sexual functions, we started to accumulate objective and subjective data prospectively.

M. SAITO
M. ONO

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