Abdominoperineal Resection Of Rectum Research Articles

Ileus conditions after rectal and Hartmann's resections.

Bowel obstruction is one of the most common postoperative complications in pelvic surgery. In most cases, adhesive mechanical ileus of the small bowel is the cause. In procedures such as Hartmann's resection or abdominoperineal rectal resection, it seems that the large wound area on the pelvic walls and pelvic floor and the dead space after the removed rectum with mesorectum contribute to the ileus condition. The aim of this paper was to identify the risk factors for ileus after selected pelvic procedures and to map the possible ways of prevention and treatment of these complications. We performed retrospective simple analysis of a set of 98 patients who underwent elective abdominoperineal resection of the rectum, pelvic exenteration or Hartmann's resection for rectal cancer between 2017-2022. Postoperative complications were recorded, especially bowel obstruction, and perineal wound or rectal stump healing complications. In all 9 patients, who needed reoperation, we searched for risk factors for ileus known from the literature. We also described the management of ileus. In the group of 9 patients subjected to detailed analysis, 8 risk factors were most common: male gender, obesity, history of radiotherapy, open surgery, requirement of adhesiolysis in primary surgery, large blood loss, difficult dissection, and impaired healing of the rectal stump/perineum. A total of 8 (88.9%) patients had a combination of 4 or more of the mentioned risk factors. Our results confirm the impact of risk factors known from the literature; furthermore, they indicate a connection with the formation of a dead space in the pelvis and with complications of the rectal stump or perineal wound healing. Some of the risk factors cannot be changed, and current preventive measures cannot completely prevent the formation of adhesions. It is therefore advisable to look for other materials and methods that would ideally limit the formation of adhesions and at the same time fill the dead space and thus separate it from the perineal wound.

The Prevalence of Back Pain in Patients Operated on Due to Colorectal Cancer Depending on the Type of Surgical Procedure Performed

Purpose: Low back pain presents a serious challenge for numerous medical specialties. The purpose of this study was to assess disability due to low back pain in patients operated on due to colorectal cancer depending on the type of surgery performed. Methods: This prospective observational study was carried out in the period of July 2019 through March 2020. Included in the study were patients with colorectal cancer for scheduled surgeries including anterior resection of rectum (AR), laparoscopic anterior resection of rectum (LAR), Hartmann’s procedure (HART), or abdominoperineal resection of rectum (APR). The Oswestry Low Back Pain Disability Questionnaire was used as the research tool. The study patients were surveyed at three time points: before surgery, six months after surgery, and one year after surgery. Results: The analysis of study results revealed that an increase in the degree of disability and functioning impairment occurred in all groups between time points I and II, with the differences being statistically significant (p < 0.05). The inter-group comparative analysis of the total Oswestry questionnaire scores revealed statistically significant differences, with the impairment of function being most severe within the APR group and least severe within the LAR group. Conclusion: The study results showed that low back pain contributes to impaired functioning of patients operated on due to colorectal cancer regardless of the type of procedure performed. A reduction in the degree of disability due to low back pain was observed one year after the procedure in patients having undergone LAR.

Impact of sociodemographic factors and screening, diagnosis, and treatment strategies on colorectal cancer mortality in Brazil: A 20-year ecological study.

Colorectal cancer (CRC) caused 261,060 deaths in Brazil over a 20-year period, with a tendency to increase over time. This study aimed to verify the sociodemographic factors predicting higher mortality caused by CRC and survival rates. Moreover, we aimed to verify whether the performance of screening, diagnostic and treatment procedures had an impact on mortality. Ecological observational study of mortality due to CRC was conducted in Brazil from 2000–2019. The adjustment variable was age, which was used to calculate the age-standardized mortality rate (ASMR). The exposure variables were number of deaths and ASMR. Outcome variables were age-period-cohort, race classification, marital status, geographic region, and screening, diagnostic, and treatment procedures. Age-period-cohort analysis was performed. ANOVA and Kruskal-Wallis test with post hoc tests were used to assess differences in race classification, marital status, and geographic region. Multinomial logistic regression was used to test for interaction among sociodemographic factors. Survival analysis included Kaplan-Meier plot and Cox regression analysis were performed. Multivariate linear regression was used to test prediction using screening, diagnosis, and treatment procedures. In Brazil, mortality from CRC increased after age 45 years. The highest adjusted mortality rates were found among white individuals and in the South of the country (p < 0.05). Single, married, and widowed northern and northeastern persons had a higher risk of death than legally separated southern persons (p < 0.05). Lower survival rates were observed in brown and legally separated individuals and residents from the North (p < 0.05). An increase in first-line chemotherapy and a decrease in second-line chemotherapy were associated with high mortality in the north (p<0.05). In the south, second-line chemotherapy and abdominoperineal rectal resection were associated with high mortality (p < 0.05). Regional differences in sociodemographic factors and clinical procedures can serve as guidelines for adjusting public health policies.

Mucinous adenocarcinoma in perianal fistula in Crohn's disease: Case report and literature review.

SummaryIntroduction and importanceCrohn's disease (CD) is a chronic bowel disease that, due to exacerbated inflammation, can lead to complications such as the development of perianal fistulas. The development of mucinous adenocarcinoma in perianal fistulas in patients with CD is rare and, consequently, few reports exist in the literature.Case presentationWe report the case of a 71-year-old man diagnosed 22 years ago with CD with perineal involvement, who came with complaints of intense perianal pain, a gluteal mass, and local bleeding. Tomography of his abdomen showed an expansive, heterogeneous, and solid perianal mass on the right, with interspersed necrotic/liquefied areas and possible mucinous content. The patient was referred to the surgery department for an incisional biopsy, which confirmed mucinous adenocarcinoma. The patient underwent extra levator abdominoperineal rectal resection (APR) with partial prostatectomy.Clinical discussionPerineal mucinous adenocarcinoma arising in a fistula associated with CD is very rare. Since the symptoms overlap, early diagnosis of malignancy is difficult. Histological analysis is the gold standard for its diagnosis. Surgical resection through APR is well-established and, despite being a complex procedure with potential complications, tends to have good results. However, the locoregional and inguinal lymph node involvement was related to a worse progression in this case.ConclusionThe diagnostic hypothesis of mucinous adenocarcinoma should be suspected in CD patients who present long-term perineal involvement with fistulas. Biopsies and imaging exams should be performed to aid the diagnosis of the condition and thus contribute to the surgical plan.

Management of Para-Aortic Lymph Node Metastasis in Rectal Squamous Carcinoma

Background: Squamous cell carcinoma (SCC) of the rectum is a rare malignancy, and retroperitoneal nodal metastasis (RNM) represent 1-2% of colorectal cancer metastasis (CRC), and radical retroperitoneal lymphadenectomy (RRL) in this setting remains controversial. However, there are no reports in the literature on how to treat SCC retroperitoneal lymph node metastasis. Case Presentation: The patient was a 47-years-old woman with SCC of the rectum. Concomitant chemoradiotherapy (CRT) followed by surgery was planned. After 8 weeks, CT of the abdomen for restaging showed a 6 cm para-aortic mass involving and obstructing the medium third of the left ureter. The patient was submitted to abdominoperineal rectal resection with left nephrectomy and en-bloc resection of para-aortic tumor (nodal bulking). Conclusion: After a thorough review of the literature regarding RNM for rectal SCC, we found no mention of how to treat RNM for rectal SCC. The purpose of this paper is to report a very rare case of RNM for rectal SCC and to discuss the surgical approach. Surgery seems to be the best option for local control and improvement in overall survival (OS).

Effects of the number of harvested lymph nodes in neoadjuvant chemoradiotherapy combined with surgery on prognosis of middle-low rectal cancer

Objective To investigate the effects of the number of harvested lymph nodes in neoadjuvant chemoradiotherapy (nCRT) combined with surgery on prognosis of middle-low rectal cancer. Methods The retrospective case-control study was conducted. The clinicopathological data of 373 patients with middle-low rectal cancer who underwent nCRT combined with surgery in the Fujian Medical University Union Hospital from January 2009 to December 2013 were collected. There were 241 males and 132 females, aged from 26 to 81 years, with the age of (55±11)years. Observation indicators: (1) treatment situations; (2) follow-up and survival; (3) influencing factors for the number of harvested lymph nodes; (4) prognostic analysis of the different number of harvested lymph nodes as cut-off for grouping; (5) stratified analysis. Follow-up using telephone interview and outpatient examination was performed to detect postoperative survival of patients once every three months within postoperative 2 years and once every 6 months during the postoperative third year up to March 2016. The endpoint of follow-up was tumor recurrence, retastasis or death. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was done using the independent sample t test. Measurement data with skewed distribution were represented as M (range), and comparison between groups was done using the Kruskal-Wallis H test. Count data was described as absolute numbers. Univariate and multivariate analyses were done by the multiple linear regression model. Survival rate was calculated by the Kaplan-Meier method, and Log-rank test was used for survival analysis. Results (1) Treatment situations: 373 patients underwent nCRT combined with surgery, including 329 combined with sphincter-sparing rectal resection and 44 combined with abdominoperineal rectal resection. The number of harvested lymph nodes was 12 ± 6 in 373 patients. There were 185 patients with the number of harvested lymph nodes 0.05). (5) Stratified analysis: with the number of harvested lymph nodes of 7, 8, 9, and 10 as cut-off for grouping in 45 of 373 patients with Ⅱ-Ⅲ regression grade of rectal cancer and negative lymph nodes (N0 staging), there was no significant difference in the 3-year disease-free survival rate between <7 group and ≥7 group, between <8 group and ≥8 group, between <9 group and ≥9 group, between<10 group and ≥10 group, respetively (χ2=3.946, 5.346, 6.375, 4.297, P<0.05). Conclusions The number of lymph nodes as 12 is not the independent factor for prognosis of patients with middle-low rectal cancer after nCRT combined with surgery. The number of harvested lymph nodes as 7 to 10 is the important factor for evaluating the prognosis of middle-low rectal cancer patients with Ⅱ-Ⅲ regression grade of rectal cancer and negative lymph nodes after nCRT combined with surgery. Key words: Rectal neoplasms; Rectal cancer; Neoadjuvant chemoradiotherapy; The number of harvested lymph nodes; Prognosis

Long-term survival after adrenal metastasectomy from colorectal cancer: a report of two cases

BackgroundSolitary adrenal metastasis from colorectal cancer is rare. Adrenal metastasis is usually detected with synchronous multiple metastases in other organs and is, therefore, considered to be unsuitable for surgical resection. The long-term outcomes of patients with solitary adrenal metastasectomy from colorectal cancer have been reported; however, the survival advantage has not been established. We herein report two cases of curative adrenal resection in patients with solitary adrenal metastasis from colorectal cancer who achieved long-term survival of > 9 years without recurrence after surgical resection.Case presentationThe first case involved a 71-year-old man who underwent abdominoperineal rectal resection for rectal cancer. Preoperative CT revealed a mass in the right adrenal, which was growing after surgery. After chemotherapy the adrenal mass decreased in size, and adrenalectomy was performed at 8 months after the first surgery. A pathological examination confirmed metastasis from rectal cancer. The patient received adjuvant chemotherapy and is currently alive without recurrence at 9 years after the adrenalectomy. The second case involved a 53-year-old man who underwent sigmoidectomy for sigmoid colon cancer. Four years later, lobectomy was performed for isolated lung metastasis. Twenty months later, PET-CT revealed solitary metastasis in the left adrenal gland and adrenalectomy was performed. A histopathological examination revealed metastatic adenocarcinoma of sigmoid cancer. Postoperative chemotherapy was administered after adrenalectomy and the patient is currently alive and apparently disease-free at more than 9 years after undergoing adrenal metastasectomy.ConclusionCurative resection for solitary adrenal metastasis from colorectal cancer may be beneficial for survival.

An appraisal of intestinal stomas at a tertiary hospital in South Western, Nigeria

Background: Intestinal stomas are frequently constructed as part of abdominal surgeries in our center especially for colorectal cancer (CRC). There has been no previous documentation of the experience at our tertiary center. Objective: The objective of this study is to document the indications, types, and complications of intestinal stomas in our center to make necessary recommendations. Patients and Methods: This was a retrospective descriptive study of all patients who had intestinal stomas constructed during a 4-year period. The demographic data of patients, the information on indications, types, and complications of intestinal stomas were obtained from theatre records, and case notes. Data were analyzed using SPSS version 23. Results: A total of 85 intestinal stomas were constructed during the study period. Forty-four (51.8%) were males and 41 (48.2%) females with a male-female ratio of 1.07 to 1. The common indications were large bowel obstruction due to CRC (21.2%), anastomotic dehiscence (15.3%), and rectal/sigmoid injuries (12.7%). The intestinal stomas constructed in patients included defunctioning stomas (61.2%), decompression stomas (31.8%), permanent end colostomy following abdominoperineal resection of rectum for cancer (3.5%), and palliative sigmoid colostomy (3.5%) in patients with anal cancer. Sigmoid loop was the commonest stoma, constructed in 26 patients (30.6%). The common complications were peristoma skin excoriation (53.5%), retraction (11.6%) pouch leakage (9.3%), and prolapse (9.3%). Conclusion: Malignant intestinal obstruction due to CRC was the most common indication for stoma construction at our institution. Consequently, massive health education campaign to ensure early presentation of CRC is needed to reduce the need for stoma creation.

Robotic colorectal surgery: previous laparoscopic colorectal experience is not essential.

A background in minimally invasive colorectal surgery (MICS) has been thought to be essential prior to robotic-assisted colorectal surgery (RACS). Our aim was to determine whether MICS is essential prior to starting RACS training based on results from our initial experience with RACS. Two surgeons from our centre received robotic training through the European Academy of Robotic Colorectal Surgery (EARCS). One surgeon had no prior formal MICS training. We reviewed the first 30 consecutive robotic colorectal procedures from a prospectively maintained database between November 2014 and January 2016 at our institution. Fourteen patients were male. Median age was 64.5years (range 36-82) and BMI was 27.5 (range 20-32.5). Twelve procedures (40%) were performed by the non-MICS-trained surgeon: ten high anterior resections (one conversion), one low anterior resection and one abdomino-perineal resection of rectum (APER). The MICS-trained surgeon performed nine high and four low anterior resections, one APER and in addition three right hemicolectomies and one abdominal suture rectopexy. There were no intra-operative complications and two patients required re-operation. Median post-operative stay was five days (range 1-26). There were two 30-day re-admissions. All oncological resections had clear margins and median node harvest was 18 (range 9-39). Our case series demonstrates that a background in MICS is not essential prior to starting RACS training. Not having prior MICS training should not discourage surgeons from considering applying for a robotic training programme. Safe and successful robotic colorectal services can be established after completing a formal structured robotic training programme.

Negative pressure wound therapy use in the treatment of patient with an active process of anal cancer in order to the further treatment – case report.

A common treatment of bad healing wounds is vacuum assisted therapy (negative pressure wound therapy). The main clinical goal are: reduced time of wound healing, decreasing frequency of septic complications, and better functional and cosmetic effect. One of the main contraidications include a malignant process in the patient, however, it is reported that in some cases it has achieved possitive results.68 years-old man was admitted to the hospital due to resection of giant anal cancer. Because of severe problems with passing stool, size of the lesions, sphincter infiltration and full dysfunction, according to the patient’s acceptation abdominoperineal rectal resection with end colostomy was performed. An open, non-healed wound was a contraindication for radiotherapy – the most advisable type of treatment in advanced anal cancer. Despite of potential malignancy in the wound, because the non-healed wound delaying the radiotherapy the negative pressure wound therapy was introduced to improve healing, close the wound and enable radiotherapy.Potential benefits and risks of npwt treatment should always be considered. In some selected cases of oncologic patients after the surgery npwt can be considered, especially when our treatment is used in palliative management or even when the proliferation of neoplastic tissues does not affect the duration of life (paliative treatment, morbidity, old age etc.)

Técnicas reconstructivas tras amputación abdominoperineal extraelevadora del recto o exenteración pélvica: mallas, plastias y colgajos

Perineal wound complications after abdomino-perineal rectal resection are frequent and clinically relevant for their impact on the length of hospitalization, costs, patients’ quality of life and oncologic results. With the diffusion of the preoperative radiotherapy and the gradual shift to the extra-elevator technique, the perineal morbidity rate has increased. Many series describing different techniques of primary closure of the perineal defect have been published, but high-quality clinical studies, indicating which is the best option, are missing.A biologic mesh, associated if possible to an omentoplasty, seems to be sufficient to close the perineal defect after extra-elevator abdomino-perineal rectal resection. However, when the proctectomy is associated to the resection of other organs, as for example vagina or sacrum, resulting in an ample perineal defect, the vertical rectus abdominis flap seems to be the best option. If the perineal defect is smaller, the gracilis or gluteus flaps could be other valid alternatives.

Primary intestinal Hodgkin's lymphoma associated with Crohn's disease

The authors present the case of a 37-years-old man with pancolic Crohn’s disease (CD) diagnosed 20 years ago, characterized by a penetrating behavior with need for surgery (segmental colon resection) for a colovesical fistula. Due to a corticodependent evolution, the patient has been in treatment with azathioprine for 8 years, with only partial clinical response, reason why he started infliximab (treatment continued for 3 years). An acute exacerbation prompted a colonoscopy that revealed severe inflammatory activity within the distal sigmoid and rectum with no changes in the remaining colonic and ileal mucosa (Fig. 1). Biopsies revealed infiltration of the mucosa by classic Hodgkin’s lymphoma (Fig. 2), with positivity for Epstein-Barr virus (Fig. 3) and severe inflammatory activity. Computed tomography (Fig. 4) and bone marrow aspirate excluded extra intestinal lymphoproliferative disease (LD). After multidisciplinary consultation, the patient underwent total colectomy plus abdominoperineal resection of rectum (Fig. 5) with permanent ileostomy, the main indication was based on the lack of response to the medical therapy for CD. Since the resected specimen had no evidence of involvement of the isolated lymph nodes, it was decided not to start any adjunctive therapy. Primary intestinal Hodgkin’s lymphoma is very rare presenting an incidence of less than 0.5 % (1). Its association with CD is even rarer, with only sporadic cases described in literature (2). There are still doubts whether the pathogenesis of the increased risk of LD in patients with CD correlates with the inflammatory disease activity or with the immunosuppressive treatment (3,4). The identification of Epstein-Barr virus infection in patients with Hodgkin’s lymphoma is often reported in the described cases, suggesting that this agent might be implicated in the pathogenesis of the LD (5). Primary intestinal Hodgkin’s lymphoma associated with Crohn's disease

Management of the perineal wound after abdominoperineal resection

Although many options are available for the management of perineal wounds after abdominoperineal resection, ranging from direct closure to flap reconstruction, treatment remains challenging. A better understanding of the aims, drawbacks and progress in perineal wound management after abdominoperineal rectal resection can help the surgeon make better choices for each patient, but it is very difficult to propose a single, optimal, evidence-based procedure for the management of pelvic exenteration. Recent progress provided by the extralevator abdominoperineal resection technique and perforator flap concepts have changed our conception of reconstruction leading to the different technical options highlighted in this review.

Kiterjesztett abdominoperinealis rectumexstirpatiót követő gáttájéki rekonstrukció verticalis rectus abdominis myocutan (VRAM) lebennyel

Perineal wound healing problems following extended abdomino-perineal resection of ano-rectal cancer represent a great challenge to the surgeon. Perineal soft-tissue reconstruction with a myocutan flap was thought to reduce surgical wound healing complications. A review of the relevant literature was carried out on perineal soft-tissue reconstruction with rectus abdominis myocutan (VRAM) flap following extended abdomino-perineal rectal resection for cancer. The more commonly used neoadjuvant chemo- and radiotherapy as well as extended surgical radicality resulted in increased perioperative risks, therefore combined procedures between the colorectal and plastic surgical teams are inevitable. This case report illustrates the above trend.

Prognostic significance of lymph node ratio in patients undergoing abdominoperineal resection of rectum

Lymph node ratio (LNR) has been shown to be an independent prognostic factor in stage III colorectal cancer. Abdominoperineal resection (APR) of rectum is historically associated with poorer oncological outcomes compared to other colorectal resections, and significance of LNR in this group of patients has not been studied. Our aim was to determine impact of LNR on oncological outcomes in a series of patients with rectal cancers undergoing APR. A series of patients who had undergone APR and had lymph node metastasis were identified from a prospectively maintained clinical, histopathological and radiological database. LNR was calculated, and Cox regression was used to determine the impact of factors affecting local recurrence, distal metastases and overall survival. Fifty-eight (42 males) patients were identified to have rectal cancer with lymph node involvement. LNR was an independent predictor of distal metastasis and overall survival at cutoff levels of 0.17, 0.41 and 0.69. Lymph node ratio is an independent predictor of survival outcomes in patients with stage III tumours undergoing APR. LNR may help improve stratification of this group of patients.

Single-incision laparoscopic surgery: outcomes from 224 colonic resections performed at a single center using SILS™

Compared with single-incision laparoscopy, multiport laparoscopy is associated with greater risk of postoperative wound pain, infection, incisional hernias, and suboptimal cosmetic outcomes. The feasibility of minimally invasive single-incision laparoscopic surgery (SILS) for colorectal procedures is well-established, but outcome data remain limited. Patients with benign diverticular disease, Crohn's disease, or ulcerative colitis admitted to Klinikum Leverkusen, Germany, for colonic resection between July 2009 and March 2011 (n = 224) underwent single-incision laparoscopic surgery using the SILS port system. Surgeons had ≥7 years' experience in laparoscopic colon surgery but no SILS experience. Patient demographic and clinical data were collected prospectively. Pain was evaluated by using a visual analog scale (0-10). Data were analyzed by using the SPSS PASW Statistics 18 database. The majority of patients underwent sigmoid colectomy with high anterior resection (AR) or left hemicolectomy (n = 150) for diverticulitis. Our conversion rate to open surgery was 6.3 %, half in patients undergoing sigmoid colectomy with high AR or left hemicolectomy, 95 % of whom had diverticulitis. Mean operating time was 166 ± 74 (range, 40-441) min in the overall population, with shorter times for single-port transanal tumor resection (SPTTR; 89 ± 51 min; range, 40-153 min) and longer times for proctocolectomy (325 min; range, 110-441 min). Mean hospital stay was approximately 10 days, longer after abdominoperineal rectal resection or proctocolectomy (12-16 days). Most complications occurred following sigmoid colectomy with high AR or left hemicolectomy [19/25 (76 %) of early and 4/5 (80 %) of late complications, respectively]. Pain was <4 on a scale of 0-10 in all cases on postoperative day 1, and typically decreased during the next 2 days. Our findings support the feasibility and tolerability of colorectal surgery, conducted by experienced laparoscopic surgeons without specific training in use of the SILS port.

Tissue expanders: early experience of a novel treatment option for perineal herniation

Acquired perineal hernias through the reconstructed pelvic floor can complicate radical pelvic operations including abdominoperineal resection of rectum. Operative intervention is indicated for symptomatic hernias. There is a lack of consensus as to the best operative technique. Here we present a novel method for repairing perineal herniation using saline-filled tissue expanders. Perineal hernia repair may be affected either via an abdominal or via a perineal approach. After adhesiolysis to remove small bowel from the pelvis, a Natrelle™ 150SH tissue expander (Allergan Inc., California, USA) or Siltex™ Round Becker (Mentor Medical Systems, Holland) of appropriate size is inserted in the pelvis and the button placed in a subcutaneous pocket in the perineal skin. The tissue expander is then filled with saline until it fills the true anatomical pelvis without bladder compression. The volume may be increased or decreased postoperatively by accessing the subcutaneous button. We have performed this procedure in three patients with some success, all of whom have experienced symptomatic relief. The tissue expander may subsequently be removed without recurrence of symptoms, due to the fibrous capsule which forms. One patient required re-operation to elevate a herniating tissue expander. The tissue expander was removed earlier than anticipated to avoid deep pelvic infection in another. Our early experience suggests that using saline-filled tissue expanders to fill dead space in the pelvis after radical surgery may prove to be a valuable approach to perineal herniation, particularly if adjuvant radiotherapy is planned.

腹会陰式直腸切断術後の正中創巨大腹壁瘢痕ヘルニアに対する１手術例

腹会陰式直腸切断術後の正中創巨大腹壁瘢痕ヘルニアに対する１手術例

腹会陰式直腸切断術後に発症した会陰ヘルニアの1例

症例は62歳，男性．肛門管癌で腹会陰式直腸切断術を施行した．最終病期はpT2，pN0，H0，P0，M0，pTNM分類でII期であった．合併症なく経過し，術後19日目に退院した．術後2カ月経過時，会陰部が膨隆し，長時間歩行や座位が困難になったため腹部CTを撮影したところ，骨盤底部から会陰皮下に脱出する小腸を認め，続発性会陰ヘルニアと診断した．経腹式にDUALMESH®による骨盤底形成術を行った．経過は良好で術後1年経過現在，ヘルニアの再発は認めていない．続発性会陰ヘルニアは腹会陰式直腸切断術後などにみられるまれな合併症であり，本邦では会議録を含めて21例の報告を検索しえた．自験例を加えて本邦報告例を集計し，臨床的な特徴について若干の文献的考察を加え報告する．

Two-Staged Surgery for Metastatic Liver Tumor in Morbidly Obese Individual-Left Hemihepatectomy Following Placement of Laparoscopic Adjustable Gastric Band

A 47-year-old male with a body mass index (BMI) 37.12 kg/m(2) was diagnosed with an ill-demarcated tumor within IVB segment of left lobe of the liver. Sixteen months earlier, he underwent laparoscopic gastric banding for morbid obesity (BMI 51 kg/m(2)). One year after bariatric procedure, he was diagnosed with rectal adenocarcinoma. Following abdominoperineal resection of rectum with total mesorectal excision and 2 months course of adjuvant FOLFOX chemotherapy, he was scheduled for liver resection. Left hemihepatectomy was performed with no major complications; wound discharge was successfully treated in outpatient clinic. Twelve months following surgery, he remains disease free with no evidence of local recurrence, metachronic primary tumor, or distant metastases. This is first to our knowledge report providing data on the outcome of left hemihepatectomy performed in postbariatric patient. The role of bariatric surgery and utilization of the time necessary for neoadjuvant chemotherapy to reduce the excessive body mass and the degree of liver steatosis is discussed.