Morphology of myenteric plexuses in the human large intestine: comparison between large intestines with and without colonic diverticula.

BACKGROUND: Large intestines with diverticula exhibit functionally abnormal peristaltic activity and elevated luminal pressure that may indicate functional changes in the myenteric plexus; however, no studies have investigated the characteristics of either normal or diverticula myenteric plexuses. METHODS: Tissue specimens obtained from 93 colorectal cancer patients without diverticula, 14 patients with perforated diverticulitis, and 12 colorectal cancer patients with asymptomatic diverticula were included in this study. Myenteric plexuses and ganglion cells were counted per centimeter, and the area and maximum diameter of the nuclei of ganglion cells were measured using an image analyzer. RESULTS: The number of myenteric plexuses and ganglion cells per centimeter was significantly higher in the descending colon, sigmoid colon, and rectum than in the cecum, ascending colon, and transverse colon. The area of the nuclei of ganglion cells was significantly larger in the descending colon and sigmoid colon than in the cecum and ascending colon. Compared with large intestines without diverticula, the number of myenteric plexuses was significantly higher in large intestines with diverticula, whereas the number of ganglion cells decreased in both right-sided and left-sided large intestines with perforated diverticulitis or asymptomatic diverticula. The area of the nuclei of ganglion cells was significantly smaller in large intestines with diverticula. CONCLUSION: The morphology of myenteric plexuses and the ganglion cells differs significantly among segments of the human large intestine. Large intestines with diverticula had significantly more plexuses but significantly fewer ganglion cells than large intestines without diverticula. The area of the nuclei of ganglion cells was also significantly smaller in large intestines with diverticula. Further studies are required to clarify how these changes are related to intestinal function and how they are involved in the etiology of diverticulosis.

Recurrence patterns after curative resection of colorectal cancer in patients followed for a minimum of ten years.

BACKGROUND/AIMS: To investigate the recurrence patterns and interval from initial surgery in patients with curatively resected colorectal cancer followed for a minimum of 10 years. METHODOLOGY: We retrospectively reviewed 418 patients who had undergone curative resection for colon cancer (n = 246) or rectal cancer (n = 169). Follow-up periods ranged from 10 to 23 years. Main outcome measures were interval until recurrence, site of first recurrence, and influence of adjuvant chemotherapy. RESULTS: 26 (6%) had been lost to follow-up by 10 years and 143 (34%) had died. The most common site of recurrence was liver in colon cancer and locoregional in rectal cancer. The cumulative recurrence rate in colon cancer was 100% at 4 years. In rectal cancer, it was 89% at 5 years, 98% at 7 years and 100% at 10 years. The interval until recurrence was longer in rectal cancer (26.0 +/- 24.2 months) than in colon cancer (17.1 +/- 11.0 months) (p = 0.03). It was also longer in patients receiving than in those not receiving adjuvant chemotherapy (p < 0.01). The interval until lung metastasis was longer than that until liver metastasis in colon cancer (p = 0.04), and longer than that until locoregional recurrence in rectal cancer (p = 0.03). The interval until recurrence in the colon cancer was shorter for stage III than for stage II (p = 0.02). CONCLUSIONS: Surveillance for recurrences, particularly for relapses in the liver and lung, should be performed for at least 4 years in colon cancer patients. Patients with rectal cancer should be followed for a longer period than those with colon cancer, focusing on locoregional, liver and lung recurrence. It is particularly noteworthy that adjuvant chemotherapy may prolong the interval until recurrence and the interval until lung metastasis is relatively longer.

Ultrasonography for the diagnosis of acute appendicitis.

Acute appendicitis is usually encountered clinically as acute abdomen. Typical cases are easy to diagnose, but it can sometimes be very difficult to make a diagnosis in atypical cases. We retrospectively studied patients who underwent ultrasonography for right-sided lower abdominal pain suggesting acute appendicitis, and assessed the accuracy of ultrasonic diagnosis. The subjects were 202 patients (100 males and 102 females) aged 6-89 years (mean: 33.3 years). From the ultrasonic findings, appendicitis was classified as follows: 1) catarrhal: a clear layer structure of the appendiceal wall and mucosal edema; 2) phlegmonous: an ill-defined layer structure of the appendiceal wall, moderate enlargement of the apendix, and maximum transverse dimension of > or = 10 mm; and 3) gangrenous: unidentifiable layer structure of the appendiceal wall and marked enlargement to form a mass. The appendix was visualized in 142 of the 202 patients (70.3 %). When the appendix was detected, the sensitivity, specificity and accuracy of ultrasound for making a diagnosis of appendicitis were 97.6%, 82.0 %, 91.5 %, respectively. With regard to assessment of the severity of inflammation, ultrasonic and histologic findings were concordant in 61.2 % of the patients. However, ultrasound was shown to possibly underestimate the extent of inflammation. On the other hand, 11 of the 60 patients with an undetectable appendix (18.3 %) were clinically diagnosed as having appendicitis. The pathologic diagnosis was catarrhal appendicitis in 3 patients and phlegmonous appendicitis in 8 patients. In patients with an undetectable appendix, the possibility of catarrhal or phlegmonous appendicitis should be kept in mind.

Improvement of 10-year survival by Japanese radical lymph node dissection in patients with Dukes' B and C colorectal cancer: a 17-year retrospective study.

This study investigated whether the Japanese radical lymph node dissection (J-LND) method was useful for improving the survival and outcome in patients undergoing surgical resection of primary colorectal cancer. The subjects were 434 patients with primary colorectal cancer treated over 17 years. The 10-year survival (10-YS), the number of retrieved and metastatic lymph nodes (LN), the extent of lymph node dissection (D0-D3), and the extent of lymph node metastasis (n0-n4) were compared with Dukes' classification by the Kaplan-Meier curves, log-rank test and multivariate analysis. Patients with a D number larger than their n number (D>n group) were defined as being treated according to J-LND principles, while those with a D number equal to their n number were used as controls (D=n group). Among Dukes' B patients, there was a significant difference of 10-YS between those with retrieval of > or =17 LN or < or =16 LN (p=0.0106). Among Dukes' C patients, a significant difference of 10-YS was observed between those with 1 metastatic node or > or =3 metastatic LN (p=0.0401). A significant difference of 10-YS was also noted between Dukes' C patients with D>n or D=n (p=0.0282). Multivariate analysis showed that retrieval of < or =16 LN (HR=9.051) and intramural invasion (se,si/a2,ai; HR=6.313) were independent determinants of 10-YS in Dukes' B patients, while D=n (HR=2.354) and > or =3 metastatic LN (HR=2.210) were independent determinants in Dukes' C patients. These results suggest that the J-LND method should be performed to retrieve at least 17 nodes when serosal dimpling of the primary tumor is observed during surgery. Effective post-operative adjuvant therapy, such as combination chemotherapy and/or radiotherapy, should be provided for Dukes' C patients with D=n and/or > or =3 metastatic nodes on histopathological examination.

Is temporary loop colostomy of the right transverse colon appropriate for complete obstruction by colorectal cancer?

We experienced 12 consecutive cases of complete bowel obstruction due to primary colorectal cancer. Among these patients, temporary loop colostomy (loop C) was performed within the resection zone for the primary tumor in 10 cases, and Hartmann's operation was performed in two cases. The loop C was located in the sigmoid colon in five cases and on the left side of the transverse colon in five cases. The interval until radical resection was from 13 to 35 days (mean: 20 days), the duration of surgery was from 2 h 5 min to 4 h 55 min (mean: 4 h 7 min), and the length of resected bowel ranged from 22.5 cm to 51.2 cm (mean: 29.8 cm). Mild wound infection was observed in two cases. Dukes' clinical stage was as follows: A in 0 case, B in 5 cases, C in 6 cases and D (distant metastasis) in 1 case. We have achieved good results over the past two years without performing standard loop C on the right side of the transverse colon.

Risk of lymph node and distant metastases in patients with early invasive colorectal cancer classified as Haggitt's level 4 invasion: image analysis of submucosal layer invasion.

PURPOSE: Tumor invasion in patients with early invasive colorectal cancer has been classified into four levels proposed by Haggitt. Level 4 invasion into the submucosa has been defined as a risk factor for lymph node metastasis; however, the false-positive rate remains high. This study was designed to determine risk factors for lymph node and distant metastases in addition to Haggitt's Level 4 invasion. METHODS: Seventy-one of 142 patients with submucosa-invasive colorectal cancer underwent intestinal resection as an initial surgical treatment between 1975 and 2000. The subjects of this study were 65 of these 71 patients, all of whom were diagnosed as having Haggitt's Level 4 invasion. The depth, width, and area of submucosal invasion were measured with an image analyzer. RESULTS: Lymph node metastasis was noted in 11 (16.9 percent) of the 65 patients. There were no significant differences in the depth or area of submucosal invasion between node-positive and node-negative patients. However, the width of submucosal invasion was significantly greater in node-positive than in node-negative patients (P = 0.001). When 5-mm-wide submucosal invasion was used as an indicator for intestinal resection, 37 patients were found to have indications for bowel resection, and 11 (29.7 percent) of the 37 had lymph node metastases. Distant metastasis was noted in five patients (7.7 percent). The depth, width, and area of submucosal invasion in patients with distant metastasis did not differ significantly from those without distant metastasis. CONCLUSION: Although further prospective investigation is required, the positive predictive value increases from 17 to 30 percent when the width of submucosal invasion is added to Haggitt's Level 4 as an indicator for bowel resection.

A successfully treated case of severe necrotizing fasciitis caused by acute appendicitis: a case report.

We successfully saved a patient with appendicitis followed by necrotizing fascitis. A 77-year-old man with a history of ambulatory treatment for depression underwent an emergency operation because of severe abdominal pain. Laparotomy demonstrated that necrotizing appendicitis was massively extending over the abdominal cavity, involving the right paracolic sulcus and Douglas pouch and posterior surface of the right kidney. Irrespective of the emergency surgery, redness and swelling in the right chest and abdomen, which was noted at the time of admission, was not decreased. Successively, a retension incision was performed under the diagnosis of necrotizing fasciitis. Necrotizing fasciitis is an extremely rare complication of appendicitis, and there were only 10 cases documented. Once necrotizing fasciitis occurs, the mortality rate is high, so that correct diagnosis and prompt debridement are mandatory. Particularly for elderly patients with appendicitis, rapid and accurate diagnosis and treatment are required.

Efficacy of combination chemotherapy for stage IV colon cancer with extensive peritoneal dissemination and multiple liver metastases: a case report.

A patient was diagnosed as having subacute ileus due to advanced cancer of the descending colon with multiple liver metastases and was treated by palliative left hemicolectomy. He was considered to have Stage IV cancer based on the finding of extensive peritoneal dissemination. Histopathological examination showed that the tumor was moderately differentiated adenocarcinoma. Postoperative palliative chemotherapy was given with 5-FU and LV twice a month as 1 course, and he received a total of 3 courses. As a result, the multiple liver metastases were completely eliminated. However, his liver metastases recurred, so CPT-11 was added to 5-FU and LV for another 3 courses. When bilateral pleural effusions developed about 1 year postoperatively, CPT-11 was changed to CDGP. Jaundice and massive ascites eventually developed, and he died about 1 year and 5 months postoperatively.