Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study.

BACKGROUND/AIMS: Anastomotic leakage is a major problem in colorectal surgery particularly in low rectal cancer. The defunctioning loop ileostomy was introduced as a technique to create a manageable stoma that would divert the fecal stream from a more distal anastomosis in order to reduce the consequences of any anastomotic leakage. Therefore, the use of a defunctioning stoma has been suggested, but limited data exist to clearly determine the necessity of routine diversion. This study was designed to evaluate early morbidity, mortality and hospital stay in patients undergoing lower rectal cancer surgery concerned with or without loop ileostomy. METHODOLOGY: This is a prospective randomized study that was performed between May 2001 and March 2008. There were 256 patients who underwent elective low anterior resection and stapler anastomosis. They were divided into two groups. Group A consisted of 120 patients who underwent straight anastomosis without ileostomy and group B consisted of 136 patients who underwent straight anastomosis with loop ileostomy. Data regarding patient demographics, underlying pathology, anastomotic problems, and ileostomy-related problems were gathered. The patients were all monitored closely after surgery for an anastomotic leak and all stoma-related complications were recorded. Inclusion criteria consisted of biopsy proven adenocarcinoma of the rectum located at < or = 5 cm above the anal verge, age > or = 22 years, and informed consent. Exclusion criteria included age more than 90 years, associated co morbid conditions Stage IV with disease spread to liver and peritoneum. RESULTS: Indications for surgery were lower rectal cancer (n=256). Mean age 55.5 years (range 22-90 years) and a male: female ratio of 1.1:1. All patients were undergoing elective surgery for lower rectal cancer. In our study 12 patients in group A developed anastomotic leak, two of them were re-explored for anastomotic leak and Hartman's colostomy was carried out. There were two deaths in Group A. In group B anastomotic leak was seen in three patients. In all three, anastomotic healing took place at a later period of time on the 18th, 20th, and 25th postoperative day respectively without any additional morbidity and mortality. Ileostomy-related problems were minor and limited to the stoma and complaints requiring stoma nurse evaluation (n=8), dehydration requiring outpatient care (n=3), bleeding at the stoma closure site (n=l). No stoma site hernias have been identified so far. CONCLUSIONS: The use of defunctioning loop ileostomy in all patients undergoing lower rectal surgery with stapler anastomosis is beneficial and safe. Defunctioning loop ileostomy use has resulted in no anastomotic leak rate and considerable low morbidity. So according to our study, we strongly recommend defunctioning loop ileostomy as a routine procedure in patients undergoing lower rectal cancer surgery.

Morphometric effects of exposure to lead during the preweaning period on the hippocampal formation of aging rats.

Our previous morphologic studies in the rat demonstrated that exposure to lead during the preweaning period induced delays in the maturation of late-developing regions of the hippocampal formation at 15 days of age, followed by normal development or hypertrophy of the same areas in young adulthood. The present study was carried out to determine whether or not subtle or latent effects of such exposure to lead may be unmasked with the additional challenge of aging. To do this, mid-dorsal sections of the hippocampal formation from middle-aged (578-631 days old) Long-Evans control rats and from rats exposed to lead from birth until weaning via dams drinking 0.2% lead acetate were analyzed by light and electron microscopy. Exposure to lead did not alter areas of either neuropil or neuronal layers of the hippocampus or the dentate gyrus or the numbers per section or numerical densities (numbers per unit area) of neurons in hippocampal CA3 stratum pyramidale or dentate stratum granulosum. It did reduce mean size of complex invaginated mossy fiber synapses without altering their numbers in the proximal (close to dentate gyrus) mossy fiber zone, which was the zone also affected at 15 and 90 days of age in our previous studies.

The effects of vitamin C, vitamin B6, and vitamin B12 supplementation on the breast milk and maternal status of well-nourished women.

The effects of vitamin supplements and/or diet on the levels of vitamin C, vitamin B6, and vitamin B12 in milk and blood of lactating women were determined. At the end of gestation, subjects were divided into two lactation groups: supplemented (10 subjects) and nonsupplemented (seven subjects). Milk samples were collected from 5 to 7 days and 43 to 45 days postpartum. Fasting blood samples were drawn at 8 and 46 days postpartum for vitamin C, B6, and B12 status measurements. Dietary records of all foods consumed by the subject were kept for 4 days at 1 and 6 weeks postpartum. The vitamin B6 level in breast milk of the unsupplemented group of mothers was significantly lower (P less than 0.05) than the supplemented group of women at 5 to 7 days postpartum. Vitamin B12 concentration in milk of nonsupplemented mothers at 43 to 45 days postpartum was significantly lower (P less than 0.05) than the supplemented group of women at 43 to 45 days postpartum. None of the milk values or the maternal blood levels measured in the women was less than published norms for vitamin C, vitamin B6, and vitamin B12.

Effects of antidepressants on the uptake and release of norepinephrine from rat cerebral cortex.

The effects of several antidepressants on the release of (3H)-norepinephrine (NE) from homogenates of rat cerebral cortex were studied. A continuous superfusion collection system was used in order to differentiate these effects from effects on reuptake. Amitriptyline, maprotiline, mianserin, and trazodone produced a statistically significant decrease in spontaneous tritium efflux when present in the superfusion medium at a concentration of 1.0 microM. The other antidepressants studied had no effect. We used a buffer with the K+ concentration raised to 56 mM as a model of depolarization-induced release. Desipramine, fluoxetine, and iprindole (again at 1.0 microM) caused a significant decrease in this measure. These results indicate that some of both the tricyclic and atypical antidepressants may alter spontaneous or depolarization-induced release of NE.

Cryopreservation of primary neurons for tissue culture.

We have developed new cryopreservation methods which allow storage of fetal rat central nervous system tissues for more than 1 week at 3-8 degrees C or for several months at -70 or -90 degrees C prior to tissue culture. For refrigeration, small brain regions (less than 2 mm thick) were placed intact into 35 mm petri dishes of 'hibernation medium' inside a humidified chamber. Optimal preservation was obtained with hibernation media of pH 6.8-7.4, containing 30-70 mM K+, 10-30 mM Na+, 5-50 mM PO4(2-), 20 mM lactic acid, 5 mM glucose, and less than 0.1 mM Ca2+. The media were made approximately isotonic by addition of sorbitol. For freezing, brain tissues were dissociated by gentle trituration (without enzymes) in the above medium supplemented with 5-10% dimethylsulfoxide. After refrigeration or freezing, neurons were very sensitive to damage from mechanical stress (e.g. centrifugation, harsh rinsing or trituration). Rapid changes in osmotic pressure or excessive polylysine on the tissue culture substratum also reduced neuronal survival after cryopreservation. Pretreatment of tissue culture substrata with media from lung cell cultures, or plating of neurons at higher density (2000 cells/mm2) improved neuronal survival after cryopreservation.

Morphometric effects of preweaning lead exposure on the hippocampal formation of adult rats.

We previously observed that lead exposure beginning at parturition reduced or retarded neuropil development and synaptogenesis in specific regions of the hippocampal formation in 15-day-old rats. To determine if morphologic effects of perinatal lead exposure persist into adulthood, the hippocampus of rats exposed to lead from parturition to weaning via the milk of dams drinking 0.2% lead acetate was analyzed by light and electron microscopy at 90-97 days of age. Preweaning lead exposure did not cause obvious hippocampal cytotoxicity, edema, damaged vasculature or altered numerical density (number per unit area) of dentate granule or hippocampal pyramidal neurons. However, lead exposure increased the area of the hilar portion of stratum pyramidale, increased the number of blood vessels per section in the dentate stratum granulosum and tended to increase the number of glial cells per section in the non-hilar CA3 stratum pyramidale. Effects of early postnatal lead exposure on synaptic profiles in the suprapyramidal mossy fiber zone (MFZ) were limited to the proximal (close to the dentate gyrus) region of the extrahilar zone. Both numerical density and areal density (proportion of neuropil covered) of complex invaginated (Ci) profiles, typical of mature mossy fiber boutons, were increased by lead exposure in the deep (close to stratum pyramidale) subfield of the proximal portion of the suprapyramidal MFZ. Lead exposure tended to increase the mean cross-sectional area of Cl profiles in the superficial (distant from stratum pyramidale) subfield of the proximal portion, and reduced the cross-sectional area of complex noninvaginated (CN) synaptic profiles in some subfields. Although lead exposure reduced or delayed neuropil development in selected late developing hippocampal regions examined at 15 days of age, it appeared to allow normal growth or to induce compensatory hypertrophy in these same regions in the adult.

Age, sex and reproductive status alter the severity of anorexia in zinc deficient rats.

Food intake and body weight gain in rats fed a zinc-deficient diet are reported. The severity of zinc deficiency-induced anorexia was observed to be dependent upon the age, sex and reproductive status of the animal. Rapidly growing rats such as weanlings, adult males, or ovariectomized females demonstrated more rapid induction of anorexia and more severe effects on cumulative food intake and body weight gain when fed zinc-deficient diets than did slowly growing (nonpregnant female adult) rats given the same diet. These results suggest that feeding in zinc-deficient animals is not regulated by dietary zinc concentration alone, but rather is mediated by one or several as yet undefined factors.

Phosphatidylethanolamine deficiency in membrane lipids inhibits keratinocyte intercellular networks formation.

Ethanolamine (Etn) is required for the growth of epithelial cells in culture. Without Etn, the amount of phosphatidylethanolamine (PE) in membrane lipids is reduced, and cell proliferation stops. When the membrane lipids are deficient of PE, some extracellular signaling processes become impaired. In this study, we examined the effect of Etn deprivation on the formation of intercellular networks in immortalized human oral keratinocytes. Keratinocytes proliferate with undifferentiated morphologies in a low-calcium medium, whereas they undergo differentiation to form intercellular networks in a high-calcium medium. The cells were first cultured with or without Etn supplement in a low-calcium (0.07 mM) medium, and then the calcium concentration was raised to 1.8 mM. The localization and organization of the following proteins were examined: (1) desmogleins and plakoglobin in desmosomes, (2) E-cadherin and beta-catenin in adherens junctions and (3) actin and keratin filaments in cytoskeletons. As expected, in the Etn-supplemented cells, the elevated level of calcium induced the junctional localization of the proteins associated with desmosomes and adherens junctions and also induced the formation of keratin and actin networks. On the contrary, in the Etn-deprived cells, the elevated level of calcium induced none of the above processes. The results suggest that having a sufficient amount of PE or proper phospholipid composition in the membranes is crucial for differentiation in epithelial cells.

[Clinical evaluation of right gastroepiploic artery (RGEA) graft--comparison of RGEA with right internal thoracic artery (RITA) graft in the coronary bypass grafting (CABG) operation using only arterial grafts].

From January, 1990 through May, 1997, 100 CABG operations were conducted using only double arterial grafts. RITA/left internal thoracic artery (LITA) (n = 38) and RGEA/LITA (n = 62) groups were compared. The incidence of left main trunk lesion was higher in the RITA/LITA group (29%: 13%), and old myocardial infarction was greater in RGEA/LITA group (77%: 55%). Mean age in the RGEA/LITA group showed high tendency (66.8 +/- 8.5: 63.9 +/- 9.2). Both groups were essentially the same with respect to sex, poor left ventricular function, pre-operative aortic baloon pumping (IABP), diabetes mellitus, hypertension, cerevral vascular disease, hyperlipidemia, smoking, pre-operative ejection fraction (EF). Focal skin infection (32%: 6%) and total operative field infection (focal skin infection + mediastinitis) (39%: 8%) were higher in the RITA/LITA group. Operation time (443 +/- 81: 405 +/- 114) and pleural effusion (29%: 15%) showed high tendency in the RGEA/LITA group. Extracorporeal circulation time, aorta cross-clamping time, reoperation due to bleeding, reoperation due to mediastinitis, post-operative IABP, and post-operative EF were the same for the two groups. The difference of survival rate and cardiac event-free rate between two groups were not recognized. The RGEA/LITA group showed lower complication and similar survival rates than the RITA/LITA group. Based on the present results. RGEA may be considered more usefull than RITA.

[A case report of pre-operative simultaneous angiography of the LITA and LAD for MIDCAB surgery].

The patient was 59-year-old man, who had a 90% stenotic lesion of LAD (seg 6, just proximal). We performed minimally invasive direct coronary artery bypass (MIDCAB) surgery. At preoperative angiography, we took a photo of the posteroanterior view which is equivalent to position of an operation. Also, photos of the LITA and LAD were taken simultaneously. This simultaneous angiography was useful for deciding on the skin incision line. During the postoperative angiography, it was recognized that the skin incision line existed at the middle of the LITA and anastomotic point. In MIDCAB surgery, to obtain a good operative view could have an influence on the difficulty of the operation and effect the results of the operation. Therefore, our new angiographic technique is though to be useful for new surgical technique (MIDCAB).

[Surgical angioplasty of isolated left coronary ostial stenosis].

A 42-year-old female had suffered from chest pain for approximately 1 month, and was admitted with unstable angina pectoris. Emergent coronary angiography showed an isolated 75% stenosis of the left coronary ostium. Repair of ostial stenosis by vein patch angioplasty was done by the transactional superior approach. Postoperative catheterization revealed an expanded left coronary orifice and the patient was discharged without any complications. We have experienced 2 other patients of isolated left coronary ostial stenosis, who had undergone double coronary artery bypass grafting. Long-term coronary angiography showed regression of ostial stenosis in 1 patient, and no progression of new lesions in either. These results suggest that direct vein patch angioplasty of the ostial lesion is an alternative procedure for isolated left coronary ostial stenosis.

Effects of lead and other inhibitors on the activation of K+-dependent p-nitrophenylphosphatase activity by glycine.

The in vitro and in vivo effects of lead on the activation of K+-dependent p-nitrophenylphosphatase activity by glycine were investigated in plasma membranes of male Wistar rat livers. This activation was markedly inhibited by lead in vitro (0.1-5.0 mM) and in vivo (intraperitoneal injection of lead at 4, 8, or 20 mg per 100 g body weight). On the other hand, the in vitro activation of this K+-dependent activity by glycine was about 77% inhibited by ouabain (10 micronM), but about 100% inhibited by oligomycin (20 micronM).

[Debakey IIIb aortic dissection from a distal arch atherosclerotic aneurysm--a case report].

We treated a 75-year-old male patient with DeBakey IIIb aortic dissection from a distal arch atherosclerotic aneurysm 75 mm in diameter. Arch replacement was carried out by separate extracorporeal circulation. The entry located juxta-atherosclerotic aneurysm. It was considered that shear stress at the turning point of blood flow would occur the dissection. The relationship between the atherosclerotic aneurysm and the aortic dissection was studied.

[Urgent coronary artery bypass surgery by only arterial graft for acute myocardial infarction].

The authors conducted urgent coronary artery bypass grafting (CABG) using only arterial graft for mild and moderate acute myocardial infarction (AMI) in 9 cases from January, 1995 through December, 1996. Mild and moderate AMI means free from cardiogenic shock by catecholamines alone or catecholamines and intra aortic balloon pumping (IABP). The period from the onset of AMI to admission was 2-24 (average 8 +/- 6) hours. Coronary arteriography (CAG) was performed immediately following admission. CABG was done immediately after CAG. CPK-MB on admission was 14-184 (average 67 +/- 61) IU/l. Three cases were main trunk disease over 90% stenosis, three cases were main trunk disease equivalent if another stenotic lesion over 99% were occluded, three cases would fall into cardiogenic shock if another stenotic lesion over 99% were occluded. Postoperative IABP was necessary for three cases. No case required repetition of IABP. For minimal operation time and to attain high graft flow, saphenous vein (SV) graft are generally used for emergencies. CABG was conducted here using only arterial graft (Mean anastomosis number was 2.3). There were 8 RITA grafts, 9 LITA grafts, and 4 RGEA grafts. Post operative CAG showed all the grafts to be patent, but string sign was noted for two LITA grafts. Prognosis was favorable in all cases. We could conduct urgent CABG surgery safely for mild and moderate AMI using only arterial grafts.

[Two cases of CABG operation using only arterial grafts for hypothyroidism patients].

CABG operation was conducted using only arterial grafts for patients with hypothyroidism. Case 1 was a 75-year-old woman in a hypothyroid state following radioactive iodine therapy for Basedow's disease. I're-operative thyroid function could not be corrected. CABG (RITA-->#7, LITA-->#14, RGEA-->#3) was thus carried out. The post-operative course was slightly unstable. Transient conduction disturbance appeared. Case 2 was a 57-year-old man with primary hypothyroidism. Pre-operative thyroid function could be corrected, and CABG (LITA-->#7, RITA-->#9, RGEA-->#4 PD) was carried out, the post-operative course was very good. CABG with only arterial graft was thus concluded applicable to the patients with hypothyroidism.

[Assessment of right gastroepiploic artery grafts by thallium scintigraphy].

From 1990 to 1996 we performed coronary artery bypass grafting using only arterial grafts. Both pre- and post-operative thallium-201 exercise myocardial scintigraphy were evaluated in 68 cases (161 grafts). The rate of improvement (%) was defined as follows: (number that showed improvement of perfusion of thallium on post-operative scintigraphy/number that showed decreased perfusion of thallium on pre-operative scintigraphy) x 100. Examination was made separately regarding cases of ischemia (102 grafts) and infarction (54 grafts). For ischemic cases, the rate of improvement using left internal thoracic artery (LITA), right internal thoracic artery (RITA) and right gastroepiploic artery (RGEA) was 80% (12/15), 70% (7/10) and 71% (5/7) respectively. For infarction cases, the rate of improvement using LITA, RITA and RGEA was 54% (7/13), 60% (6/10) and 53% (9/17) respectively. Among these three groups no significant differences were noted. As a result, RGEA is thought to have usefulness equivalent to LITA and RITA.

Mechanism of glyceryl trinitrate-induced vasodilation. II. Lack of evidence for specific binding of GTN to bovine pulmonary vein.

Radioligand binding studies were conducted to test the hypothesis that specific receptor sites for glyceryl trinitrate (GTN) exist in vascular smooth muscle. The radioligand, [3H]GTN (9.98 Ci/mmol), was incubated with whole homogenate or subcellular fractions (10,000 X g pellet, 100,000 X g pellet and 100,000 X g supernatant) of bovine pulmonary vein (BPV) at 4 degrees C, 37 degrees C or room temperature. After incubation for 5, 15, 30 or 60 min, unbound and bound ligand were estimated by physical separation and liquid scintillation spectrometry. Separation of bound from free ligand was accomplished by vacuum filtration, centrifugation, equilibrium dialysis, gel filtration or precipitation. No evidence of specific binding of [3H]GTN to BPV whole homogenate or any subcellular fraction was observed. The viability of the BPV preparations was verified by demonstrating specific binding of [3H]nitrendipine to the 100,000 X g pellet. To ensure that the ligand was present throughout the incubation procedure in sufficient concentration to detect specific binding, the ability of BPV whole homogenate and subcellular fractions to biotransform GTN to glyceryl dinitrate was measured. After 60-min incubation at 37 degrees C, greater than 95% of the GTN added was unaltered; at 90 min, more than 83% of the radioactivity was associated with GTN. Our data are interpreted as not supporting the concept of a GTN receptor in BPV.

Endothelium-dependent relaxation of rabbit aorta by acetylcholine requires ethylenediaminetetraacetic acid.

Experiments were conducted to determine if ethylenediaminetetraacetic acid (EDTA) was essential for the acetylcholine (ACh)-induced relaxation of blood vessels. Isolated rabbit aortic rings were prepared for recording isometric tension. They were maintained in Krebs bicarbonate solution with various concentrations of EDTA. With EDTA concentrations of 0 or 0.003 mM, no ACh-induced relaxation was observed; only the contractile effect of ACh was seen. With 0.03 and 0.30 mM EDTA, ACh induced relaxation with EC50 values of 0.11 and 0.098 microM, respectively. Under the experimental conditions used, EDTA was essential for demonstration of ACh-induced relaxation.