Jejunal Crohn's disease is associated with a higher postoperative recurrence rate than ileocaecal Crohn's disease.

OBJECTIVE: Crohn's disease is a chronic inflammatory, panintestinal disease of uncertain aetiology. The recurrence rate of Crohn's disease, often taken as the time when further surgical procedure is undertaken, has been reported to be as high as 76% in 10 years. The site of the disease has not yet been associated with the recurrence rate of Crohn's disease. The aim of the study was to compare the outcome of patients who were surgically treated for jejunal Crohn's disease to those whose diseases was confined to the ileocaecal region. METHOD: The information was tracked from our database of 724 surgically treated Crohn's disease patients between 1943 and 2002. Twenty-eight patients with jejunal Crohn's disease at their first operation (12 jejunum alone, 16 also involving other sites) were identified. For each of these patients, 3 patients with ileocaecal Crohn's, matched for age, sex, and smoking habits (n = 84) were identified as controls. RESULTS: The median age in both groups was 21 years (range 16-52 years) with a median follow-up period of 19 years. The 3, 5 and 10 years re-operation rate for the groups with jejunal disease were 43%, 50% and 61% compared to 22%, 30% and 51% with ileocaecal disease, respectively. CONCLUSIONS: The presence of jejunal Crohn's disease is associated with a higher rate of early disease recurrence compared to ileocaecal disease but long-term recurrences rate do not differ significantly.

Long strictureplasty is as safe and effective as short strictureplasty in small-bowel Crohn's disease.

BACKGROUND: For the past 20 years it has been shown that intestinal strictureplasty is safe and effective in the management of short strictureplasty. Long strictureplasty (> 20 cm) may be an alternative to resection in some patients, especially in diffuse disease or after previous extensive resections. We reviewed the outcome of long strictureplasty for Crohn's Disease, to examine safety and recurrence rates, compared with conventional short strictureplasty. METHODS: Sixty-two patients have undergone single strictureplasty for jejunoileal Crohn's disease since 1974. Median follow-up was 121 (range 7-253) months. Twenty-one operations involved a single long strictureplasty, and 41 operations had a single short strictureplasty. RESULTS: No significant differences were identified between the groups. The postoperative complications in long strictureplasty included 2 abscesses only and after short strictureplasty there was one anastomotic leak and one postoperative abscess. The median hospital stay was 10 days after long strictureplasty and 9 days after short strictureplasty. Three-, 5- and 10-year disease-free rates for long and short strictureplasty, respectively, were 3-year 80.4% and 62.1%; 5-year 55.2% and 49.8% and 10-year 49.1% and 33.5% (NS). CONCLUSIONS: These data indicate that long strictureplasty is safe and produces equivalent results to conventional (short) strictureplasty.

Reliability of radiographic measurement of small intestinal length.

OBJECTIVE: The capacity for absorption of nutrients after small intestinal resection is related to the remaining length of intestine, and short bowel syndrome has major implications. Accurate pre-operative determination of bowel length may be useful in conditions where further resection of small bowel is contemplated. The aim of this study is to evaluate the accuracy of small bowel length measured by barium follow-through (BaFT) examination. PATIENTS AND METHODS: Twenty-two patients underwent both intra-operative measurement of small bowel length, and BaFT examination where length was measured using an opisometer. RESULTS: The difference between operative and radiological measurement (mean +/- standard deviation: 15.7 +/- 16 9%) was least in those with the shorter small intestine (overall variation: r = 0.703, P < 0.01, regression coefficient: -0.118, intercept: 15.1). There was no difference in whether BaFT was performed pre or postoperatively. CONCLUSION: Assessment of small bowel length by BaFT radiography is accurate, particularly in those with shorter small bowel lengths.

Duration of pneumoperitoneum on chest radiograph after open colorectal surgery.

BACKGROUND: Postoperative pneumoperitoneum on a plain chest radiograph is a potentially important medicolegal document of possible complication. However, pneumoperitoneum may be observed without significance after intra-abdominal procedures. METHODS: Between April 2001 and March 2002, 204 consecutive open laparotomies for colorectal surgery were studied. Sixty-three patients had 97 chest radiographs taken before the twenty-fifth postoperative day. RESULTS: Only one patient had subdiaphragmatic air (height >20 mm) on the tenth postoperative day associated with a visceral perforation. Normal subdiaphragmatic pneumoperitoneum was observed on 11 films in 8 patients (13%). Small amounts of air (<15 mm high) were observed in 7 (15%) of 47 radiographs on days 0-5, in 4 (18%) of 25 radiographs on days 6-10, but in no radiograph of 24 after day 10. CONCLUSIONS: Subdiaphragmatic pneumoperitoneum less than 20 mm high is often observed between the sixth and tenth postoperative days, without clinical importance.

Vascular anatomy for right colon lymphadenectomy.

Since the superior mesenteric artery (SMA) mostly originates on the left side of the superior mesenteric vein (SMV), the ileocolic artery (ICA) and the right colic artery (RCA) cross the SMV. Understanding the three-dimensional relation of these vessels is important for dissecting these arteries to their origin. Hence, we conducted a study of the vascular anatomy of the right colon in 27 cadavers. The RCA was separate from the SMA in eight cases (30%). The RCA passed the SMV either anteriorly (5 cases, 63%) or posteriorly (3 cases, 38%). In seven (88%) of these eight cases, the ICA was posterior to the SMV. The ICA was identified in all 27 cases, and passed the SMV anteriorly in nine cases (33%) and posteriorly in 18 cases (67%). Thus, the ICA and the RCA may pass on either side of the SMV. The surgeon must dissect the arteries with the SMV, being aware of both possibilities.

Clinical significance of tissue blood flow during esophagectomy by laser Doppler flowmetry.

OBJECTIVES: We sought to investigate the effect of tissue blood flow on the incidence of anastomotic leakage during esophagectomy. METHODS: Reconstruction was done with a gastric tube, and all cases involved cervical anastomosis. Tissue blood flow of 43 patients was measured with a laser Doppler flowmeter before emplacement and after anastomosis during surgical intervention. The reconstruction route and tissue blood flow before emplacement and that after anastomosis were analyzed as possible factors influencing anastomotic leakage. RESULTS: Tissue blood flow after anastomosis with leakage was 9.1 +/- 2.0 mL/min per 100 g, and that without leakage was 13.7 +/- 2.9 mL/min per 100 g. Tissue blood flow with leakage was significantly lower than that without leakage (P <.01, unpaired t test). Twenty-one patients had tissue blood flow after anastomosis of greater than 13 mL/min per 100 g, and none of them had leakage, whereas 5 patients had blood flow of less than 10 mL/min per 100 g, and all 5 had leakage. CONCLUSION: Tissue blood flow can be an important and useful indicator of the presence of current anastomotic leakage. Low tissue blood flow after anastomosis may mediate for appropriate surgical or pharmacologic interventions to detect, localize, and counteract leakage.

Overexpression of heme oxygenase-1 protects allogeneic thyroid grafts from rejection in naive mice.

BACKGROUND: Endocrine allografts are an option for the treatment of endocrine failure. METHODS: One lobe of the thyroid was transplanted under the kidney capsule. RESULTS: C57BL/10 (H2(b)) thyroids were rejected in naive CBA (H2(k)) mice within 14 days after transplantation. When mice were treated with anti-CD4 monoclonal antibodies (mAb), all grafts survived for more than 60 days. The first grafts still survived after second C57BL/10 or Balb/c (H2(d)) thyroid grafts that were transplanted into the same recipients were rejected acutely, which suggests that the primary grafts were modified under anti-CD4 mAb treatment. To confirm this hypothesis, C57BL/10 thyroid grafts from anti-CD4 mAb-treated mice were retransplanted. All grafts survived in naive mice; this correlated with the overexpression of heme oxygenase-1 (HO-1) in the grafts. Next, an inhibitor of HO-1 (zinc protoporphyrin) or control compound (copper protoporphyrin) was injected intraperitoneally after transplantation of C57BL/10 thyroid grafts into the primary CBA recipients that had been treated with anti-CD4 mAb. The grafts in mice that had been treated with zinc protoporphyrin, but not copper protoporphyrin, were rejected when retransplanted to naive recipients. CONCLUSIONS: Overexpression of HO-1 correlated with the protection of fully allogeneic thyroid grafts from rejection when retransplanted into naive recipients.

[Reconstruction of anal function after abdomino-perineal resection].

After abdomino-perineal resection for rectal cancer, most surgeons believe that colostomy is necessary after anal function is abolished and that patients are satisfied with this. Recently, reconstruction of anal function has been performed using new surgical techniques such as creation of an artificial sphincter, dynamic graciloplasty, gluteoplasty with pudendal nerve anastomosis, and smooth muscle implanted neoanus. However, most surgeons do not have sufficient knowledge of reconstruction of anal function. Since all reconstruction methods are associated with low mortality and morbidity rates, and can be converted to conventional colostomy when required, surgeons must consider first-line reconstruction of anal function after resection of the anal sphincter.

Vascular anatomy of gracilis muscle: arterial findings to enhance graciloplasty.

Dynamic graciloplasty has recently been developed for reconstruction of anal function in patients who are fecally incontinent in preference to permanent abdominal colostomy. Since the muscular portion of gracilis is wrapped around the neoanus, the length of the gracilis arc influences the functional outcome of graciloplasty. Although dissection of the main pedicle (i.e. the main artery and vein) can facilitate gracilis to have enough muscle arc, it has been unclear whether there are any vessels proximal to the main pedicle or through the origin of the muscle which could support blood flow into the whole of gracilis. In this study, the vascular anatomy of gracilis in both legs of 26 Japanese cadavers was examined. All muscles had a main pedicle, mean maximum diameter 1.08 mm, entering at the proximal one-third of the muscle. However, only 18 muscles (34.6%) had an accessory artery in the proximal portion in addition to the main pedicle. Some arteries always exist at the origin of the muscle, having a mean maximum diameter of 0.34 mm, suggesting that they might be able to support the whole gracilis without supply from the main pedicle.

[Recent advances is surgical adjuvant chemotherapy for colorectal cancer].

To evaluate the significance of surgical adjuvant chemotherapy, randomized controlled trials (RCTs) of adjuvant chemotherapy after curative resection for colorectal cancer were reviewed. Several multi-drug systemic chemotherapies (MOF, MMC/FT, 5-FU, UFT p.o.) were useful as adjuvant treatment to improve survival or disease-free survival of patients with colorectal cancer. Moreover, a worldwide meta-analysis suggested that continuous intraportal 5-FU infusion improves survival. Combination chemotherapy trials utilizing 5-FU and levamisol (LEV) demonstrated a survival advantage in patients with high risk colon cancer. Recently, many RCTs have substantiated the benefits of treatment with 5-FU/Leucovorin (LV) and this treatment is widely used as adjuvant treatment for the patients with Dukes C resected colon cancer in Europe and the U.S.A. Now, with the increasing use of oral chemotherapy drugs, new trials comparing oral UFT/LV with intravenous 5-FU/LV are being implemented to investigate these drugs in terms of QOL, toxicity and cost. Furthermore, the new drug irinotecan (CPT-11) is now under investigation to see if it brings added efficacy to 5-FU/LV. In Japan, two major groups (N-SAS-CC and TAC-CR) are comparing surgery alone and UFT alone in patients with Dukes C colon and rectal cancer. From these results, surgical adjuvant chemotherapy seems to be effective in the treatment of patients with high risk colon cancer and those with rectal cancer.

A new method of peritoneal closure following laparoscopic herniorrhaphy.

Of the three most commonly used methods of repairing inguinal hernias laparoscopically, we believe that the transabdominal (TAPP) approach is the most effective. To perform this technique successfully, complete closure of the peritoneum is recommended to avoid the formation of postoperative adhesions. Here we describe a technique that employs the Endo Stitch instrument, facilitating easier closure of the peritoneum.

A new approach to dynamic graciloplasty.

The reestablishment of anal function by transposition of the gracilis muscle, combined with the implantation of electrodes and a neuromuscular stimulator (dynamic graciloplasty), has recently been developed. With this method, the transposed muscle maintains contraction by electrical stimulation to maintain neoanal pressure without fatigue. It is necessary to convert the fatigue-prone gracilis muscle to fatigue-resistant muscle by long-term electrical stimulation (conditioning). In most patients receiving dynamic graciloplasty, the conditioning is accomplished after the transposition. However, conditioning before graciloplasty should reduce the risk of ischemia in the transposed muscle after the graciloplasty and improve the outcome. This new sequence of procedures is described, in combination with J-pouch construction, in a patient who required abdominoperineal excision of the rectum for lower rectal cancer. The graciloplasty was performed after conditioning of the gracilis muscle in situ; the conditioning did not cause the patient discomfort and resulted in good anal function.

[Management of aortoesophageal fistula due to thoracic aortic aneurysm].

Aortoesophageal fistula (AEF) is a rare but fatal disease without prompt diagnosis and treatment. A 82-year-old woman was admitted because of repeated hematemesis. Endoscopic examination suspected submucosal tumor with blood clot at the top on the mid-esophagus. The CT scan of the thorax and the aortography revealed a thoracic aortic aneurysm. AEF was diagnosed and the operation was performed. The ruptured aneurysm was resected and patched with Dacron graft. At the same time, subtotal esophagectomy with esophagostomy and gastrostomy were performed. The reconstruction at five weeks after operation induced oral intake. She died from an aspiration pneumonia five month later.

Conversion of the rabbit gracilis muscle for transposition as a neoanal sphincter by electrical stimulation.

To re-establish anal function in fecally incontinent patients it may be feasible to transpose the gracilis muscle around the anal canal, using electrical stimulation to trigger contraction. However, because the fast-twitching gracilis muscle is incapable of prolonged contraction without fatigue, it is necessary to convert it to a slow-twitching, fatigue-resistant muscle. We demonstrated this conversion by longterm electrical stimulation at low frequencies using a rabbit model. The nerve to the gracilis muscle was continuously stimulated at 2 Hz, 5 Hz, and 10 Hz for 2, 4, or 6 weeks. In the 6-week conditioning group, the percentage of type I fibers, identified by ATPase staining, increased as the conditioning frequency became higher, but the twitch contraction speed reduced with conditioning at a frequency of more than 5 Hz. The fatigue resistance improved by conditioning at 10 Hz, and conversion occurred in 6 weeks. Thus, we concluded that conditioning at 10 Hz for 6 weeks can convert rabbit gracilis muscle to a slow-twitching, fatigue-resistant muscle suitable for use as a neoanal sphincter.

Splenic abscess associated with colon cancer: a case report.

The present report describes a case of colon cancer which presented with a rare complication of splenic abscess. A 52-year-old Japanese man with diarrhea, fever and chills was admitted to our hospital. He complained of fever, with chills at night, and abdominal pain occurring during the last month. The origin of the fever was investigated, and Escherichia coli grew from a blood culture. Multilocular splenic abscesses and wall thickening of the descending colon were revealed by CT scan, magnetic resonance imaging and ultrasound. A cancer of the descending colon was found by barium enema and colonoscopy. A curative resection was performed and the pathological report revealed the splenic abscess to have developed from a direct extension of, and perforation by, the carcinoma of the descending colon.

Light and electron microscopic study of vestibular sensory epithelia in 17 cases with acoustic neurinoma.

Vestibular sensory epithelia were studied histologically and ultrastructurally in 17 cases with acoustic neurinoma (AN). The superior vestibular nerve (SVN) near the fundus was also histologically studied in 5 of these 17 cases. Histologically, severe fibrotic change of the vestibular sensory epithelia was found in 1 case, and severe fibrotic change of the SVN was also found in this case. Intra-epithelial cysts were found at the edge of the utricular sensory epithelia in 2 cases. The cysts consisted of the transitional epithelium and were filled with the darkly stained substances. Ultrastructurally, abnormal accumulation of darkly stained masses within the nerve ending and abnormal accumulation of the fibrillar material below the normal basal lamina were frequently observed. These morphological changes described above were regarded as the pathological changes due to AN. In addition, the relationship among the histologic changes, ultrastructural changes and clinical data were fully investigated, and some histologic and ultrastructural changes were regarded as artifacts or age-related changes.