[Function of the Puborectalis Muscle in Patients with or without Fecal Incontinence Three Years after Low Anterior Resection for Lower Rectal Cancer].

To clarify the function of the puborectalis muscle(PM)in fecal incontinence(FI)prevention after low anterior resection (LAR)for lower rectal cancer(LRC), PM function at 3 years after LAR was studied. A total of 29 patients aged 40-79 years (19 men and 10 women, mean age: 63.9 years)who underwent LAR for LRC were enrolled in the present study. Based on the presence of postoperative FI, these patients were divided into 2 groups[group A: patients with FI(n=13), 11 men and 2 women aged 43-75 years(mean age: 64.8 years)and group B: patients without FI(continence, n=16), 8 men and 8 women aged 41-79 years(mean age: 62.9 years)]. These groups were compared with group C of control subjects[n=38; 28 men and 10 women aged 42-76 years(mean age: 64.5 years)]. Magnetic stimulation at the S2-4 sacral levels has been shown to activate the sacral motor nerve(SMN)root of the cauda equina. SMN latency(SMNL)was determined on the right, left, and posterior sides of the upper anal canal. FI after LAR was also evaluated using the Wexner score(WS), with a score of 8 or more being associated with FI according to our data. All patients had pathological Stage Ⅰ disease(19 patients: T1, N0, M0; 10 patients: T2, N0, M0). Group A had a larger proportion of men than group B(p<0.1). The distance of anastomosis from the anal verge(DAAV)was significantly shorter in group A(2.2±1.2 cm)than in group B(4.6 ±1.3 cm)(p<0.001). Regarding WS of group A, 23.1% patients had a score of 8-10(mean: 9.0), 53.8% of 11-15 (mean: 13.4), and 30.7% of 16-20(mean: 17.0). All patients in group A(WS: 8 or more)were incontinent. In contrast, all patients in groups B(WS: 0)and C(WS: 0)were continent. Patients with preoperative defecation ability(WS: 0)were also continent. As for SMNL on the right(9 o'clock), left(15 o'clock), and posterior(18 o'clock)sides of the PM located in the upper anal canal, conduction delay was significantly longer in group A(8.4±0.6 ms, 8.2±1.9 ms, and 8.3±0.9 ms, respectively)than in groups B(4.4±0.5 ms, 4.3±0.7 ms, and 4.4±0.9 ms, respectively)and C(4.1±0.5 ms, 4.0±0.5 ms, and 4.2±0.7 ms, respectively)(p<0.001, all). FI after LAR with a short DAAV, especially in men, may cause PM dysfunction due to operative damage of the SMN.

[Malignant small bowel ileus due to recurrent colorectal cancer with peritoneal metastasis].

PURPOSE: To investigate the clinical findings of patients who underwent surgery for small bowel obstruction following a previous operation for colorectal cancer. We assessed consecutive patients operated on for peritoneal metastasis with small bowel ileus. PATIENTS AND METHODS: We evaluated the clinical characteristics of 7 consecutive patients with malignant small bowel ileus due to recurrent colorectal cancer with peritoneal metastasis. RESULTS: 1) Primary cancer location: descending colon, 2 cases (28.6%); sigmoid colon, 1 case (14.3%); and rectum, 4 cases (57.1%). 2) Peritoneal dissemination grade: P2, 1 case (14.3%); and P3, 6 cases (85.7%). 3) Liver metastasis grade: H1, 1 case (14.3%); H2, 5 cases (71.4%); and H3, 1 case (14.3%). 4) Lymph node metastasis grade: N2, 1 case (14.3%); and N3, 6 cases (85.7%). 5) Extra-abdominal metastasis: multiple lung metastases were detected in 3 cases (42.9%). 6) Pathological type: moderately differentiated tubular adenocarcinoma (tub2), 3 cases (42.3%); poorly differentiated adenocarcinoma (por), 1 case (14.3%); and mucinous adenocarcinoma (muc), 3 cases (42.3%). The differentiated type (tub2) was more common than the undifferentiated types(por and muc). 7) Malignant small bowel stenosis and/or obstruction: there were 3 or more cases with stenosis and/or obstruction in jejunum and ileum. 8) OPERATIVE PROCEDURE: gastrostomy was performed in 2 cases (28.6%); nephrostomy was performed in 1 case (14.3%); gastrostomy with nephrostomy was performed in 1 case (14.3%); and probe laparotomy was performed in 3 cases (42.9%). 9) Survival time of patients with recurrent colorectal cancer, from readmission to death: 0.5-1 month, 3 cases (42.9%); 1-1.5 months, 3 cases (42.9%); and 1.5-3 months, 1 case (14.3%). All patients died in less than 3 months. CONCLUSIONS: The prognosis of the malignant small bowel ileus due to recurrent colorectal cancer with peritoneal metastasis is very bad.

[Hepatocellular adenocarcinoma with fundic gland polyposis in adolescents associated with ileal J -pouch anal anastomosis for familial adenomatous polyposis].

Familial adenomatous polyposis(FAP) is characterized by colonic polyps that undergo malignant change, and benign and malignant extracolonic lesions such as upper gastrointestinal polyps, osteoma, desmoids tumor, and papillary cancer of thyroid. We found a case of hepatocellular carcinoma(HCC) in a 23-year-old male patient after an ileal J pouch-anal anastomosis for FAP. He also had fundic gland polyposis at the fundus and upper corpus in his stomach. Genetic counseling was rejected by his mother. The patient's condition was followed up routinely in the surgical outpatient clinic. Liver dysfunction was detected by blood examination 5 years after surgery. Abdominal ultrasonography and computed tomography also showed a single nodular type of the HCC at S8 in his liver. Partial hepatectomy at S8 was performed and the postoperative course has been uneventful.

[Intraoperative localization of recurrent pancreatic insulinoma-a resected case of the metastatic lesions in the residual pancreas and the lymph node].

We describe herein a 39-year-old woman with tumor recurrence in the residual pancreas and metastasis to the lymph node about 5 years after an eneclation for insulinoma in the body of the pancreas. A certain day in the morning in June 2002, she was immediately admitted to our hospital due to impairment of consciousness based hypoglycemia. On diagnostic imaging including an arterial stimulation venous sampling, localization of the recurrent lesions was not identified. In October 2002, we underwent laparotomy for the purpose of localization of the recurrent lesions and treatment. During the operation, peripheral blood glucose level, portal blood glucose level and portal insulin level were measured periodically. The mobilization started from the tail of the pancreas. Blood glucose levels were gradually elevated during the mobilization. The pancreas was mobilized to the right edge of the portal vein and was resected. Histopathological diagnosis was recurrent insulinoma in a peripancreatic lymph node and intra-pancreatic subcapsular tumor embolization. Postoperative course was uneventful. More than 8 years after surgery, she is doing well without signs of recurrence.

Substance P and vasoactive intestinal peptide in rat small-bowel isografts.

BACKGROUND: It is established that substance P (SP) is released by stimulation of nonadrenergic noncholinergic (NANC) excitatory nerves and vasoactive intestinal peptide (VIP) by stimulation of NANC inhibitory nerves. To evaluate the function of peptidergic nerves such as SP and VIP in small-bowel isografts, we examined the enteric nerve responses to SP and VIP in the isografted rat jejunum, using the normal rat jejunum as a control. METHODS: Orthotopic entire small bowel transplantation (SBT) with portocaval drainage was performed from Lewis rats to Lewis rats. Grafted tissue specimens were obtained 130 days after SBT (n = 9). As controls, normal segments of the jejunum were obtained from untransplanted Lewis rats (n = 22). A mechanograph was used to evaluate in vitro jejunal responses to electrical field stimulation of the enteric nervous system before and after treatments with various autonomic nerve blockers and neuropeptides (SP and VIP). RESULTS: SP concentration-dependently mediated the contraction reaction of NANC excitatory nerve in the isografted jejunum and to a lesser extent in the normal jejunum. In addition, there were significant diferences in the percentages showing contraction at 1 x 10(-8) and 1 x 10(-6)g/mL SP between the normal and isografted jejunal muscle strips (P < .05, respectively). VIP concentration dependently mediated the relaxation reaction of NANC inhibitory nerve in the normal jejunum and to a lesser extent in the isografted jejunum. In addition, there was a significant difference between the relaxation frequencies of the normal and those of isografted jejunal muscle strips at 1 x 10(-6) g/mL SP (P < .01). CONCLUSIONS: Contraction reactions of SP were observed in both the normal and isografted jejunum but were increased in the isografted jejunum. Relaxation reactions of VIP were also observed in both the normal and isografted jejunum but were decreased in the isografted jejunum. The increase of the effects of SP via NANC excitatory nerves and the decrease of the effects of VIP in mediating NANC inhibitory nerves may be largely related to the peristaltic abnormalities seen in the isografted LEW rat jejunum.

The clinicopathological studies on patients with pancreaticobiliary maljunction that was detected by intraoperative cholangiography under laparoscopic cholecystectomy.

BACKGROUND/AIMS: The objective of this study was to evaluate the clinicopathological features of patients with pancreaticobiliary maljunction, which was detected by intraoperative cholangiography in laparoscopic cholecystectomy. METHODOLOGY: Among 78 patients who underwent intraoperative cholangiography in laparoscopic cholecystectomy, 8 patients had the radiological findings of pancreaticobiliary maljunction. The clinicopathological factors were analyzed in them. RESULTS: They consisted of 2 males and 6 females with a mean age of 57.8 years (range: 36-76 years). Preoperatively, 7 patients were diagnosed as cholelithiasis and one was diagnosed as polypoid lesions of the gallbladder. None of them had dilated choledochus. All of them underwent cholecystectomy alone extrahepatic bile duct resection was omitted, and was performed. Histopathologic examinations of the resected gallbladder revealed epithelial hyperplasia in one patient, in whom amylase level of the gallbladder bile was also highly elevated. Postoperatively, none of them had acute pancreatitis, cholangitis, or biliary cancer. CONCLUSIONS: Further prolonged careful follow-up is warranted in our series of patients.

Physiologic studies on nitric oxide in rat small bowel isografts.

The enteric nervous system (ENS), especially the nonadrenergic noncholinergic (NANC) inhibitory nerves, is an important factor in intestinal peristalsis. Recently, it was established that nitric oxide (NO) is released after stimulation of NANC inhibitory nerves. Inhibitory nerves such as NANC inhibitory nerves in the ENS are more easily damaged than excitatory nerves by reperfusion or ischemic injuries during small bowel transplantation (SBT). To evaluate the effects of reperfusion and ischemic injuries to the ENS in the transplanted small bowel, we examined the ENS responses, including the effects of NO in the isografted rat jejunum, using the nontransplanted jejunum as a control. To avoid potentially confounding immune phenomena, we used syngeneic Lewis (LEW) rats. Orthotopic entire SBT with portocaval drainage was performed from LEW rats to LEW rats. Isografted muscle strips were obtained from 8 LEW rats 130 days after SBT (n = 24). As controls, normal muscle strips of the jejunum were obtained from 20 nontransplanted LEW rats (n = 60). A mechanograph was used to evaluate in vitro jejunal responses to electrical field stimulation of the adrenergic and cholinergic nerves before and after treatment with various autonomic nerve blockers, N(G)-nitro-Ll-arginine ( L-NNA), and L-arginine. The results indicated that excitatory nerves, especially NANC excitatory nerves, were more dominant in the isografted jejunum than in the normal jejunum (p < 0.01). NANC inhibitory nerves were found to act on the normal jejunum and to a lesser extent on the isografted jejunum (p < 0.05). NO mediates the relaxation reaction of NANC inhibitory nerves in the normal jejunum and to a lesser extent in the isografted jejunum. These results indicated that the intrinsic intestinal innervation contains excitatory and inhibitory nerves and that the former, especially NANC excitatory nerves, are more dominant in the isografted jejunum than in the normal jejunum. In addition, reduction of the action of NANC inhibitory nerves such as that by NO may be largely related to impaired motility in the isografted jejunum. Thus over a long period of time (more than 130 days after SBT) transplanted small bowel dysmotility may be influenced by reperfusion or ischemic injury to the ENS (especially NANC inhibitory nerves) via NO in the transplanted jejunum after syngeneic SBT.