Acupuncture protects the interstitial cells of Cajal by regulating miR-222 in a rat model of post-operative ileus.

BACKGROUND: Recovery of the interstitial cells of Cajal (ICCs) during post-operative ileus (POI) is important for the restoration of gastrointestinal (GI) motility. Acupuncture can protect ICCs, but the underlying mechanisms remain unclear. In this study, we investigated whether miR-222, c-kit and endothelial nitric oxide synthase (eNOS) are involved in the putative effects of acupuncture on ICC recovery. METHODS: A POI model was established in Sprague-Dawley rats by colo-colic anastomosis, and then acupuncture was performed at bilateral ST36, SP6 and LR3 once daily for 3 consecutive days. C-kit protein expression in the colonic tissue adjacent to the incision site was determined by immunohistochemistry and Western blotting. mRNA levels of c-kit, eNOS and miR-222 were measured by real-time polymerase chain reaction (RT-PCR). RESULTS: The levels of c-kit mRNA/protein and eNOS mRNA decreased, while miR-222 increased in the colonic tissues of POI model rats. Acupuncture treatment improved GI motility, inhibited the up-regulation of miR-222 and blocked the down-regulation of c-kit mRNA/protein and eNOS mRNA. The levels of miR-222 and c-kit were negatively correlated. CONCLUSION: Acupuncture at ST36, SP6 and LR3 facilitates ICC recovery and improves post-operative GI motility in part through regulation of miR-222, c-kit and eNOS.

[A Case of Para-Aortic Lymph Node Metastases of Sigmoid Colon Cancer Treated with Complete Resection].

We present a case of sigmoid colon cancer with isolated para-aortic lymph node metastasis in a 67-year-old male patient. We treated this patient using simultaneous curative lymph node dissection with primary tumor resection. After inserting a transanal tube and decompressing the proximal colon for obstructive colitis, we performed high anterior resection with paraaortic lymph node dissection without neoadjuvant chemotherapy. The pathology results were as follows: tub2, SE, N3, H0, P0, M1(No. 216, 280), stage Ⅳ, curability B. Adjuvant chemotherapy with the XELOX regimen was administered, and the patient remains alive with no signs of recurrence 24 months after surgery. Although simultaneous dissection of para-aortic lymph node metastasis is controversial, curative dissection is advisable for localized cases.

[A Case in Which Eating Ability Was Restored after Chemotherapy for Gastric Metastasis Following Colon Cancer Resection].

We report here a rare case of gastric metastasis after resection ofa transverse colon cancer in which eating ability was restored following mFOLFOX6 (folinic acid plus fluorouracil plus oxaliplatin) plus cetuximab (Cet) chemotherapy. A 56-year-old man with chief complaints of constipation and abdominal fullness was referred to our hospital. In February 2013, he was diagnosed with transverse colon cancer via enema and colonoscopy. We performed transverse colon cancer resection followed by a 6-month course of capecitabine chemotherapy. In July 2014, the patient's serum carcinoembryonic antigen level increased, in October, he was again referred to our hospital with complaints of appetite loss and vomiting. He was diagnosed with multiple lymph node and gastric metastases via ultrasonography, computed tomography, and endoscopy, as well as multiple lung metastases via computed tomography. As the gastric metastases and vomiting rendered him unable to eat, a nasogastric tube was inserted and was administered mFOLFOX6 plus Cet chemotherapy. After 2 courses of chemotherapy his ability to eat was restored. As of March 2015, the patient remains alive following 12 courses of chemotherapy.

Gastrointestinal surgery in cystic fibrosis: a 20-year review.

OBJECTIVES: The purpose of this study was to evaluate outcomes of the surgical management for meconium ileus (MI) and Distal Intestinal Obstruction Syndrome (DIOS) in Cystic Fibrosis (CF). METHODS: Children born between 1990 and 2010 were identified using a regional CF database. Retrospective case note analysis was performed. Outcome measures for MI were mortality, relaparotomy rate, length of stay (LOS), time on parental nutrition (TP), and time to full feeds (TFF). Outcome measures for DIOS were: age of onset, number of episodes, and need for laparotomy. RESULTS: Seventy-five of 376 neonates presented with MI. Fifty-four (92%) required laparotomy. Contrast enema decompression was attempted in nineteen. There were no post-operative deaths. Thirty-nine (72%) neonates with MI were managed with stomas. LOS was longer in those managed with stomas (p=0.001) and in complex MI (p=0.002). Thirty-five patients were treated for DIOS. Twenty-five patients were managed with gastrograffin. Ten patients underwent surgical management of DIOS. Overall, MI did not predispose to later development of DIOS. There was a significantly greater incidence of laparotomy for DIOS in children who had MI. CONCLUSION: The proportion of neonates with complex meconium ileus was high (49%) and may explain the infrequent utilisation of radiological decompression. Complex MI or management with stomas both significantly increase LOS. Re-laparotomy rate is high (22%) in MI irrespective of the type of management. DIOS is not a benign condition, particularly when the child has had previous abdominal surgery. Early referral to a surgical team is essential in these children.

[Outcomes of laparoscopic surgery after preoperative metallic stent placement for obstructive colorectal cancer].

AIM: To assess the outcomes of preoperative colonic stent placement for obstructive colorectal cancer. PATIENTS AND METHODS: A total of 30 patients with colorectal cancer were treated after preoperative colonic metallic stent placement between July 2012 and March 2014. We reviewed their medical records to assess the usefulness of stent placement and the clinical course. The effects of various clinicopathological variables on post-operative complications were analyzed statistically. RESULTS: Stent insertion was effective in 93% of the 30 patients with obstructive colorectal cancer. Preoperative colonoscopy or enema for proximal colonic survey was possible in 70% of the patients after stent placement; colonic lesions requiring simultaneous resection were noted in 5 patients (24%). The mean interval between stent insertion and operation was 19 days, and 23%of the patients underwent laparoscopic surgery. Statistical analysis revealed that the occurrence of complications was associated with laparoscopic surgery and the amount of operative blood loss. CONCLUSION: Preoperative stent placement in patients with obstructive colorectal cancer is feasible and laparoscopic surgery can be selected after stent placement.

Severely high serum unbound bilirubin level after abdominal surgery in a newborn.

We report a newborn with intestinal malrotation who developed a severely high serum unbound bilirubin level and a low serum albumin level without a marked increase in serum total bilirubin level after abdominal surgery, which required exchange transfusion and albumin supplementation. The serum unbound bilirubin level may be highly relative to the serum total bilirubin level in newborns who have undergone abdominal surgery soon after birth and are hypoalbuminemic after surgery.

Management of obstructive colorectal cancer: evaluation of preoperative bowel decompression using ileus tube drainage.

PURPOSE: This study evaluated a better treatment for patients with obstructive colorectal cancer (CRC) that have a poor prognosis. METHOD: This study compared the outcomes of 138 patients with obstructive CRC, including 70 primary resections, 50 resections after bowel decompression using an ileus tube, and 18 delayed resections after colostomy. RESULTS: The ileus tube and delayed resection groups included more left-sided primary lesions. The physiologic POSSUM, types 3-4, tumor size, CEA, and hospital stay of the delayed resection group were different, in comparison to both the primary resection and ileus tube groups. The histopathological type and depth of invasion of the delayed resection group included less well types and more T4 than those of the ileus tube group. The operative blood loss of the delayed resection group was more than that of the ileus tube group. There were no differences in the overall and disease-free survival among the three groups. CONCLUSION: Separately analyzing the data of the right-sided cancer group and the left-sided cancer group demonstrated that primary resection might be acceptable for right-sided obstructive CRC and delayed resection might be done for patients with poorer general conditions (high PPS) and poorer oncological prognostic factors such as more type 3/type 4 cases, a larger tumor size, a less well-differentiated histopathological type, more T4 cases, and a higher CEA level.

Meconium-related ileus in extremely low-birthweight neonates: etiological considerations from histology and radiology.

BACKGROUND: A nationwide survey on neonatal surgery conducted by the Japanese Society of Pediatric Surgeons has demonstrated that the mortality of neonatal intestinal perforation has risen over the past 15 years. The incidence of intestinal perforation in extremely low-birthweight (ELBW) neonates has been increasing as more ELBW neonates survive and as the live-birth rate of ELBW has increased. In contrast to necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP), the pathogenesis of meconium-related ileus, defined as functional bowel obstruction characterized by delayed meconium excretion and microcolon, remains unclarified. METHODS: The histology of 13 ELBW neonates with intestinal perforation secondary to meconium-related ileus was reviewed, and the radiology of 33 cases of meconium-related ileus diagnosed on contrast enema was reviewed. Specimens obtained from 16 ELBW neonates without gastrointestinal disease served as age-matched controls for histological assessment. RESULTS: The size of the ganglion cell nucleus in meconium-related ileus and in control subjects was 47.3 ± 22.0 µm(2) and 37.8 ± 11.6 µm(2), respectively, which was not significantly different. In all cases of meconium-related ileus, contrast enema demonstrated a microcolon or small-sized colon, with a gradual caliber change in the ileum and filling defects due to meconium in the ileum or colon, showing not-identical locations of caliber changes and filling defects. CONCLUSION: Morphological immaturity of ganglia was not suggested to be the pathogenesis of meconium-related ileus. Impaction of inspissated meconium is not the cause of obstruction, but the result of excessive water absorption in the hypoperistaltic bowel before birth, although the underlying mechanism responsible for the fetal hypoperistalsis remains unclear.

Issues in the management of simple and complex meconium ileus.

INTRODUCTION: Various surgical methods are used to treat meconium ileus (MI), including resection with enterostomy (RES), primary anastomosis (RPA), and purse-string enterotomy with intra-operative lavage (PSI). The aim of this study is to discuss the surgical treatment of MI, based on our experience. PATIENTS AND METHODS: Of the 41 MI patients treated at our institution between 1984 and 2007, 18 had simple MI and 23 had complex MI. These groups were analyzed according to treatment modality, concentrating on length of hospital stay, complications [peritonitis, septicemia, adhesive small bowel obstruction (ASBO), and malabsorption/diarrhea], need for additional surgical procedures, mortality. RESULTS: Of the 18 patients with simple MI, 7 (39%) were successfully treated with diluted Gastrografin® enema. The remaining 11 patients were treated surgically: two underwent RPA, of whom one died; five had RES, of whom one developed ASBO; four underwent PSI, of whom two developed peritonitis. In the complex MI group, 14 patients underwent RPA, with peritonitis occurring in three (one died); nine underwent RES, of whom two developed ASBO. CONCLUSION: In patients with simple MI, conservative treatment with diluted Gastrografin® enema is an effective initial treatment in our hands. In case of failure, RES is advisable. Patients with complex MI are candidates for RES. RPA and PSI seem to have higher complication rates.

Diminishing role of contrast enema in simple meconium ileus.

PURPOSE: Contrast enema is the initial study of choice for simple meconium ileus to confirm diagnosis and to relieve obstruction. Despite favorable historically published results, our clinical impression suggests decreased effectiveness of the contrast enema resulting in more surgical interventions in contemporary practice. METHODS: A retrospective multiinstitutional review for a 12-year period was conducted for neonates diagnosed with meconium ileus by contrast enema. The neonates were divided into 2 groups-historic group (HG = before 2002) and contemporary group (CG = after 2002). T test was used for comparison of continuous variables and chi(2) for categorical data. RESULTS: Thirty-seven total patients were identified (21 females and 16 males). Obstruction was relieved in 8 neonates (22% overall success rate). Average enema attempt per patient was decreased in the CG group compared to HG (1.4 vs 1.9). The success rate in the CG group was 5.5% (1/18) compared to 39% (7/18) in HG. CONCLUSIONS: In this review, success of contrast enema for relief of meconium ileus has significantly decreased over time. These findings may be because of reluctance to repeat enemas, change in radiologist experience, or use of contrast agent. As a result, higher rates of operative intervention are now observed. In stable patients, surgeons should recommend repeat enemas before exploration.

[Laparoscopic coincidental finding in a case of incomplete ileus: adenocarcinoma of the small intestine as first manifestation of Crohn's disease]. / Laparoskopischer Zufallsbefund bei inkomplettem Ileus: Adenokarzinom des Dünndarms als Erstmanifestation eines Morbus Crohn.

The case-study reminds of adenocarcinoma of the small intestine as a rare complication of Crohn's disease. A few more than 100 of these cases have been published. Epidemiological studies concerning small bowel carcinoma showed consumption of sugar and carbohydrates as pathogenetic factors, other conditions like ileostoma, ileumconduit, Crohn's disease and coeliac disease have been identified to some extent. An adenoma-carcinoma sequence as in large intestine carcinoma has been discussed. Immunohistochemical and oncogenetic findings failed to demonstrate any result of practical clinical value. Diagnosis of early stages of adenocarcinoma of the small intestine is very difficult and thus might be impossible to differentiate from exacerbation or progressive stenosis of preexisting Crohn's disease. If non-invasive diagnostic measures (ultrasound, small bowel enema, CT-scan, intestinoscopy, radiography, NMR-Sellink, capsule-endoscopy) fail to clear the situation a diagnostic laparoscopy or even laparotomy should not be delayed. This constitutes the only chance to discover early stages which can possibly be cured in accordance with oncosurgical principles. Otherwise the prognosis remains poor with a high percentage of late stages and a 5-year-survival-rate between 20 and 50 percent.

[A case of advanced rectal carcinoma with multiple lung metastases responding to irinotecan combined with 5-fluorouracil and l-leucovorin (IFL) as neoadjuvant chemotherapy (NAC)].

A 53-year-old man, admitted for inguinal hernia, complained of body weight loss in a preoperative condition check. We examined the digestive tract and diagnosed stage IV advanced rectal carcinoma with multiple lung metastases. It caused ileus, so emergency colostomy was performed. After that his general condition recovered, and two cycles of neoadjuvant chemotherapy (NAC) by irinotecan combined with 5-fluorouracil and l-leucovorin (IFL) therapy were performed on an outpatient basis. Lung metastatic nodules disappeared. We established a diagnosis of down staging for stage IIIa, and performed a lower anterior resection with D 2 lymph node dissection to allow a curability-A resection. The pathological effect of NAC was Grade 2. Post-operatively, two cycles of IFL therapy were then performed. There has been no sign of recurrence, and no adverse effects by chemotherapy have been seen during this treatment. Thus, NAC by IFL therapy can be one of the useful treatment approaches for patients with advanced rectal cancer.

[A case report: an ileus caused by cecal volvulus and intersigmoidal hernia due to mesenterium commune].

A 33-year old woman was referred to our hospital because of gradually progressing abdominal pain and abdominal distension. A computed tomography demonstrated that distended cecum was located in the left retroperitoneal space. Barium enema revealed that the descending colon was positioned at the right side of the abdomen and transverse colon became severely tapered. Ceacal volvulus in addition to the internal herniation into the left retroperitoneal space was clinically diagnosed. The patient received an emergent operation. Operative findings showed that mesenterium commune, no fixation of the colon to the retroperitonium, and the internal herniation of terminal ileum to transverse colon into the sigmoid mesentery. Moreover, the cecal volvulus was diagnosed at the left retroperitoneal space. The mesenterium commune with internal herniation and cecal volvulus is extremely rare but one of important causes of acute abdomen.

[Acute treatment of colon cancer]. / Akut behandling af coloncancer.

The primary treatment of left-sided colonic ileus due to cancer is after localisation of the tumor with water-soluble contrast enema placement of an intraluminal, self-expanding metal stent. If this treatment is unsuccessful, open resection with primary anastomosis is the treatment of choice. In the case of a perforated tumor, resection and primary anastomis may be performed if the patient s general condition is acceptable.

Colon stenosis caused by old portal vein thrombosis.

A 58-year-old female with a history of portal vein thrombosis was referred to our hospital with abdominal pain and distention. Colon fiber and enema of the colon showed stenosis at the transverse colon and the ascending colon, with edematous mucosa. Laparotomy revealed no abnormal findings other than chronic ischemia of the colon. To our knowledge, this is the first reported case of colon stenosis caused by portal vein thrombosis.