Successful treatment of recurrent volvulus in the afferent limb of the pouch following proctocolectomy for ulcerative colitis: a case report.

BACKGROUND: Pouch volvulus after proctocolectomy for ulcerative colitis is a very rare postoperative complication. The common site of pouch volvulus has been reported to be the ileal pouch-anal anastomosis and the middle part of the pouch, but no reports on pouch volvulus in the afferent limb of the pouch have been observed. Here, we report the case of a patient with afferent limb volvulus who underwent afferent limbpexy, but required reoperation 7 months later. CASE PRESENTATION: A 38-year-old man with refractory ulcerative colitis had undergone open proctocolectomy 10 years ago at another hospital. He had been aware of lower abdominal pain and bowel movement difficulty for 2 years. After repeated bowel obstruction, he was referred to our hospital for surgery. Based on the radiographic findings, we diagnosed a pouch volvulus and performed an operation. Laparoscopically, counterclockwise rotation of the afferent limb of the pouch was recognized. Moreover, the ileal mesentery was adhered and fixed to the presacral space 20 cm from the oral side of the pouch. The antimesenteric side of the afferent limb was fixed using interrupted stiches on the left peritoneal wall of the pelvis. He was discharged uneventfully 18 days after surgery, and defecation improved immediately. However, he was readmitted 7 months after surgery with the same abdominal pain and defecation difficulty. A similar finding was found and diagnosed as recurrent volvulus. Therefore, we performed a laparoscopic surgery. The same volvulus as in the previous surgery was confirmed. The site fixed during the previous surgery showed scars, but the afferent limb was free. The dilated ileum that contained the volvulus was excised only on the oral side of the pouch and an intraluminal anastomosis was performed on the anterior wall of the pouch. He had a good postoperative course and was discharged. CONCLUSION: Proper diagnosis of volvulus based on the characteristic imaging findings is important. In principle, bilateral row fixation of the rotated ileum is the basic procedure for volvulus. However, fixation with this technique is sometimes difficult. Therefore, this procedure is one of the useful options for the fixation of difficult or recurrent cases.

Safe transanal tumor resection using a harmonic scalpel.

We performed a safe and simple transanal tumor resection involving total layer resection using a harmonic scalpel as a resecting device. Here we report the results of our experience with this technique between 2005 and 2011. This study involved 32 patients who underwent transanal tumor resection using a harmonic scalpel. The subjects comprised 18 men and 14 women ranging in age from 34 to 87 years (mean: 64.5 years). The tumors measured 8 to 70 mm (mean: 31 mm) in diameter. The operation took 7 to 86 minutes (mean: 29 minutes), and the amount of bleeding was 0 to 165 mL (mean: 16.2 mL). There was no intraoperative blood loss that necessitated hemostatic procedures. Histopathologically, the lesions included hyperplastic polyp in 1 case, adenoma in 9, carcinoma in situ in 7, submucosal invasive cancer in 6, muscularis propria cancer in 4, carcinoid in 1, malignant lymphoma in 1, gastrointestinal stromal tumor in 1, mucosal prolapsed syndrome in 1, and mucosa-associated lymphoid tissue lymphoma in 1. With our technique, en bloc resection was achieved in all patients, and the use of a harmonic scalpel enabled us to complete the operation within 30 minutes, on average, without intraoperative bleeding.

Depth of submucosal invasion in the sessile and superficial types of submucosal invasive colorectal carcinoma: objective versus subjective measurement.

BACKGROUND/AIMS: When endoscopic resection (ER) is performed for submucosal invasive colorectal carcinoma (SICC), it may be difficult to determine whether to perform follow-up observation or surgical resection with lymph node dissection. The Japanese Guidelines provide guidelines for additional treatment after ER. Depth of submucosal invasion (SM depth) is measured in the same manner for both the sessile type and the superficial type. We compared the SM depth in the sessile and superficial types of SICC. METHODOLOGY: Among patients who underwent surgical resection of SICC between 1990 and 2010, this study included 118 consecutive patients with SICC. The SM depth in the sessile and superficial macroscopic morphological types was evaluated on the basis of both objective and subjective measurement of SM depth. RESULTS: The SM depth overall was significantly greater in the sessile type (p < 0.0001). In SM1 cancer, no significant difference was seen between the two groups. In SM2 and SM3 cancer, SM depth in the sessile type was significantly greater than that in the superficial type (p < 0.0001). CONCLUSIONS: In the basis of subjective measurement of SM depth, it was suggested that the sessile and superficial types of SICC may need to be evaluated separately to determine the correlation.