Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery.

BACKGROUND: Defaecatory function is often poor after anterior resection. Denervation of the neorectum following high ligation of the inferior mesenteric artery (IMA) is a possible cause of impaired defaecatory function. The purpose of this randomized clinical trial was to clarify whether the level of ligation of the IMA in patients with rectal cancer affects defaecatory function. METHODS: Between 2008 and 2011, patients who underwent anterior resection for rectal cancer were randomized to receive either high or low ligation of the IMA. The primary endpoint was to demonstrate the superiority of low ligation in terms of defaecatory function. RESULTS: One hundred patients were enrolled in the study; 51 were randomized to high ligation of the IMA and 49 to low ligation. There were no differences between the groups in terms of clinical data, except tumour stage, which was more advanced in the high-ligation group (P = 0·046). Nor were there any differences in defaecatory function, self-assessment of defaecation, Faecal Incontinence Quality of Life scale or continence score between groups at 3 months and 1 year. The number of harvested lymph nodes was similar. The rate of symptomatic anastomotic leakage was 16 per cent in the high-ligation group and 10 per cent in the low-ligation group (P = 0·415). CONCLUSION: The level of ligation of the IMA in patients with rectal cancer did not affect defaecatory function or the incidence of postoperative complications. REGISTRATION NUMBER: NCT00701012 (http://www.clinicaltrials.gov).

Brachytherapy technique for abdominal wall metastases of colorectal cancer: ultrasound-guided insertion of applicator needle and a skin preservation method.

PURPOSE: To report a technique of interstitial brachytherapy for the treatment of subcutaneous metastatic abdominal wall tumors. MATERIAL AND METHODS: We developed a brachytherapy technique consisting of ultrasound-guided insertion of applicator needles to avoid the organs at risk, such as intestines, and saline injection into the subcutaneous tissue between the tumor and the skin to decrease the skin dose. We encountered three patients with painful metastases from rectal carcinoma in the abdominal wall refractory to external radiotherapy. They were subjected to this brachytherapy with a single dose of 20 Gy. RESULTS: The procedure was safely achieved in all three patients. Long-lasting pain reduction and tumor shrinkage was obtained without early or late complications. CONCLUSION: This interstitial brachytherapy technique seems to be feasible in the treatment of metastatic abdominal wall tumors.

Effectiveness of the clinical pathway to decrease length of stay and cost for laparoscopic surgery.

BACKGROUND: Although clinical pathways have become popular strategies to improve the quality of medication in the field of laparoscopic surgeries, their economical effectiveness is not well defined. The aim of this study was to investigate the effect of clinical pathways for laparoscopic surgeries on cost and length of hospital stay. METHODS: From January 2000 to June 2001, clinical pathways were introduced for laparoscopic surgeries, such as laparoscopic cholecystectomy (Lap. C, n = 210), laparoscopically assisted distal gastrectomy with Billroth-I reconstruction (Lap. B-I, n=33), and laparoscopically assisted colectomy (Lap. colon, n=34). We compared total lengths of hospital stay and the economical efficiency before and after pathway implementation at Wakayama Medical University Hospital. RESULTS: The length of hospital stay in Lap. C was shortened from 7.8+/-2.6 (mean+/-SD) days to 6.9+/-2.0 days (p = 0.03) and the total costs during hospitalization decreased from yen 509,320+/-58,800 to yen 489,130+/-43,860 (p=0.009), resulting in less burden for patients. At the same time, the daily costs were increased from yen 66,230+/-8920 to yen 70,840+/-6820 (p=0.0001), indicating that more efficient medical care was being given to patients. Similar results were obtained in Lap. B-I and Lap. colon groups. CONCLUSIONS: In our study, the implementation of clinical pathways in the field of laparoscopic surgeries produced significant decreases in length of total hospital stay and cost while maintaining the quality of patient outcomes.

Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature.

HYPOTHESIS: Hepatic portal venous gas (HPVG) has been considered a rare entity associated with a grave prognosis. Since 1978, when Liebman et al reviewed 64 cases of HPVG and reported a mortality of 75%, the number of reported cases has been increasing. DESIGN: Case series. PATIENTS AND METHODS: We reviewed the literature on 182 cases of HPVG in adults, including 4 of our patients, (transplantation and abdominal trauma cases were excluded) and analyzed the cause, pathogenesis, and clinical features. RESULTS: In this series, the underlying clinical events associated with HPVG were bowel necrosis (43%), digestive tract dilatation (12%), intraperitoneal abscess (11%), ulcerative colitis (4%), gastric ulcer (4%), Crohn disease (4%), complications of endoscopic procedures (4%), intraperitoneal tumor (3%), and other (15%). The overall mortality was 39% but varied depending on the underlying disease. CONCLUSIONS: Hepatic portal venous gas is a lethal or curable entity caused by various diseases. The underlying disease associated with HPVG determines the clinical features and prognosis of the patients. The treatment of patients with HPVG should be directed to the underlying disease.

[Adverse effects of intravenous fat emulsion administration].

Fat emulsion has been widely accepted a parenteral nutrient for the prevention of essential fatty acid deficiency and the supply of a high energy source. The following problems associated with the administration of fat emulsion are, however, well recognized: 1) The soy protein detected slightly in soy bean oil may induce allergic reactions. 2) Although administered in small quantities emulsified fat particles over 5 microns in diameter can cause fat emboli, including as pulmonary, splenic, placental, and cerebral emboli. 3) Hyperlipidemia may cause pulmonary hypertension and hemophagocytosis when triglycerides contained in the fat emulsion are intravenously administered at a rate greater than 0.1g/kg/hour. 4) Fat emulsion may have immunosuppressive effects, because emulsified fat particles phagocytized by the reticuloendothelial system reduce its functions. Long-chain triglyceride of the omega-6 series can suppress the functions of lymphocytes and neutrophils through prostaglandins. 5) Fungal infections, especially with Malassezia furfur which requires fat for growth, are sometimes associated with intravenous fat emulsion infused through a central venous catheter.

Laparoscope-assisted Billroth I gastrectomy.

We performed a distal gastrectomy, including regional lymph node dissection, under laparoscopic observation followed by Billroth I. (B-I) anastomosis using autosuture in five patients with early gastric cancer. We had previously evaluated the technique for reconstructive surgery in animal experiments. Our method was determined to be safe without marked deformation caused by applying the autosuture for gastroduodenostomy. The wound was small, and an almost closed operation was possible. Furthermore, unlike endoscopic mucosal resection or laparoscopic partial resection, a major part of the regional lymph nodes can be extirpated; the lesion site may not be limited to the half of the stomach on the distal side. Our method of distal gastrectomy under laparoscopy is a potentially useful limited operation in patients with early gastric cancer.

[Clinical effect of arbekacin on MRSA infections after gastrointestinal surgery].

From January 1991 to July 1993, 58 patients with MRSA infections in our clinic at Wakayama Medical College and six affiliated hospitals were administered with arbekacin (ABK). The clinical results were as follows: 1. The clinical efficacy rates of ABK were 84% in pneumonia, 100% in both wound infections and hepatobiliary tract infections, and 85% in total. The bacteriological efficacy rate was 83%. 2. Regarding the administration route, the clinical efficacy rates were 60-79% by the intravenous treatment and inhalation therapy. Especially by the local administration with ABK, MRSA was eradicated in all cases. 3. The sufficient efficacy was obtained by the treatment of ABK alone (89%) and by the combined treatment with ABK (82%) and another antibiotics. From these results, it is concluded that ABK is useful for the treatment of MRSA infections after gastrointestinal surgery.

Endoscopic microwave coagulation therapy for villous adenoma of the duodenum--a case report.

The effects of endoscopic microwave coagulation therapy on duodenal adenoma in a 58-year-old man are reported. The patient had a 35-mm sessile tubulo-villous adenoma in the duodenal bulb. Endoscopic polypectomy followed by microwave coagulation therapy for duodenal adenoma was performed to avoid a major surgical procedure which would disturb the physiological functions of the gastrointestinal tract. After partial polypectomy which included the core of the adenoma, the entire remaining adenoma was destroyed after three microwave therapy sessions. During a follow-up period of 14 months, neither endoscopic nor histologic evidence of recurrence has been noted. Endoscopic microwave coagulation therapy is considered to be useful in the treatment of large sessile duodenal villous adenoma, provided that repeated endoscopic follow-up surveillance is also performed.

[Arteriovenous malformation associated with cyst. Case report].

The authors present the fifth reported case of arteriovenous malformation (AVM) associated with cyst formation. Among these five cases, computed tomography has demonstrated two types of cyst: round, and slit-like with low density. The three patients with slit-like cysts experienced sudden, severe headache, probably due to hemorrhage. The two patients with round cystic lesions did not have sudden headache, and at surgery the cysts were found to contain a mural nodule. These facts suggest that there may be two different mechanisms of cyst formation in the vicinity of an AVM: hemorrhage (slit-like cysts) and exudation (round cysts).

Cystic arteriovenous malformation. A case report.

The authors report on a rare case of arteriovenous malformation (AVM) associated with cyst formation. Only five similar cases have been reported. CT findings of the cyst are divided into two types: 1) slit-like low density and 2) round one. Three patients showing slit-like cysts had experienced sudden severe headaches, probably due to haemorrhage. In contrast, two patients showing round cystic lesions had not experienced such sudden headaches and they revealed a nodule in the cyst at surgery. These facts suggest that there may be two different mechanisms for cyst formation in AVM's: haemorrhage and exudation. Slit-like cysts may result from old haemorrhage from the AVM nidus. Round cystic lesions may be due to exudation from the AVM nidus.

[5-FU concentration in tumor tissue and the antitumor effect in patients with gastric cancer after oral administration of UFT].

Serum and tumor tissue concentration of FT, 5-FU and uracil were measured in 23 patients with gastric cancer who were administered UFT preoperatively. The degeneration of cancer cells was evaluated histologically and the correlation between 5-FU concentration in the tumor tissue and the antitumor effect was assessed. The average concentration of 5-FU in tumor tissue (0.122 microgram/g) was significantly higher than that in normal gastric tissues. Serum 5-FU concentration was very low, suggesting no accumulation of 5-FU in blood. A positive correlation between the concentration of 5-FU and uracil in tumor tissues was found. A 5-FU level higher than 0.05 microgram/g was frequently demonstrated in tumor tissue, resulting in moderate degeneration of cancer cells in many cases. When tumors were classified according to histological type, intratumoral 5-FU concentration was not always correlated with degeneration of cancer cells. The above results suggested that UFT was a very effective drug for stomach cancer because of high tumor affinity for 5-FU, but that it is necessary to consider the sensitivity of tumor cells to antitumor drugs in order to obtain an excellent antitumor effect.