Unusual right upper quadrant Stump Appendicitis.

Stump appendicitis is often not considered in patients with a surgical history of appendectomy. We report an unusual case of right upper quadrant stump appendicitis after previous operation for intussusception with incidental appendectomy. Abdominal computed tomographic scan is more efficient to make an early diagnosis of stump appendicitis to prevent further complications and prolonged hospitalization.

The learning curve for hand-assisted laparoscopic colectomy: a single surgeon's experience.

BACKGROUND: Surgical experience and outcomes for hand-assisted laparoscopic colectomy were evaluated to define a learning curve. METHODS: This study included 60 patients who underwent hand-assisted laparoscopic colectomies performed by a single surgeon. They were analyzed as three consecutive equal groups: A, B, and C. Pearson's chi-square test and one-way analysis of variance (ANOVA) were used to compare differences in demographics and perioperative parameters. Operative times were analyzed to document the learning curve for the procedure. RESULTS: There were no significant differences between the three groups in terms of age, sex, operative procedure, or comorbidity. Groups B and C showed significantly shorter operative times, significantly earlier recoveries of gastrointestinal function, less blood loss, and shorter hospital stays than group A. The incidence of operative complications was not significantly different among the three groups (35% vs 5% vs 15%; p = 0.07). CONCLUSIONS: Approximately 21 to 25 cases were needed to achieve proficiency in this series.

Irrigation management of sigmoid colostomy.

Questionnaires were sent to 270 patients who had undergone abdominoperineal resection and sigmoid colostomy at the Mayo Clinic, Rochester, Minn, during the ten years from 1972 to 1982; 223 patients returned their questionnaires with evaluable data. Sixty percent of the patients were continent with irrigation, and 22% were incontinent with irrigation. Eighteen percent had discontinued irrigation for various reasons. The proportion continent was higher in women, younger patients, and previously constipated patients. A poorly constructed colostomy may cause acute angle, parastoma hernia, stomal prolapse, or stenosis and thus be the cause of failure of irrigation.

Surgical treatment of radiation injuries of the colon and rectum.

Between 1950 and 1983, radiation-induced proctitis was diagnosed proctoscopically in 720 patients at the Mayo Clinic. Sixty-two patients with severe colorectal symptoms were treated surgically. The interval from cessation of radiotherapy to onset of symptoms ranged from 3 weeks to 24 months (mean 33 months). The 62 patients underwent a total of 143 operations with 8 operative deaths (13 percent), and 40 patients (65 percent) had 61 complications. The morbidity rate was lower after colostomy alone (44 percent in 27 patients) than after more aggressive operations (80 percent in 35 patients). Transverse loop colostomy and descending colostomy were safer than sigmoid colostomy. The dissection adhesions, opening of tissue planes, and careless manipulation of intestine may result in necrosis and perforation of the intestine, bladder, or vaginal wall; these were the main causes of fecal and other internal fistulas in our study.

Hand-assisted laparoscopic colectomy vs open colectomy: a prospective randomized study.

BACKGROUND: We compared the perioperative parameters and outcomes achieved with hand-assisted laparoscopic colectomy (HALC) vs open colectomy (OC) for the management of benign and malignant colorectal disease, including cancer patients treated with curative intent. METHODS: Sixty eligible patients were randomized to either HALC (n = 30) or OC (n = 30) treatment groups. We used Pearson's chi-square and two-sample t-tests to compare the differences in demographics and perioperative parameters. RESULTS: There were no significant differences in age, gender distribution, disease pattern, operative procedure, comorbidity, or history of abdominal surgery. The HALC patients had significantly shorter hospital stays and incision lengths, faster recovery of gastrointestinal function, less analgesic use and blood loss, and lower pain scores on postoperative days 1, 3, and 14. There were no significant differences in operative time, complications, or time to return to normal activity. CONCLUSION: Hand-assisted laparoscopic colectomy (HALC) is safe and produces better therapeutic results in terms of perioperative parameters than OC.

Rectal prolapse as initial clinical manifestation of colon cancer.

Rectal prolapse as the initial clinical manifestation of colorectal cancer is uncommon. We describe the case of a 75-year-old woman who was diagnosed as having adenocarcinoma of the sigmoid colon after presenting with complete rectal prolapse. The tumor caused rectosigmoid intussusception and then it prolapsed out through the anus. She underwent rectosigmoidectomy and rectopexy. The postoperative course was uneventful. The relationship between colorectal cancer and rectal prolapse has not been clearly established. This case report describes an unusual presentation of colorectal cancer. It suggests that rectal prolapse can present as the initial symptom of colorectal cancer and may also be a presenting feature of the occult intra-abdominal pathology. The importance of adequate investigation such as colonoscopy should be emphasized in patients who develop a new onset of rectal prolapse.

Surgical management and clinical outcome of gastrointestinal stromal tumor of the colon and rectum.

BACKGROUND: A standardized treatment for gastrointestinal stromal tumors (GIST) of the colon and rectum has not been clearly established. The objective of this study is to examine our experience in patients with colorectal GISTs and review the appropriate surgical management. METHODS: The medical records of patients with colorectal GIST treated in our institution between 1995 and 2005 were reviewed. The malignant potential of the GIST was assessed with the current consensus criteria defined by the National Institutes of Health. Clinical parameters were also evaluated to determine prognostic factors. RESULTS: There were 10 male and 7 female patients, with a median age of 64 years (range: 19 - 84). Bloody stool and abdominal pain were the most commonly reported symptoms in colorectal GISTs. There were 7 colonic GISTs and 10 rectal GISTs. Sixteen patients underwent surgery with a margin of negative resection including 12 radical surgical resections, 3 transanal wide excisions, and one colonoscopic excision. Pathological results revealed a high risk in 8 patients (47.1 %), an intermediate risk in 4 (23.5 %), a low risk in 3 (17.6 %), and a very low risk in 2 (11.8 %). Three patients (3 / 16, 18.6 %) developed disease relapse after primary radical resection. All the three patients were high-risk rectal GISTs, accounting for 42.9 % (3 / 7) in the high-risk group. The median time to disease relapse was 15.7 months (range: 6 - 24). Cox regression analysis showed that variables including age, gender, and tumor size were not presenting statistically significant differences between groups of relapse and non-relapse patients. CONCLUSION: Non-high-risk colorectal GISTs bear a good prognosis after margin-negative surgery. Transanal wide excision for non-high-risk GISTs is mandatory if a complete resection can be performed. Abdominoperineal resection would be preserved only in patients with high risk or large non-high-risk lower rectal GISTs. The high-risk group has high incidence of relapse even though a complete resection was achieved. Adjuvant therapy with a tyrosine kinase inhibitor would be beneficial to these patients.

Comparison of the effects of thoracic epidural analgesia and i.v. infusion with lidocaine on cytokine response, postoperative pain and bowel function in patients undergoing colonic surgery.

BACKGROUND: Both thoracic epidural analgesia (TEA) and i.v. lidocaine were able to decrease postoperative pain and duration of ileus. We compared TEA and i.v. lidocaine (IV) regarding their effects on cytokines, pain and bowel function after colonic surgery. METHODS: Sixty patients were randomly allocated to one of the three groups. TEA group had lidocaine 2 mg kg(-1) followed by 3 mg kg(-1) h(-1) epidurally and an equal volume of i.v. normal saline. The IV group received the same amount of lidocaine i.v. and normal saline epidurally. The control group received normal saline via both routes. These regimens were started 30 min before surgery and were continued throughout. Blood cytokines were measured at scheduled times within 72 h. RESULTS: Both TEA and IV groups had better pain relief. The total consumptions using patient-controlled epidural analgesia were 81.6 (6.5), 55.0 (5.3) and 45.6 (3.9) ml (P<0.01) and the times of flatus passage were 50.2 (4.9), 60.2 (5.8) and 71.7 (4.7) h (P<0.01) in the TEA, IV and control groups, respectively. The TEA group exhibited the best postoperative pain relief and the least cytokine surge. The IV group experienced better pain relief and less cytokine release than the control group. CONCLUSIONS: The TEA lidocaine had better pain relief, lower opioid consumption, earlier return of bowel function and lesser production of cytokines than IV lidocaine during 72 h after colonic surgery; IV group was better than the control group.

Combined general-epidural anesthesia decreases the desflurane requirement for equivalent A-line ARX index in colorectal surgery.

BACKGROUND: The present study used the A-line ARX index, derived from auditory evoked potential measurements, to examine the effect of epidural lidocaine on the end-tidal concentration of desflurane during general anesthesia. METHODS: Thirty ASA I-II patients scheduled for elective colorectal surgery were included and randomized, in a double-blinded fashion, to receive general anesthesia, and 15 ml of either 2% lidocaine (group GE, n=15) or normal saline (group GS, n=15) was administered epidurally with a maintenance infusion rate of 6 ml h-1. After a 10-min high-flow oxygen wash-in period, desflurane was titrated to a target A-line ARX index (AAI) of 20+/-5. RESULTS: Epidural lidocaine reduced the end-tidal concentration of desflurane required to maintain an adequate clinical effect by 42% compared to general anesthesia alone (2.6% vs. 4.5%, respectively; P<0.001). The initial mean value of AAI was 87.8 (range 78-99) in group GE and 88.13 (79-99) in group GS before general anesthesia induction, the AAI values were approximately 19.7 (15-25) in group GE and 20.2 (16-25) in group GS during anesthesia maintenance, and returned to 84.53 (77-98) in group GE and 86.87 (79-98) in group GS when the patients regained consciousness in the recovery room. No statistical difference in the AAI values was observed either before, during, or after emergence of anesthesia. No patient reported intraoperative awareness. CONCLUSIONS: Lower-than-expected concentrations of volatile anesthetics are sufficient to maintain appropriate a clinical anesthesia effect during combined general-epidural anesthesia under auditory-evoked potential monitoring.

Effect of germanium on 1,2-dimethylhydrazine-induced intestinal cancer in rats.

Through recent research, the trace element, germanium, was found to have an anticancer effect. The purpose of this research was to determine the effect of germanium on 1,2-dimethylhydrazine-induced intestinal cancer in rats. Ninety-six 8-week-old Sprague-Dawley male rats were divided into 4 groups, with 24 rats in each group. All received dimethylhydrazine, 20 mg/kg body weight, subcutaneously, once a week for 20 weeks. Except for one control group, the other three groups were subdivided into six groups and administered three different kinds of germanium (inorganic germanium, organic germanium, and natural organic germanium) one month before and during dimethylhydrazine treatment, and during dimethylhydrazine treatment, respectively. Twenty-four weeks after carcinogen exposure, all surviving animals were sacrificed and examined for intestinal tumors. The number and location of the tumors were recorded and the pathology examined. The incidence of intestinal cancer in the control group (dimethylhydrazine only) was 91 percent; in groups provided with inorganic germanium one month before and during dimethylhydrazine treatment, and during dimethylhydrazine treatment only, it was 91 and 78 percent; in groups provided with organic germanium one month before and during dimethylhydrazine treatment, and during dimethylhydrazine treatment only, it was 64 and 64 percent; in groups provided with natural organic germanium one month before and during dimethylhydrazine treatment and during dimethylhydrazine treatment only, it was 50 and 45 percent. From these results, the authors conclude that natural organic germanium has the best prevention effect for intestinal cancer in this animal model (P less than 0.01), followed by organic germanium (P less than 0.05). Inorganic germanium has no effect. However, there is no difference in the cancer prevention effect of germanium provided one month before and during dimethylhydrazine treatment, and during dimethylhydrazine treatment only.

Effect of selenium on 1,2-dimethylhydrazine-induced intestinal cancer in rats.

PURPOSE: This study was designed to determine the cancer prevention and therapeutic effects of selenium on rats treated with 1,2-dimethylhydrazine (DMH). METHODS: One hundred sixty Spraque-Dawley male rats were divided into seven groups and received 20 mg/kg/week DMH, subcutaneously for 20 weeks. Two different dosages of selenium (8 and 4 ppm) were administered to the rats through drinking water during DMH treatment (B and C groups) or one month before and during DMH treatment (D and E groups). The rats of Groups A (control group), B, C, D, and E were killed immediately after the last DMH injection. The incidence of intestinal cancer in each group was compared. Eight ppm selenium was also administered to rats after DMH treatment (Group F), and survival times were observed and compared with Group G (treated with DMH only). RESULTS: Rats of Groups B and D received 8 ppm selenium and had a significantly decreased incidence of intestinal cancer (from 65.8 percent (Group A) to 33.3 percent (Group B) and 27.8 percent (Group D); P = 0.0225 and 0.0038). Rats receiving 4 ppm selenium had a relatively decreased incidence of intestinal cancer (from 65.8 percent (Group A) to 44.4 percent (Group C) and 47.1 percent (Group E) but P > 0.05). Survival time of Groups F and G showed no difference. CONCLUSIONS: Eight ppm selenium provided via drinking water has a significant intestinal cancer prevention effect in the presence of a high dose of DMH (20 mg/kg x 20 weeks), and the cancer therapeutic effect of selenium is doubtful in this animal model.

Lymphatic cyst of the colon: a case report.

A rare case of a lymphatic cyst of the ascending colon is reported. The lobulated and fluctuant lesion, located in the hepatic flexure, was diagnosed by barium enema and colonoscopy, incidentally. Surgical treatment with segmental resection of the ascending colon was done because of the risk of obstruction and the question of an underlying malignancy. The clinical features, appropriate treatment, preoperative diagnosis and histopathology are discussed. We emphasize that lymphatic cysts are very rare and are difficult to identify by radiology or colonoscopy before surgery. They must be included in the differential diagnosis of submucosal tumors such as lipomas, leiomyomas and hemangiomas.

Microencapsulation [corrected] of tumor cells and assay for selecting anticancer drugs.

A microencapsulation of living tumor cells by an improved membrane and droplet forming technique was established in our laboratory. This semipermeable microencapsulating membrane was impermeable to serum albumins (M.W. 66,000 or 45,000) and human hemoglobin (M.W. 64,000), but permitted passage of low molecular weight substances (alpha-Lactalbumin, or Trypsinogen; M.W. 14,200 or 24,000). The in vivo results showed that microencapsulated tumor cell lines (KB, human oral epidermoid cell; P-388 lymphocytic leukemia; GBM 8401/TSGH, glioma) and human colorectal carcinoma cells grew and proliferated exponentially within twenty days. The in vivo growth exhibited better than that in vitro. Histological and morphological findings of these four different kinds of tumor cells are similar to those of original tumor cells. Treatment of the microencapsulated tumor cells (MTC) with cytotoxic drugs (adriamycin, 5-fluorouracil and cyclophosphamide) in vitro showed no significant difference in percent inhibition (p greater than 0.05) between the encapsulated and non-encapsulated cells. The in vivo data indicated that different anti-cancer drugs had different inhibition effects. The results showed that the MTC model was useful for screening an appropriate cytotoxic drug and could be applied to clinical medicine in the near future.