Colon Ischemia Associated with Buerger's Disease: Case Report and Review of the Literature

Buerger''s disease, or thromboangiitis obliterans, is a nonatherosclerotic inflammatory disease affecting the small- and medium-sized arteries and veins of the extremities (arms, hands, legs, and feet). It is most common in the Orient, Southeast Asia, India, and the Middle East, and usually affects men aged between 20 and 40 years, although it is becoming more common in women. It is well established that most such patients smoke heavily and experience an improvement in symptoms following smoking cessation. Mesenteric involvement in Buerger''s disease is extremely rare; however, we describe herein two cases of colon ischemia in patients who were previously diagnosed with lower-extremity Buerger''s disease. In one case, the patient developed colonic obstruction, and surgical resection was performed. Histopathologic findings were compatible with the chronic stage of Buerger''s disease. In the other case, angiography revealed abrupt occlusion of the inferior mesenteric artery with numerous collateral vessels, just like the corkscrew appearance found in the extremities. If patients with established Buerger''s disease of the extremities complain of gastrointestinal symptoms, early interventional diagnosis should be performed to prevent intestinal obstruction and gangrene.     

Nutritional therapy in gastrointestinal disease]

Gastrointestinal tract is an organ for digestion, absorption and utilization of nutrients. Also it functions as an immunological organ in the human body. Patients with gastrointestinal disease are at increased risk for nutritional problem due to dietary restriction during the treatment or diagnostic examinations, anorexia or altered nutritional requirement. Clinically, it is important for gastroenterologists to be aware of the principles of nutritional therapy and the relationship between gastrointestinal diseases and the combined nutritional abnormalities. Removal of enteral feeding causes mucosal atrophy and leads to increased mucosal permeability to bacteria and endotoxin. The intestinal endotoxemia results from the translocation of bacteria and endotoxin to systemic circulation, may triggers off systemic inflammatory response syndrome. Therefore, it is crucial in critically ill patients to maintain the gastrointestinal mucosal integrity along with the intestinal flora that enables the host immunity to be maintained or enhanced. Immunonutrition is a therapeutic approach to enhance the gastrointestinal mucosal barrier with various specific nutrients. The intestinal endotoxemia and immunonutrition will also be reviewed briefly.     

Reconstruction of burned lower extremities by free flaps

Summary Three latissimus dorsi muscle flaps with skin grafts, one latissimus dorsi myocutaneous flap, and one scapular flap were used in reconstruction of deep burns of the heels and calf caused by various agents. The follow-up period was 11 to 46 months. Of the five patients treated, two sustained electrical injuries, two had contact burns and one suffered a degloving injury with a contact burn resulting from a car accident. The latissimus dorsi muscle flaps with skin grafts gave excellent results in reconstruction of the calf and ankle areas due to their large caliber vessels and versatility. The latissimus dorsi myocutaneous flap was indicated in a case with extensive soft tissue loss on the sole of the foot with stiffness of the ankle joint in plantar flexion. A non-sensory scapular flap was satisfactory for reconstruction of the medial half of the heel since the remaining lateral half of the heel provided adequate sensation for weight-bearing and protection. Early reconstruction of the burned lower part of the leg with free flaps shortens hospitalization and prevents further extension of the injury. Reconstruction of a burned distal lower extremity provides a challenge for the reconstructive surgeon due to limited availability of local tissue; there is durable soft tissue in the weight-bearing area and a relatively poor blood supply compared to other areas of the body. The basic requirement in the treatment of a full thickness burn is early debridement and immediate coverage of the defect with a skin graft or a well vascularized flap. Even though multiple local flaps, such as axial [7, 17], muscle [1], musculocutaneous [5], fasciocutaneous [11], and island flaps [4], have been described. These flaps are useful in relatively small wounds with undamaged sourrounding tissues. Electrical injuries are manifested in a variety of clinical and pathologic ways with early, as well as delayed, tissue damage complicating reconstruction. With the advent and refinement of microvascular techniques, it has become possible to reconstruct extensive defects of the distal lower extremity with either free muscle flaps with skin grafts [8], myocutaneous free flaps [10], or axial free flaps [18]. This paper relates our experience in reconstruction of extensive defects of the lower extremities caused by various burning agents.     

Hand-sewn coloanal anastomosis for distal rectal cancer: Long-term clinical outcomes

As the oncologic safety of coloanal anastomosis (CAA) has been proved by many other authors, the incidence of CAA following ultralow anterior resection has increased. The purpose of this study is to evaluate the functional outcome and complications of patients who underwent ultralow anterior resection and CAA for distal rectal cancer. Fifty-seven patients underwent CAA following ultralow anterior resection between July 1997 and November 2003. Forty-four patients, who were followed up more than 6 months after diverting ileostomy closure, were evaluated for recurrence, complications, and functional outcomes. The mean follow-up period was 36.3 +/- 22.8 months (range, 8-83 months). The complications were multiple fistula (n = 3), fistula with anal stenosis (n=1), local recurrence with anal stenosis (n = 1), and anal stenosis (n = 7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements were observed more than six times per day in 16 patients. Overall recurrence occurred in six patients (13.6%). The 5-year survival rate was 85.3%, and the disease-free 5-year survival rate was 73.3%. Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, and tolerable function, complications and poor functional outcomes of CAA do occur. Therefore, the choice of this method should be considered carefully.     

Changes of smoking behavior and serum adrenocorticotropic hormone, cortisol, prolactin, and endogenous opioids levels in nicotine dependence after naltrexone treatment

This study was done to evaluate the therapeutic effects of naltrexone on smoking behaviors and to measure the changing of brain substances for elucidating the mode of action by naltrexone. Twenty-five voluntarily participated healthy male smokers were randomly assigned to naltrexone group or placebo group for 2 weeks. In this study, naltrexone group showed significant reduction in daily cigarette consumption amount, the expiratory CO levels, brief questionnaire for smoking urge (B-QSU) score, and FTQ score. However, only 2 subjects in naltrexone group quitted smoking completely at 4th week. Plasma levels of pituitary hormones (ACTH, cortisol, and prolactin) and endogenous opioids (beta-endorphin and dynorphin A) were checked weekly before and after the 'provocation and smoking coupled' stimulus once in a week for 3 weeks. In naltrexone group, pituitary hormones showed upward tendencies even though only the prolactin had statistical significance. However, beta-endorphin and dynorphin A were not significantly different between the two groups. It was suggested that naltrexone made effects on hypothalamo-pituitary-adrenocortical axis activity as well as smoking behavior. However, the meaning of these endocrinal changes by naltrexone is not conclusive, whether it is beneficial or aversive.     

Early revascularization of membranous inlay bone graft in canine mandible model

The early revascularization of a membranous inlay bone graft in a canine mandible was investigated using bone scans and histological examinations. Eight 5-month-old mongrel dogs were used as the subjects. The inlay bone graft, a 1- x 2-cm critically sized bone, was completely separated from the lower border of the canine mandible and then refixed to the original site. Bone scans and histological examinations were performed in the first, second, third, and fourth postoperative weeks. The bone scan in the first postoperative week revealed radioisotope uptake on the margin of the grafted bone with an isotope count that was 21% of the normal bone uptake. In the second postoperative week, the radioisotope uptake in the grafted bone increased to 52% of the normal bone uptake. In the third and fourth postoperative weeks, the isotope uptakes were 111% and 124%, respectively. The histological findings in the first postoperative week showed an absence of osteoblastic activity and 6 viable blood vessels in a field magnified x 200, which was the equivalent of 25% of the vessels of the normal bone. In the second postoperative week, osteoblastic activity was noted, and the number of viable blood vessels increased to 15, that is, 63% of the vessels of the normal bone. In the third postoperative week, there was an increase in osteoblastic activity, and the number of viable blood vessels was 21, that is, 88% of the vessels of the normal bone. In the fourth postoperative week, there was a marked increase in osteoblastic activity with the number of vessels reaching 23, that is, 96% of the normal bone. In summary, revascularization of the membranous inlay bone graft began within the first week after the bone graft and thereafter gradually increased. In the third postoperative week, revascularization returned to a near-normal value compared with the value of the adjacent normal mandibular bone.     

Vascular responses in normal canine carotid arteries: comparison between various self-expanding stents of the same unconstrained size

RATIONALE AND OBJECTIVES: To compare long-term vascular responses upon the insertion of various self-expandable stents, all the same unconstrained size, in canine carotid artery models. MATERIALS AND METHODS: Twenty-two stents (5 SMARTs, 5 Wallstents, 6 Niti-Ss, 6 Niti-Ds) of the same unconstrained size (6 mm in diameter, 20 mm in length) were endovascularly placed in canine common carotid arteries. The luminal changes were measured on three occasions, on prestenting, immediate poststenting, and angiograms taken before specimens were killed. After en-bloc harvest of the stented carotid arteries at 6 months, the intraluminal surface was evaluated by gross observation and scanning electron microscopy (SEM). Neointimal thickness was measured at several points both over the wire and between the wires. RESULTS: Niti-D was excluded from analysis because of high rate of poststenting occlusion. SMART stent showed the greatest expansibility with average initial luminal gain ( < 0.05) of 21.2% (Niti-S: 16.5%, Wallstent: 12.9%). At 6 months follow-up, the dilated arterial lumen had returned almost to the prestenting caliber without any significant differences among the stent types ( > 0.05). The thickness of neointimal coverage was more prominent with SMART stent (354 microm over the wire and 258 microm between the wires) than Niti-S (228 microm and 83 microm) or Wallstent (187 microm and 78 microm). CONCLUSION: Stent types with its higher initial luminal gain appeared to be associated with thicker neointimal formation at 6 months. The acute expanding force of a self-expanding stent may be the key to the cause of neointimal hyperplasia. Regardless of the inserted stent type, the variations in neointimal response were offset by luminal gains of varying degree, thus preserving the arterial patency almost to the prestenting size.