Depth of tumor invasion in locally advanced rectal cancer correlates with patients’ prognosis: The usefulness of elastic stain for its measurement

Purpose The relationship between the prognosis and the extent of colorectal carcinoma (CRC) is still unclear. As a simple parameter of the local invasion of CRC, we assessed the extent of tumor invasion beyond the outer border of the muscularis propria (MP). Methods We examined 147 cases of CRC using a slight modification of the procedure established by the Japanese Society for Cancer of the Colon and Rectum. For the statistical analysis, the patients were divided into two groups, namely, a “shallow” group and a “deep” group, using a specific cut-off value (COV). A multivariate analysis to identify independent prognostic factors was performed. Results Significant differences in the 5-year survival rate were observed between the “shallow” and “deep” groups in 39 cases of rectal carcinoma (COV 4 mm; 72.4% vs. 30.0%, hazard ratio = 3.204), but not observed in 147 cases of CRC. In addition, the outcome for patients with “deep” cancer in the lower rectum was markedly worse than that for patients with “shallow” cancer (COV 4 mm; 81.8% vs. 12.5%, hazard ratio = 5.371). Conclusions The depth of tumor invasion beyond the MP is thus considered to be an important prognostic factor for patients with T3/T4 rectal carcinoma, especially in the lower rectum. A careful follow-up is required for the patients with rectal carcinoma that has invaded more than 4 mm beyond the MP.     

Postoperative Fecoflowmetric Analysis in Patients with Anorectal Malformation

Because conventional methods of evaluating anorectal function do not necessarily provide good correlations between investigative results and symptoms in patients who have undergone surgery for an anorectal malformation (ARM), we recently introduced feco-flowmetry (FFM) to simulate natural anorectal evacuation. The purpose of this study was to embody significant parameters to elucidate the dynamics of anorectal activity on FFM. The parameters of FFM were compared with those of manometry and Kelly's clinical score (KCS) in 24 patients who underwent surgery for an ARM. There were three fecoflow patterns, namely, block (B) type, segmental (S) type, and flat (F) type. The B-type or S-type patterns were seen in patients classified as "clinically good." There were close relationships between the fecoflow pattern and both the operative procedure and the KCS (P = 0.01 and 0.001, respectively). Maximum fecal stream flow rate (Fmax) precisely reflected the tolerance rate of intended normal saline solution in the colorectum (TR), the evacuative rate (ER), and KCS. Fmax > 45 ml/s or TR > 70% or ER > 50% was statistically regarded as the borderline of fecal continence. Thus, the fecoflow pattern might reflect the motor activity of the pelvic floor muscle. FFM provided quantiative and qualitative evaluations concerning anorectal motor activity in patients who had undergone surgery for an ARM.     

Bladder-Sparing Extended Resection of Locally Advanced Rectal Cancer Involving the Prostate and Seminal Vesicles

Purpose Total pelvic exenteration (TPE) is the standard procedure for locally advanced rectal cancer involving the prostate and seminal vesicles. We evaluated the feasibility of bladder-sparing surgery as an alternative to TPE. Methods Eleven patients with advanced primary or recurrent rectal cancer involving the prostate or seminal vesicles, or both, underwent bladder-sparing extended colorectal resection with radical prostatectomy. The procedures performed were abdominoperineal resection (APR) with prostatectomy (n = 6), colorectal resection using intersphincteric resection combined with prostatectomy (n = 4), and abdominoperineal tumor resection with prostatectomy (n = 1). Local control and urinary and anal function were evaluated postoperatively. Results Cysto-urethral anastomosis (CUA) was performed in seven patients and catheter-cystostomy was performed in four patients. Coloanal or colo-anal canal anastomosis was also performed in four patients. There was no mortality, and the morbidity rate was 38%. All patients underwent complete resection with negative surgical margins. After a median follow-up period of 26 months there was no sign of local recurrence, and ten patients were alive without disease, although distant metastases were found in three patients. Five patients had satisfactory voiding function after CUA, and three had satisfactory evacuation after intersphincteric resection (ISR). Conclusion These bladder-sparing procedures allow conservative surgery to be performed in selected patients with advanced rectal cancer involving the prostate or seminal vesicles, without compromising local control.     

Initial steroid bolus injection promotes vigorous CD8+ alloreactive responses toward early graft acceptance immediately after liver transplantation in humans.

We have found that steroid bolus withdrawal prior to graft reperfusion increased the incidence of acute cellular rejection (ACR). This study aims to clarify how initial steroid bolus (ISB) injection at reperfusion influences the kinetics of CD8(+) alloreactive immune responses immediately after living donor liver transplantation (LDLT). A total of 49 hepatitis C virus (HCV)-infected recipients were classified into 3 groups according to hierarchical clustering by preoperative CD8(+)CD45 isoforms. The naive T cell proportion was considerably higher in Group I than in Groups II and III, whereas Group II recipients had the highest effector memory (EM) T cells and Group III the highest effector T cells. The frequency of ACR was significantly higher in recipients without ISB than in those with ISB. In particular, the ACR rates were the highest in Group II without ISB. Following ISB, the proportion of effector T cells was promptly upregulated within 6 hours after graft reperfusion, simultaneously with the upregulation of CD27(-)CD28(-) subsets, interferon-gamma (IFN-gamma), tumor necrosis factor-alpha and perforin expression, which significantly correlated with increasing interleukin (IL)-12 receptor beta 1 cells. These were then downregulated to below preoperative levels by tacrolimus (Tac) administered at 24 hours. These changes did not occur in the absence of ISB. In Group II without ISB, the downregulation of IL-12Rbeta1(+) cells was the greatest, consistent with the highest rates of ACR and mortality (60%). In conclusion, ISB must be done in place, especially in Group II with preexisting high EM T cells, to enable the development of early allograft acceptance.     

Inguinal hernia repair with the mesh plug method is safe after radical retropubic prostatectomy

Purpose

We evaluated the safety and efficiency of using the mesh plug method (MP) to repair inguinal hernias in patients with a history of radical retropubic prostatectomy (RRP). We also investigated how RRP influences the development of inguinal hernias and impacts their repair.

Methods

Among 488 adult male patients who underwent inguinal hernia repair during a recent 5-year period, 37 had a history of RRP. We compared the characteristics and surgical outcomes of the patients who had undergone RRP (post-RRP group) with those who had not (non-RRP group).

Results

All post-RRP hernias were treated by MP. The 37 post-RRP patients had a collective 41 hernias, 40 of which were of the indirect type. The side affected by the hernia did not differ significantly between the groups. We compared the short-term surgical outcomes of the indirect post-RRP hernias vs. the indirect non-RPP hernias without recurrence and incarceration. The operation times, postoperative hospital stay, and mobility rates did not differ significantly between the two groups. The blood loss was almost equal in both groups.

Conclusion

Inguinal hernia repair after RRP may be difficult because of inflammatory changes in the preperitoneal cavity, but the surgical outcomes of MP were equivalent in patients with or without a history of RPP in this study. MP is a safe and effective method for post-RPP hernia repair.     

Improved survival rate by temperature control at compression sites in rat model of crush syndrome

Background

Crush syndrome (CS) has been reported in disasters, terrorist incidents, and accidents, and the clinical and pathologic picture has gradually been clarified. Few lethal and reproducible animal models of CS with use of a quantitative load are available. A new model is needed to investigate pathologic and therapeutic aspects of this injury.

Materials and methods

Using a device built from commercially available components, both hindlimbs of anesthetized rats were respectively compressed for 6 h using 3.6-kg blocks. The effects of trunk warming alone without compressed hindlimbs (Group A), non-warming at room temperature (Group B), whole-body warming including compressed hindlimbs (Group C), or warming of compressed hindlimbs alone (Group D) during compression were examined. Survival rates were compared and hematological and histologic analyses were performed at specific time points after compression release.

Results

Limb or whole-body warming significantly worsened the survival of rats. We found a much lower survival rate of 0%–10% in animals, in which the hindlimbs were warmed during compression (Groups C and D) at 12 h after compression release, compared with 90%–100% in animals without warming of the hindlimbs (Groups A and B). Groups C and D showed significantly enhanced hyperkalemia at ≥4 h after compression release and all blood samples from dead cases showed hyperkalemia (>10 mEq/L).

Conclusions

We developed a new lethal and reproducible rat CS model with a quantitative load. This study found that warming of compressed limbs worsened the survival rate and significantly enhanced hyperkalemia, apparently leading to cardiac arrest.     

Endoscopic treatment or surgery for undifferentiated early gastric cancer?

BACKGROUND: Although almost all (96%) the surgical cases of undifferentiated intramucosal early gastric cancer (EGC) have been found not to have lymph node metastasis (LNM), local treatment by endoscopic mucosal resection (EMR) is not accepted as an alternative treatment to surgery for this type of EGC. If a subgroup of patients with undifferentiated EGC with negligible risk of LNM can be defined, unnecessary surgery can be avoided. This study was conducted to determine this subgroup among undifferentiated EGC patients in whom the risk of LNM can be highly ruled out in an attempt to identify candidates who can be treated by EMR. METHODS: Data from 175 patients surgically resected for undifferentiated EGC were retrospectively collected, and clinicopathological factors were multivariately analyzed to identify predictive factors for LNM. RESULTS: Multivariate logistic regression analysis identified two independent risk factors for LNM, namely, a large tumor (>/=20 mm, P = 0.011) and presence of lymphatic involvement (P = 0.0005). Using these two risk factors as the predictive factors, LNM was observed in 5.8% of patients who had neither of the two predictive factors, whereas 23.1% or 13.1% of patients with one or two predictive factors had LNM, respectively. In contrast, the LNM rate was calculated to be 60% in patients who had both factors. Lymph node metastasis was not found in any of 6 patients with small intramucosal lesions (<10 mm) without lymphatic involvement. CONCLUSIONS: An intramucosal undifferentiated EGC that is smaller than 10 mm without lymphatic involvement can safely be treated by EMR alone, given the negligible possibility of LNM. When histological examination of endoscopically resected specimens shows lymphatic involvement or unexpectedly larger tumor size than that determined at pre-EMR endoscopic diagnosis, an additional surgical procedure should be considered.     

Arterial stiffness in predialysis patients with uremia

BACKGROUND: Hemodialysis patients have advanced arterial wall stiffening as shown by increased aortic pulse wave velocity (PWV), an independent predictor of cardiovascular mortality. We compared aortic PWV of uremic patients before starting hemodialysis treatment with that of patients on maintenance hemodialysis. METHODS: The subjects were 71 patients with end-stage renal disease (ESRD) before starting hemodialysis (predialysis group), 144 patients on maintenance hemodialysis, and 140 healthy control subjects. These three groups were all nondiabetic and comparable in age and gender. RESULTS: The hemodialysis group had greater aortic PWV than the healthy subjects, and the predialysis patients showed a still higher value than the hemodialysis group. Multiple regression analysis in the total subjects revealed that the presence of renal failure was significantly associated with increased aortic PWV independent of age, gender, blood pressure, body mass index, smoking, high-density lipoprotein (HDL) and nonhigh-density lipoprotein (non-HDL) cholesterol levels. In contrast, hemodialysis was associated with decreased aortic PWV independent of renal failure and the other factors. Further analyses in the combined uremic patients again indicated the favorable impact of hemodialysis on aortic PWV independent of the classical risk factors, use of antihypertensive medications, including angiotensin-converting enzyme inhibitors and calcium channel blockers, hematocrit, serum calcium, phosphorus, parathyroid hormone levels, and the use of calcium carbonate. Insulin resistance using homeostasis model assessment (HOMA-IR) was associated with increased aortic PWV. CONCLUSION: Aortic stiffening was present in uremic patients before starting hemodialysis treatment and no adverse effect of hemodialysis was observed, suggesting the important roles of renal failure and/or metabolic alterations secondary to renal failure in arterial stiffness in patients with uremia.     

Oxygen pressure measurement during grip exercise reveals exercise intolerance after radial harvest

BACKGROUND: Exercise intolerance of the hand after harvest of the radial artery is not well understood, although mild reductions of blood flow to the hand are reported. To ascertain its prevalence, patient symptoms implying potential exercise intolerance were evaluated by measuring transcutaneous oxygen pressure of the hand during grip exercise. For ascertaining predictive values, we verified ulnar flow reserve measured by Doppler ultrasonography before the harvest of radial artery. METHODS: Forty patients whose radial artery was harvested for coronary bypass graft, were interviewed and tested 1 year after operation, and their preoperative ultrasonographic data compared. RESULTS: Five patients (12.5%) had mild symptoms implying exercise intolerance. Exercise tests revealed severe decreases in tissue oxygenation in 7 patients (17.5%), but in accordance with symptoms (p = 0.0018). Tissue oxygenation in the operated hand was lower than in the nonoperated even in asymptomatic patients (p = 0.0011). Preoperative Doppler echography revealed that ulnar arteries of symptomatic patients were smaller (p = 0.0019) and carried lower blood flows during manual compression of the radial artery (p = 0.0004) compared with those of asymptomatic patients. Smaller ulnar arteries (less than 1.4 mm/m(2)) with poor flow reserves (less than 60 mL x min(-1) x m(-2) during radial compression) appear to indicate risks for exercise intolerance (p = 0.0004). CONCLUSIONS: More than 10% of patients after harvest of radial arteries had mild symptoms implying exercise-intolerance, which accorded with abnormal tissue oxygenation during grip exercise. Work habits of patients should be considered in radial harvest decisions, especially if preoperative Doppler echography indicates lower flow reserves for the ulnar artery.     

CT portography by multidetector helical CT: comparison of three rendering models

PURPOSE: To assess the value of multidetector CT portography in visualizing varices and portosystemic collaterals in comparison with conventional portography, and to compare the visualizations obtained by three rendering models (volume rendering, VR; minimum intensity projection, MIP; and shaded surface display, SSD). METHODS: A total of 46 patients with portal hypertension were examined by CT and conventional portography for evaluation of portosystemic collaterals. CT portography was performed by multidetector CT (MD-CT) scanner with a slice thickness of 2.5 mm and table feed of 7.5 mm. Three types of CT portographic models were generated and compared with transarterial portography. RESULTS: Among the 46 patients, 48 collaterals were identified on CT transverse images, while 38 collaterals were detected on transarterial portography. Forty-four of 48 collaterals identified on CT transverse images were visualized with the MIP model, while 34 and 29 collaterals were visualized by the VR and SSD methods, respectively. The average CT value for the portal vein and varices was 198 HU with data acquisition of 50 sec after contrast material injection. CONCLUSIONS: CT portography by multidetector CT provides excellent images in the visualization of portosystemic collaterals. The images of collaterals produced by MD-CT are superior to those of transarterial portography. Among the three rendering techniques, MIP provides the best visualization of portosystemic collaterals.