Laparoscopic restorative proctocolectomy for patients with ulcerative colitis

BACKGROUND: Significant concern continues about the feasibility of laparoscopic restorative proctocolectomy (RP) with an ileal J pouch anal anastomosis in the surgical treatment of patients with ulcerative colitis (UC). The aim of this study was to clarify the feasibility of laparoscopic RP at a single institution where the surgical routine of laparoscopic colorectal surgery has already been established. PATIENTS AND METHODS: Between July 1994 and December 2001, 18 patients with UC underwent laparoscopic RP. The median age was 30 (range, 18-51) years, and the median follow-up was 20 (range, 5-89) months. Five trocars were placed. After the entire colon and rectum were mobilized and the vessels were divided intracorporeally, the rectum was divided with use of a laparoscopic linear stapler. A pouch anal anastomosis was fashioned with use of a double stapling technique. A diverting loop ileostomy was fashioned. RESULTS: There were no conversions to the open procedure. The median operative time and median blood loss were 360 (range, 290-500) minutes and 105 (range, 10-586) mL, respectively. Six postoperative complications occurred (wound sepsis, 2; bowel obstruction, 1; anastomotic stricture, 2; pouchitis, 1). In one patient, a bowel obstruction developed 3 months after the operation, which was managed conservatively. The median length of the hospital stay was 9 (range, 7-21) days. CONCLUSIONS: The laparoscopic RP is safe and feasible in selected patients with UC. New laparoscopic instrumentation, such as a linear stapler, and a more reliable laparoscopic coagulating and dividing tool should be designed, which would make it possible to perform this procedure more frequently in the surgical treatment of UC.     

The intentional oblique transection double stapling technique in anterior resection for rectal cancer

The double stapling technique (DST) is an intestinal reconstruction technique that has been widely adopted in anterior resection (AR) for rectal cancer. However, anastomotic leakage (AL) after the operation remains a major concern for colorectal surgeons. The sharp-angled corner of the remnant rectum that is often created by the ordinary DST can be a risk factor for AL. We have developed a new method of performing intentional oblique transection DST (IOT-DST). Using this technique, the anal side of the rectum is intentionally obliquely transected with linear staplers, and the area of the sharp-angled edge is totally punched out with a circular stapler. Between September 2015 and March 2016, we used the IOT-DST technique in the treatment of 15 consecutive rectal cancer patients and experienced no anastomosis-related complications, including leakage and stenosis. IOT-DST is easy to use and less stressful to perform than other techniques. IOT-DST has the potential to become the standard technique for AR in rectal cancer surgery.     

Surgical Apgar Score Predicted Postoperative Morbidity After Esophagectomy for Esophageal Cancer

Background

Recently, a simple and easy complication prediction system, the Surgical Apgar Sore (SAS) calculated by three intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate), has been proposed for general surgery. This study aimed to determine if the SAS could accurately predict perioperative morbidity in patients undergoing esophagectomy for esophageal cancer.

Methods

We investigated 399 patients who underwent esophagectomy at the Kumamoto University Hospital between April 2007 and March 2015. Clinical data, including intraoperative parameters, were collected retrospectively. Patients had postoperative morbidities classified as Clavien–Dindo grade III or more. Univariate and multivariate analyses were performed to elucidate factors that affected the development of complications.

Results

The mean age of the study population was 65.7 years, 357 patients (89.5 %) were male. The frequency of any morbidity was 32.3 %. Univariate analyses showed that the SAS as well as preoperative chemotherapy, volume of bleeding, and reconstruction of organs were associated with morbidities. Multivariate analysis showed that a SAS < 5 was found to be an independent risk factor for morbidities.

Conclusion

The SAS is considered to be useful for predicting the development of postoperative morbidities after esophagectomy for esophageal cancer.

     

Distress and social dysfunction following prostate cancer treatment: a longitudinal cross-cultural comparison of Japanese and American men

We assessed the impact of bother with urinary and bowel dysfunction on social activities among men in Japan and the United States following primary therapy for localized prostate cancer. In paired longitudinal outcomes studies, we measured general and disease-specific health-related quality of life in 400 Japanese and 427 American men who underwent radical prostatectomy or brachytherapy for localized prostate cancer. Outcomes included the social function domain of the Medical Outcomes Study Short Form-36 and the University of California, Los Angeles Prostate Cancer Index, all of which are scored 0-100. Participants completed the questionnaires before and 1, 12 and 24 months after treatment. Among men who reported any urinary bother, Japanese men had slightly better urinary function than American men (84 vs 77, P<0.01). Before brachytherapy, urinary bother was weakly correlated with social function in both the countries; after brachytherapy, urinary bother was strongly correlated with social function in American but not Japanese men. After brachytherapy, bowel dysfunction had a stronger correlation with social function in American than Japanese men (P<0.05). The bother associated with urinary and bowel dysfunction after surgery or brachytherapy for prostate cancer has a greater impact on social function in American men than in Japanese men.     

Laparoscopic subtotal cholecystectomy for severe cholecystitis

Purpose

To evaluate the efficacy and outcome of laparoscopic subtotal cholecystectomy (LSC) for patients with severe cholecystitis.

Methods

Between April 1992 and May 2008, 1226 patients underwent laparoscopic cholecystectomy (LC). From 2000 onward 60 patients with severe cholecystitis underwent LSC. The outcomes of LC were compared between patients who underwent the procedure between 1992 and 1999 (group A; n = 643) and those who underwent the procedure between 2000 and 2008 after the introduction of LSC (group B; n = 583), respectively. In Group B, operative outcomes were also compared between the LC and LSC groups.

Results

The incidence of bile duct injury (1.6% vs 0.3%, P = 0.040) and conversion to open cholecystectomy (2.2% vs 0.3%, P = 0.046) was significantly lower in group B. The mean operative time was significantly longer (119.6 min vs 71.0 min., P < 0.001), and the mean blood loss was significantly higher (53.4 ml vs 12.9 ml, P < 0.001) in the LSC group. No significant differences were observed between LC and LSC in the incidence of postoperative morbidities or postoperative hospital stay. No patient had remnant gallstones or gallbladder cancers after a median follow-up of 42 months.

Conclusions

Laparoscopic subtotal cholecystectomy is safe and effective for preventing bile duct injuries and lowering the conversion rate in patients with technically difficult severe cholecystitis.     

Prevalence of Adenomas and Carcinomas in the Ileal Pouch After Proctocolectomy in Patients with Familial Adenomatous Polyposis

Purpose  Restorative proctocolectomy has become the most common surgical option for patients with familial adenomatous polyposis (FAP). However, adenomas may develop in the ileal pouch mucosa over time, and even carcinoma in the pouch has been reported. Our aim was to evaluate the prevalence, nature, and etiology of ileal pouch and nonpouch adenomas and carcinoma in patients with FAP. Patients and methods  This was a retrospective study of 31 FAP patients with Kock’s continent ileostomy (Kock; n = 8), ileorectal anastomosis (IRA; n = 7), and ileal pouch–anal anastomosis (IPAA) (n = 16). All patients were followed with a standardized protocol including chromoendoscopy and biopsies of visible polyps in the ileal pouch and nonpouch mucosa. Results  Sixteen of 24 pouch patients (Kock and IPAA) developed adenomas in the ileal pouch mucosa, and all patients with IRA developed adenomas in the rectal mucosa. The prevalence of ileal adenomas was significantly higher in pouch patients than in IRA patients (P = 0.002). Only one patient with Kock showed adenoma in the prepouch area. Two cases of adenocarcinomas and one case of advanced adenoma were found in the ileal pouch mucosa. Conclusion  Our results show a high frequency of adenomas in the ileal pouch mucosa, with evolution into carcinoma in some patients. Regular endoscopic surveillance of the pouch is recommended at a frequency similar to that for the rectal mucosa after IRA in pouch patients with FAP.     

A new ultrasound‐guided pubic approach for proximal obturator nerve block: clinical study and cadaver evaluation

We evaluated an alternative technique for ultrasound‐guided proximal level obturator nerve block that might facilitate needle visualisation using in‐plane ultrasound guidance. Twenty patients undergoing transurethral bladder tumour resection requiring an obturator nerve block were enrolled into a prospective observational study. With the patient in the lithotomy position, the transducer was placed on the medial thigh along the extended line of the inguinal crease, and aimed cephalad to view a thick fascia between the pectineus and obturator externus muscles that contains the obturator nerve. A stimulating nerve block needle was inserted at the pubic region and advanced in‐plane with the transducer in an anterior‐to‐posterior direction. Eight ml levobupivacaine 0.75% was injected within the fascia. The median (IQR [range]) duration for ultrasound identification of the target and injection were 8.5 (7–12 [5–24]) s and 62 (44.5–78.25 [39–383]) s, respectively. All blocks were successful. A cadaver evaluation demonstrated that the dye injected into the target fascia using our technique travelled retrogradely through the obturator canal, and surrounded the anterior and posterior branches of the obturator nerve both proximally and distally to the obturator canal. We believe that this is a promising new technique for ultrasound‐guided proximal level obturator nerve block.     

Morphological changes of the ligamentum flavum as a cause of nerve root compression

The ligamentum flavum is considered to be one of the important causes of radiculopathy in lumbar degenerative disease. Although there have been several reports anatomically examining the positional relationship between the ligamentum flavum and nerve root, there are few reports on ventral observation. The purpose of this study is to clarify the shape of the ligamentum flavum seen ventrally, and to obtain anatomic findings related to nerve root compression. The subjects were 18 adult embalmed cadavers, with an average age of 78 years at the time of death. The ventral shapes of the ligamentum flavum were observed. The relationships between the morphological change of the ligamentum flavum and nerve root compression or radiographic findings were statistically evaluated. Among the shapes of the ligamentum flavum, bulging of the ligament was most frequently observed. Proximal bulging indicates the type with the cranial portion bulging from the subarticular zone to the foraminal zone of the ligamentum flavum. In this type associated with a decrease in disc height, nerve root compression was frequently observed. Thus, we could more realistically grasp the relationship between bulging morphology of the ligamentum flavum and nerve root compression.     

Contribution of CD4+ and CD8+ T cells and interferon-gamma to the progress of chronic rejection of kidney allografts: the Th1 response mediates both acute and chronic rejection

T cells mediating chronic rejection (CR) of human kidney allografts were characterized by comparing them with those mediating acute rejection (AR). Two lines of analysis were performed using biopsy specimens (23 CR and 8 AR). First, the extent of infiltration of CD4+ and CD8+ T cells into allografts was assessed from mRNA expression of CD4 and CD8. The group of CR specimens was not significantly different from the group of AR specimens in terms of the extent of CD4+ and CD8+ T cell infiltration, underlining the importance of the immunological contribution to the progress of CR. Second, Th1/Th2 polarization in infiltrating T cells was investigated by measuring mRNA expression of interferon gamma (IFN-gamma; a Th1 cytokine) and interleukin 4 (IL-4; a Th2 cytokine). IFN-gamma expression was detected in most CR specimens, and was not significantly different between the group of CR specimens and the group of AR specimens. On the other hand, IL-4 expression was detected in only two CR specimens and one AR specimen; from its pathological features, the AR in this last case was concomitant with CR. These results suggest that most cases of CR and of AR are mediated by Th1 mechanisms, although some cases of CR show features of both Th1 and Th2.