Surgical Strategy for Low Imperforate Anus in Girls -Cutback Anoplasty , Anal Transplantation or Limited Posterior Sagittal Anorectoplasty?-

From 1991 to 2001, we performed 5 re-operations with limited posterior sagittal anorectoplasty (PSARP) for low imperforate anus in girls who had anteriorly located anus after primary surgery. Four girls were diagnosed with anocutaneous fistula and one girl with anovestivular fistula. Primary operations were one cutback anoplasty and four anal transplantation. None of them underwent colostomies before re-operation with the limited PSARP. The sphincter muscle was cut through a median perineal skin incision and then the rectum was placed at the center of the complex muscles. This limited PSARP could give good anal function and satisfactory cosmetic appearanc

Omental Pedicle Graft to Protect Compromised Double-Stapled Anastomosis in Anterior Resection for Rectal Cancer

PURPOSE: The purpose of this study was to investigate the effects of omental pedicle graft (OPG) wrapping to limit leakage from compromised double-stapled anastomoses after anterior resection for rectal cancer. PATIENTS AND METHODS: Between 1994 and 1997, a prospective study was conducted on 80 consecutive patients who had undergone double-stapled anastomoses after anterior resection for rectal cancer. Decisions to perform OPG were made intraoperatively because of compromised doublestapled anastomoses. RESULTS: Twenty-one patients (26%) received OPG to protect anastomosis, the remainder of patients had no OPG. Ten of the 21 patients underwent OPG for stapler-related operative complications, 5 for rectal carcinoma with stenosis, 3 for obstructive colitis or diverticulitis in the sigmoid colon, and 6 for very low anterior resection with coloanal anastomosis after total mesorectal excision. Three of 21 patients had more than one indication for OPG. The two types of patients were comparable with respect to patient characteristics and operative procedures, although tumor diameter in the OPG patients was significantly larger than in the non-OPG patients. Anastomotic leakage was noted in 1 non-OPG patient (2%) but in none of the OPG patient. There were no statistically significant differences between the two types of patients with regard to postoperative course and anastomotic or other postoperative complications. CONCLUSION: We conclude that OPG wrapping provides an effective protection for a compromised anastomosis of anterior resection in selected patients with rectal cance

Ileocecal actinomycosis : A case report and review of the literature

A case of actinomycosis in the ileocecal area of a 44-years-old man which manifested as a painful lump in the right iliac fossa is reported. Clinical and laboratory findings suggested the diagnosis of perityphlitic abscess due to acute appendicitis. Upon a laparotomy, a malignant tumor was suspected and so a right hemicolectomy was performed. Gram staining of cecum tissues demonstrated gram positive pleomorphic filaments. Postoperative penicillin therapy was successful. Despite the fact that infection accompanying an actinomycotic organism is relatively rare, the possibility of such an infection should be kept in mind because the organism is known to be commensal in the oral cavity, lungs and intestinal tract

Serum Level of Hyaluronic Acid Does not Correlate with Changes of Hepatic Volume after Portal Vein Embolization

The serum hyaluronic acid (HA) levels are associated with liver regeneration after hepatectomy. In the present study, the HA concentrations were examined to evaluate the relationship with changes of hepatic volume after right portal vein embolization (PVE). The HA level of serum samples from 10 patients who underwent PVE before hepatectomy of the right lobe was measured, and the results were compared to the changed volume of embolized right lobe and unembolized left lobe of the liver. The mean serum HA level in patients with chronic viral liver disease (CVLD) (202+/-118 ng/ml) was significantly greater than in those without CVLD (70+/-24 ng/ml) (p<0.05). The volume of embolized liver decreased 72+/-96 CM3 (-8.9+/-5.5 %), while the volume of unembolized liver increased 106+/-67 CM3 (+8.9+/-5.5 %) 2 weeks after PVE. HA concentrations after 2 weeks of PVE (296+/-216 ng/ml) tended to be greater than that before PVE (134+/-108 ng/ml) but not statistically significant (p=0.105). There were no correlations between serum HA levels before PVE and the changes of hepatic volume in embolized and unembolized lobe after PVE. Our results indicate that the measurement of HA level is not useful for predicting the effect of PVE

An Immunohistochemical Study of Tumor Vascularity and Proliferation Activity in Cholangiocellular Carcinoma: Relationship to Clinicopathologic Factors and Prognosis after Hepatic Resection

This study was designed to provide an immunohistochemical analysis of tumor biological factors in 28 patients who underwent hepatectomy for cholangiocellular carcinoma (CCC). Analyzed factors were microvessel counts (stained by CD34) and proliferating cell nuclear antigen (PCNA). PCNA L.I. was correlated with serum level of CA19-9, which was correlated with a higher recurrence rate and shorter patient survivals. Microvessel counts were negatively correlated with tumor size. Furthermore, the microvessel count in CCC with mass-forming (MF) plus periductal infiltrating (PI) type associated with poorer survivals, was significantly lower compared to that of CCC with MF type or PI type. Neither microvessel counts nor PCNA L.I. were associated with any other clinicopathologic factors or cancer recurrence. The five-year overall and cancer-free survival rates were 26% and 13%, respectively. Patients with MF plus PI type, poorer differentiated carcinoma, stage 4A and higher CA19-9 level had shorter cancer-free and overall survivals after hepatectomy (p<0.05). Cancer-free and overall survivals in patients with lower microvessel counts tended to be slightly worse but were not significantly different. Although tumor microvessel count and proliferating activity were correlated with prognostic clinicopathologic parameters, both factors might not be prognostic markers for predicting CCC recurrence and patient survival

Spontaneous Closure of a Rectovaginal Fistula that Developed after Double-stapled Anastomosis in Low Anterior Resection

Management of a rectovaginal fistula (RVF) following low circular-stapled colorectal anastomosis is difficult and often unsatisfactory. We report herein the case of a 66- year-old woman who developed a RVF following low anterior resection using the double-stapling technique for rectal cancer. The RVF spontaneously closed with nonoperative treatment that included simple observation without dietary restrictions. The spontaneous closure occurred within approximately 25 days. Minimally symptomatic patients may be candidates for nonoperative treatment

Acute inflammatory response to colorectal cancer resection according to different laparotomy incision lengths

The aim of this study was to clarify a correlation between acute inflammatory response to surgery and different laparotomy lengths in patients who underwent colorectal cancer resection via a single minimal laparotomy. Between April 2005 and May 2008, 131 consecutive patients (59 women, 72 men), who were scheduled to undergo elective surgery for resection of primary colorectal cancer using a single minimal skin incision, were enrolled in this study to investigate the correlation between postoperative acute inflammatory responses (as measured by serum C-reactive protein (CRP) levels and white blood cell count (WBC)) and different laparotomy lengths. According to the length of laparotomy, the patients were grouped into 3 categories, "small-incision" ( 7 cm), "medium-incision" (>7 and 14 cm), and "large-incision" (>14 cm) for comparison. Statistical analyses were conducted using the Kruskal-Wallis test with multiple comparison post-hoc and chi-square tests. The small-, medium-, and large-incision groups included 68 (51.9%), 42, (32.1%) and 21 (16.0%) patients, respectively. On the 1st postoperative day, median serum levels of CRP and WBC of the small-incision group were significantly lower than those of the medium-incision and large-incision groups (CRP, P=0.0051 and P=0.0015, respectively; WBC, P=0.049 and P =0.0007, respectively). In addition, the median serum levels of CRP and WBC on the 1st postoperative day were proportional to the length of laparotomy. These data suggested that the extent of acute inflammatory response may be proportional to length of laparotomy. In addition, only the use of small-incisions ( 7 cm) among the three investigated categories of laparotomy lengths may be a factor which is associated with statistical significance with minimal invasiveness of colorectal cancer resection

Colorectal cancer with high-frequency microsatellite instability expresses high-level thymidine phosphorylase but not dihydropyrimidine dehydrogenase

Recent clinical studies have reported that microsatellite instability (MSI) colorectal cancers show a high sensitivity to 5-FU, but these reports are contradictory to findings from in vitro analyses. In this study, we analyzed the relationship between MSI phenotypes and the expression of 5-FU metabolic enzymes in human colorectal cancer specimens. MSI phenotypes in 174 sporadic colorectal carcinomas were determined and grouped into the following three categories based on the Bethesda guidelines: high-frequency MSI (MSI-H), low-frequency MSI (MSI-L), and stable microsatellite (MSS). The expressions of dihydropyrimidine dehydrogenase (DPD) and thymidine phosphorylase (TP) in tumor specimens were measured by enzymelinked immunosorbent assays. The ratio of TP to DPD expression (TP/DPD ratio) was calculated for each tumor. These three factors were compared with regard to MSI phenotypes by non-parametric and logistic regression analyses using cut-off values at their medians. MSI-L tumors were excluded from statistical analyses. Thirteen tumors were classified as MSI-H, 8 tumors as MSI-L, and 153 tumors as MSS. DPD expression did not differ between MSI-H tumors and MSS tumors. TP expression and the TP/DPD ratio were significantly higher in MSI-H tumors than in MSS tumors [TP, 160.1± 104.0 vs 97.3 ± 53.7 (Units/mg protein) (P=0.009); TP/DPD ratio, 3.04 ± 1.62 vs 2.07 ± 1.08, (P=0.016)]. These differences were also significant in multivariate analysis. In conclusion, these data suggest that 5-FU catabolic activity in cancer tissue does not differ between MSI-Hand MSS tumors. However, 5-FU anabolic activity in cancer tissue is higher in MSI-H than in MSS colorectal carcinomas

Laparoscopic Partial Gastrectomy for Early Gastric Cancers using Plastic T-fasteners for Lifting Gastric Wall

Between September 1992 and July 1996, 2 patients with type I early gastric cancer, 3 with type IIa, and 14 with type IIc, totaling 19 patients underwent laparoscopic partial gastrectomy (gastric wedge resections in 17 and Billroth II distal gastric resection in 2). There were 12 men and 7 women. Mean age was 65.4 years ranging from 44 to 86. Gastric lesions were located on the anterior wall in 7, posterior wall in 8 and lesser curvature in 4. In 15 of 19 patients, we performed laparoscopic surgery by a lesion lifting method using plastic T-fasteners. Average operative time was 164.8±49.6 min (range 85-252) in all, 153.7±46.7 min for the lesion lifting method, and 227 ± 33 min for diatal gastrectomy. Average blood loss was 44.1 ± 57.3 ml, 30.9 ± 43.7 ml, and 97 ± 61 ml, respectively. Mean hospital stay after surgery was 13.6 ± 6.8 (6-30) days. There was no mortality and no postoperative complications. The average size of tumors in type I, IIa and lie was 30 mm, 17.3 mm and 20 mm, respectively. In histologic examination, 16 cases were differentiated carcinoma and the remaining 3 cases were signet cell carcinoma. One of 4 cases diagnosed as SM cancer preoperatively was m (mucosal) cancer, two were sm (submucosal), and one was mp (muscularis propria) cancer histologically, but no one was involved in regional lymph nodes. These results indicate that laparoscopic partial gastrectomy will play an increasing role in the treatment of early gastric cancer without lymph node involvement as well as benign gastric tumors

Local Recurrence in the Pectoralis Major Muscle Following Modified Radical Mastectomy for Breast Cancer

Local recurrence in the pectoralis muscle after modified radical mastectomy for breast cancer is rare. We encountered a 53-year-old woman who developed a small nodule on her right antero-lateral chest wall after modified radical mastectomy. Excision biopsy of the mass lesion was performed, and pathological examination revealed a local recurrence in the pectoralis major muscle. Resection of the pectoralis major and minor muscles, subclavicular lymph nodes dissection and postoperative radiation therapy were performed. After operation, no local recurrence appeared, but the patient died of multiple liver and bone metastases two and a half years later