Detection of HBV DNA and HCV RNA in Public Bath; A Study about Safety of Prolapsed Hemorrhoidal Patients

PURPOSE: The Sitz bath is a commonly used nonsurgical treatment for patients with hemorrhoids. When these patients use public baths, possibilities exposure to infectious diseases due to public-bath utilization by exist for person infected with many kinds of diseases. In particular, because Hepatitis type B and type C viruses are infection sources for chronic liver diseases, we shall examine the risks of infections of HBV and HCV in acute hemorrhoids patients by examining the existences of HBV DNA and HCV RNA in the waters of public baths. RESULTS: From March 2005 to March 2006, 29 hot-water samples and 22 cold-water samples were obtained from public baths within Busan. With each sample, COBAS Amplicor HBV DNA monitor and HCV RNA monitor were used to run a quantitative (PCR) for HBV DNA and HCV RNA. Additionally, HBsAg and HBeAg were examined through chemiluminescent microparticle immuno assay (CMIA). RESULTS: HBV DNA was detected in 4 samples and HCV RNA was detected in an other 4 samples of the 29 samples from the hot baths. In 22 samples from the cold baths, HBV DNA was detected in 3 samples and HCV RNA in an other 2 samples. The mean levels of HBV DNA detected were 162.8 IU/ml and 1,586 IU/ml and the mean levels of HCV RNA were 276 IU/ml and 3,067 IU/ml from specimens in hot and cold baths, respectively. In the tests for HBs Ag and HBeAg, among 51 samples, 2 hot-water samples showed positive for HBs Ag while the others showed negative. CONCLUSIONS: HBV DNA and HCV RNA were detected in both the hot and the cold waters of public baths. However, this result cannot be regarded as demonstrating infectivity, but further studies are thought to be needed to examine the risks of infections to patients with acute hemorrhoids of higher than third degree or patients with open wounds or external orifices. A patient with hemorrhoids or fistulas with external orifices should not use public baths and should undergo curative surgery.

Regional Distribution of Peptide YY Concentrations in Human Lower Gastrointestinal Mucosa

PURPOSE: Peptide YY is composed of 36 amino acids, and its functions are suppression of gastric acid secretion, delay of gastric emptying, increase of intestinal motility, inhibition of pancreatic exocrine secretion, and enhanced postprandial colonic absorption of water and electrolyte. PYY is released from PYY cells, which are mainly distributed in the ileum and colon, in response to the presence of intraluminal lipids. This study was designed to determine the regional distribution of PYY in the normal human ileum, colon, rectum, and anal canal by studying mucosal concentrations. METHODS: Fresh tissues were obtained from specimens of segmental resections of the small bowel, colectomies, ileostomies, and abdominoperineal resections for the management of colonic or rectal carcinomas or benign diseases of the bowel. Only specimens devoid of advanced luminal obstruction were included. Mucosa was separately recruited by microdissection of frozen sections. Radioimmunoassays were performed using the methods of Adrian et al. RESULTS: The concentration of PYY was highest at 25 cm proximal to the ileocecal valve in the ileum (307.6 pmol/ g) and in the upper rectum at the colon (653.1 pmol/g). The concentration of PYY was 27.3 pmol/g in the anal canal distal to the dentate line. A clear differential distribution of PYY was shown in the ileum and colon. CONCLUSIONS: This study showed PYY was present in large amounts in the mucosa of the ileum and colon, with high concentrations in locations 25 cm proximal to ileocecal valve and in the upper rectum, respectively. The trend of regional differences in PYY in the colonic mucosa probably reflects local differences in functions, such as absorption and storage. Also, the peak concentration in the ileum at 25 cm proximal to ileocecel valve suggests that this region is the most abundant production site of PYY in the ileum.

Intersphincteric Resection for Very Low Rectal Cancer

PURPOSE: In the treatment of rectal cancer, sphincter saving resection is increased but low anterior resection is limited in treatment for low rectal cancer below 4 cm from the anal verge. In other reports intersphincteric resection can allow an oncologically safe resection margin and has good functional results in very low rectal cancer. The aim of this study is to evaluate the morbidity, mortality and the oncological and functional results of intersphincteric resection. METHODS: Between 2000 and 2002, 18 patients (mean age 54 years, range 35~70) with adenocarcinoma of the rectum underwent intersphincteric resection by an transanal approach with a colonic J-pouch anal anastomosis and ileostomy. The mean distance between the tumor and anal verge was 3.75 (range 2.5~5) cm. Patients with T3 lesion were 8 and they were received preoperative radiochemotherapy. Others with T2 lesion were not received preoperative radiochemotherapy. RESULTS: There was no postoperative mortality and local recurrance after median follow up of 32 (18~54) months. Morbidity occurred in 9 patient but were not serious. Two anastomotic leakages occurred. One was recovered after only conservative therapy, but the other one was received colostomy because of functional problem. Downstaging was observed in 62.5% (5/8) of the patients. Continence was good (Kirwan classification I, II) in 72% (13/18) of patients. CONCLUSIONS: These results suggest that intersphincteric resection can be an alternative procedure to abdominoperineal resection for very low rectal cancer without losing chance of cure.

Anterior Extrasphincteric Anorectoplasty with an Illuminating Intrarectal Indicator for Repair of an Anorectal Malformation

PURPOSE: This study was conducted to evaluate the functional results of an anterior extrasphincteric anorectoplasty (AEA) guided by an illuminating intrarectal indicator, in which a transperineal positioning of the anal canal was performed without cutting the perineal sphincter muscle. METHODS: Point A which would be a anal orifice in future was designated 0.3 mm anterior to the anal dimpling site. A semicircular incision was made in the front of the anus. The flap, which included from the anal skin to the upper margin of the external anal sphincter, was everted posteriorly. A quarter of the frontal upper rim of the external anal sphincter was exposed, and the center of the uppermost portion was designated as point B. From point A toward point B, a spinal needle was inserted through the anal sphincter, and needle's tract was dilated under direct identification of the sphincter muscle by electronic stimulation. An illuminating intrarectal indicator with a laparoscopic light source was pushed through the distal stoma of a sigmoid colostomy toward its distal lumen so that the blind rectal pouch was perineally exposured. On the blind pouch, a cruciate incision was made, and it was anastomosed to the anus. RESULTS: From 1991 to 2000, 11 patients with imperforate anus of high and intermediate type were operated by our method. In one case, the urethral injury was found intraoperatively and was immediately repaired. One case of anal stenosis was improved after serial Hegar dilatation. The postoperative bowel function in the Kirwan's clinical assessment at 12 th month was grade I in 9 cases and grade II in 2 case. Conclusion: This AEA with an illuminating intrarectal indicator shows acceptable clinical results and could be considered to be an effective surgical option for anorectal malformations.

Transanal Posterior Anorectoplasty of Rectal Prolapse

PURPOSE: Many different procedures for rectal prolapse have been described, but optional surgical treatment remains controversial. The aim of this report is to introduce an innovative and effective method of surgical treatment to restore anal continence and anatomic correction of rectal prolapse. METHODS: Data were retrospectively collected and analyzed on 11 patients (7 male and 4 female) who underwent transanal posterior anorectoplasty for complete rectal prolapse between Jan. 1995 to Dec. 2000. This procedure is summarized to five steps as follows: 1. Partial resection of posterior rectal ampulla. 2. Longitudinal plication with posterior fixation. 3. Posterior levatorplasty. 4. One layer suture as longitudinal fashion. 5. Gant-Miwa operation-like procedure on anterior rectum. RESULTS: There were no cases of postoperative infection and bleeding. There were no cases of recurrence of the rectal prolapse except 1 case of ant. mucosal prolapse which was successfully treated with one more Gant-Miwa operation-like procedure at postoperative 3 months. Fecal incontinence were in two cases at postoperative 12 months which were estimated as grade 2 by assessment of bowel function by Kirwan. CONCLUSIONS: Although, the best operation for rectal prolapse remains controversial subject, authors believe that transanal posterior anorectoplasty should be considered as effective new surgical procedure for the treatment of rectal prolapse.

Comparison of an Antiperistaltic Ileostomy with the Conventional Ileostomy

Permanant ileostomy is necessary in the case of a total proctocolectomy for a cancerous change in the distal rectum due to ulcerative colitis or familial adenomatous polyposis coli, but the fecal content after a conventional ileostomy is usually liquid or semiliquid. Sometimes, this resultes in dehydration and some nutrient loss. Nahm-gun Oh has designed an antiperistaltic ileostomy for formed stool evacuation. About a 25 cm length of the most distal ileum is cut, this segment is reversed, and then the antiperistaltic ileostomy is performed. The authors have performed antiperistaltic ileostomies in 6 cases of familial adenomatous polyposis or ulcerative colitis with a cancerous change in the low rectum. During the past 5 years and 7 months at the Department of Surgery, Pusan National University Hospital, we found that the profuse ileostomy discharge of the conventional ileostomy was decreased in the antiperistaltic ileostomy group, and that the antiperistaltic ileostomy discharge had a liquid component which was markedly decreased compared to that of the conventional ileostomy discharge. In addition, the antiperistaltic ileostomy discharge appeared to be much more solid and less voluminous. In conclusion, the antiperistaltic ileostomy should be considered for creating the effect of a reservoir by producing intestinal stasis proximal to the segment. The antiperistaltic ileostomy is effective in reducing the daily amount of ileostomy discharge and is convenient for stoma care due to the diminished water content in the discharge.

Posterior Sagittal Anorectal Myectomy for Repair of Hirschsprung's Disease

PURPOSE: In small portion of patients with Hirschsprung's disease, the aganglionic stagment extends only up to the mid-rectum. This report describes an innovative and effective posterior sagittal anorectal myectomy for curative repair of ultrashort segment Hirschsprung's disease in neonates. METHODS: The procedure was performed on ten patients with ultrashort segment Hirschsprung's disease between 1995 to 1998. The procedure was performed by making a sagittal incision in midline posterior perineum to expose the posterior rectum.4 longitudinal strip of muscular layer is removed from the aganglionic portion of the anorectum from the upper rectum to the internal sphincter. The patients were followed postoperatively to determine the effectiveness of the procedure and to observe the presence of any complications. RESULTS: Seven patients (70.0%) were under three months old. Operative biopsy showed that four patients had aganglionosis in the upper rectum, three patients in the middle rectum and three patients in the lower rectum. The posterior sagittal anorectal myectomy was successful in the treatment of ultrashort segment Hirschsprung's disease- symptom recurred for one patient due to total aganglionosis and for another patients due to rectosigmoid aganglionosis. These two patients received the staplingprocedure after colostomy. Some transient complications included mucosal perforation during surgery (30.0%) and incisional wound infection (20.0%). CONCLUSION: For those neonates with ultrashort segment Hirschsprung's disease, the posterior sagittal autorectal myectomy should be considered a safe and effective method for treatment and confirmatory diagnosis. In addition, preliminary colostomy is not required prior to this procedure.

Gambee Anastomosis Using U-shaped Suturing Needle in Surgery of Lower Gastrointestinal Tract

BACKGROUND: It is commonly accepted that the Gambee suture is a precise and reliable suturing method in the anastomosis of the intestine, especially in the aspect of the exact apposition of the submucosal layer. Generally, Gambee suturing technique requires much time and effort, as well as complicated actions and skills. For this reason, the Gambee suture is avoided by many surgeons. PURPOSE: Nahm-gun Oh has devised a U-shaped needle, which can prevent submucosal tearing of the posterior bowel wall, owing to the short distance between its both ends. As a result, an operator to perform a Gambee stitch more easily, safely. This study was undertaken to evaluate the usefulness, reliability of the U-shaped needle. METHODS: The clinical analysis was made on 104 cases with Gambee anastomosed colo rectal disease who have been admitted and operated at the Department of Surgery, Pusan National University Hospital, from January, 1996 to December, 1997 and the disease and patients status, operative procedure, postoperative complication, needle holder grasping count according to anastomosis level of 104 cases were analyzed. RESULTS: Gambee anastomosis was performed in 71 cases(68.3%) of colorectal cancers and 33 cases(31.7%) of nonmalignant colorectal diseases. Postoperative complication was 20 cases(19.2%) and 2 cases(1.9%) of anastomotic site leaks were observed. In aspect of needle holder grasping according to anastomosis level, U-shaped needles allow for an entire Gambee suture from one fixed grasp, while the common half-circled suturing needle requires at least 2 or 3 different grasping positions of the needle holder. In case of anterior bowel wall anastomosis, undesirable slipping-off of the submucosal tissue was founded. Authors also suggest a hook-style barb tip so that barb tip should prevent the slipping-off. CONCLUSION: The half-ellipsed or half-track needle can prevent submucosal tearing of the posterior bowel, owing to the short distance between its both ends. Barb feature on the suturing needle tips will be able to prevent slipping-off of the submucosa contralateral from the needle holder during an entire Gambee stitch on the anterior bowel wall. We recommended, based on our results, with U-shaped suturing needle, as well as barb-tip needle feature, operators can save a lot of time and effort formerly required by other common needle in Gambee suture.

An Antiperistaltic Ileostomy on Total Proctocolectomy in familial Adenomatous

Permanent ileostomy is usually recommended in the cases of total proctolectomy for cancerous change on the distal rectum from ulcerative colitis or familial adenomatous polyposis, but fecal content through conventional ileostomy is usually liquid or semiliquid. Sometimes, it accompanies dehydration and some nutrient loss as complication. So, the author has devised namely, "antiperistaltic ileostomy" for formed stool evacuation. About 25cm length of the most dismal ileum was cut and this distal segment was reversed with intact mesentery and then antiperistaltic ileostomy was performed. The author has performed antiperistaltic ilestomy in 5 cases of familial adenomatous polyposis, or ulcerative colitis with a cancerous change in the low rectum for the past 5 years at the Department of Surgery in Pusan National University Hospital. The results obtained were as follows. 1) In theantiperistaltic ileostomy, the 24-hour ileostomy discharge was averagely 748 cc, in contrast to 1124 cc from conventional one. 2) In terms of weight, the 24-hour evacuated material from the conventional ileostomy weighed 810 gm on the average, but only 540 gm from the antiperistaltic ileostomy. 3) The 24-hour filtered liquid through a coffee filter of the 24-hour ileostomy discharge weighed averagely 514 gm in the conventional group, which was 63.5% of the prefiltered discharge, and weighed averagely 160 gm in the antiperistaltic group, which was 29.6% of the 24-hour discharge. In conclusion, the antiperistaltic ileostomy is claimed to create the effect of a reservoir by producing intestinal stasis in the segment, forming bacterial proliferation. The antiperistaltic ileostomy as a terminal segment is effective in reducing the daily amount of stool and facilitates stoma care owing to diminished liquid component in the ileostomy discharge.