Modified open posterior internal sphincterotomy with sliding skin graft for chronic anal fissure and anal stenosis: Low recurrence rate and no serious faecal incontinence postoperative complication.

AIM: Lateral internal sphincterotomy (LIS) remains a standard for chronic anal fissure even though other surgical techniques have shown high efficacy. Faecal incontinence is a well-documented complication of LIS. We devised modified open posterior internal sphincterotomy (m-OPIS) with sliding skin graft (SSG), which is a combined procedure of OPIS and anal advancement flap. The aim of this study is to evaluate m-OPIS+SSG. METHODS: This was a retrospective, observational, single-arm study. m-OPIS+SSG was performed for chronic anal fissure and anal stenosis. m-OPIS involved incision of the internal sphincter muscle at the posterior midline until four fingers could be passed. The incision wound was closed by anastomosis of the anoderm and skin. Then, an arcuate skin incision was created and the skin graft was advanced into the anal canal. Follow-up was conducted by clinical consultation and telephone interview. Faecal continence was assessed by Cleveland Clinic Faecal Incontinence (CCFI) score. RESULTS: m-OPIS+SSG was performed in 143 patients. The mean patient age was 50±16 years. The success and overall recurrence rates after m-OPIS+SSG were 99% and 0.7%, respectively, with a median follow-up period of 16.3 years. One patient developed incontinence with liquid stools once during the 6-month period. None of the other patients suffered permanent faecal incontinence postoperatively. The postoperative CCFI score was 0.5±0.9. CONCLUSIONS: We consider m-OPIS+SSG as one of the efficacious options of procedure for chronic anal fissure and anal stenosis, owing to its high success rate, low recurrence rate and no postoperative complication of serious faecal incontinence.

Modified Gant-Miwa-Thiersch procedure (mucosal plication with anal encircling) for rectal prolapse.

AIM: Rectal prolapse (RP) is usually associated with elderly women and is well recognized as having a detrimental effect on quality of life. A number of surgical procedures for RP are available, but morbidity and mortality are substantial. The Gant-Miwa-Thiersch procedure (GMT) has been frequently used for RP in Japan. However, as GMT has a high recurrence rate it is not widely used elsewhere. The aim of this study was to evaluate a modified version of GMT (mGMT) in comparison with other procedures. METHOD: mGMT was performed under spinal or local anaesthesia in 187 patients with RP. No normal mucosa was left between the tags and lateral wounds were created in the Thiersch procedure. Morbidity, mortality and recurrence rates were recorded. RESULTS: No serious postoperative complications and no operative deaths occurred after mGMT. Eight per cent of patients suffered from infection of the strings. The overall recurrence rate after mGMT was 7.5% with a median follow-up period of 13.8 years. CONCLUSION: On the basis of these results, we consider that mGMT has a number of advantages: it is minimally invasive, does not require general anaesthesia, is technically simple to perform and is associated with satisfactory outcomes and low morbidity. mGMT should be considered an option for the treatment of RP in elderly patients.

Predicting difficulty in extending the ileal pouch to the anus in restorative proctocolectomy: investigation of a simple predictive method using computed tomography.

AIM: This study aimed to assess the ability of preoperative axial computed tomography (CT) to predict surgical difficulty in bringing the ileal pouch to the level of the anus during restorative proctocolectomy (RPC). METHOD: Patients who underwent RPC with an ileal pouch-anal anastomosis (or ileal pouch-anal canal anastomosis) in our institution between January 2008 and April 2014 were enrolled. The patients were divided into two groups, including those in whom CT indicated potential difficulty in extending the pouch downwards (extension difficult (ED) group) and patients with no CT evidence of potential difficulty (normal group). The groups were compared for clinical factors and the thickness of the slices of CT showing the root of the superior mesenteric artery, the point of communication of the ileocaecal artery with the marginal artery (tICA) and the anal verge (AV). Receiver-operating characteristic analysis was performed, and a cut-off value was calculated for predicting the degree of difficulty in bringing the ileal pouch down to the anal canal. RESULTS: Thirty-four patients were entered in the study. The ED group included significantly taller patients and more with familial adenomatous polyposis than the normal group. The distance between tICA and AV was significantly longer in the ED group, with a cut-off of 21 cm giving a sensitivity of 100% and a specificity of 83.3%. CONCLUSION: The distance between tICA and AV measured by axial CT can be a useful predictor for the difficulty in bringing the ileal pouch down to the anus during RPC.

Hepatocellular carcinoma after radiofrequency ablation therapy: dynamic CT evaluation of treatment.

The aim of this study is to analyze the dynamic CT findings after radiofrequency (RF) ablation for hypervascular hepatocellular carcinoma (HCC). RF ablation was used for 22 tumors in 20 patients. Peripheral enhancement was noted in 89% of regions within 1 month in the arterial phase. In 1-3 months, peripheral enhancement remained at 56% and was reduced to 22% by 3-6 months. It is difficult to determine the therapeutic result within 3 months due to continued peripheral enhancement in the arterial phase.

[The alternative or simultaneous excretion of different species of mycobacteria in atypical mycobacteriosis--15 cases in 7 years].

Five hundreds and five cases of Mycobacterium tuberculosis infection admitted to our hospital during 7 years from 1993 to 1999. Numbers of newly diagnosed cases were 390, of which 329 (84.4%) were bacilli positive with sputum examination on admission. The recurrent cases were 115, of which 55 (47.8%) were bacilli positive cases. During the same period, mycobacteria other than tuberculosis (atypical mycobacteria) were detected in the sputum of other 121 cases. The 63 (52.1%) out of these 121 cases were diagnosed as atypical mycobacteriosis (AM) due to repetitive detection of bacilli with fulfilled the criteria according to the Japanese Mycobacteriosis Research Group of the National Chest Hospitals. The ratio of 63 AM cases to 329 bacilli positive TB cases was 19.1%, but it range from 8.2% to 31.3% year by year. In these 63 AM cases, 9 (14.3%) cases excreted AM bacilli simultaneously or alternately with TB bacilli. The other 15 (23.8%) cases excreted different AM bacilli simultaneously or alternately. The changes or combinations with M. avium and M. intracellulare were most frequently observed (in 12 cases). The manners of changes and combinations with different species were described in detail.

Evaluation of glass microspheres for intra-arterial radiotherapy in animal kidneys.

PURPOSE: To evaluate the histologic distribution of nonradioactive microspheres when intra-arterially infused into normal kidneys, and to evaluate the histologic changes after the infusion. MATERIALS AND METHODS: The glass microspheres were SiO2 microspheres with a smooth spherical shape measuring 20-30 micrometers in diameter with a specific gravity of 2.2 g/cm3. After the microspheres were mixed with contrast medium, they were infused into the renal artery. Twelve rabbits were sacrificed at 1 day, 3 days, 1 week, and 8 weeks after the treatment, respectively. The specimen was fixed with 10% buffered formalin, specially embedded in methyl methacrylate (MMA) resin and was stained by hematoxylin-eosin. The distribution of the microspheres in the kidney was analyzed microscopically, and histologic changes were also evaluated. RESULTS: The microspheres were found in arterioles whose diameters were about 20-30 micrometers, within normal kidneys. All vessels containing microspheres were confined to arterioles or arteries. No migration of microspheres was detected in the normal lung or the contralateral kidney. Severe ischemic changes were observed in kidneys, developing within 8 weeks of the infusion. CONCLUSION: Glass microspheres seemed to be a useful embolic material for intra-arterial radiation therapy.

Cerebral blood volume and oxygenation among poststroke hemiplegic patients: effects of 13 rehabilitation tasks measured by near-infrared spectroscopy.

OBJECTIVE: To measure with near-infrared spectroscopy (NIRS) the changes in cerebral hemodynamics and oxygenation in the prefrontal cortex of poststroke patients with hemiplegia performing several rehabilitation tasks and to analyze the different effects of the tasks. DESIGN: Case series pilot study. SETTING: Hospitals and facilities near Tsukuba, Japan. PARTICIPANTS: Twenty-four healthy volunteers and 44 patients with hemiplegia. INTERVENTIONS: For healthy volunteers, conventional rehabilitation tasks of head-up tilt (HUT), calculation, and ergometer. For patients with hemiplegia, these 3 tasks plus reading aloud, listening to music, reciprocal extension, nonparalyzed extension, passive range of motion, pulley, bridge, facilitation, stand-up, and gait. MAIN OUTCOME MEASURES: Changes in cerebral blood volume (CBV) and cerebral oxygen volume (COV) in the prefrontal region sensed by a noninvasive NIRS device placed midforehead in healthy volunteers or on the impaired side in patients with hemiplegia. Computer analysis of the quality and quantity of the CBV and COV change patterns. RESULTS: In healthy subjects, the change patterns of the 3 tasks were clearly different: decrease in COV with HUT, limited increase in CBV and COV with calculation tasks, and gradual increase in CBV and COV with ergometer tasks. In patients with hemiplegia, significant (positive) CBV changes were observed in ergometer, facilitation, stand-up, and gait and significant (negative) changes with Romover. Significant (positive) COV changes were observed in ergometer and facilitation and (negative) in HUT. CONCLUSIONS: NIRS is useful for monitoring the change in regional hemodynamics and oxygenation in rehabilitation; some tasks commonly used in rehabilitation, such as ergometer and facilitation, increase both CBV and COV in the affected prefrontal cortex of patients with hemiplegia.

Pulmonary alveolar proteinosis in a patient with chronic myelogenous leukemia.

We describe the case of a 53-year-old Philadelphia-chromosome-positive woman with chronic myelogenous leukemia, who developed pulmonary alveolar proteinosis (PAP). The possible mechanism involved in the pathogenesis of PAP are discussed based on the clinical and laboratory data for this patient as well as on experimental and clinical data reported in the literature.

[Percutaneous transcatheter coil embolization of the patent ductus arteriosus for elderly patient with left ventricular disfunction].

We performed the coil embolization for 64-year-old male with patent ductus arteriosus and left ventricular dysfunction. We used "snare method" and "cross catheter technique" delivering one coil transvenously and one coil transarterially. Echocardiograms at 7 month after the procedure demonstrated complete occlusion of the ductus, though small shunt was detected at discharge.

Regional tissue blood flow and pH in the brain during deep hypothermic retrograde brain perfusion.

Deep hypothermic retrograde brain perfusion is used to protect the brain during aortic arch operations. However, all experiments have failed to demonstrate retrograde blood flow in the brain tissue. We developed an experimental model of sagittal sinus and simultaneous superior vena cava perfusion. Brain tissue blood flow was mapped with colored microspheres during deep hypothermic retrograde brain perfusion in 9 dogs. Regional brain pH was mapped photometrically using neutral red as a pH-indicating dye after 90 min of retrograde brain perfusion in 28 dogs and after 60 min of circulatory arrest in 8 dogs. Cerebral surface blood flow was also measured during retrograde brain perfusion. They were analyzed as functions of driving pressure between sagittal sinus and aorta. Total brain blood flow (ml/min/100 g) was 1.4 +/- 1.3, 3.8 +/- 2.6, and 4.6 +/- 2.6 when the driving pressure was 15, 25, and 35 mmHg, respectively (P < 0.05, 15 mmHg vs 25 mmHg). Regional cerebral blood flow (ml/min/100 g) with a driving pressure of 25 mmHg was 12.1 +/- 9.4, 7.0 +/- 5.6, 4.4 +/- 2.8, and 2.2 +/- 1.4 in the frontal cortex, anterior, mid, and posterior cerebrum, respectively. Cerebral cortex pH was 6.86 +/- 0.23, 7.15 +/- 0.18, and 6.46 +/- 0.13 after 90 min of retrograde brain perfusion with driving pressure of less than 20 mmHg, after that of above 20 mmHg, and after 60 min of circulatory arrest, respectively. Brain tissue pH, blood flows measured with microspheres, and laser flowmetry were highest when driving pressure was between 25 and 35 mmHg. We conclude that retrograde brain perfusion may provide maximum brain protection with driving pressure of 25 to 35 mmHg.

Pre-operative serum levels of CA72-4 in patients with gastric adenocarcinoma.

BACKGROUND/AIMS: A retrospective study was designed to evaluate the clinical significance of preoperative serum levels of carcino-embryonic antigen (CEA) and CA72-4 in patients with advanced gastric adenocarcinoma. METHODOLOGY: Pre-operative serum levels of CEA and CA72-4 were analyzed and compared with the proliferative activity of cancer cells, monitored in terms of the number of argyrophilic nucleolar organizer regions (AgNORs), in tumors from 153 patients with resected gastric adenocarcinoma with serosal invasion. RESULTS: Elevated levels of CEA were frequently found in patients with lymph node metastasis and liver metastasis. By contrast, elevated levels of CA72-4 were frequently found in patients with peritoneal metastasis at the time of operation. A close correlation was found between pre-operative levels of serum CA72-4 and the AgNOR scores of tumors. Even when apparently curative operations were performed, peritoneal metastasis occurred these were detected quite soon, after apparently curative operations in patients with high pre-operative serum levels of CA72-4 and tumors with high proliferative activity. CONCLUSIONS: This phenomenon might explain the poor prognosis of patients with high levels of CA72-4.

Biological characteristics of esophageal squamous cell carcinoma associated with contiguous intraepithelial carcinoma.

To evaluate the biological significance of esophageal squamous cell carcinoma that is associated with contiguous intraepithelial carcinoma, we analyzed 95 patients with operated esophageal carcinoma. Of these 95 patients, eight had in situ carcinoma. Among 87 cases in which the tumo had invaded more deeply than the lamina propria, there were 42 cases (48.3%) of contiguous intraepithelial carcinoma associated with the main tumor. The biological characteristics (proliferative activity of cells, as revealed by immunostaining with the Ki-67 monoclonal antibody) of 45 tumors without contiguous intraepithelial carcinoma (group A) were compared with those of 42 tumors with contiguous intraepithelial carcinoma (group B). The more advanced was the main lesion, the lower was the incidence of contiguous intraepithelial carcinoma. The mean Ki-67 score of the main tumors in group A was 51.6% and that of the main tumors in group B was 45.9%. The mean Ki-67 score of the main tumors in group B was very similar to that of the contiguous intraepithelial carcinomas that were associated with the main tumors (44.4%, P = 0.682). Furthermore, the mean Ki-67 score of contiguous intraepithelial carcinomas associated with main tumors was very similar to that of carcinomas in situ (41.2%, P = 0.529). From our results, it is suggested that tumors with high proliferative activity may be assumed to grow rapidly and, as a result, the region of intraepithelial carcinoma may develop into an invasive tumor. By contrast, tumors with low proliferative activity may grow slowly and, in such cases, the carcinoma may remain in the epithelium around the invasive tumor.

Gallbladder cancer associated with cholesterosis.

We report herein two cases of carcinoma in situ of the gallbladder associated with cholesterosis. The patient in case 1 was an 81-year-old man who underwent a cholecystectomy for cholelithiasis. The resected specimens revealed gallbladder cancer in the fundus which was diagnosed histologically as mucinous carcinoma. Other findings included 13-mm, 12-mm, and 5-mm polypoid lesions in the neck of the gallbladder which macroscopically appeared to be cholesterol polyps, but histologically demonstrated carcinoma in situ with cholesterosis. The patient in case 2 was a 76-year-old man in whom ultrasonography revealed a highly echogenic, elevated lesion in the gallbladder. Cholecystectomy was performed, and a 33 x 28-mm papillary, elevated lesion with cholesterosis was resected from the neck of the gallbladder. Histologically, this was demonstrated to be papillary adenocarcinoma in situ with cholesterosis surrounded by glandular dysplasia. The distribution of the carcinomas and cholesterosis in both of these patients suggests that the adenoma or carcinoma of the gallbladder had occurred first. Then, the tumor epithelium absorbed cholesterol from the bile, and foamy cells were produced. Thus, when treating cholesterol polyps, it should be remembered that it is often difficult to distinguish between cholesterol polyp and gallbladder cancer with cholesterosis.

The role of radiotherapy in the management of extrahepatic bile duct cancer: an analysis of 145 consecutive patients treated with intraluminal and/or external beam radiotherapy.

PURPOSE: To determine the feasibility of high dose radiotherapy and to evaluate its role in the management of extrahepatic bile duct (EHBD) cancer. METHODS AND MATERIALS: Between 1983 and 1991, 145 consecutive patients with EHBD cancer were treated by low dose rate intraluminal 192Ir irradiation (ILRT) either alone or in combination with external beam radiotherapy (EBRT). Among the primarily irradiated, 77 patients unsuitable for surgical resection, 54 were enrolled in radical radiotherapy, and 23 received palliative radiotherapy. Fifty-nine received postoperative radiotherapy, and the remaining 9 preoperative radiotherapy. The mean radiation dose was 67.8 Gy, ranging from 10 to 135 Gy. Intraluminal 192Ir irradiation was indicated in 103 patients, and 85 of them were combined with EBRT. Expandable metallic biliary endoprosthesis (EMBE) was used in 32 primarily irradiated patients (31 radical and 1 palliative radiotherapy) after the completion of radiotherapy. RESULTS: The 1-, 3-, and 5-year actuarial survival rates for all 145 patients were 55%, 18%, and 10%, for the 54 patients treated by radical radiotherapy (mean 83.1 Gy), 56%, 13%, and 6% [median survival time (MST) 12.4 months], and for the 59 patients receiving postoperative radiotherapy (mean 61.6 Gy), 73%, 31%, and 18% (MST 21.5 months), respectively. Expandable metallic biliary endoprosthesis was useful for the early establishment of an internal bile passage in radically irradiated patients and MST of 14.9 months in these 31 patients was significantly longer than that of 9.3 months in the remaining 23 patients without EMBE placement (p < 0.05). Eighteen patients whose surgical margins were positive in the hepatic side bile duct(s) showed significantly better survival compared with 15 patients whose surgical margins were positive in the adjacent structure(s) (44% vs. 0% survival at 3 years, p < 0.001). No survival benefit was obtained in patients given palliative or preoperative radiotherapy. Gastroduodenal complications increased in those receiving doses of 90 Gy or more, and serious biliary bleeding was experienced in three preoperatively irradiated patients. Complications in other patients was tolerable. CONCLUSIONS: High-dose radiotherapy, consisting of ILRT and EBRT, appears to be feasible in the management of EHBD cancer, and it offers a survival advantage for patients not suited for surgical resection and patients with positive margins in the resected end of the hepatic side bile duct. Expandable metallic biliary endoprosthesis assists the internal bile flow and may lengthen survival after high dose radiotherapy.

[Relationship between birch pollen allergy and oral and pharyngeal hypersensitivity to fruit].

We evaluated the relationship between birch pollen allergy and oral and pharyngeal hypersensitivities to certain fruits. 1. Of 171 birch pollen CAP positive (score > or = 2) patients, twenty two (13%) were revealed to be hypersensitive to apples, eleven (6%) to be hypersensitive to peaches, both rates being higher than those found in patients with other CAP positive reactions (orchard grass pollen CAP, mugwort pollen CAP or Dermatophagoides pteronyssius CAP positive). 2. Among the birch pollen CAP positive patients, the higher the CAP score for birch pollen, the higher the prevalences of hypersensitivity to apples and peaches were found to be. 3. Of 171 birch pollen CAP positive patients, six (3.5%) were revealed to be hypersensitive to kiwi fruit. Of 253 patients with other CAP positive reactions, three (1%) were revealed to be hypersensitive to kiwi fruit.

[Amyloid deposition in chronic joint disease].

As a screening procedure for the detection of amyloidosis secondary to rheumatoid arthritis, abdominal subcutaneous fat tissues were aspirated, and were examined after Congo red staining by polarized microscopy. Positive amyloid deposits were found in 7.1 percent of the rheumatoid patients, and the amyloid in the subcutaneous fat was determined to be AA type by permanganate oxidation. The occurrence of amyloid deposition was significantly correlated with the duration of the articular symptoms, the progression of the class, and also with proteinuria. Additionally the joint capsules, including the synovium and synovial fluid sediment, from patients with rheumatoid arthritis and osteoarthritis were examined for amyloid deposition. Deposits of amyloid in the hip and knee joints were found more frequently in those with rheumatoid arthritis than in those with osteoarthritis. In osteoarthritis, the frequency of amyloid deposition tended to increase with advancing age. However these amyloid deposits in the joint structure were discovered to be resistant to permanganate oxidation. Therefore it was suspected that these amyloid deposits were of a type different from AA amyloid.