Use of Insoluble Dietary Fiber and Probiotics for Bowel Preparation Before Colonoscopy: A Prospective Study.

BACKGROUND: In screening colonoscopy, patients usually have to ingest large amounts of bowel-cleansing agents, including polyethylene glycol (PEG). This is difficult and has various side effects; thus, patients avoid undergoing a colonoscopy. We tested a novel bowel preparation method before colonoscopy using insoluble dietary fiber and probiotics (PB). METHODS: This was a prospective clinical study conducted between October 2018 and March 2019 at a general hospital. Forty participants were randomly assigned to low-volume PEG solution diet (MoviPrep), wheat bran fiber (WBF) and probiotic Bifidobacterium animalis subsp. lactis GCL2505 (PB GCL2505), or standard-volume regimen (1.0 to 1.5 L of MoviPrep) (control group). The patient compliance and the quality of bowel preparation were evaluated. RESULTS: Forty individuals aged 38 to 83 years were randomly assigned to the WBF with PB (n=20) and control (n=20) groups. All participants underwent bowel preparation before colonoscopy according to each protocol. The mean required volume of MoviPrep was significantly lower in the WBF with PB group than in the control group (582.5 vs. 1305 mL, P<0.0001). Successful bowel-cleansing rates were not significantly different between the 2 groups; however, the ratio of the Harefield Cleansing Scale grades C and D was significantly lower in the WBF with PB group than in the control group (P=0.0471). CONCLUSIONS: The intake of WBF and GCL2505 before colonoscopy reduces the required PEG quantities while maintaining bowel-cleansing quality. This novel, minimally invasive pretreatment method makes colonoscopy more accessible contributing to the prevention and early treatment of colorectal cancer.

Histomorphological investigation of intrahepatic connective tissue for surgical anatomy based on modern computer imaging analysis.

BACKGROUND/PURPOSE: Computer-assisted tissue imaging and analytical techniques were used to clarify the histomorphological structure of hepatic connective tissue as a practical guide for surgeons. METHODS: Approximately 5000 histological slides were prepared from liver specimens of five autopsied patients. Three-dimensional (3D) reconstruction was performed and subjected to computer imaging analysis. Scanning electron microscopy was also performed on the liver specimens. RESULTS: The 3D reconstructed images revealed the running form of the vasculature and the relationship between the hepatic lobule and connective tissue. The hepatic capsule or portal pedicle was consistently located at the periphery of the hepatic lobules. An artificial intelligence random forest approach clearly segmented hepatic cells, type I collagen (CF), type III collagen (RF), and other cells. The hepatic lobule, portal region, and hepatic capsule were significantly distinguished based on CF and RF occupancy. The capsule directly covering the liver lobule with an RF concentration up to 87% was provisionally named the proper hepatic capsule. The existence of a proper hepatic ligament with distinct occupation rates of CF and RF was also suggested. CONCLUSIONS: The identified proper hepatic capsule and ligament can be important markers for demarcating the dissecting layer during surgical procedures.

Coexistence of mucinous cystic neoplasm occurring in the head of the pancreas with annular pancreas: report of a case.

Mucinous cystic neoplasms (MCN) of the pancreas are rare tumors that are almost exclusively located in the body or the tail of the pancreas. A 60-year-old woman with no history of pancreatic disease was referred to our hospital with a chief complaint of dull pain in the upper abdomen. Abdominal computed tomography showed a multilocular cystic mass of 7.0 cm in the head of the pancreas, and endoscopic retrograde cholangiopancreatography showed no communication between the cystic mass and the main pancreatic duct. A pancreatoduodenectomy was performed for the complete resection of the tumor, and an annular pancreas was discovered by accident. The pathological examination of the tumor led to a definitive diagnosis of MCN with ovarian-type stroma. To our knowledge this is the first documented case of MCN occurring in the head of the pancreas and associated with annular pancreas.

Pancreatogastrostomy with an elastic purse-string suture around the gastric orifice after pancreatoduodenectomy.

Postoperative pancreatic fistula (POPF) is a potentially fatal complication of pancreatoduodenectomy (PD). Fixation of the remnant pancreas to the gastric wall is considered essential to prevent anastomotic leakage in patients undergoing pancreatogastrostomy (PG) after PD. PG was performed with invagination of the pancreatic stump. To limit the number of sutures in the pancreas parenchyma to three or four, we placed an elastic purse string suture around the orifice of the posterior gastric wall in an attempt to fix the gastric wall to the remnant pancreas. We performed PG using this technique in 30 patients. According to the international POPF criteria, POPF developed in three (10%) patients; as grade A in one, and grade B in two. These results demonstrate the potential advantage of performing PG after PD, by using this invaginated technique with an elastic suture.

Laparoscopic rectopexy for recurrent rectal prolapse: a safe and simple procedure without a mesh prosthesis.

Two female patients, 65 and 61 years old, respectively, suffering from a recurrent rectal prolapse underwent laparoscopic rectopexy. Our modified method using an ultrasonically activated scalpel (Harmonic Scalpel) and a laparoscopic suturing device (Endo Stich) both shortened and simplified the operation. The operation times were 140 minutes and 120 minutes, respectively. Neither of the patients demonstrated either intraoperative complications or recurrence of the prolapse during the 24-month follow-up. Our procedure using these new instruments could be performed simply, safely, and in a short time, without the use of a mesh prosthesis.

New therapeutic strategy of open pelvic fracture associated with rectal injury in 43 patients over 60 years of age.

BACKGROUND/AIMS: A diversion of the fecal stream is generally regarded as an integral component of minimizing both the infectious morbidity and mortality associated with an open pelvic fracture. However, the efficacy of the fecal diversion in elderly has yet to be clearly elucidated. We performed a formal retrospective comparison between the elderly patients who underwent diversion and those who did not. METHODOLOGY: Forty-three consecutive patients who were over 60 years of age and suffered a pelvic fracture associated with rectal injury. The use of fecal diversion was used to delineate the comparison groups: group 1, underwent diversion; group 2, did not undergo diversion. The 2 groups were compared based on the outcome variables and patient demographics. RESULTS: The diverted patients were more severely injured as demonstrated by a higher ISS (p < 0.05). The length of hospital stay was also significantly greater for the diverted patients than for the non-diverted patients (p < 0.05). The number of abdominal injuries (p < 0.05) and the number of total diagnoses (p < 0.05) were also significantly greater for the diverted patients than for the non-diverted patients. There was a significant difference in the distribution of intraabdominal fecal contamination (p < 0.05). No significant difference was observed in the distribution of fracture stability, fracture patterns, wound location, or wound severity between the diverted and non-diverted groups. On the other hand, the chi 2 test for trend (Mantel-Haenszel) for fecal diversion and the Gustilo grade produced a P value of 0.04. A primary repair with end-colostomy was performed in 7 of 23 patients and a resection with an end-colostomy was performed in 16 of 23 patients in group 1. On the other hand, a primary repair was performed in 3 of 20 patients and a resection with anastomosis was performed in 17 of 20 patients in group 2. By the third postoperative month, no significant difference was seen in the survival rate: 61% in group I versus 65% in group 2 (P = 0.40). By the first postoperative month, the survival rate was significantly lower in group 1 than in group 2 (P = 0.04). CONCLUSIONS: Diversion should not be regarded as an absolutely safe intervention for open pelvic fracture associated with rectal injury. However, if a failure of the primary repair or resection with anastomosis once occurs, then the patient's condition could change suddenly or worsen. Elderly patients especially have a poor physiological reserve, and thus a failure to perform a primary repair or resection with anastomosis can quickly lead to patient mortality. There may be some bias when selecting fecal diversion or not based on each surgeon's subjective judgment. In our cases, diversions tended to be done in severe cases. If surgeons encounter a pelvic fracture with severe rectal injury, then aggressive fecal diversion may thus be the procedure of choice in emergency elderly cases.

Results of endotoxin absorption after a subtotal resection of the small intestine and a right hemicolectomy for severe superior mesenteric ischemia.

BACKGROUND/AIMS: The purpose of this study is to analyze the results of endotoxin absorption therapy after a subtotal resection of the small intestine and a right hemicolectomy for severe superior mesenteric ischemia. METHODOLOGY: From April 1980 through August 1999, 82 patients with severe superior mesenteric ischemia were operated on an emergency basis, and they were divided into two groups. Group 1 (n = 51), did not undergo postoperative endotoxin absorption therapy, while group 2 (n = 31), underwent this therapy. The two groups were compared based on the outcome variables. RESULTS: When the number of risk factors was 1 or 2, the mortality rate in group 2 was significantly lower than in group 1 (p < 0.05). For postoperative lung or liver failure, the mortality rate was significantly higher in group 1 than in group 2. For an intraabdominal abscess, the mortality rate was significantly higher in group 1 than in group 2. Twenty-two of the thirty-one patients in group 2 survived. In the surviving cases, this therapy significantly decreased the intravenous concentration of endotoxin (p = 0.04). As for the fatalities (n = 9), no significant change in the concentration of endotoxin before or after endotoxin absorption was recognized. By the first postoperative month, the survival rate was significantly lower in group 1 than in group 2 (58.8% vs. 71.0%, P = 0.04). CONCLUSIONS: In conclusion, we may now safely say that both stoma and a resection are recommended while endotoxin absorption using blood filtration may also be an effective additional therapy for post-operative septic shock.

New insight for management of blunt splenic trauma: significant differences between young and elderly.

BACKGROUND/AIMS: Although highly successful in children and young patients, the non-operative management of blunt splenic injury in the elderly has yet to be clearly studied. The purpose of this study was to determine whether or not a relationship exists among the mechanism of injury, the grade of splenic injury, the associated injuries, and whether patterns of injury differ between the young group (younger than 60 years old) and the elderly group (60 years and older than 60 years). METHODOLOGY: One hundred and sixty-seven patients (116 young patients including 30 early deaths and 51 elderly patients including 20 early deaths) with blunt splenic injury were admitted to our clinic from 1983 to 1997. Computed tomography scans were interpreted in a blind fashion. In addition, the Injury Severity Score, Glasgow Coma Scale, blunt splenic injury grade, length of hospital stay, length of intensive care unit stay, survival, number of abdominal injuries and number of total diagnoses were investigated in both the young and elderly groups. The different types of management for blunt splenic injury were also studied. RESULTS: Higher injury severity scores, lower Glasgow Coma Scales, and higher mortality all indicated that the elderly were more severely injured than the young patients. The rate of non-operative treatment was also significantly greater for young patients than for elderly patients (62.8 vs. 32.3%, P < 0.05) and the rate of a splenectomy was significantly less for the young patients than for the elderly patients (29.1 vs. 51.6%, P < 0.05). Regarding infectious complications, the rates of pneumonia (14.0 vs. 23.1%, P < 0.05), subphrenic abscess (9.3 vs. 23.1%, P < 0.05), and urosepsis (7.0 vs. 23.1%, P < 0.05) was significantly greater for the elderly patients than for the young patients. The overall failure of non-operative management was 5.2% in the young patients and 9.8% in the elderly patients. CONCLUSIONS: The final selection of splenic management decision was individualized for each patient and based on multiple variables. For persistent hemodynamic instability or unresolved concerns for other individual pathologic conditions, aggressive management is recommended. In the absence of these two important conditions, the variables that predicted a need for operative intervention include an Injury Severity Score above 20 in younger and elderly patients; an American Association for the Surgery of Trauma splenic grade above III in elderly; a large hemoperitoneum on an initial computed tomography scan; the presence of active extravasation on an initial computed tomography scan; and high-energy mechanisms. In conclusion, selecting the optimal non-operative management of blunt splenic injury in elderly patients remains difficult. An aggressive initial operation is thus recommended because the specific fragility of the spleen and the decreased physiologic reserve in elderly patients is difficult to estimate, especially at small hospitals where performing emergency splenic angiography and treating embolisms is difficult.

Anatomic resection for severe blunt liver trauma in 100 patients: significant differences between young and elderly.

The liver is the organ most commonly injured during blunt abdominal trauma. As our society ages, emergency surgery for active elderly patients increases, but data on aggressive emergency hepatic resection remain scarce in the literature. The purpose of this study was to determine whether the elderly (70 years of age or older) can tolerate major liver injury and subsequent hepatic resection. We investigated 100 patients who were treated by an anatomic resection for severe blunt liver trauma (29 elderly patients who were 70 years of age or older and 71 young patients who were younger than 70 years of age) in a retrospective study. The elderly patients were more severely injured as demonstrated by a higher Injury Severity Score, a lower Glascow Coma Scale, and lower survival (80.3% vs. 65.5%; p < 0.05). The total number of associated injuries was greater in elderly patients. Motor vehicle accidents were responsible for 71.8% of the injuries in the young group, and the predominant mechanism in the elderly patients was also motor vehicle accidents (51.7%). The 71 anatomic hepatic resections performed on the young patients included right hemihepatectomy (n = 45), left lateral segment resection (n = 14), bisegmentectomy (n = 5), and others. The 29 anatomic hepatic resections performed for the elderly patients were right hemihepatectomy (n = 15), left lateral segment resection (n = 5), left hemihepatectomy (n = 4), and others. Pneumonia, subphrenic abscess, and urosepsis occurred at a significantly higher frequency in elderly patients than in young patients. Our data clearly indicated that (1) the mechanism of injury, grade of associated intraabdominal injuries, distribution of surgical procedures, and complications differ significantly between young and elderly patients; and (2) the survival rate (65.5%) in elderly patients may be sufficient to consider anatomic hepatic resection to be a useful, safe procedure.

Therapeutic strategy of emergency surgery for colon cancer in 71 patients over 70 years of age in Japan.

BACKGROUND/AIMS: The prognosis for colon cancer is poorest in cases of emergency situation in the elderly not only in Japan, but worldwide. The aim was to design a therapeutic approach used for colon cancer in the elderly. METHODOLOGY: Seventy-one patients, who were all older than 70 years, with colon carcinoma in an emergency situation were examined. Lethality, surgical procedure, risk of comorbidity, multiple organ system failure and the effect of endotoxin absorption were examined. RESULTS: Any increase in comorbidity was associated with a higher clinical lethality in the lungs, heart, kidney, and diabetes. The highest postoperative mortality rate was recorded in patients who underwent primary resection after perforation, while the lowest postoperative mortality rate was recorded in patients who underwent primary resection after obstruction. Postoperative failure of the lungs and heart and renal failure were associated with a significantly higher mortality rate. Twenty-five septic patients received an endotoxin adsorption due to blood filtration and 8 patients survived. Of the eight survivors, the endotoxin concentration was significantly decreased by an endotoxin absorption. CONCLUSIONS: In cases of ileus, the resection may be performed positively. In cases of perforation, we may safely say now that stoma and resection is to be recommended. Endotoxin absorption due to blood filtration may be an effective additional therapy for post-operative septic shock.