Extraperitoneal colostomy in laparoscopic abdominoperineal resection using a hand inserted from the perineal side.

INTRODUCTION: Extraperitoneal colostomy is considered to be more effective at preventing post-colostomy complications than intraperitoneal colostomy. However, this operation is difficult via laparoscopic surgery alone. We present an extraperitoneal colostomy technique using a hand inserted from the perineal side. MATERIALS AND SURGICAL TECHNIQUE: Extraperitoneal colostomy was performed in five patients. After the rectum was resected, a hand was inserted into the abdominal cavity from the perineal side, and pneumoperitoneum was created. The peritoneum was dissected to make the extraperitoneal route, and the proximal colon was passed along this route with fingers and laparoscopic manipulation. All procedures were completed without tissue damage or hemorrhage. No patient developed a hernia or ileus postoperatively. DISCUSSION: Laparoscopic abdominoperineal resection for an extraperitoneal colostomy is difficult via laparoscopic ports only. It can be simplified by operating with manual assistance via the perineal wound.

Clinical significance of upper airway obstruction pattern during apneic episodes on ultrafast dynamic magnetic resonance imaging.

OBJECTIVES: In order to assess the relationship between upper airway obstruction pattern and the clinical characteristics of obstructive sleep apnea syndrome (OSAS), we evaluated dynamic changes in the pharyngeal airway of patients with the disorder by using ultrafast dynamic magnetic resonance imaging (MRI). METHODS: MRI while asleep was performed on 31 patients with OSAS (29 men, 2 women; mean age, 46.6+/-8.2 years; mean body mass index, 26.7+/-4.9kg/m(2); mean AHI, 40.6+/-21.7episodes/h). Relationships between obstruction pattern focusing on differences between single-site obstruction (SO) and multiple-site obstructions (MO) and titrated value of nasal CPAP in addition to respiratory variables were investigated. RESULTS: The velopharynx (VP) was the main obstructive site among most of the cases with SO (17 of 18 cases), and all of the cases with MO (n=13) showed obstruction at and below the VP. AHI was significantly higher in cases with MO than in those with SO (P<0.01). As for SaO(2) variables, minimum value during sleep was significantly lower and total time with SaO(2) pound90% was longer in cases with MO than in those with SO (P<0.05 each). Titrated value of n-CPAP was also significantly higher in cases with MO than in cases with SO (P<0.05). CONCLUSIONS: Our results strongly suggest that formation of MO manifested on ultrafast dynamic MRI could be related to increased severity of the disorder. Considering the higher titrable value of CPAP, MO could be brought about by high pharyngeal pressure.

Age-related changes in cerebral lactate metabolism in sleep-disordered breathing.

Thirty-one patients, aged 22-71 years, with nocturnal apneic episodes and/or habitual snoring were studied with magnetic resonance spectroscopy (MRS) and diagnostic polysomnography separately to determine whether accumulation of lactate caused by cerebral hypoxia during sleep is associated with sleep-disordered breathing (SDB), aging and co-morbidities related to SDB. Eight proton magnetic resonance spectra for sleep and two for periods of arousal were obtained from the right centrum semiovale. All patients were evaluated for the presence or absence of co-morbidities including hypertension, cardiac disease, diabetes mellitus, and hyperlipidemia. Significant lactate signals were found in seven patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) during sleep periods, and none during periods of arousal. Aging was significantly related to the presence or absence of significant lactate signals during sleep periods as determined by logistic regression analysis (beta=0.2480; 95% confidence interval, 0.0905-0.5094; P=0.0001). Apnea index (AI), apnea-hypopnea index (AHI), and minimum value of peripheral oxyhemoglobin saturation each significantly interacted with age (P=0.0081, 0.0284, and 0.0302, respectively). Our findings suggest that SDB combined with aging is related to accumulation of lactate during sleep.