Early diagnosis of thoracic spinal dural arteriovenous fistula using lumbar magnetic resonance imaging: A case report.

In middle-aged and older men, clinicians often suspect lumbar spine disease when gait is impaired with intermittent claudication, but spinal dural arteriovenous fistula (SDAVF) may be the etiology. An understanding of the key magnetic resonance imaging findings of SDAVF is necessary for early diagnosis, appropriate treatment, and minimization of complications.

Dysmotility by mechanical bowel preparation using polyethylene glycol.

BACKGROUND: The effects of mechanical bowel preparation (MBP) on morbidity (e.g., anastomotic leakage and surgical site infection) have been evaluated. Its effect on early recovery after surgery has drawn renewed attention, and its use is discouraged in the postsurgical management of enhanced recovery. However, most surgeons in Japan prefer polyethylene glycol (PEG) for MBP. We investigated the effect of MBP with PEG on postoperative intestinal motility. MATERIALS AND METHODS: We prospectively evaluated a consecutive series of 258 colon cancer patients who underwent colonic resection and primary anastomosis. We orally administered 2000 mL of PEG in the PEG group and did not administer PEG to patients in the no-PEG group. Postoperative gastrointestinal motility was assessed with radiopaque markers. All patients ingested radiopaque markers 2 h before surgery. Postoperative intestinal motility was radiologically assessed by counting the number of residual markers. Abdominal radiography was conducted on postoperative days 1, 3, and 5 to count residual markers in the large and small intestines. RESULTS: The total number of residual markers in the no-PEG group was less than that in the PEG group on day 5 (P < 0.01) but not on days 1 and 3. On all 3 d, the numbers of residual markers in the small intestine were significantly less in the no-PEG group than in the PEG group (P < 0.001). There were no differences in postoperative complications between the no-PEG and PEG groups. CONCLUSIONS: PEG can negatively affect postoperative intestinal motility, and MBP using PEG is unnecessary in elective colon cancer surgery.

Gene profiling and bioinformatics analyses reveal time course differential gene expression in surgically resected colorectal tissues.

It has previously been reported that gene profiles in surgically-resected colorectal cancer tissues are altered over time possibly due to the different tissue-acquisition methods and sample extraction timing that were used. However, the changes that occur are still not clearly understood. In the present study, time-dependent changes in gene expression profiling in colorectal surgical specimens were analyzed. Normal and tumor tissues at several time-points (0, 30, 60 and 120 min) were extracted, and RNA quality, microarray experiments, quantitative PCR and bioinformatics clustering were performed. Although RNA integrity was preserved 2 h after resection, inherent increased/decreased gene expression was observed from 30-120 min in approximately 10% of genes. Bioinformatics clustering could not distinguish case-by-case, probably due to gene profiling changes. Irregular changes in gene expression after surgical resection were found, which could be a crucial confounding factor for quantitative analyses.

[Reduction in oxaliplatin-related neurotoxicity by the administration of Keishikajutsubuto(TJ-18)and powdered processed aconite root].

Oxaliplatin (L-OHP)is an important chemotherapeutic drug for the treatment of colorectal cancer. Peripheral neuropathy was observed in 90% of patients who received L-OHP.Neuropathy often results in the discontinuation of treatment or a decrease the quality of life(QOL). The most effective method for reducing neuropathy is the discontinuation of L-OHP. To reduce neuropathy, we administered Keishikajutsubutou(TJ-18)with powdered processed aconite root(TJ-3023), and we report the effect of these compounds. The subjects comprised 11 patients with metastatic colorectal cancer. L-OHP(85mg/m2)was administered as part of the FOLFOX6(10 patients)or FOLFOX7(1 patient)regimen. All patients had experienced neuropathy. We administered TJ-18(7.5 g)and T-3023(1 g). After 2 weeks, the TJ-3023 dose was increased to 2 g for nonresponders. The response was evaluated according to the Neurotoxicity Criteria of DEBIOPHARM. Reduction in neuropathy was observed in 5 cases(45.5% ). Among 6 patients whose feet and hands felt warm, reduction in neuropathy was observed in 5(83.3% ).

Objective assessment of postoperative gastrointestinal motility in elective colonic resection using a radiopaque marker provides an evidence for the abandonment of preoperative mechanical bowel preparation.

BACKGROUND: It has been suggested that mechanical bowel preparation (MBP) has no benefit in terms of anastomotic healing, infection rate, or improvement in the postoperative course in patients undergoing elective colorectal surgery, and that it should be abandoned. However, the effect of MBP on postoperative gastrointestinal motility has been assessed subjectively. In this randomized trial, we objectively assessed the effect of MBP on postoperative gastrointestinal motility and mobility in elective colonic resection. METHOD: In total, 79 patients scheduled to undergo elective colonic resection for cancer were randomized to MBP or no-MBP groups prior to surgery. All patients ingested radiopaque markers before surgery to evaluate postoperative gastrointestinal motility, objectively evaluated by the transition of the markers at postoperative days (PODs) 1, 3, 5 and 7. The groups were then further subdivided into open and laparoscopic-assisted colectomy (LAC) groups and evaluated in terms of gastrointestinal motility and postoperative mobility. RESULTS: There was no significant difference between the no-MBP and MBP groups in terms of perioperative and postoperative course. In the LAC subgroup, there was no significant difference between the no-MBP and MBP groups in terms of marker transition. However, in the open subgroup, there was a significant difference between the groups in terms of the residual ratio of markers in the small intestine at POD 3 (no-MBP 35.3% vs. MBP 69.2%; p=0.041), excretion rate of markers at POD 5 (no-MBP 49.7% vs. MBP 8.8%; p=0.005), and residual ratio in the small intestine at POD 7 (no-MBP 3.1% vs. MBP 28.8%; p=0.028). Additionally, the excretion rate in the no-MBP group was significantly higher than in the MBP group at POD 7 (74.1% vs. 33.8%; p=0.007). CONCLUSIONS: Our data provide additional evidence to support the abandonment of MBP in elective open colonic surgery.

Success rate of collagen gel droplet-embedded culture drug sensitivity test in colorectal cancer: are antibiotics a prerequisite for specimen irrigation?

The collagen gel droplet-embedded culture drug sensitivity test (CD-DST) is one of the best chemosensitivity tests owing to its high success rate. However, CD-DST is often a culture method, and contamination is a serious problem, especially in the case of colorectal cancer, which is contaminated by enteric bacteria. It has been reported that the success rate of CD-DST is 64.0% in the case of colorectal cancer. Therefore, the sampling and washing of specimens before culture are extremely important. By washing specimens carefully with normal saline containing antibiotics, we achieved a success rate of 85.3% in the case of colorectal cancer. To improve the success rate, we started specimen irrigation with a large amount of normal saline in January 2007. As a result, a success rate exceeding 90% was acquired. For the success of CD-DST for colorectal cancer, it is important to irrigate specimens many times with a large amount of normal saline.

Prosthetic repair of an incarcerated groin hernia with small intestinal resection.

PURPOSE: No consensus has been reached on the use of prostheses in a potentially infected operating field. In this study, we evaluated the validity of a mesh prosthesis for the repair of incarcerated groin hernias with intestinal resection. METHODS: Twenty-seven patients underwent operations for correction of incarcerated groin hernias with small intestinal resection at our hospital between January 2000 and March 2010. The patients were divided into two groups: those who underwent repair with a prosthetic mesh and those who underwent primary hernia repair. Patients with intestinal perforations, abscess formations, panperitonitis, and those who required colon resections were excluded. The length of the operation, blood loss, and incidences of surgical site infection, postoperative ileus, and recurrence were evaluated in each group. RESULTS: Of the 27 patients studied, 10 (37%) underwent tension-free repair with a mesh, and 17 (63%) underwent primary hernia repair. Although the patients who underwent primary hernia repair were significantly older than the patients who underwent mesh repair (P = 0.015), no statistically significant differences in morbidity, including surgical site infection, or mortality, were identified. CONCLUSION: Strangulated inguinal hernias cannot be considered a contraindication to the use of a prosthetic mesh even in cases requiring small-intestinal resection.

Placement of percutaneous transhepatic biliary stent using a silicone drain with channels.

This report describes a method for percutaneous transhepatic biliary stenting with a BLAKE Silicone Drain, and discusses the usefulness of placement of the drain connected to a J-VAC Suction Reservoir for the treatment of stenotic hepaticojejunostomy. Percutaneous transhepatic biliary drainage was performed under ultrasonographic guidance in a patient with stenotic hepaticojejunostomy after hepatectomy for hepatic hilum malignancy. The technique used was as follows. After dilatation of the drainage root, an 11-Fr tube with several side holes was passed through the stenosis of the hepaticojejunostomy. A 10-Fr BLAKE Silicone Drain is flexible, which precludes one-step insertion. One week after insertion of the 11-Fr tube, a 0.035-inch guidewire was inserted into the tube. After removal of the 11-Fr tube, the guidewire was put into the channel of a 10-Fr BLAKE Silicone Drain. The drain was inserted into the jejunal limb through the intrahepatic bile duct and was connected to a J-VAC Suction Reservoir. Low-pressure continued suction was applied. Patients can be discharged after insertion of the 10-Fr BLAKE Silicone Drain connected to the J-VAC Suction Reservoir. Placement of a percutaneous transhepatic biliary stent using a 10-Fr BLAKE Silicone Drain connected to a J-VAC Suction Reservoir is useful for the treatment of stenotic hepaticojejunostomy.

A case of an intramesosigmoid hernia.

We report an extremely rare case of an intramesosigmoid hernia with small bowel herniation in a defect on the right (medial) leaf of the mesosigmoid. A 46-year-old man was admitted to the hospital complaining of lower abdominal pain, nausea, and vomiting for 6 days. He had undergone an operation for a right inguinal hernia and an appendectomy during childhood. An abdominal X-ray film obtained at admission showed small bowel gas with niveau formation which was diagnosed as small-bowel obstruction. A decompression tube was immediately inserted, and the symptoms subsided. Enterography revealed two strictures separated by approximately 10 cm. However, the contrast medium flowed smoothly through the anal side of the strictures. After the decompression tube was removed, small-bowel obstruction recurred, and laparotomy was performed on the 18th day after admission. During the operation, small bowel herniation with a 4 x 3-cm defect was found on the right leaf of the mesosigmoid, and intramesosigmoid hernia was finally determined to be the cause of the small-bowel obstruction. The resection of the incarcerated part was necessary because a large amount of scar tissue was present on the surface. The postoperative course was uneventful, and no recurrence was observed after discharge. A review of this case indicated that the diagnosis might have been successfully obtained with enterography. Although we did not choose laparoscopic surgery, this surgical modality may also be an appropriate treatment for this disease.

An improvement in the quality of life after performing endoscopic balloon dilation for postoperative anastomotic stricture of the rectum.

A 55-year-old woman underwent a low anterior resection for rectal cancer 7 years earlier at a different hospital. Thereafter, she often had such symptoms as abdominal pain, frequent bowel movements, and constipation. We considered postoperative bowel adhesion to be the cause of these symptoms, and a laparoscopic adhesiotomy was therefore performed twice. However, the symptoms did not substantially improve thereafter. A colonoscope of conventional diameter could barely pass through the anastomotic site of the operation, but we initially judged the anastomotic stricture to not be severe. However, we finally determined the anastomotic stricture to be the cause of these symptoms; X-ray examinations frequently showed the blockage of feces or the collection of gas images in the colon when the symptoms occurred. We therefore performed endoscopic balloon dilation (EBD) after performing electroincision of the scar tissue of the anastomotic ring. We dilated the area of the lesion to a diameter of 20 mm using the EBD technique, and thereafter the patient finally showed an improvement in quality of life. There have been some reports describing the usefulness of EBD for the treatment of colorectal anastomotic stricture. Past studies have reported the indications of EBD to include stricture, which is defined as a narrowed anastomosis through which a 12-mm-diameter colonoscope cannot be passed. Nevertheless, it seemed that when the clinical manifestations of anastomotic stricture are clear, such as those observed in our case, we should not too strictly adhere to this definition.

Multiple early gastric cancer with duodenal invasion.

BACKGROUND: Early gastric cancers with duodenal invasion are rare, and no previous case of multiple early gastric cancer, one invading the duodenal bulb, has been reported. CASE PRESENTATION: A 79-year-old woman was investigated for upper abdominal discomfort. Endoscopic examination revealed an irregular nodulated lesion in the antrum area, and a reddish aggregated-type semi-circumferential nodulated lesion extending from the prepyloric area to the duodenal bulb through the normal mucosa with the antrum lesion. Biopsy revealed a tubular adenoma for the antrum lesion and a well-differentiated tubular adenocarcinoma for the prepyloric lesion. Distal gastrectomy with sufficient duodenal resection was performed. Microscopically, the antrum lesion appeared as a papillary adenocarcinoma, and the prepyloric lesion as a mainly papillary adenocarcinoma which partially invaded the submucosa without any sequential elongation for endoscopic findings. The lesion extended into the duodenal bulb, and was 12 mm in length from the oral end of Brunner's gland's area and limited within the duodenal mucosa. CONCLUSION: Here, we present an unusual case of multiple early gastric cancer, one of which invaded the duodenum with relative wide mucosal spreading. This case illustrates that even early stage cancers located in the gastric antrum, particularly in the prepyloric area can invade the duodenum directly.

Boerhaave syndrome treated conservatively following early endoscopic diagnosis: a case report.

We report on a 41-year-old man with hematemesis and severe epigastric pain. Three hours after the onset of symptoms, we carefully performed upper gastrointestinal endoscopy for suspected upper gastrointestinal perforation. Endoscopy revealed a 2.5-cm-long longitudinal laceration of the lower esophagus without active gastric or duodenal ulcers. The laceration could be partially closed with endoscopic clipping. Computed tomography of the chest revealed a small amount of extraluminal air in the mediastinum. Neither pleural effusion nor pneumothorax was detected. We treated the patient conservatively on the basis of the following factors: a stable general condition without sepsis, limitation of the esophageal disruption to the mediastinum, and early diagnosis. The treatment course was uneventful, and the patient was discharged from the hospital after we had confirmed with endoscopy that the esophageal ulcer was completely healed. Although Boerhaave syndrome is generally considered to have poor prognosis, conservative therapy may be effective in select cases with early detection of the perforation.