Chikashi Shibata

Biliopancreatic limb plays an important role in metabolic improvement after duodenal–jejunal bypass in a rat model of diabetes

BACKGROUND AND AIMS Roux-en-Y gastric bypass improves glucose metabolism in clinical practice, and duodenal-jejunal bypass (DJB), an experimental bypass procedure, also improves metabolism in animals. However, the mechanism remains controversial; especially, the role of the biliopancreatic limb (BP-limb) remains unclear. Our aim was to examine the importance of the function of the BP-limb after DJB using a novel operative model. METHODS Otsuka Long-Evans Tokushima Fatty rats with diabetes were divided into the following groups: DJB with a short alimentary limb (A-limb) and long BP-limb (B-DJB group), DJB with jejunectomy (J-DJB group) in which the entire length of the jejunum used for the BP-limb of the B-DJB group was excised; and a sham operation group. Glucose tolerance, plasma bile acid levels, and the gut microbiota were assessed postoperatively. RESULTS Glucose tolerance was improved and weight gain was suppressed after surgery in the B-DJB group. In contrast, these effects were cancelled in the J-DJB group. The plasma levels of bile acids in the B-DJB group were greater than those in other groups. The analysis of gut microbiota showed distinct differences between the B-DJB and other groups; especially, the relative abundance of genus Bifidobacterium was much higher in the B-DJB group. CONCLUSION The BP-limb played an important role in the control of weight gain, glucose tolerance, and increased plasma bile acid levels after DJB in this rat model of type 2 diabetes mellitus. Plasma bile acids and gut microbiota may be involved in these processes.

Thoracoscopic esophagectomy for a patient with perforated esophageal epiphrenic diverticulum after kidney transplantation: a case report

A 58-year-old man who underwent cadaveric kidney transplantation twice presented to hospital with a perforated epiphrenic diverticulum. Computed tomography revealed epiphrenic diverticulitis and right pleural effusion. Upper gastrointestinal fibroscopy showed an epiphrenic diverticulum full of food residue. He was transferred to our hospital, where we performed percutaneous endoscopic gastrostomy under general anesthesia in the supine position before thoracoscopy. Thoracoscopic esophagectomy was performed in the semi-prone position under 6-10 mmHg artificial pneumothorax via the right thoracic cavity. We performed subtotal esophagectomy to remove sources of infection because the esophageal wall surrounding the diverticulum was too thick to close or to perform diverticulectomy. A cervical esophagostomy was constructed after the thoracic procedure. The patient was managed with continuous hemodiafiltration and administered immunosuppressants and steroids to preserve the transplanted kidney. Continuous hemodiafiltration was stopped on postoperative day (POD) 4. The patient was discharged from the intensive care unit on POD 10 and transferred to the original hospital on POD 24 for rehabilitation. The second operative stage was performed on POD 157 at our hospital. We performed gastric tube reconstruction via the ante-sternal route and anastomosed the tube to the cervical esophagus. The postoperative course was uneventful; the patient was transferred to the original hospital on POD 15 after the second operation. Minimally invasive surgery was sufficient to treat perforated epiphrenic diverticulum while preserving the transplanted kidney. We recommend completely removing the source of infection and reducing surgical invasiveness to preserve the transplanted kidney in cases of esophageal perforation following kidney transplantation.

Oral rehydration solution normalizes plasma renin and aldosterone levels in patients with ulcerative colitis after proctocolectomy

Objectives: The possible effects and benefits of oral rehydration solution (ORS) on chronic dehydration after total proctocolectomy. Methods: To evaluate the effect of ORS on the renin-angiotensin system after remnant proctocolectomy in patients with ulcerative colitis (UC), we selected 20 patients after remnant proctocolectomy, ileal J pouch-anal anastomosis, and construction of a diverting ileostomy for UC. Patients were randomly divided into two groups, A (n=9) or B (n=11), 2 weeks after the surgery. In group A, ORS (1000 mL/day) was given for the first 7 days and mineral water (1000 mL/day) for the next 7 days. In group B, mineral water (1000 mL/day) was given for the first 7 days and ORS (1000 mL/day) for next 7 days. Plasma levels of renin, aldosterone and excretion of sodium in urine were evaluated at days 0, 7, and 14. We defined day 0 as the day of beginning this study. Results: Mean plasma renin levels on day 0 were six to eight times greater than the upper normal limit. In group A, ORS lowered plasma renin levels. In group B, plasma levels of renin and aldosterone after ORS were lower than those at days 0 and 7. Conclusions: ORS corrected increased plasma levels of renin and aldosterone to within the normal range in patients after proctocolectomy.

Laparoscopic Surgery for Severe Ulcerative Colitis

Ulcerative colitis is occasionally exacerbated by fulminant manifestation of colitis. Severe ulcerative colitis is usually defined based on Trulove and Witts’ criteria (Table 1) (Truelove & Witts, 1955). The incidence of severe colitis in ulcerative colitis is 5 to 15 percent (Chen et al., 1998). If the patient is not improving despite intensive medical therapy, emergency colectomy is mandatory. In such a case, the patient is often malnourished and anemic, and has received high dose of steroids; therefore, the usual option in patients with severe ulcerative colitis is subtotal colectomy and ileostomy with preservation of the rectum (Gurland & Wexner, 2002). Restorative proctectomy can be done at a later time after the patient has recovered fully and steroids have been withdrawn (Fig. 1).

Moderate-to-Severe Refractory Ulcerative Colitis: Focus on Tacrolimus

Tacrolimus, a 23-member macrolide lactone discovered in 1984 from the actinomycete Streptomyces tsukubaensis, was the first macrolide immunosuppressant agent. Tacrolimus was first used for patients after liver transplantation to reduce the activity of the patients immune system and the risk of organ rejection. Oral tacrolimus was recently approved for use in steroid-refractory moderate-to-severe ulcerative colitis in Japan. This review focuses on the clinical efficacy and safety data of tacrolimus in moderate-to-severe refractory ulcerative colitis.

A Case Report: Repeat Ileal Pouch-anal Anastomosis in a Patients with Severe Ulcerative Colitis Complicated with Intractable Perianastomotic Abscess

回腸肛門吻合術後に難治性吻合部膿瘍を合併したため, 回腸J嚢を再造設し, 回腸肛門再吻合を行った重症潰瘍性大腸炎の1例を経験し, 良好な結果を得たので報告する. 症例は32歳の男性で, 重症潰瘍性大腸炎に対し分割的回腸肛門吻合術を施行したが, ストーマ閉鎖前の回腸.造影にて吻合部周囲に筋筒内膿瘍(cuff abscess)形成が認められた. 難治性のため吻合部の掻爬, 膿瘍ドレナージ, 筋筒部分切除, 再吻合を3度にわたり行ったが, 改善が見られないため, 吻合部を含む回腸J嚢切除と新J嚢回腸肛門再吻合を行った. 術後経過は良好で回腸ストーマ閉鎖後は, 夜間のsoilingはあるもののほぼ満足すべき排便機能を保っている.