K. Masumori

Pathophysiology and prevention of loop stomal prolapse in the transverse colon

Abstract.We investigated both pathogenesis and prevention of loop transverse stomal prolapse. Seven patients with reducible prolapsed stoma were studied under fluoroscopy after staining the prolapsed stoma and the colon by barium medium while prolapsing or reducing the stoma with or without the stomal wall pressed on to the abdominal wall of fascial plane. All prolapses occurred in the distal limbs of the loop stoma with the distal transverse colons redundant. The prolapse started around the mucocutaneous suture with the stoma inflated and the colon in it depressed and proceeded in accordance with an addition of abdominal pressure, but did not occur by pressing of the stomal wall. Prolapse of transverse loop stoma occurs when redundant colon invades the stoma with an abdominal pressure. Stomal prolapse might be prevented by fixation of the colon to the fascia.

Who Can Get the Beneficial Effect from Lateral Lymph Node Dissection for Dukes C Rectal Carcinoma Below the Peritoneal Reflection

PurposeThis study was designed to identify those patients with Dukes C rectal carcinoma below the peritoneal reflection who might benefit from lateral lymph node dissection.MethodsThe study involved 104 consecutive Dukes C patients who received total mesorectal excision with lateral lymph node dissection for rectal carcinoma below the peritoneal reflection between 1990 and 2002. The patients were retrospectively divided into three groups: patients without lateral spread (Group I: n = 52), patients with nodal involvement between the inferior hypogastric nerve and the internal iliac artery (Group II: n = 16), and patients with nodal involvement in the obturator space (Group III: n = 36). The patients also were divided into two groups according to the number of lateral nodes involved: less than four (n = 42) and at least four (lateral nodes involved: n = 10). Nodal involvement was determined histologically.ResultsThe local recurrence and overall five-year survival rates were 5.8 and 66.9 percent in Group I, 18.8 and 59.8 percent in Group II, and 33.3 and 23.6 percent in Group III, respectively. These outcomes did not differ significantly between Groups I and II, but they were significantly worse in Group III than in Groups I and II, with the survival being significantly better in the patients with less than four histologically positive lateral nodes involved (43.2 percent) than in those with at least four positive lateral nodes involved (0 percent).ConclusionsLateral lymph node dissection was effective for Dukes C rectal carcinoma below the peritoneal reflection with positive lateral nodes involved in the space between the autonomic nerve and the internal iliac artery and in patients with less than four positive lateral nodes.

Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele

Abstract.Background:We evaluated functional and morphological outcomes of transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele.Methods:Ten women (median 68 years) underwent transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele. Symptoms and continence were monitored before and after surgery. Manovolumetric study and defecography were performed in 9 of 10 patients before and 3–6 months after surgery. Twenty-one females without anorectal diseases were used as controls in manovolumetric study. The patients were followed up after a median of 89 months (range, 3–103).Results:Main symptoms (defecatory disorders in 9 patients, vaginal mass in 6, perineal discomfort in 2) disappeared after surgery. Six patients performed digitation preoperatively and gave up digitation on defecation after surgery. Stool incontinence disappeared in 4 of 5 preoperatively incontinent patients (Cleveland clinic score, 5–12) and continence score improved from 5 to 2 in the remaining patient. Three patients with urinary cough incontinence preoperatively did not experience incontinence after surgery but cough incontinence occurred occasionally in an 81-year-old patient postoperatively. Rectocele demonstrated on defecography disappeared postoperatively in all 9 patients who underwent defecography. High threshold volume and maximum tolerable volume, which were observed preoperatively, decreased to control levels after surgery.Conclusion:Transvaginal anterior levatorplasty with posterior colporrhaphy might be an option for symptomatic rectocele to improve anorectal and urinary dysfunctions with morphological disorders.

Minimally invasive transanal surgery for localized rectal carcinoid tumors

Abstract Local excision is often fully justified for rectal carcinoid tumors. However insufficient surgical field and difficult access to proximal tumors have been drawbacks in performing pre-existing local excision procedures. A novel local excisional technique called minimally invasive transanal surgery (MITAS) has been experimented for local removal of carcinoid tumors in the rectum. A specially designed anal retractor connected to the Octopus retractor holder was used and an ENDO-stapler allowed the simultaneous excision and anastomosis to be performed. Eight patients with carcinoid tumors in the rectum (4 tumors in the upper rectum) underwent MITAS. Median distance from anal verge to proximal tumor was 6.5 cm (range, 5–12 cm). The median diameter of the tumor was 9 mm. Median operative time was 18.5 minutes and blood loss was minimal. No analgesics were needed postoperatively, and there was no morbidity or mortality. Full-thickness excision of the rectum was accomplished and the tumors confined in the submucosa were demonstrated histologically to be with free surgical margins. No recurrences have been observed with a median follow-up period of 39 months. The technique facilitates total excisional biopsy for rectal carcinoid tumors and reduces operative time, blood loss and complications.

Effect of oral diazepam on anal continence after low anterior resection: a preliminary study

Abstract The aim of the present study was to investigate the effect of oral diazepam on anal incontinence after low anterior resection for rectal cancer. Five patients with persistent incontinence after low anterior resection for rectal cancer (median level of anastomosis was 4.0 cm from the anal verge) were treated with oral diazepam (2 mg/day) 9–90 months after surgery. Grade and frequency of anal incontinence, the need for a protective pad and changes of lifestyle were recorded to the Cleveland Clinics continence grading scale; anorectal manometry was performed before and after 3 months of treatment. All patients improved on treatment although occasional minor soiling persisted in two patients. Continence score improved from 14 (median, range 9–16) to 0 (range 0–12) after taking diazepam. Improvement occurred within a week after administration of diazepam. Although the patients improved symptomatically, anorectal manometry failed to demonstrate any significant changes. In conclusion, oral administration of diazepam may be worthwhile in the attempt to improve anal continence after low anterior resection.

Enterocele associated with rectocele revealed by dynamic pelvic CT

Enterocele is often associated with other pelvic floor disorders but it is not always possible to detect by clinical examination. Defecography with peritoneography and/or barium meal intake has recently been developed as a new method to identify enterocele, but this method is an invasive procedure. Multislice computed tomography was performed at rest and during simulated defecation to evaluate an 80-year-old female patient who had a defecation disorder and was diagnosed as having rectocele based on results from defecography and clinical findings. Multiplanar reconstruction images were generated for image evaluation. Using this novel method of dynamic pelvic computed tomography, a third-degree enterocele was clearly demonstrated in this case.

The long-term outcome of transvaginal anterior levatorplasty for intractable rectovaginal fistula

Several procedures have been described for rectovaginal fistula with a wide range of success, but there is little information on the long‐term outcome. The aim of the present study was to investigate the long‐term outcome after transvaginal anterior levatorplasty (ALP) for intractable rectovaginal fistula.

Section 6. Digestive organs: Minimally invasive surgery for carcinoid tumors in the rectum

Most carcinoid tumors of the rectum are confined to the submucosa with a size less than 1-2 cm and are usually suitable for local excision, as metastasis to the regional nodes is limited. Endoscopic excision of carcinoid tumors has been performed for this entity as a least invasive method but incomplete resection and/or unclear surgical margin and curability have been reported to occur in 24-42% of cases because of a limited resection up to the submucosal layer and burn effect. Transanal local excision has often been applied for rectal carcinoid tumor as a least invasive method among local excision procedures to accomplish full thickness excision for determining the curability. However, it is often difficult to obtain free access with a sufficient surgical field by the conventional method. Transanal endoscopic microsurgery (TEM) has appeared as a useful option to access a high tumor with fine visibility but special caution has to be taken for tumors sited above the peritoneal reflection. To facilitate full thickness excision even for high tumors, novel local excisional technique called minimally invasive transanal surgery (MITAS) has been developed and used for local removal of carcinoid tumors in the rectum. A specially designed anal retractor connected to the Octopus retractor holder with several novel techniques facilitated excisional procedures around the anus with a sufficient fixed surgical field and an ENDO-stapler allowed the simultaneous excision and anastomosis to be performed. The technique facilitated total excisional biopsy with less operative time and blood loss, and no mobility or mortality in 12 patients with rectal carcinoid tumors.