Kazuhiko Yoshioka

Physiologic and anatomic assessment of patients with rectocele.

Clinical, physiologic, and anatomic assessments were carried out in 22 female patients with symptomatic rectocele (Group A), 15 patients with asymptomatic rectocele (Group B), and 14 subjects having no rectocele (Group C). Resting anal pressure, rectal pressure, rectal compliance, anorectal inhibitory reflex, and rectal sensation did not differ among the groups. Proctography revealed that the lengths of the rectocele during attempted defecation in groups A (1.6 [1.0–3.5] cm) (median and range) and B (1.6 [1.0–3.0] cm) were significantly greater than that in Group C (0.4 [0.1–0.9] cm) (P<0.001 in both groups). Median pelvic floor descent at rest in Groups A (4.3 [1.6–7.5] cm) (median and range) and B (4.3 [1.3–6.9] cm) were significantly greater than that in Group C (2.5 [1.2–5.0] cm) (P<0.001 andP<0.02, respectively). These results indicate that rectocele is not associated with any physiologic change apart from a significant increase of pelvic floor descent.

Changing Site Distribution of Colorectal Cancer in Japan

AbstractPURPOSE: In North America and other high-risk areas, there has been a proximal shift in the subsite distribution of colorectal cancer. We wanted to determine whether any similar change has occurred in Japan, and where the incidence of this disease has increased sharply. METHODS: Data from the Reports of the Japanese Society for Cancer of the Colon and Rectum were used to analyze the time trend of colorectal cancer in Japan between 1974 and 1994 according to the patients’ age at diagnosis and sex, and the site of the tumor within the colon or rectum. RESULTS: The percentage of patients over the age of 70, especially females, increased. The increase in the percentage of right-sided colon cancer in colorectal cancer cases was accompanied by a continuous decline in the percentage of rectal cancer in both sexes at all ages. In general, the percentage of right-sided colon cancer in colon cancer cases was stable in men, but increased in women. The rate among patients older than 70 years increased in men, but predominated and remained stable in women. No proximal shift in colon cancer was found in either sex under the age of 69. CONCLUSION: These findings indicated that a proximal shift in the subsite distribution of colorectal cancer has occurred in Japan. This rightward shift of colorectal cancer is due to the decreasing proportion of rectal cancer. Furthermore, the increasing proportion of older patients, especially females, may be another major determinant of the changing colon cancer subsite distribution.

Sphincter repair for fecal incontinence

Twenty-seven patients who had sphincter repair by one surgeon over the last ten years were reviewed. Previous surgery, childbirth, and perineal trauma were the most common causes. Twelve patients had been treated previously using an anal continence device (N=6), postanal repair (N=5), and rectopexy (N=1). A covering colostomy was used in ten patients. At the initial operation only 7 patients were rendered completely continent, 13 others were improved, but results were poor in the other 7. Four of the 7 patients were rendered completely continent after secondary operations. Maximum anal pressure and maximum squeeze pressure did not change significantly after surgery; however, preoperative maximum squeeze pressure in patients who achieved complete continence was significantly greter than in those that did not Poor results usually were associated with severe obstetric trauma

Timing of Resection for Synchronous Liver Metastases from Colorectal Cancer

BackgroundThis study aimed to compare the surgical outcome and long-term survival between simultaneous and delayed resection of liver metastases from colorectal cancer (LM), and to identify the factors influencing hepatic disease-free survival in patients with synchronous LM.MethodsSeventy-four patients with LM were divided into two groups, i.e., 32 patients who underwent hepatectomy at the time of colorectal surgery (simultaneous group) and 42 patients who underwent delayed liver resection (delayed group).ResultsThe hepatic disease-free survival rates of patients from the delayed group with either ≥3 or <3 liver metastases were significantly better than that of the simultaneous group. Multivariate analysis showed that simultaneous resection was one of three independent prognostic indicators with an influence on hepatic disease-free survival. In 13 of the 42 (31%) patients from the delayed group, new metastatic lesions were found in the same and/or different segments after re-evaluation during the interval between operations. These patients had a higher incidence of poorly differentiated or mucinous adenocarcinoma, shorter interval between procedures, and larger tumors than patients without tumor progression.ConclusionsTumor progression could be recognized and occult metastases were detected during the interval between operations. Delayed resection of synchronous LM may be useful to reduce the risk of rapid recurrence in the remnant liver. Patients with poorly differentiated or mucinous adenocarcinoma and those with larger tumors who undergo delayed liver resection should receive neoadjuvant chemotherapy during the interval between operations.

A Randomised Prospective Controlled Study of Ciprofloxacin with Metronidazole versus Amoxicillin/Clavulanic Acid with Metronidazole in the Treatment of Intra-Abdominal Infection

SummaryA prospective randomised study was undertaken in 80 patients to assess the combined regimen of ciprofloxacin with metronidazole against amoxicillin/clavulanic acid with metronidazole as treatment for established intra-abdominal infection. Treatment was for five days. Seventy-eight patients were clinically evaluable (38 patients on ciprofloxacin with metronidazole and 40 patients on amoxicillin/clavulanic acid with metronidazole). The overall clinical success rate in the treatment of intra-abdominal infections was 96% for the ciprofloxacin with metronidazole group, and 90% for the amoxicillin/clavulanic acid with metronidazole group. Over half of all patients were able to change from intravenous to oral antibiotic administration within the study period. One patient receiving ciprofloxacin with metronidazole developed pruritus near the injection site.Zusammenfassung80 Patienten mit gesicherter abdomineller Infektion wurden im Rahmen einer prospektiven randomisierten Studie entweder mit der Kombination Ciprofloxacin plus Metronidazol oder mit Amoxicillin/Clavulansäure plus Metronidazol behandelt; die Behandlungsdauer betrug fünf Tage. Zur klinischen Auswertung standen 78 Patienten zur Verfügung (38 Patienten waren mit Ciprofloxacin plus Metronidazol, 40 mit Amoxicillin/Clavulansäure plus Metronidazol behandelt worden). In der Ciprofloxacin-Metronidazol-Gruppe sprachen 96% der Patienten klinisch auf die Therapie an, in der Gruppe, die Amoxicillin/Clavulansäure plus Metronidazol erhalten hatte, 90%. Bei mehr als der Hälfte der Patienten konnte die Antibiotikatherapie nach anfänglicher intravenöser Gabe auf die orale Applikation umgestellt werden. Bei einem Patienten trat nach Gabe von Ciprofloxacin plus Metronidazol neben der Injektionsstelle Pruritus auf.

FKBP51 expressed by both normal epithelial cells and adenocarcinoma of colon suppresses proliferation of colorectal adenocarcinoma.

It has been reported, as a result of Western blot analyses, that FKBP51 is expressed in various tissues, but that it is not expressed in the pancreas, lung, colon, stomach, or spleen. In this paper, we show, using Western blot analyses, reverse transcriptase polymerase chain reaction, and immunohistochemical analyses of samples from colon cancer patients, that both normal epithelial cells and adenocarcinoma in the human colon express FKBP51, and that there are no significant differences in the expressions of FKBP51 between them. We also show that FKBP51 suppresses the proliferation of colorectal adenocarcinoma, possibly due to the suppression of functions of the glucocorticoid receptors.

A solitary fibrous tumor in the perianal region with a 13-year follow-up: Report of a case

A case of a solitary fibrous tumor (SFT) of the perianal region in a 62-year-old man is reported herein. The patient had undergone an abdominoperineal excision of the rectum for an anorectal tumor 13 years previously, and had been referred to our hospital for a perineal mass. Computerized tomography and angiography revealed a markedly hypervascular tumor measuring 11×8 cm in size in the pelvic cavity. After preoperative radiotherapy (total 58 Gy) and the embolization of the feeding arteries, he underwent an en bloc excision of the tumor. Microscopically, the tumor was composed of spindle shaped cells with a “patternless” arrangement in a collagenous background. There was immunohistochemical evidence that these cells were strongly positive for CD34, thus suggesting the tumor to be SFT. The previously resected anorectal tumor showed similar histological and immunohistochemical findings. The patient’s recovery was uneventful.

Pouchitis atlas for objective endoscopic diagnosis.

Abstract“Pouchitis” is a term for nonspecific mucosal inflammation of the pouch after total proctocolectomy and ileal pouch–anal anastomosis for ulcerative colitis. Pouchitis is the most frequent complication of the pelvic pouch at the late stage. To improve the accuracy of the pouchitis diagnosis, sets of clinical symptoms and endoscopic findings (with or without histology of biopsy samples) have previously been evaluated. Endoscopic findings are central to the diagnosis, and a universal consensus of various endoscopic findings must be the initial step toward an objective diagnosis of pouchitis. Since a proper signpost for the endoscopic evaluation of pouchitis has been absent, we developed this pouchitis atlas to minimize the diagnostic variation inherent among individual endoscopists. We also propose new criteria for the diagnosis of pouchitis: the Japanese criteria for diagnosis of pouchitis. These criteria are based on clinical symptoms and endoscopic findings that are clearly categorized in the atlas, and exclude infectious enteritis, anastomotic insufficiency, pelvic infection, anal dysfunction, and Crohns disease. Advantages of the new criteria include ease of bedside diagnosis, without the calculation of points required by the other criteria for pouchitis. This pouchitis atlas, together with our new criteria, should contribute to the establishment of a clear-cut diagnosis for pouchitis and promote better evaluation and treatment of this novel intestinal inflammation.

Double-barreled wet colostomy

An easy and simple method for constructing a urinary diversion in patients undergoing pelvic exenteration for advanced rectal cancer is described. This procedure features double-barreled colostomy with a segment of the sigmoid colon 8 to 10 cm distal to the stoma as a urinary conduit.

Genetic alterations in normal epithelium of colorectal cancer patients may be a useful indicator for subsequent metachronous tumor development.

BackgroundWe attempted to identify areas of microsatellite alterations specific to histologically normal colorectal epithelium and to clarify the correlations among those molecular events and clinicopathologic features.MethodsWe conducted a prospective observation study on 51 colorectal cancer patients. Preoperative blood and microdissected histologically normal colorectal epithelium and neoplastic tissues were collected. Microsatellite analyses with seven microsatellite loci were performed to examine the genetic potential of individual tumors and histologically normal colorectal epithelium.ResultsIn the sporadic colorectal cancer group, p53 LOH in the neoplastic epithelium had a significant correlation with the maximum tumor diameter and the preoperative serum cancer antigen 19-9 level, but not with the depth of invasion of the primary tumor. Among the patients who had p53 LOH in the histologically normal colorectal epithelium, four additional tumors were discovered within 30 months after curative surgery. For those patients, microsatellite alterations in normal colorectal epithelium were more sensitive than tumor markers.ConclusionsFor accurate LOH analysis, nonmalignant lymphocytes from blood should be used as the appropriate normal DNA sample. Focusing on the identification of high-risk patients for microsatellite alterations in histologically normal colorectal epithelium can be a useful indicator of subsequent metachronous tumor development after colorectal surgery.