Masato Kusunoki

Long-term results of stapled and hand-sewn anastomoses in patients with Crohn's disease.

Aim: This study aimed at determining the reoperation rates of patients with anastomoses for Crohn’s disease. The outcome of patients undergoing stapled anastomoses was compared with that of patients having hand-sewn anastomoses. Methods: Sixty-three patients undergoing intestinal resection for Crohn’s disease at our institution from 1987 to 1996 were studied in a prospective, randomized trial. The group undergoing stapling comprised 30 patients and 37 anastomoses. The group with a hand-sewn anastomosis comprised 33 patients and 45 anastomoses. The median follow-up period was 87 (range 36–140) months. Results: There were no significant differences in operative indications or patients’ age and sex between the groups. There was a significant difference in cumulative recurrences between the groups (Cox-Mantel test: p = 0.022). Conclusion: A stapled anastomosis after resection for Crohn’s disease may delay reoperation in patients with symptomatic recurrence.

Steroid complications in patients with ulcerative colitis

Physicians treating patients with ulcerative colitis are confronted with the difficult task of deciding whether medical or surgical treatment is best for their patients. There are no definitive criteria to indicate when medical therapy should be exchanged for definitive surgery. Even in patients who respond well to glucocorticoid treatment, the side effects of these drugs may necessitate surgery. We reviewed the steroid complications of our operative cases retrospectively. Although ulcerative colitis was usually in remission, severe steroid complications were no longer tolerable and definitive surgery was required. We also reviewed the literature regarding the adverse effects of steroid. Because of advances in sphincter-preserving surgery, re-evaluation of the treatment of ulcerative colitis is necessary. Although conservative treatment remains the first choice, tolerance of irreversible side effects (especially in children) no longer seems to be justified. In such patients, early definitive surgery may offer more than it appears to sacrifice.

Quality of life after total proctocolectomy and ileal J-pouch-anal anastomosis

We investigated the daily life and opinions of patients after total proctocolectomy and ileal J-pouch-anal anastomosis. Eighty patients answered a questionnaire, completed Cattells anxiety scale, and recorded bowel function for one month. Both colitis and polyposis patients defecated five times daily, had 1.6 episodes of nocturnal motions weekly, and soiled twice weekly. However, colitis patients were more satisfied with their bowel function and surgical outcome than were polyposis patients. This difference had a close relationship to the personality factors of ego strength and frustration. All patients with either disease who defecated less than three times daily, had no nocturnal motions, and had no soiling showed normal ego strength and frustration and were completely satisfied with their bowel status and operation. In contrast, patients defecating more than seven times daily or more than once per week nocturnally and soiling more than four times weekly had high frustration and were dissatisfied. Thus, satisfaction with surgery correlated not only with the objective outcome but also with personality and lifestyle.

Inhibitory Effect of Barbiturates and Local Anaesthetics on Protein Kinase C Activation

A calcium- and phospholipid-dependent protein kinase C subspecies purified from rat brain was inhibited by thiamylal, thiopentone, pentobarbitone, mepivacaine and bupivacaine. This was attributed to the inhibition of the activation process rather than to direct interaction with the active site of the enzyme. It is well established that unsaturated diacylglycerol markedly increases the affinity of protein kinase C for calcium ions. Kinetic analysis suggested that pentobarbitone brought about the inhibition by competing with the diacylglycerol diolein and that mepivacaine and bupivacaine competed with the phospholipid phosphatidylserine used in the assay. The possibility exists that the effects of local anaesthetics on the function of various tissues are due, in part, to an inhibitory action on protein kinase C.

A Comparison of Stapled and Hand-Sewn Anastomoses in Crohn’s Disease

Sixty-eight patients with Crohn’s disease who underwent intestinal resection were randomly divided into 2 groups: the stapled group (32 patients, 40 anastomoses) with functional end-to-end anastomoses made with linear staplers and with circular stapling anastomoses, and the hand-sewn group (36 patients, 48 anastomoses), with anastomoses achieved by layer-to-layer suturing. There were no significant differences in operative indications, age, sex, blood loss, or length of hospital stay between the groups. The operation times for right hemicolectomy and total colectomy in the stapled group were significantly shorter than those in the hand-sewn group. There were no significant differences in anastomotic dehiscence or recurrence between the stapling and hand-sewn procedures. These results indicate that these stapling techniques, even though producing an everted anastomosis, are not an adverse procedure for Crohn’s disease.

Results of pharmacokinetic modulating chemotherapy in combination with hepatic arterial 5-fluorouracil infusion and oral UFT after resection of hepatic colorectal metastases

Pharmacokinetic modulating chemotherapy (PMC) is a new therapeutic concept in combination with continuous 5‐fluorouracil (5‐FU) infusion and UFT. UFT enhanced plasma 5‐FU concentration and antitumor effects during 5‐FU infusion. The authors report on their experiences with arterial 5‐FU infusion and UFT after resection of hepatic colorectal secondaries.

Gastroesophageal Reflux After Distal Gastrectomy: Possible Significance of the Angle of His

Objective:We investigated whether the angle of His influences gastroesophageal reflux after distal gastrectomy.Methods:Thirty-eight patients having distal gastrectomy and 10 controls underwent upper gastroesophageal fluoroscopy to measure the angle of His, and gastroesophageal reflux was assessed by scintigraphy. The association between scintigraphic reflux and the angle of His was then evaluated.Results:In distal gastrectomy patients with and without reflux symptoms, the angle was 108.82 ± in 21.88° and 96.07 ± 13.25°, respectively; it was 74.14 ± 10.85° in the controls. The angle was significantly larger in the patients than in the controls (p < 0.01). In addition, the angle in the symptomatic gastrectomy group tended to be larger than in the asymptomatic group. The angle was also significantly larger in patients with a scintigraphic reflux index ≥6% than in those with an index < 6% (p < 0.05).Conclusions:These findings suggest that the angle of His plays a role in reflux after distal gastrectomy and that the severity of reflux may be estimated by measuring this angle.

Cholecystokinin octapeptide-evoked [3H]acetylcholine release from guinea pig gallbladder

Cholecystokinin-octapeptide (CCK-OP) produced a contractile response in isolated guinea pig gallbladder; the response consisted of scopolamine-sensitive and scopolamine-insensitive components, neither of which were affected by tetrodotoxin or hexamethonium. In the presence of tetrodotoxin, CCK-OP evoked [3H]acetylcholine (ACh) release from strips of gallbladder in a concentration-dependent manner. These results suggest that CCK-OP acts at two sites in the guinea pig gallbladder, viz. the smooth muscle cell and the postganglionic cholinergic nerve terminal.

Protein Kinase C Activity of Colonic Mucosa in Ulcerative Colitis

Protein kinase C (PKC) activity was measured in the inflamed colonic mucosa of 24 patients with ulcerative colitis and in the normal colonic mucosa of 10 patients with other benign diseases. The particulate fraction activity in ulcerative colitis mucosa was significantly increased compared with that of normal mucosa (320 +/- 47 versus 200 +/- 30 pmol/min/mg protein; p less than 0.05). Inflamed ulcerative colitis mucosa also showed significantly increased total PKC activity in the particulate fractions compared with normal mucosa (147 +/- 26 versus 37 +/- 8 pmol/min/mg tissue; p less than 0.05). Mucosal samples from ulcerative colitis patients were divided into 12 with mild and 12 with severe inflammation by histologic examination. The particulate PKC activity of severely inflamed mucosa was significantly lower than that of mildly inflamed mucosa (p less than 0.05). These results indicate that colonic inflammation in ulcerative colitis may be associated with altered cellular PKC activity.

Hemodynamics in the prone jackknife position during surgery

We examined the hemodynamic changes occurring with prone jackknife positioning during colorectal surgery. The operative procedure was restorative proctocolectomy with ileal J-pouch anal anastomosis in five patients with adenomatosis coli and six patients with ulcerative colitis and anoabdominal resection of the rectum with colonic J-pouch anal anastomosis in eight patients with rectal cancer. Nineteen patients (10 men and 9 women aged 41 +/- 19 years) were monitored with arterial and Swan-Ganz catheters during positioning. Measurements were obtained in the supine and prone positions (1 minute, 3 minutes), and the jackknife position (1, 3, 5, and 10 minutes), as well as before and after adoption of the Lloyd-Davies position (1, 3, 5, and 10 minutes). Turning the patient from the supine position to the prone position resulted in a significant decrease in the cardiac index (CI). However, following head-down rotation, the CI increased and returned to the value seen in the supine position (p less than 0.05). Heart rate (HR) slowed and mean arterial pressure (MAP) increased in the prone jackknife position. We concluded that the extent of the changes in cardiac function presented no serious problems.