Masayuki Hotokezaka

Effect of radiotherapy on anorectal function in patients with cervical cancer

PURPOSEnThe acute and long-term effects of pelvic radiation on defecation were studied.nnnMETHODnAnorectal function was assessed based on manometry and subjective symptoms in 31 patients with cervical cancer treated by radiotherapy alone. Sixteen of 31 patients were examined periodically before, during, and after radiotherapy (early group). Fifteen others were examined more than six months after completion of radiotherapy (late group).nnnRESULTSnOne-third of patients in both groups had symptoms, mainly diarrhea and increased stool frequency. Patients in the late group also suffered from disturbed gas-stool discrimination, urgency, a sense of residual stool, and soiling. Anal canal resting pressure was significantly higher after radiotherapy (47 +/- 15.5 mmHg) than before radiotherapy (36.3 +/- 12.5 mmHg; P < 0.05). The maximum tolerable volume decreased with radiation, from 163.3 +/- 45 before to 119.2 +/- 41.4 ml during, 112.7 +/- 36.6 ml immediately after, and 94.6 +/- 34.4 ml in the late group (P < 0.01). Rectal compliance also decreased over time and was lower in the early group (before, 5.7 +/- 1.3 ml/mmHg; P < 0.01; during, 4.6 +/- 2.2 ml/mmHg, P < 0.01; after, 3.7 +/- 1.4 ml/mmHg; P < 0.05) than the late group (2.1 +/- 1.5 ml/mmHg) and lower before than after in the early group (P < 0.01). Although rectal pressure initiating continuous desire to defecate did not change, the maximum tolerable pressure was significantly higher in the late group (81 +/- 19.5 mmHg) than during (59 +/- 16.8 mmHg) or after (59.9 +/- 16.9 mmHg) radiotherapy in the early group (P < 0.05).nnnCONCLUSIONnRadiation reduces the capacity of the rectal reservoir, even in asymptomatic patients. These changes develop during radiotherapy and progress over time.

Histological and Immunological Features of Appendix in Patients with Ulcerative Colitis

Patients with ulcerative colitis (UC) have a less frequent prior history of appendectomy than the general population. The aim of the present investigation was to elucidate histological and immunological characteristics of the appendix in UC and to assess the effect of appendectomy on the disease. Nine subjects with mildly active UC were treated by surgical appendectomy. In four subjects, the histological findings of the appendix were compatible with ulcerative appendicitis. CD3+CD4+CD25+, CD3+CD4+CD45RO+, and CD3+CD8+CD45RO+ appendiceal mononuclear cells were significantly higher in UC than in acute appendicitis and in normal appendix. There was a trend towards higher mRNA transcripts of IFN-γ in the appendix of UC than those in other two groups. Clinical activity index decreased significantly four weeks after the appendectomy, although the effect was transient. The appendix is a site of involvement in UC, where mononuclear cells are presumed to be at a state of basal activation.

COMPARISON OF BLOOD FLOW ASSESSMENT BETWEEN LASER DOPPLER VELOCIMETRY AND THE HYDROGEN GAS CLEARANCE METHOD IN ISCHEMIC INTESTINE IN DOGS

Blood flow of the colon and the ileum was measured before and after intestinal devascularization by laser Doppler velocimetry and the hydrogen gas clearance technique in 10 dogs in order to evaluate the clinical usefulness of laser Doppler velocimetry. The submucosal blood flow of the colon and the ileum measured by the hydrogen gas clearance method was significantly decreased, as was the subserosal blood flow of both sites measured by laser Doppler velocimetry. There was a linear relationship between the flow values using the two methods both in the colon (r = 0.7192, p less than 0.001) and in the ileum (r = 0.7646, p less than 0.001). These data suggested laser Doppler velocimetry may be a useful method to assess the degree of intestinal ischemia because of its noninvasiveness and good correlation with submucosal blood flow by the hydrogen gas clearance technique.

Gallstone formation and gallbladder bile composition after colectomy in dogs

A high prevalence of gallstones has been described in patients following colectomy. The aim of this study was to examine whether lithogenicity is attributed to colectomy. In the present study, changes in gallbladder bile composition and the mechanism of gallstone formation after colectomy were examined in dogs. Ten mongrel dogs underwent restorative proctocolectomy. Seven dogs which received sham operations served as controls. Over a 12-week postoperative period, samples of gallbladder bile, formed gallstones and serum were collected and analyzed. In 7 of the 10 (70%) colectomized dogs, gallstones were found in the gallbladder, while the control dogs had no stones. Macroscopically the gallstones were similar to black pigment stones observed in humans. Chemical analysis and Fourier transform-infrared spectroscopy examination revealed that the stones were composed mainly of sodium bilirubinate and proteins, with minor amounts of calcium salts and cholesterol. Significant increases in biliary pH and concentrations of ionized calcium and unconjugated bilirubin were observed in the gallbladder bile of the colectomy group compared with that of the control group. The total bile acid and total bilirubin concentrations were significantly decreased in the colectomy group. Cholesterol crystal nucleation did not occur. The inhibitory effect of gallbladder bile on calcium carbonate precipitation in anin vitro assay system was preserved even after colectomy. In conclusion, proctocolectomy increases the concentration of unconjugated bilirubin in gallbladder bile and induces pigment gallstones which are composed mainly of sodium bilirubinate and proteins since calcium ions and cholesterol are stabilized in dogs.

Morphology following Proctocolectomy in Dogs: Effect of Introduction of a ‘Neocolon’ Using an Interposed Jejunal Segment

Intestinal mucosal morphology was studied in dogs given a new reconstruction procedure following proctocolectomy in which a jejunal segment was interposed between the terminal ileum and the anus to function as a neocolon. Chronic inflammatory cell infiltration, villous atrophy, and fibrosis of the lamina propria were sought in three different intestinal sites and assigned a severity score. Twenty-four weeks after proctocolectomy, villous atrophy and fibrosis of the lamina propria were noted both in the interposed jejunum (neocolon) (p < 0.05, p < 0.01, respectively) and the terminal ileum (p < 0.05, p < 0.05, respectively). Similar changes were also observed in the proximal jejunum, but a significant difference compared to the preoperative time was not seen. Fibrosis of the lamina propria in the interposed jejunum tended to be more advanced than that in the other two sites. A statistical difference in severity was obtained between the interposed jejunum and the proximal jejunum (p < 0.05). Chronic inflammatory cell infiltration was similar in all sites examined. No obvious evidence of acute inflammation was found at any site examined. These data suggest that chronic morphologic changes inevitably occur at any site in the remaining intestine after proctocolectomy and that an interposed jejunal segment is most severely affected. The new interposition procedure may be effective in reducing the morphologic changes in the terminal ileum because of its proximal displacement.

A simplified defaecographic procedure for the assessment of faecal incontinence or obstructed defaecation

Various types of defaecography have been reported for research purposes. A simplified method for clinical use has not been devised for the assessment of disordered defaecation. The aim of this study was to describe a simplified procedure of defaecography and evaluate its usefulness in the diagnosis of faecal incontinence or obstructed defaecation.

Side-to-side isoperistaltic strictureplasty for chronic ischemic enteritis: Report of a case

Chronic ischemic enteritis can cause intestinal strictures, but extensive resection of the small intestine may leave patients with short bowel syndrome. Thus, the importance of preserving diseased small bowel is now recognized. We report a case of successful side-to-side isoperistaltic strictureplasty (SSIS), performed to prevent short bowel syndrome, in a patient with ischemic enteritis caused by strangulated intestinal obstruction. SSIS is useful for preserving the intestinal absorptive function in patients with a long narrowed bowel loop caused by ischemic change. To our knowledge, this is the first report of the successful treatment of a long stricture resulting from ischemic enteritis, achieved by performing SSIS.

A Case of Perforated Esophageal Ulcer Caused by an Iron Tablet

鉄剤によるまれな上部食道潰瘍, 穿孔例を経験したので報告する. 症例は21歳の女性で, 鉄欠乏性貧血で処方されたフェロ・グラデュメットの内服後に頸部痛を訴え前医を受診した. ガストログラフィンによる透視で頸部食道から造影剤の漏出を認め食道穿孔が疑われ, 当科に紹介された. CTでは頸部から後腹膜に及ぶ気腫を認めた. 食道内視鏡検査では頸部食道に埋没した赤色の錠剤と膜状の変性した組織を認めた. 内視鏡下食道異物除去術および上縦隔ドレナージ術を施行した. 錠剤摘出部には深い潰瘍を認め穿孔部位と診断した. 術後に食道狭窄を生じたためバルーン拡張術を要した. 病理組織学的には傷害された上皮に食道webを示唆する膠原線維の増生があり, 以前より嚥下困難と鉄欠乏性貧血があったことからPlummer-Vinson症候群が発症に関わっていたと推測された. 鉄欠乏性貧血患者に鉄剤を投与する場合は, 嚥下困難の有無について注意深く問診することが重要である.

Effect of peptide YY on intestinal and hepatic blood flow in dogs

Objective: To investigate the effect of peptide YY (PYY) on the flow of splanchnic blood and bile in dogs. Methods: Under general anaesthesia, the dogs received porcine PYY at doses of 100, 400, or 800 pmol/kg/h for 1.5h. Blood flow was measured in the subserosa of the jejunum, ileum, and colon as well as in the liver, using the hydrogen gas clearance method, before, during, and after PYY infusion. Choledochal bile was collected and its volume measured. Results: Colonic blood flow was significantly inhibited by 100, 400, and 800 pmol/kg/h PYY compared with the pre-infusion levels (P<0.05, P<0.05, and P<0.01, respectively). It was also inhibited by 800 pmol/kg/h PYY (P< 0.05) compared with the non-infusion group. Jejunal blood flow was significantly decreased by 800 pmol/kg/h of PYY (P<0.01), while ileal blood flow was decreased by 100pmol/kg/h of PYY (P<0.05). PYY did not change hepatic blood flow, but inhibited bile flow in a dose-dependent manner. Conclusions: These data show that PYY has an inhibitory effect on intestinal blood flow and varying regional effects. PYY does not affect hepatic blood flow; its inhibitory effect on bile flow is therefore probably not the result of decreased hepatic perfusion.

Manometric and Histologic Assessment following Proctocolectomy and Straight Enteroanal Anastomosis in Canines

Serial manometric studies were performed in mongrel dogs before and after total colectomy, mucosal proctectomy and interposed jejunoanal anastomosis without pouch. Fecal continence and body weight gain were clinically satisfactory by 28 weeks after surgery. Even at 28 weeks after the mucosal proctectomy, the mean maximal resting anal sphincter pressure was significantly lower than the preoperative level (p less than 0.001). Neorectal compliance also decreased. The rectoanal inhibitory reflexes were not observed 2 weeks after the mucosal proctectomy but atypical to typical patterns gradually appeared up to 28 weeks following the mucosal proctectomy. Histologic examination showed no injury of anal sphincter muscles. Mild inflammation was found in the neorectal mucosal layer in all animals. Meissners plexus in rectal muscular cuff was almost completely disrupted. These data suggested that there is certain limitation in restoration of anoneorectal function after mucosal protectomy and enteroanal anastomosis, though with gentle and careful operations.