Shigehisa Inokuma

Impact of Oral Antimicrobial Prophylaxis on Surgical Site Infection and Methicillin-Resistant Staphylococcus aureus Infection After Elective Colorectal Surgery. Results of a Prospective Randomized Trial

Abstract The impact of oral antimicrobial prophylaxis on the surgical site infection and methicillin-resistant Staphylococcus aureus (MRSA) infection after elective colorectal surgery was evaluated by a prospective randomized single-blind study. The patients were randomly allocated to receive either mechanical bowel cleansing with polyethylene glycol alone (group 1) or mechanical cleansing plus oral antimicrobial prophylaxis with kanamycin and erythromycin for 2 days prior to surgery (group 2). In both groups, cefotiam was intravenously given twice a day for 3 days. A total of 143 patients (71 for group 1 and 72 for group 2) were eligible. The incidence of a surgical site infection was 23.9% in group 1 and 11.1% in group 2 (P = 0.04). The incidence of MRSA infection including at surgical and remote sites was 11.1% in group 1 and 5.6% in group 2 (P = 0.19). A multivariate logistic regression analysis showed that the risk of surgical site infection was influenced by the choice of the chemical bowel preparation (P = 0.03) and blood loss (P < 0.01), while an MRSA infection was predominantly influenced by blood loss (P < 0.01) followed by coexisting underlying diseases (P = 0.07). These results suggest that preoperative antimicrobial prophylaxis would be useful for reducing the incidence of a surgical site infection without increasing the risk of an MRSA infection following elective colorectal surgery.

Fulminant amoebic colitis with perforation successfully treated by staged surgery: a case report

Radical surgery for fulminant amoebic colitis leads to extremely high mortality; however, resective surgery is mandatory if a patient develops massive fecal peritonitis. We herein report an extremely rare case of fulminant amoebic colitis with multiple perforations, which was successfully treated by staged surgical procedures. A 48-year-old man who had been treated with predonisolone under a diagnosis of ulcerative colitis was admitted. Biopsy specimens from the colonic mucosa revealed Entamoeba histolytica. On the day of diagnosis, he developed severe abdominal pain and underwent emergency laparoptomy, showing total colonic gangrene with multiple perforations associated with massive fecal peritonitis. Subtotal colectomy, mucous fistula of the rectosigmoid, and ileostomy were performed. He recovered well although disseminated intravascular coagulopathy developed postoperatively. As the middle and upper part of rectum was found to be severely stenotic 4 months after surgery, we performed proctectomy, ileal pouch anal canal anastomosis, and diverting ileostomy, which was reversed 6 months later. The patient has been well with satisfactory anal function 37 months after the initial surgery. This case suggests that (1) early and accurate diagnosis of amoebiasis is important to avoid surgical intervention, and (2) staged surgery including total colectomy should be considered as one of the treatment choices even in patients with total necrotizing amoebic colitis.

APC gene mutations in a jejunal adenoma causing intussusception in a patient with familial adenomatous polyposis

Adenomatous polyps of the jejunum/ileum in patients with familial adenomatous polyposis (FAP) are usually small (<5 mm) and are considered to be of little clinical importance. Genetic alterations in these polyps have not previously been analyzed. We herein report an extremely rare case of FAP presenting with intussusception caused by jejunal adenomas. Both somatic and germline mutations of the APC gene were detected in one of the polyps. A 40-year-old man with FAP was admitted for closure of an ileostomy that had been created because of an anastomotic leak after subtotal proctocolectomy with ileo-anal-canal anastomosis. During the follow-up after that surgery, he had occasionally complained of colicky abdominal pain, but it had quickly subsided. At the second laparotomy, for closure of the ileostomy, jejuno-jejunal intussusception was incidentally found, and segmental resection of the jejunum, including the leading point of the intussusception, was performed. There were five polyps clustered in the resected jejunum. Histologically, the polyps, ranging from 5 to 26 mm in diameter, were adenomas with moderate to severe atypia. Genetic examinations of one of the largest polyps, using polymerase chain reaction single-strand conformation polymorphism (PCR-SSCP) and direct sequencing methods, revealed somatic (T insertion at codon 1557) and germline mutations (4 base-pair deletion at codons 181–182) of the APC gene. This is the first evidence that the coexistence of somatic and germline alterations in the APC gene is involved in the development of a jejunal adenoma causing small-bowel intussusception.

Anorectal Agenesis with a Rectourethral Fistula Diagnosed in an Adult: Report of a Case

We report an unusual case of anorectal agenesis with a rectourethral fistula diagnosed in a 48-year-old man. The patient presented after noticing hematuria, although he had been aware of urinary leakage from his colostomy with occasional fecal urine for about 4 years. He had had a double-barrel colostomy created soon after birth for an imperforate anus, with revision at the age of 4 years to correct a prolapse of the stoma, but his malformation had never been repaired. We performed a physical examination, which did not reveal a perineal fistula, but urethrocystography demonstrated high anorectal agenesis with a rectourethral fistula. Thus, we resected the rectourethral fistula and created an end-colostomy. The patient had an uneventful postoperative course, and was discharged in good health on postoperative day 19. To our knowledge, this is the oldest patient to be diagnosed with anorectal agenesis and undergo resection of a rectourethral fistula.

Usefulness of Postoperative Spiral Computed Tomography Combined with Drip Infusion Cholangiography in Patients with Congenital Biliary Dilatation.

近年, 経静脈性胆道造影 (drip infusion cholangiography) 併用下のspiral computed tomography (以下, DIC-SCT) が, 胆道系疾患の新しい非侵襲検査として普及した. そこで今回, 先天性胆道拡張症術後症例におけるDIC-SCTの有用性について検討を行った.先天性胆道拡張症の診断で, 以前に胆嚢・拡張胆管切除, 肝管腸吻合術を施行した7例を対象にDIC-SCTを行った. 手術時の年齢は, 4か月～40歳2か月で, 術後の経過観察期間は, 1年6か月～10年7か月であった.全例において, 肝内胆管1次分枝, 吻合部, および吻合部以下の腸管が描出され, 吻合部の横径は4mm～25mm, 前後径は3mm～20mmと測定できた. IV-A型の1例では, 右枝に拡張を認め, 左枝は描出されなかった.DIC-SCTは, 先天性胆道拡張症術後症例における吻合部の形態や胆汁うっ滞の有無を簡便に知る方法として優れていた.