Shuji Naka

Factors Affecting the Early Mortality of Patients with Nontraumatic Colorectal Perforation

Abstract.Purpose: We attempted to identify the factors associated with the early mortality of patients with nontraumatic colorectal perforation. Methods: Eighty patients who underwent surgery for nontraumatic colorectal perforation between May 1986 and December 1999 were retrospectively reviewed. Age, sex, cause of perforation, duration of symptoms, associated preoperative septic shock, concomitant disorders (including cardiac disease, chronic obstructive pulmonary disease, hemodialysis, and steroid treatment), operative findings (such as the site of perforation and the degree of peritonitis), and results of preoperative laboratory blood tests (such as the white blood cell count and platelet count) were analyzed for their association with early outcome using univariate and multivariate analyses. Results: Fourteen of the 80 patients died during hospitalization. According to the univariate analysis, advanced age, preoperative septic shock, concomitant disabling cardiac disease, hemodialysis, diffuse peritonitis, and a low preoperative platelet count were more frequent in the patients who died during hospitalization. According to the logistic regression analysis, preoperative septic shock (odds ratio 8.443, 95% confidence interval (CI) 1.625–43.873), concomitant end-stage renal failure (odds ratio 13.641, 95% CI 1.643–113.244), and diffuse peritonitis (odds ratio 13.212, 95% CI 1.441–121.102) were the most significant factors related to in-hospital mortality. Conclusion: Early diagnosis before the patients general condition deteriorates is a key to improving the early mortality associated with nontraumatic colorectal perforation, especially in patients with concomitant end-stage renal failure.

Alanyl-glutamine-supplemented total parenteral nutrition improves survival and protein metabolism in rat protracted bacterial peritonitis model

BACKGROUND The effects of glutamine-enriched total parenteral nutrition (TPN) solution on survival, and protein turnover in the whole body and in individual organs were investigated in a rat protracted peritonitis model. METHODS Twenty-three rats underwent venous catheter insertion. Osmotic pumps were implanted in the peritoneal cavity to allow continuous delivery of Escherichia coli (4 x 10(8) CFU/d). The conventional TPN group received a conventional amino acid solution. The Ala-Gln TPN group received an alanyl-glutamine-enriched TPN solution. The two TPN solutions were isocaloric and isonitrogenous. RESULTS Over the 5 days of TPN treatment, the survival rate of the Ala-Gln group was significantly higher than that of the conventional group. The Ala-Gln group tended to have increased whole-body protein turnover compared with the conventional group. Fractional protein synthetic rates (FSR) in the liver and gastrocnemius muscle of the Ala-Gln group were significantly higher than those of the conventional group. The serum glutamine concentration correlated positively with the FSR of both liver and muscle. The Ala-Gln group showed significantly greater mucosal height and mitoses per crypt, in the small intestine, than did the conventional group. CONCLUSIONS Our results suggested that, in comparison with standard glutamine-free TPN, Ala-Gln-supplemented TPN increases protein synthesis in the liver and skeletal muscle, protects the morphology of the intestinal mucosa, and improves survival in protracted bacterial peritonitis. Ala-Gln supplementation may be useful in septic patients.

Glutamine-Enriched Enteral Diet Enhances Bacterial Clearance in Protracted Bacterial Peritonitis, Regardless of Glutamine Form‡

BACKGROUND The effects of glutamine (Gln)-enriched enteral diets on bacterial clearance were investigated in a rat protracted peritonitis model. The effects of the Gln form, peptide-based vs free amino acid-based, were also compared. METHODS Twenty-three rats underwent gastrostomy. An osmotic pump was implanted in the peritoneal cavity. The rats received a continuous intragastric infusion of one of three diets: Gln-depleted (Gln 0), Gln-enriched with the Gln in free amino acid form (Gln F), or Gln-enriched with the Gln in oligopeptide form (Gln P). The three formulas were isocaloric and isonitrogenous. The pumps delivered a continuous infusion of Escherichia coli, starting at 48 hours after implantation, for 24 hours. Then, the animals were killed. RESULTS Bacterial numbers in peritoneal lavaged fluid (PLF) and the liver were significantly lower in the Gln P and Gln F groups than in the Gln 0 group. The bacterial number in PLF correlated with that in the liver. Neither the number nor the population of peritoneal exudative cells differed among groups. Plasma levels of proline, alanine and citrulline were significantly higher in the Gln P and Gln F groups than in the Gln 0 group. Both Gln supplemented groups showed significantly greater villous height, crypt depth, and numbers of mitoses per crypt in the small intestine than the Gln 0 group. CONCLUSIONS Supplemental Gln enhances peritoneal and hepatic bacterial clearance, regardless of Gln form. Gln-enriched may be more beneficial than Gln-depleted enteral diets in peritonitis.

Influence of diabetes on persistent nonhealing ischemic foot ulcer in end-stage renal disease

The aim of this study was to identify important atherosclerotic risk factors for characteristic nonhealing ischemic foot ulcers in patients with end-stage renal failure. We retrospectively studied 534 consecutive hemodialysis patients in five dialysis units of the Tokyo metropolitan area between 1980 and 1999. The influence of risk factors for ischemic foot ulcers in hemodialysis patients was determined using a multivariate logistic model. The characteristic features were also evaluated with further comparison of the prevalence of risk factors between hemodialyzed diabetic patients with ischemic foot ulcers and another 61 age- and gender-matched nonhemodialyzed diabetic patients with ischemic foot ulcers. In the logistic model, two factors emerged as important risk factors for ischemic foot ulcers: renal failure due to diabetes [odds ratio 21.580 (95% CI 4.838–96.251); p=0.0001] and a history of cerebrovascular disease [odds ratio 2.782 (1.015–7.624); p=0.0467]. On the basis of a comparison of age- and gender-matched control patients, associated diabetic triopathy, a history of cerebrovascular disease, and hypertension were more frequent in the hemodialysis patients. The development of ischemic foot ulcers in those with end-stage renal failure is strongly influenced by underlying advanced diabetic microangiopathy and such other factors as sequelae of cerebrovascular disease and patient debilitation.RésuméLe but de cette étude a été de déterminer les facteurs de risque de l’athérosclérose et leur rôle dans la cicatrisation d’ulcères ischémiques chroniques du pied, lésion caractéristique de l’insuffisance rénale terminale. Nous avons étudié de façon rétrospective 534 patients consécutifs en hémodialyse dans cinq unités de dialyse dans la région métropolitaine de Tokyo entre 1980 et 1999. Les facteurs favorisants de l’ulcère ischémique du pied chez le patient en hémodialyse ont été déterminés par un modèle de régression logistique. Les facteurs caractéristiques ont également été évalués par une comparaison ultérieure de la prévalence des facteurs de risque entre les patients diabétiques porteurs d’ulcère ischémique du pied et 61 autres patients diabétiques non hemodialyses, appariés pour l’âge et le sexe. Selon le modèle logistique, deux facteurs ont émergé comme facteurs de risque importants pour l’ulcère ischémique du pied: l’insuffisance rénale en rapport avec le diabète [rapport de côte: 21.580 (95% IC: 4.838–96.251), p=0.0001] et histoire de maladie cérébrovasculaire [rapport de côte=2.782 (1.015–7.624), p=0.0467]. Basé sur la comparaison des patients appariés pour l’âge et le sexe, la triopathie diabétique associée, une histoire de maladie cérébrovasculaire et une hypertension sont plus fréquemment constatées chez lez patients hemodialyses. Le développement d’ulcère ischémique du pied dans l’insuffisance rénale terminale est fortement influencé par la microangiopathic diabétique avancée et d’autres facteurs tels les séquelles de maladie cérébrovasculaire et la debilitation du patient.ResumenEl trabajo trata de averiguar la importancia de los factores de riesgo arterioescleróticos en la génesis del mal perforante plantar, en pacientes en estadio terminal por fracaso renal. Se efectúa un estudio retrospectivo que comprende 534 pacientes hemodializados, en 5 unidades de hemodiálisis ubicadas en el área metropolitana de Tokio, entre 1980 y 1999. Utilizando un modelo logÍstico multivariante se determinó, en pacientes hemodializados, los factores de riesgo en la génesis de la úlcera isquémica del pie. Se compararon además, los factores de prevalencia entre el mal perforante plantar de los diabéticos hemodializados, con 61 pacientes diabéticos, homologables por lo que al sexo y edad se refiere, con mal perforante plantar pero que no precisaron hemodiálisis. El modelo logÍstico demostró, la existencia de dos factores de riesgo importantes, por lo que al mal perforante plantar atañe: el fracaso renal diabético [odds ratio=21.580 (95% CI 4.838-96.251), p=0.0001] y los antecedentes de enfermedad cerebro-vascular [odds ratio=2.782 (1.015–7.624), p=0.0467]. Comparando con pacientes control, homologables por lo que a la edad y sexo se refiere, constatamos que en los pacientes hemodializados es más frecuente la asociación de diabetes, enfermedad cerebro-vascular e hipertensión. El desarrollo del mal perforante plantar en el estadio final de pacientes con fracaso renal, viene propiciado por la grave microangiopatÍa diabética, asÍ como por otros factores tales como: secuelas de la enfermedad cerebro-vascular y el mal estado general del paciente.

Hepatic Portal Venous Gas Caused by Blunt Abdominal Trauma : Is It a True Ominous Sign of Bowel Necrosis? : Report of a Case

Abstract.A case of transient portal venous gas in the liver following blunt abdominal trauma is described. Computed tomography (CT) demonstrated hepatic portal venous gas 4 h after the injury. An exploratory laparotomy revealed segmental necrosis of the small intestine with a rupture of the bladder. Pneumatosis intestinalis was evident on the resected bowel. A histopathologic study revealed congestion and bleeding in the bowel wall and a great deal of the mucosa had been lost because of necrosis. However, neither thrombus nor atherosclerotic changes were observed in the vessels. A bacteriological examination demonstrated anaerobic bacteria from the bowel mucosa, which was most likely to produce portal venous gas. Although the present case was associated with bowel necrosis, a review of literature demonstrated that portal venous gas does not necessarily indicate bowel necrosis in trauma patients. There is another possibility that the portal venous gas was caused by a sudden increase in the intra-abdominal pressure with concomitant mucosal disruption, which thus forced intraluminal gas into the portal circulation in the blunt trauma patients.

Alanylglutamine-enriched total parenteral nutrition improves protein metabolism more than branched chain amino acid-enriched total parenteral nutrition in protracted peritonitis

Branched chain amino acids (BCAAs) and glutamine are both recommended in catabolic states. The object of this study was to compare the efficacies of alanylglutamine (Ala-Gln)-enriched and BCAA-enriched total parenteral nutrition (TPN) on the protein kinetics in peritonitis. Rats were divided into Ala-Gln and BCAA groups after intraperitoneal implantation of an osmotic pump, delivering a continuous infusion of Escherichia coli. Glutamine composed 30.0% (w/v) of the total amino acids in the Ala-Gln group, and BCAA composed 30.5% (w/v) of the total amino acids in the BCAA group. The two solutions were isocaloric and isonitrogenous. Whole body protein turnover and organ fractional protein synthetic rates (FSR) were measured on days 3 and 5. Serum amino acid levels and mucosal morphology were determined. Ala-Gln group had higher rates of whole body protein turnover, and hepatic FSR on both days. Serum glutamine levels correlated with hepatic and muscle FSR. Ala-Gln TPN group had greater mucosal thickness, numbers of mitoses per crypt, and FSR in distal intestine. Ala-Gln-enriched TPN may be a useful nutritional treatment modality in sepsis.

Role of Ganglion Cells in Sigmoid Volvulus

The aim of this study was to clarify the role of ganglion cells in the development and recurrence of sigmoid volvulus. We analyzed 9 samples obtained from 9 patients who had undergone sigmoidectomy for sigmoid volvulus, and, for comparison, 18 samples from 18 patients who had undergone sigmoidectomy or low anterior resection for rectal cancer. Neuron-specific enolase was used for immunohistochemical staining to detect ganglion cells, and the number of ganglion cells in 20 contiguous fields was counted at 200? magnification. The average number of ganglion cells per 1000 cm3 was corrected using the ratio of the circumference of the resected sigmoid colon to the average circumference in the control group.The raw numbers of ganglion cells in the Meissner’s and Auerbach’s plexuses in the volvulus group were significantly lower than those in the non-volvulus group (Meissner: p = 0.017, Auerbach: p = 0.007). The circumference of the resected sigmoid colons with volvulus was greater than that of those without volvulus (p = 0.00013). There was no significant difference in the corrected numbers of ganglion cells in the Meissner’s plexus or Auerbach’s plexus per 1000 cm3 between the volvulus and non-volvulus groups (Meissner: p = 0.410, Auerbach: p = 0.890).Furthermore, there was no significant difference in the corrected numbers of ganglion cells between the revolvulus and non-revolvulus groups. These findings led us to conclude that functional disorder of bowel movement or elongation of the bowel in sigmoid volvulus or revolvulus is not related to the number of ganglion cells in Auerbach’s or Meissner’s plexus.

Intestinal evisceration through the anus caused by fragile rectal wall.

Dear Sir, Spontaneous prolapse of small bowel through a rupture of the rectum is extremely rare. Fifty-five cases of evisceration of the small intestine through the anus due to rupture of the rectum have been documented in the world literature since the first report in 1827 by Benjamin Brodie. Our report describes the microscopic findings in a patient with a second-degree uterine prolapse and rectal prolapse complicated by a spontaneous rectal laceration and anal evisceration of the small intestine. A 68-year-old woman was admitted to our hospital following prolapse of many loops of small intestine, which extruded through her anus while straining at defecation. There was a history of rectal prolapse, uterine prolapse, and rheumatoid arthritis treated with steroid hormone (prednisolone 5 mg/day). The patient was conscious, and physical examination revealed many loops of small intestine protruding from the anus and second-degree uterine prolapse, associated with signs of shock with hypotension (80/56 mmHg). The extruded bowel appeared viable, although its mesentery was fastened by the anus. We suspected that her rectum or sigmoid colon was ruptured and the small intestine prolapsed from the anus. The prolapsed bowel, which had not been contaminated, was gently delivered back into the peritoneal cavity to prevent bowel necrosis. At laparotomy, we found a longitudinal tear in the anterior wall of the rectosigmoid colon. The tear was 4 cm long and extended down to the level of the rectouterine peritoneal reflection. The serosa and mesentery of the jejunum from about 100 cm distal to Treitz’s ligament to the ileum 10 cm proximal to the ileocecal valve were red and edematous but showed no tear or hematoma. We recognized that almost all the small intestine had prolapsed through the rectal tear. A small quantity of contaminated ascites was seen in the peritoneal cavity. Because the patient was taking a steroid hormone for rheumatoid arthritis, we performed Hartmann’s procedures after careful peritoneal toilet. The patient recovered uneventfully and, after rehabilitation, was discharged on the 44th postoperative day. Histological study revealed hemorrhage and slight ischemic change of the perforated part of the rectal wall. Moreover, edematous and fibrous change was observed surrounding the perforated portion. The resected specimen revealed focal fibrosis of the rectal wall without a change of thickness, indicating recurrent mechanical damage of the rectal wall. Marked fibrosis secondary to severe ischemia was not found in the rectal wall. However, the rectal wall did not reveal thinning due to recurrent severe ischemia or vascular changes due to rheumatoid arthritis. Int J Colorectal Dis (2008) 23:721–722 DOI 10.1007/s00384-008-0459-3

Interleukin-1 and tumor necrosis factor alter plasma concentration and interorgan fluxes of taurine in dogs.

We examined the effects of interleukin-1μ (IL-1), tumor necrosis factor (TNF), and alanylglutamine (Ala-Gin) infusion on the plasma concentrations and interorgan fluxes of taurine and taurine precursors, including methionine and serine, using chronically catheterized awake dogs. In the first study, the dogs received 5 /μg/kg/h of either human recombinant IL-1 or TNF intravenously for 2 h. Taurine fluxes in the liver and gut were calculated by blood flows and arteriovenous differences during infusion and for 2 h after discontinuation of the cytokine infusions. The 2 h continuous infusions of TNF and IL-1 resulted in 60 and 90% increases, respectively, in the arterial plasma taurine concentration. Hepatic taurine flux changed from uptake to release after 2 h of continuous IL-1 infusion. In the second study, we investigated whether Ala-Gin infusion affects taurine metabolism under normal and stress conditions. The dogs were given a constant 2 h intravenous infusion of IL-1 or saline. Ala-Gin (6 μmol/kg/min) was infused simultaneously during the second hour. Plasma concentrations and fluxes, across the liver, gut, and lung, of taurine and taurine precursors were studied. IL-1 administration increased the plasma concentration, hepatic release, and lung uptake of taurine. Ala-Gin infusion did not affect either plasma concentrations or organ fluxes of taurine. These data suggest that cytokines play a role in taurine metabolism under stress conditions.

Gastric carcinoma presenting with extensive extraluminal growth: Report of a case

We report a 48-year-old-man with gastric carcinoma presenting with an unusual extraluminal growth. The patient underwent a barium meal examination and gastrofiberscopy because of progressive anemia over 6 months. These examinations revealed a Borrmann type 3 advanced gastric carcinoma of the greater curvature of the antrum. Biopsies showed moderately differentiated tubular adenocarcinoma. The intraoperative findings showed gastric carcinoma associated with extensive extraluminal invasion into the adjacent organs, i.e., the transverse colon and mesocolon. A palliative distal gastrectomy with a partial resection of the transverse colon was performed because of peritoneal dissemination found in the mesocolon and rectovesical pouch. A histological examination of the specimen confirmed adenocarcinoma which had massively infiltrated the transverse colon and mesocolon. His postoperative course was uneventful. However, he died of peritonitis carcinomatosa 9 months later.