Tetsuo Yamana

Risk factors for postoperative intra-abdominal septic complications after bowel resection in patients with Crohn's disease.

BACKGROUND: Postoperative intra-abdominal septic complications are a serious concern with regard to postoperative morbidity and mortality in Crohn’s disease. OBJECTIVE: The aim of this study was to identify the clinical variables that potentially impact the risk of intra-abdominal septic complications in patients with Crohn’s disease, as well al analyze the short-term prognosis in patients with postoperative intra-abdominal septic complications. DESIGN: This study is a retrospective review with the use of hospital medical records. SETTINGS: This investigation was conducted at a single-institution, tertiary referral center in Tokyo, Japan. PATIENTS: We reviewed 550 patients that had undergone 728 intestinal anastomoses during 633 operations for primary or recurrent Crohn’s disease between January 2005 and December 2010. Postoperative intra-abdominal septic complications were defined as anastomotic leakage or intra-abdominal abscesses occurring within 1 month after surgery. MAIN OUTCOME MEASURE: Twenty-four clinical variables were evaluated as potential risk factors for postoperative intra-abdominal septic complications. These factors were analyzed by use of univariate and multivariate methods. RESULTS: Postoperative intra-abdominal septic complications occurred in 17 cases (2.7%), with no fatalities. Of the 17 patients, 13 had anastomotic leakage and 4 had intra-abdominal abscesses. In the univariate and multivariate analyses, penetrating type (p = 0.014), operation time >180 minutes (p = 0.004), and handsewn anastomoses (p = 0.005) were significantly independent risk factors for postoperative intra-abdominal septic complications. Patients experiencing intra-abdominal septic complications had significantly higher 1-year reoperation rates (41.2%) than patients without intra-abdominal septic complications (2.3%, p < 0.0001). LIMITATIONS: This study was limited by being a retrospective review, and the details regarding postoperative complications other than intra-abdominal septic complications were not completely available. CONCLUSIONS: Penetrating type, operation time >180 minutes, and handsewn anastomoses significantly increased the risk of postoperative intra-abdominal septic complications in Crohn’s disease. Postoperative intra-abdominal septic complications had a negative influence on the short-term outcome in Crohn’s disease.

A Prospective Randomized Comparison Between an Open Hemorrhoidectomy and a Semi-Closed (Semi-Open) Hemorrhoidectomy

Abstract A semi-closed hemorrhoidectomy is a popular surgical procedure among Japanese coloproctologists because it is thought that the risk of postoperative bleeding is reduced, and postoperative pain is milder after a semi-closed hemorrhoidectomy than after an open hemorrhoidectomy. However, no prospective randomized trial comparing an open and semi-closed hemorrhoidectomy has yet been published. We conducted a prospective randomized trial comparing both clinically and physiologically an open and semi-closed hemorrhoidectomy. Thirty-four consecutive patients undergoing a hemorrhoidectomy for third-degree hemorrhoids were randomized to receive either an open hemorrhoidectomy (n = 17) or a semi-closed hemorrhoidectomy (n = 17). Postoperative pain was evaluated using an analog scale by the patients themselves. An anorectal physiological study was performed before the operation and 2 months after the operation. Pain at 1 week after operation was significantly more severe after a semi-closed hemorrhoidectomy than after an open hemorrhoidectomy. The postoperative physiological parameters including sphincter pressures did not differ between the two forms of hemorrhoidectomy. However, younger patients and patients having higher sphincter pressures preoperatively had more severe pain at 2 weeks after a semi-closed hemorrhoidectomy. Although both forms of hemorrhoidectomy appear to be almost equivalent, the degree of early postoperative pain may be less after an open hemorrhoidectomy in both young patients and in those patients having high preoperative anal sphincter pressures.

Perineal puborectalis sling operation for Fecal incontinence: Preliminary report

PURPOSEThis study was designed to evaluate the safety, efficacy, and impact on quality of life of the perineal puborectalis sling operation for fecal incontinence.METHODSSince August 2001, we performed the perineal puborectalis sling operation on eight patients with idiopathic fecal incontinence. A specially designed polyester mesh sling was introduced along the puborectalis muscle, from a posterior perianal incision, running to a small suprapubic incision. The ends were tied together with moderate tension. Patients were evaluated with the Fecal Incontinence Severity Index, the Cleveland Clinic Score of Incontinence, and the Fecal Incontinence Quality of Life Scale. Manometry and defecography were performed before and six months after the operation.RESULTSEight patients (7 females; mean age, 63 (range, 44–77) years) were evaluated. A wound infection developed in one patient, which subsided with antibiotics. A rectal ulcer developed in one patient, necessitating sling removal. In the remaining seven patients, the Fecal Incontinence Severity Index improved from 27 to 9, and the Cleveland Clinic Score of Incontinence improved from 13 to 5 (P < 0.05). All parameters in the Fecal Incontinence Quality of Life Scale improved: lifestyle from 2.1 to 3.6; coping/behavior from 1.5 to 3.4; depression/self perception from 2.3 to 3.7; and embarrassment from 2 to 3.6 (P < 0.05). No significant difference was found between preoperative and postoperative maximum resting pressure and maximum squeeze pressure. However, the median anorectal angle on defecography after the operation was significantly reduced (P < 0.05).CONCLUSIONSWe believe that the perineal puborectalis sling operation is technically feasible, with low morbidity, and can be an effective procedure for idiopathic fecal incontinence.

Preoperative anal sphincter high pressure zone, maximum tolerable volume, and anal mucosal electrosensitivity predict early postoperative defecatory function after low anterior resection for rectal cancer

PURPOSE: The aims of this study were to correlate postoperative defecatory function after low anterior resection with clinical factors and physiologic parameters and to explore the possibility of predicting early postoperative defecatory function after low anterior resection. METHODS: Thirty-two patients who underwent low anterior resection for rectal cancer were studied. Anorectal physiologic studies were performed preoperatively and six months postoperatively; maximum resting pressure, maximum squeeze pressure, length of the high pressure zone, neorectal sensory threshold, neorectal maximum tolerable volume, and anal mucosal electrosensitivity were recorded. Preoperative and postoperative defecatory function was scored between 0 (worst) and 6 (best) on the basis of bowel frequency, fecal incontinence, and urgency. RESULTS: In univariate regression analyses, a longer preoperative high pressure zone and a more sensitive anal mucosa were associated with better postoperative defecatory function. Using multiple regression analysis, in which age, gender, the level of anastomosis, and preoperative physiologic parameters were examined as independent variables, a longer preoperative high pressure zone, a larger preoperative maximum tolerable volume, and lower sensory threshold of the anal canal were associated with better postoperative defecatory function. Postoperative function score was found to be predictable using the following formula: 1.47+0.496×high pressure zone (cm)+0.007×maximum tolerable volume (ml)−0.247×sensory threshold (mA) of the anal canal. CONCLUSION: Early postoperative defecatory function after low anterior resection is predictable from preoperative high pressure zone, maximum tolerable volume, and anal mucosal electrosensitivity.

Mucosal plication (Gant-Miwa procedure) with anal encircling for rectal prolapse: A review of the japanese experience

Although mucosal plication for rectal prolapse, known as the Gant-Miwa procedure, is described in some English textbooks, it has been infrequently performed in the West. However, this procedure has been used and developed in conjunction with anal encircling in Japan since the 1960s and is still considered to play a major role in the treatment of rectal prolapse. Certain technical details have been found necessary to ensure the success of the procedure, especially in the technique of anal encircling. For example, the use of Teflon® tape and routing relatively deeply and outside the external anal sphincter are necessary. Clinical results show a recurrence rate of 0 to 31 percent with no mortality and almost never any serious complications such as significant bleeding or severe sepsis, which are occasionally encountered in other perineal procedures. Most patients report improved continence after this procedure, and worsening of evacuation is rarely encountered based on our experience. Some physiologic studies have shown improved resting pressure and rectal sensation, which can have a positive influence on the defecatory function. We believe that the Gant-Miwa procedure with anal encircling should be considered as a treatment of choice among perineal procedures for rectal prolapse.

Long-term results and quality-of-life outcomes in patients with transsphincteric fistulas after muscle-filling procedure

AbstractPURPOSE: This study was designed to evaluate long-term results and quality-of-life outcomes after the muscle-filling procedure for posterior transsphincteric fistulas. METHODS: A questionnaire was mailed to 207 patients who had been treated by the muscle-filling procedure for posterior transsphincteric fistulas with cryptoglandular origin at the Social Health Insurance Hospital during a ten-year period. One hundred fifty-one patients who returned their questionnaires were included in this retrospective study. Information regarding fistula recurrence, time required for wound healing, postoperative incontinence, overall satisfaction with the procedure, and quality-of-life data were surveyed from the returned questionnaires. RESULTS: One hundred fifty-one patients (140 males) with a mean age of 48 (range, 17–75) years were analyzed. The mean follow-up was 70 (range, 12–131) months. Fistulas recurred in seven patients (4.6 percent). Fifty-eight patients (38 percent) healed within 3 months, and 52 (34 percent) healed within 6 months. Eighty-four patients (56 percent) reported some reduction in their sense of sphincter-tightening ability after surgery. Seventy-eight patients (52 percent) reported some degree of incontinence. One hundred thirty-three patients (88 percent) were satisfied or very satisfied with their outcomes. Of the 18 patients (12 percent) who reported unsatisfactory or very unsatisfactory results, 7 experienced recurrence. Thirty-seven patients (25 percent) indicated one or more lifestyle alterations, including social activities (11 percent), travel (12 percent), sports (5 percent), diet (4 percent), housework (1 percent), or sexual activities (1 percent), because of incontinence after surgery. Eighteen patients (12 percent) had more than one restriction in their quality-of-life parameters. CONCLUSION: The muscle-filling procedure is a viable option in the treatment of transsphincteric fistulas, with a favorable recurrence rate and an overall patient satisfaction rate above 88 percent.

Adenocarcinoma within anorectal fistulae: different clinicopathological characteristics between Crohn’s disease-associated type and the usual type

Adenocarcinoma within anorectal fistulae is rare and is sometimes associated with Crohn’s disease. Crohn’s disease-associated adenocarcinoma within anorectal fistulae has a poor prognosis; however, little is known about the clinicopathological differences between Crohn’s disease-associated adenocarcinoma within anorectal fistulae and usual adenocarcinoma within anorectal fistulae. We retrospectively searched patients’ charts and pathology archives at Tokyo Yamate Medical Center and Tokyo Medical and Dental University Hospital for adenocarcinoma within anorectal fistulae. Clinical and pathological data were collected and immunohistochemical examinations were conducted. Overall survival rate was estimated using the Kaplan–Meier method. Prognostic factors of overall survival were assessed using univariate and multivariate Cox regression analyses. We examined 82 cases of adenocarcinoma within anorectal fistulae. Fifty-nine of 82 cases (72%) had usual adenocarcinoma within anorectal fistulae, while the remaining 23 cases (28%) had Crohn’s disease-associated adenocarcinoma within anorectal fistulae. Patients with Crohn’s disease-associated adenocarcinoma within anorectal fistulae were diagnosed at a younger age and at a more advanced stage than those with usual adenocarcinoma within anorectal fistulae. Macroscopic and histological types were also different between usual adenocarcinoma within anorectal fistulae and Crohn’s disease-associated adenocarcinoma within anorectal fistulae. Crohn’s disease-associated adenocarcinoma within anorectal fistulae included more ulcerative types and high-grade adenocarcinomas. The rate of lymphovascular invasion was higher in Crohn’s disease-associated adenocarcinoma within anorectal fistulae. Immunohistochemically, the expression of E-cadherin, p53, and MUC5AC differed between usual adenocarcinoma within anorectal fistulae and Crohn’s disease-associated adenocarcinoma within anorectal fistulae. Patients with Crohn’s disease-associated adenocarcinoma within anorectal fistulae exhibited worse overall survival than those with usual adenocarcinoma within anorectal fistulae, and vascular invasion was the strongest significant independent predictor of overall survival in patients with adenocarcinoma within anorectal fistulae. In conclusion, usual adenocarcinoma within anorectal fistulae and Crohn’s disease-associated adenocarcinoma within anorectal fistulae have different clinicopathological characteristics and should be considered separate clinical entities.

Distribution of Human Papillomavirus Genotype in Anal Condyloma Acuminatum among Japanese Men: the Higher Prevalence of High Risk Human Papillomavirus in Men Who Have Sex with Men with HIV Infection.

Human papillomavirus (HPV) infection is known to cause anal condyloma acuminatum (CA) and squamous cell carcinoma. Men who have sex with men (MSM) with HIV infection are frequently co-infected with HPV, especially high risk HPV (HR-HPV) that causes anal squamous cell carcinoma. However, there are few reports of HPV genotype studies in anal lesion of Japanese men. We tried to estimate the distribution of HPV genotypes in anal CA tissue specimens from the Japanese men to elucidate the risk of anal cancer. A total of 62 patients who had anal CA surgically excised were enrolled. They included 27 HIV-positive MSM, 18 HIV-negative MSM, 1 HIV-positive man who have sex with women (MSW), and 16 HIV-negative MSW. HPV genotypes in anal CA tissue were determined by the polymerase chain reaction technique with reverse line blot hybridization. HR-HPV was detected in 45.2% of the CA tissue specimens and high grade squamous intraepithelial lesion (HSIL) was observed in 15.3%. Moreover, the prevalence of HR-HPV in the HIV-positive MSM (70.4%) was higher than the HIV-negative MSM (33.3%, p = .0311) or the HIV-negative MSW (18.8%, p = .0016). The conditional logistic regression analysis suggested HIV positivity as the primary risk factor for the HR-HPV infection in CA. In addition, HSIL was detected in higher frequency in CA tissues from HIV-positive MSM (25.9%) than HIV-negative MSW (0.0%, p = .0346). HR-HPV and HSIL were frequently detected in anal CA tissues from Japanese MSM patients with HIV infection, suggesting the necessity of surveillance for this population.