Yasutsugu Shoji

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.

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.

Current trends in restorative proctocolectomy : Introduction of an ultrasonically activated scalpel

PURPOSE: We evaluated the usefulness of an ultrasonically activated scalpel (Harmonic Scalpel®) for mucosal proctocolectomy and ileal J-pouch-anal anastomosis. METHODS: Seventy-four patients with ulcerative colitis (70 patients) and familial adenomatous polyposis (4 patients) underwent mucosectomy using the Harmonic Scalpel® since 1997. We compared the clinical and functional results with those of the monopolar electrocoagulator (forceps coagulation technique, 86 patients with colitis and 7 with polyposis). RESULTS: We performed graduated mucosal proctectomy by using the Harmonic Scalpel®. The operative time (Harmonic Scalpel®, 42 minutesvs. forceps coagulation technique, 85 minutes) and blood loss (Harmonic Scalpel®, 33 mlvs. forceps coagulation technique, 86.8 ml) were significantly reduced by this method. The Harmonic Scalpel® enabled restorative proctocolectomy by the synchronous approach within three hours. The functional results and complications were not significantly different between the two groups. CONCLUSION: The Harmonic Scalpel® shortened the operative time, decreased blood loss, and was useful for restorative proctocolectomy in our study.

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.

Preoperative detection of distal intramural spread of lower rectal carcinoma using transrectal ultrasonography

Purpose: Usefulness of transrectal ultrasonography (TRUS) for detecting distal intramural spread of rectal carcinoma was investigated. METHODS: Thirty-seven patients with advanced rectal carcinoma, who had not received preoperative adjuvant therapy, underwent TRUS before surgery. Distal intramural spread was evaluated by TRUS and by pathologic examination of resected specimens. RESULTS: Distal intramural spread was found in 7 of 37 patients (19 percent) by pathologic examination. Presence or absence of distal intramural spread was correctly diagnosed by TRUS in 86 percent of the 37 patients. Misdiagnosis by TRUS mainly occurred when distal intramural spread was 5 mm. Tumor penetration of muscularis propria, lymph node involvement, and a higher histologic grade of malignancy showed a significant relationship with the presence of distal intramural spread. CONCLUSION: TRUS was useful for detecting distal intramural spread >5 mm in patients with lower rectal carcinoma and may be helpful for selecting appropriate surgery.

Disappearance of hyperplastic polyposis after resection of rectal cancer

Since 1980, when the first description of hyperplastic polyposis of the colon appeared, 18 cases of hyperplastic polyposis have been reported in the literature. Only two of them bore colonic cancer. Here we add two cases of hyperplastic polyposis accompanying rectal carcinoma following cancer resection, in which residual hyperplastic polyps disappeared after resection.

Functional results after “high” coloanal anastomosis and “low” coloanal anastomosis with a colonic J-pouch for rectal carcinoma

The aim of this study was to determine the postoperative function of neorectoanal components using two different types of very low coloanal reconstruction. The two groups of patients assessed were 22 who underwent abdominal rectal resection and stapled “high” coloanal anastomosis without a pouch, being the HCAA-P group; and 34 who underwent anoabdominal rectal resection and “low” coloanal anastomosis with a colonic J-pouch, being the LCAA+P group. Manometric metric examination was performed 1, 3, 6, and 12 months postoperatively, and the patients were also assessed by a questionnaire. The LCAA+P group had remarkably less daily stool frequency and urgency, but there were no significant differences in the other functional parameters. Maximum resting pressure (MRP) was significantly less, while threshold volume (TV) and maximum tolerable volume (MTV) were greater in the LCAA+P group than in the HCAA-P group. The colonic J-pouch compensated for decreased MRP. Thus, when HCAA-P is performed, 3.0 cm of residual rectum with internal anal sphincter may be required, and construction of the pelvic pouch is desirable in low coloanal anastomosis.

Transanal mucosectomy using an ultrasonically activated scalpel for ulcerative colitis

We describe herein our technique of using an ultrasonically activated scalpel (Harmonic Scalpel [HS]) to simplify the procedure of anorectal mucosectomy for ulcerative colitis (UC). This technique was successfully employed to perform restorative proctocolectomy and ileoanal anastomosis (IAA) in ten patients with UC. By using the HS, thermal injury of the internal anal sphincter was avoided during mucosectomy, and we were able to dissect the inflamed mucosa sharply without causing bleeding. HS reduced the operative time and blood loss compared with the traditional forceps-coagulation technique. These results indicate that the introduction of this new scalpel will facilitate an increase in the number of cases of mucosectomy for IAA.

Usefulness of bipolar scissors for total colectomy

PURPOSE: Total colectomy is frequently used in colorectal surgery. We evaluated the usefulness of bipolar scissors in this operation. METHODS: Twenty patients with ulcerative colitis underwent total colectomy at Hyogo College Hospital. Bipolar scissors were used in ten randomly chosen colectomies. The resected major vessels of the colonic mesentery were stained by hematoxylin and eosin. The bursting pressure of the artery weld was measured with a water-filled, open-tip catheter. RESULTS: Both number of ligations and operating time were reduced by use of bipolar scissors. The cut edge of the major artery was occluded by the weld created, with a mean bursting pressure of 213 (range, 175–250) mmHg. CONCLUSION: Use of bipolar scissors was safe and had the advantage of shortening the operating time by decreasing the number of clamping and ligating procedures.