Yusuke Watadani

Sacrocolpopexy with rectopexy for pelvic floor prolapse improves bowel function and quality of life

BACKGROUND: Sacrocolpopexy with rectopexy is advocated for combined rectal and vaginal prolapse, but limited outcome data have been reported. OBJECTIVE: The purpose of this study was to evaluate the indications and outcomes of sacrocolpopexy and rectopexy by comparing pre- and postoperative function and quality of life. DESIGN: A retrospective review of prospectively collected data was performed of all patients undergoing sacrocolpopexy and rectopexy at our institution from 2004 to 2011. INTERVENTIONS AND OUTCOME MEASURES: Preoperatively, all patients underwent physiology testing and completed 4 validated questionnaires assessing bowel symptom severity and associated quality of life. Patients completed the same questionnaires in 2012. RESULTS: A total of 110 women (median age, 55 years; range, 28–88) underwent a sacrocolpopexy and rectopexy, 33 with concomitant hysterectomy. All patients had rectal prolapse (n = 96) or rectal intussusception (n = 14), and each also had either enterocele (n = 86) or vaginal prolapse (n = 48). Rectal prolapse with enterocele was the most common presentation (n = 75). Previous surgery included rectal prolapse repair (21%) and hysterectomy (57%). Complications included presacral bleeding (n = 2), ureteral injury (n = 2), wound infection (n = 8), and pulmonary embolism (n = 2). There were no mortalities. Fifty-two patients completed the follow-up questionnaires, with a median follow-up of 29 (range, 4–90) months, and preoperative surveys were available in 30 of these patients. Preoperatively, 93% reported constipation; 82% reported resolution or improvement postoperatively. Constipation severity, measured with the Patient Assessment of Constipation Symptom Questionnaire, demonstrated improvement (1.86–1.17; p < 0.001). Fecal incontinence severity scores (Fecal Incontinence Severity Index) improved (39–24; p < 0.01), and 82% of incontinent patients reported cure or improvement. Quality-of-life scores also improved significantly. No patient developed recurrent rectal prolapse. LIMITATIONS: This was a retrospective review, and the response rate to questionnaires was limited. CONCLUSIONS: Sacrocolpopexy and rectopexy for combined middle and posterior compartment prolapse is a safe procedure, with low risk for recurrence, and improves bowel function and quality of life in most patients.

Usefulness of computed tomography as a preoperative diagnostic modality in a case with acute jejunogastric intussusception.

A 72-year-old man was admitted to our hospital with an acute abdomen 1 h after the abrupt onset of hematemesis and upper abdominal pain. His medical history included a distal gastrectomy for gastric cancer 15 years previously and a subsequent gastrojejunostomy with Braun’s anastomosis because of an anastomotic stricture. Physical examination at the time of admission revealed diffuse abdominal tenderness with muscular guarding and a palpable firm mass in the left upper quadrant. A plain X-ray of the abdomen showed dilatation of the small intestine, but this finding was not specific enough to lead to a diagnosis. A subsequent abdominal computed tomography (CT) showed intestinal loops intussuscepted into the patient’s severely dilated gastric remnant through the gastrojejunostomy (Fig. 1a). Contiguous CT sections identified a normal afferent loop and intussuscepted efferent loops extending into the lower abdomen (Fig. 1b, c). Together, these findings suggested that the intussusception into the stomach involved the efferent loop, indicating the presence of a type II jejunogastric intussusception (JGI). The patient was immediately taken into surgery. Surgery revealed a severely dilated stomach stump and an 80-cm-long efferent intestinal loop that had intussuscepted in a retrograde direction at the gastrojejunostomy into the remnant gastric lumen, passing over the Braun’s anastomosis, which is in agreement with the preoperative diagnosis made by CT (Fig 2). After unsuccessful efforts to reduce this invagination by Hutchinson’s procedure,partial resection of a 100-cm-long small intestine, with end-to-end anastomosis and efferent loop fixation, was subsequently performed. The resected specimen was found to be gangrenous without perforation for a distance of 10 cm below the Braun’s anastomosis. No abnormalities such as a tumor, ulcer, diverticulum, or stenosis were identified that could have acted as a leading point for the intussusception. The JGI in this case was thus considered to be a late complication of gastrojejunostomy with Braun’s anastomosis. J Gastrointest Surg (2007) 11:1078–1080 DOI 10.1007/s11605-007-0125-z

Dieulafoy's disease as a possible cause of gallbladder hemorrhage

To the Editor, Dieulafoy’s disease is a rare form of gastrointestinal hemorrhage, often severe, which arises from an abnormally large artery running within the submucosa. The initial case reports involved the stomach, but subsequent reports have demonstrated that Dieulafoy’s disease can occur in various locations throughout the gastrointestinal tract. We now present a case report of Dieulafoy’s disease of the gallbladder, in which the source of a massive hemorrhage appeared to be a large-caliber artery situated within a mucosal erosion of the gallbladder wall. A 56-year-old man with no history of prior abdominal intervention or prior gastrointestinal surgery was admitted to Oda Municipal Hospital with severe epigastralgia. A physical examination showed muscle guarding in the upper abdomen. Laboratory chemistry studies found moderately elevated levels of serum biliary enzymes and transaminases. A blood cell count showed leukocytosis and a hemoglobin of 9.9 g/dL. Abdominal ultrasonography revealed a distended gallbladder containing relatively high-echo material. Percutaneous transhepatic gallbladder drainage (PTGBD) was performed, yielding a massive flow of fresh blood at the initial puncture. In light of this evidence of hemorrhage of the gallbladder, an urgent laparoscopic cholecystectomy was performed.At surgery, the gallbladder was enlarged and firm, but the surrounding tissues were only mildly inflamed. The resected specimen revealed an 8 ¥ 10-cm gallbladder filled with approximately 100 mL of fresh blood, blood clots, and a gallstone 1 cm in diameter. Fresh blood and blood clots were also found in the cystic duct. Ulceration with bleeding from an exposed vessel was observed in the neck of the gallbladder. This ulcerative lesion was distinct from the PTGBD insertion site and both edges of the resected specimen (Fig. 1a). On histological examination an ulcer with a tortuous enlarged artery was found in the submucosal layer immediately beneath an area of the gallbladder mucosa, showing inflammatory changes consistent with mild chronic cholecystitis (Fig. 1b). No vascular abnormalities were observed in any of the other gallbladder sections. The pathological diagnosis was Dieulafoy’s disease of the gallbladder. Dieulafoy’s lesions are most often found in the proximal stomach but have been reported at sites throughout the gastrointestinal tract. In the present case a massive hemorrhage in the interior of the gallbladder appeared to arise from an unusually large-caliber submucosal artery close to the mucosa, which had eroded the overlying epithelium in the absence of a primary ulcer, an appearance similar to that seen in gastrointestinal Dieulafoy’s lesions. To our knowledge, this case is the first report of Dieulafoy’s disease of the gallbladder, which in this instance was treated with laparoscopic cholecystectomy. The etiology of Dieulafoy’s disease is still unknown, and no triggering causes have been identified. Although it has been reported that most cases of Dieulafoy’s disease are not associated with a mucosal inflammatory reaction at the site of arterial rupture, mild cholecystitis was observed in the present case. Juler et al. studied a series of nine cases with gastric Dieulafoy’s disease and hypothesized that chronic gastritis predisposed to vascular dysplasia, leading to thrombosis and necrosis of the arterial wall prior to rupture. However, published study data to date are insufficient to determine whether vascular dysplasia resulting from cholecystitis could cause disruption of overlying epithelium and hemorrhage. Some reports have suggested hemorrhagic cholecystitis as a possible cause of hemobilia leading to gastrointestinal bleeding. Although this case did not present with gastrointestinal bleeding, the presence of blood in the cystic duct as well as inside the gallbladder, without ductal obstruction, raises the prospect that if the patient had delayed seeking medical attention, the disease may Figure 1 Dieulafoy’s lesion of the gallbladder. (a) The resected specimen contains a small ulcerative lesion at the neck of the gallbladder (white arrow). This lesion is distinct from the percutaneous transhepatic gallbladder drainage insertion site (black arrow). Magnified view of the ulcerative lesion (inset, white arrowhead). (b) Histological examination of the area of ulceration shows a thrombus located immediately beneath the gallbladder mucosa adjacent to a tortuous large artery in the submucosal layer (black arrow, HE, original magnification ¥40). doi:10.1111/j.1440-1746.2007.04296.x

Pharmacokinetics of piperacillin-tazobactam in plasma, peritoneal fluid and peritoneum of surgery patients, and dosing considerations based on site-specific pharmacodynamic target attainment

Piperacillin-tazobactam (PIP-TAZ) is commonly used to treat intraabdominal infections; however, its penetration into abdominal sites is unclear. A pharmacokinetic analysis of plasma, peritoneal fluid, and peritoneum drug concentrations was conducted to simulate dosing regimens needed to attain the pharmacodynamic target in abdominal sites. PIP-TAZ (4 g-0.5 g) was intravenously administered to 10 patients before abdominal surgery for inflammatory bowel disease. Blood, peritoneal fluid, and peritoneum samples were obtained at the end of infusion (0.5 h) and up to 4 h thereafter. PIP and TAZ concentrations were measured, both noncompartmental and compartmental pharmacokinetic parameters were estimated, and a simulation was conducted to evaluate site-specific pharmacodynamic target attainment. The mean peritoneal fluid:plasma ratios in the area under the drug concentration-time curve (AUC) were 0.75 for PIP and 0.79 for TAZ, and the mean peritoneal fluid:plasma ratios in the AUC were 0.49 for PIP and 0.53 for TAZ. The mean PIP:TAZ ratio was 8.1 at both peritoneal sites. The regimens that achieved a bactericidal effect with PIP (time above minimum inhibitory concentration [MIC] >50%) at both peritoneal sites were PIP-TAZ 4.5 g twice daily for an MIC of 8 mg/L, as well as 4.5 g three times daily, and 3.375 g four times daily for an MIC of 16 mg/L. These findings clarify the peritoneal pharmacokinetics of PIP-TAZ, and help consider the dosing regimens for intraabdominal infections based on site-specific pharmacodynamic target attainment.

Hand-assisted laparoscopic restorative proctocolectomy for ulcerative colitis.

AIM To evaluate the utility of hand-assisted laparoscopic restorative proctocolectomy (HALS-RP) compared with the conventional open procedure (OPEN-RP). METHODS Fifty-one patients who underwent restorative total proctocolectomy with rectal mucosectomy and ileal pouch anal anastomosis between January 2008 and July 2015 were retrospectively analyzed. Twenty-three patients in the HALS-RP group and twenty-four patients in the OPEN-RP group were compared. Four patients who had purely laparoscopic surgery were excluded. Restorative total proctocolectomy was performed with mucosectomy and a hand-sewn ileal-pouch-anal anastomosis. Preoperative comorbidities, intraoperative factors such as blood loss and operative time, postoperative complications, and postoperative course were compared between two groups. RESULTS Patients in both groups were matched with regards to patient age, gender, and American Society of Anesthesiologists score. There were no significant differences in extent of colitis, indications for surgery, preoperative comorbidities, and preoperative medications in the two groups. The median operative time for the HALS-RP group was 369 (320-420) min, slightly longer than the OPEN-RP group at 355 (318-421) min; this was not statistically significant. Blood loss was significantly less in HALS-RP [300 (230-402) mL] compared to OPEN-RP [512 (401-1162) mL, P = 0.003]. Anastomotic leakage was noted in 3 patients in the HALS-RP group and 2 patients in the OPEN-RP group (13% vs 8.3%, NS). The rates of other postoperative complications and the length of hospital stay were not different between the two groups. CONCLUSION HALS-RP can be performed with less blood loss and smaller skin incisions. This procedure is a feasible technique for total proctocolectomy for ulcerative colitis.

Two Cases of Severe Ulcerative Colitis with Colonic Dilatation Resolved with Tacrolimus Therapy

We report 2 cases of ulcerative colitis (UC) with intestinal tract dilatation treated with tacrolimus. They were 53- and 64-year-old males, who had been admitted to local hospitals for increasing severity of their UC symptoms. Treatment for severe UC was immediately started, but both cases were refractory to corticosteroid therapy; they were then transferred to our hospital. When they were referred to our hospital, they had frequent bloody diarrhea, fever, severe abdominal pain, and even dilatation of the transverse colon on abdominal X-ray test. They were treated with oral tacrolimus medication, and their symptoms improved immediately. Dilatation of the transverse colon was improved on plain X-ray at 2 weeks after starting therapy, and emergency colectomy could be avoided. These 2 cases may suggest that tacrolimus is effective for UC with colonic dilatation as a rescue therapy.