Yutaka Nishioka

Permanent end-sigmoid colostomy through the extraperitoneal route prevents parastomal hernia after laparoscopic abdominoperineal resection.

BACKGROUND: The prevalence of a paracolostomy hernia has been reported to be from 10% to 50%, with serious impairment of the quality of life and sometimes life-threatening morbidity in some cases. Most essential in avoiding the need for further treatment of an end-sigmoid colostomy is prevention of a parastomal hernia. OBJECTIVE: We examined the effects of the extraperitoneal route for stoma creation to prevent parastomal hernia after laparoscopic abdominoperineal resection for rectal neoplasms. DESIGN: This is a study of a retrospective cohort. SETTING AND PATIENTS: Data on a total 37 consecutive patients who underwent abdominoperineal resection from March 2005 to December 2010 in Kochi Health Sciences Center were examined retrospectively in this study. Group A included 22 patients whose stoma was created through the extraperitoneal route, and group B included 15 patients whose stoma was created through the transperitoneal route. MAIN OUTCOME MEASURES: The main outcome measures were the rate of parastomal hernia determined through CT and clinical examinations in the 2 groups. RESULTS: In Group A, 1 case was diagnosed as having a parastomal hernia, whereas, in Group B, 5 cases were diagnosed by CT examination as having a parastomal hernia; the difference in incidence between the 2 groups was significant (p = 0.0305). Furthermore, median duration of the follow-up period between the latest CT examination and the primary operation was 722 days in group A, which was significantly longer than that in group B (442 days) (p = 0.001). LIMITATIONS: This study was limited by its nonrandomized retrospective design. CONCLUSION: Group B developed parastomal hernia more frequently within a significantly shorter period. A permanent sigmoid colostomy created through the extraperitoneal route can prevent the incidence of parastomal hernia after laparoscopic abdominoperineal resection.

Laparoscopic permanent sigmoid stoma creation through the extraperitoneal route.

About 50% of patients who have a permanent stoma experience some degree of parastomal hernia formation. To prevent this complication, the extraperitoneal route is considered to be more effective than the transperitoneal route in the case of open colorectal surgery. This technique also has superiority in avoiding postoperative intestinal obstruction. Although laparoscopic surgery for rectal cancer has not been proved to be as safe as open surgery by a randomized-controlled trial, some studies have shown the equality of long-term results with laparoscopic low anterior resection and laparoscopic abdominoperineal resection. It is anticipated that cases of laparoscopic abdominoperineal resection will increase in the near future. However, a laparoscopic technique for creation of a permanent stoma has hardly been discussed. Most operative procedures for laparoscopic stoma creation have been performed with transperitoneal route, which may cause parastomal hernia and/or intestinal obstruction. This report describes a laparoscopic technique for permanent sigmoid stoma creation through the extraperitoneal approach.

Resected xanthogranulomatous pancreatitis

Xanthogranulomatous changes in the pancreas are extremely rare. A 66-year-old man presented with a 2-year history of epigastralgia. Computed tomography scan revealed a 4-cm low-density area around the body of the pancreas. Magnetic resonance imaging demonstrated that the mass appeared hyperintense on a T2-weighted image and isointense on a T1-weighted image. Based on a diagnosis of invasive ductal carcinoma of the pancreas, distal pancreatectomy and splenectomy were performed. Sections examined from the mass showed an aggregation of many foamy histiocytes, lymphocytes, and plasma cells. The surrounding pancreatic tissue showed fibrosis and chronic inflammation. These findings suggested a xanthogranulomatous inflammation, and resulted in a diagnosis of xanthogranulomatous pancreatitis.

Neoadjuvant chemotherapy with S-1 and surgical resection for a mucinous gastric cancer with peritoneal dissemination

We herein report the case of a patient with mucinous gastric carcinoma with peritoneal dissemination that disappeared after neoadjuvant chemotherapy with S-1 alone. The patient has survived for over 23 months after surgery, without recurrence. A 60-year old man was referred to our hospital because of an advanced gastric cancer, detected by upper gastrointestinal endoscopy at another hospital. Staging laparoscopy was performed on October 25, 2002, and revealed massive peritoneal dissemination. Two courses of neoadjuvant chemotherapy with S-1 were administered, at 120 mg/day for 28 days, as one course. Total gastrectomy, with D2 lymph node dissection, was performed on January 24, 2003. The peritoneal dissemination had macroscopically disappeared and the cytology of the peritoneal lavage fluid was class III. His final diagnosis was gastric carcinoma, MLU, type 3, T2(SS), P0, H0, M0, N3, CY0, stage IV.

Synchronous Double Cancer of the Stomach and Colon Occurring in a Dermatomyositis Patient: A Case Report

早期胃癌, 大腸癌同時性重複癌を合併した皮膚筋炎と診断された興味ある1例を経験した. 症例は72歳の男性. 平成11年6月頃より顔面～頸胸部を中心とする落屑を伴う紅斑が出現した. 同年9月検診目的の胃内視鏡検査にて胃体上部に1型胃癌を指摘された. CPK 394 IU/L, LDH 686 IU/Lであったが, 術前皮膚生検では皮膚筋炎の確診は得られなかった. 同年10月8日開腹術施行し, 術中腹腔内検索にて発見された横行結腸癌とともに切除した. 術後3日目には上半身の紅斑, 掻痒感ともに消失したが, 術後約1か月目より自力歩行困難となるほどの筋力低下を来した. ミオグロビン-S 454 ng/mlであり, 筋生検, 筋電図, 臨床経過から皮膚筋炎と診断した. 12月25日よりプレドニン50mg/dayで内服を開始したところ, 内服後3日目より自力歩行も容易となり筋力は著しく改善した.