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PubMed1997

Perioperative tumor localization for laparoscopic colorectal surgery.

BACKGROUND: Because of the inability to palpate colonic tumors during laparoscopy, their location must be precisely identified before resection is undertaken. METHOD: A retrospective study was performed of 58 patients in order to be able to describe our methods of tumor localization for laparoscopic colorectal operations and to review their effectiveness. RESULTS: In all patients, the entire colon was examined preoperatively by colonoscopy. In one patient, preoperative colonoscopic localization was inaccurate. In 31 patients, tumors were easily detectable at surgery. In five patients with the tumor in the right colon, even though the lesion was not detectable at surgery, right colectomy was performed without marking because preoperative colonoscopy reliably identified the lesion adjacent to the ileocecal valve. Twenty-two patients required some type of procedure to localize the tumor. The procedures and their problems were as follows: preoperative tattoo (five)--tattoo not visualized (one); intraoperative colonoscopy alone (six), combined with intraoperative tattoo (four) or clip (three)--poor operative exposure due to bowel distension (nine), hard to see the clip (three), dislodged clip (two), inadequate resection margin (one); intraoperative proctoscopy alone (two), combined with laparoscopic stitch (two)--no problems. In no patient was tumor present at a resection line and in no patient was the wrong segment resected. CONCLUSIONS: Reliable preoperative identification of the tumor adjacent to the ileocecal valve can permit right colectomy without marking. Lesions in the upper rectum can be approached via intraoperative proctoscopy +/- suture placement. If the surgeon anticipates intraoperative localization may be difficult, lesions other than rectal or cecal ones should probably be marked by preoperative tattooing. Further studies regarding the technique of tattooing are warranted.

Colonoscopy↗
PubMed1998

Combined laparoendoscopic colon resection and anastomosis using the "no touch technique" and fibrin glue. An experimental study.

BACKGROUND: Laparoscopic colon anastomosis are technically demanding. A new technique for colon resection and anastomosis using a combined laparoendoscopic approach is presented. METHODS: In 10 pigs, pneumoperitoneum was induced and 5 trocars were placed. A sigmoid segment was isolated; a vein stripper was inserted from the anus, and the head was secured with a tie; the segment was intussuscepted pulling the stripper out; 4 seromuscular sutures were placed at the anastomotic site and fibrin glue was spread all around; an electrical wire loop, introduced via a colonoscope, was used to resect the intussuscepted segment that was removed from the anus. RESULTS: All animals but one survived until sacrifice at 30, 60, 90, and 120 days. Macroscopically, the anastomosis appeared well healed; microscopically, after 90 days, there was a complete restitutio ad integrum of the intestinal wall. CONCLUSIONS: This technique is feasible and quick; it could be used clinically in small tumors not removable endoscopically.

Anal Canal↗
PubMed1999

Use of the laparoscope to perform intraoperative enteroscopy.

BACKGROUND: In a small number of patients with recurrent gastrointestinal bleeding, standard diagnostic studies fail to identify the source. Intraoperative enteroscopy is useful in these cases. Usually a colonoscope is used to perform peroperative enteroscopy. METHOD: We describe the technique that we use to perform intraoperative enteroscopy via a laparoscope. RESULTS: The bleeding site was identified in two of three cases. In one patient, a vascular malformation in the proximal jejunum was found. In the other, an ulceronodular lesion was seen in the midjejunum. CONCLUSION: The laparoscope can be used successfully to visualize the entire small bowel in the diagnosis of obscure gastrointestinal bleeding.

Biopsy↗
PubMed2005

Monozygotic twins concordant for intestinal Behçet's disease.

Although Behçet's disease (BD) is a multisystem disorder of unknown causes, both genetic and environmental factors have been suggested. This is the second reported case of monozygotic twins concordant for Behçet's disease and the first such report of intestinal Behçet's disease. Patient 1 was a 17-year-old man with fever, recurrent oral aphthae, and skin eruptions. He developed hematochezia and was given corticosteroid empirically. One month after he was discharged, he again developed oral ulcerations, fever, and hematochezia. Colonoscopy was performed again, showing aphthous ulcerations in the entire colon, and deep oval ulcers with marginal elevation around the ileocecal valve, which are characteristics of intestinal Behçet's disease. He was treated with colchicine and azathioprine in combination with salazosulfapyridine (SASP) and prednisolone (PSL) and achieved remission. Patient 2 was the twin brother of patient 1. He was admitted because of oral aphthous ulcerations, fever, pustules on his face and body, and genital ulcers. Two weeks later he developed hematochezia. Colonoscopic and barium enema findings were similar to those of his brother. SASP, PSL, colchicines, and azathioprine were also required to achieve remission. Both of the patients were diagnosed with intestinal Behçet's disease. Their monozygosity was confirmed by detailed genetic typing, and HLA-B51 was negative.

Adolescent↗
PubMed2005

Association of pseudomembranous colitis with Henoch-Schönlein purpura.

A 79-year-old man was admitted because of cholecystitis that occurred about 40 days after sigmoidectomy had been performed for colonic cancer. Though antibiotics improved his condition, the patient had hematochezia, diarrhea, and left lower abdominal pain. Colonoscopic findings showed multiple ring-like areas of redness and petechiae in the rectosigmoid colon and marked edema from the descending to the transverse colon. The patient then developed purpura on the extensor surfaces of the legs and bilateral gonalgia, and exacerbation of the hematochezia. A second colonoscopy (CS) showed multiple ring-like areas of redness and ecchymosis throughout the colon. The patient was diagnosed with Henoch-Schönlein purpura (HSP), and the symptoms were attenuated after the administration of prednisolone. However, diarrhea recurred in about a week; stool culture confirmed Clostridium difficile, and a third CS revealed pseudomembranes throughout the colon. The patient was diagnosed with pseudomembranous colitis (PMC), and the administration of vancomycin attenuated the symptoms. In conclusion, we have reported a rare adult case of PMC that occurred during prednisolone treatment for HSP. The PMC may have been caused by changes in the intestinal bacterial flora after the sigmoidectomy and by the intestinal lesions of HSP, as well as by the administration of antibiotics after the sigmoidectomy and for the treatment of cholecystitis, and by the use of prednisolone for the treatment of the HSP.

Aged↗
PubMed1998

Fulminant hepatitis complicated by small intestine infection and massive hemorrhage.

A 34-year-old man diagnosed with fulminant hepatitis, caused by hepatitis B virus, and acute renal failure was referred to our hospital. After admission to the intensive care unit, the liver and renal failure were ameliorated. Melena requiring transfusion occurred during the course of his illness. Endoscopic examination demonstrated pseudomembranes, erosions, ulcers, and hemorrhage in the duodenum, the upper jejunum, and the terminal ileum, suggesting widespread lesions throughout the small intestine. Pseudomonas putida, Xanthomonas maltophilia, and Candida glabrata were cultured from ileal fluid. Candida glabrata was also detected in sputum, feces, and on an intravenous catheter tip. The patient was treated with amphotericin B and miconazole. The melena was ameliorated, but inflammation of the small intestine persisted. Although we had difficulty in treating the enteritis, the patient survived, and 1 year later colonoscopic examination demonstrated no abnormalities. The small intestine is a difficult site to examine, but endoscopic examination of this site is important when massive hemorrhage develops.

Adult↗
PubMed1998

Appendico-ileo-vesical fistula.

Appendico-vesical fistula is a rare condition. In total, 109 cases, most secondary to appendicitis, have been reported in the English-language literature. We report the first case, to our knowledge, of appendico-ileo-vesical fistula secondary to appendiceal diverticulitis. An enterovesical fistula was diagnosed by urine culture, cystoscopy, and computed tomography. The locations of enteric opening sites were demonstrated by barium enema and colonoscopy. Ileocecal resection and fistulectomy with primary reconstruction were performed. We believe that accurate pre- and intra-operative diagnosis is essential for cure. This case demonstrates the importance of barium enema and colonoscopic examinations in the diagnosis and treatment of complicated enterovesical fistula.

Adult↗
PubMed1999

Cyclooxygenase (COX)-2 immunoreactivity and relationship to p53 and Ki-67 expression in colorectal cancer.

The tumor-suppressive effects of nonsteroidal antiinflammatory drugs (NSAIDs) have been suggested to be due to a reduction in cyclooxygenase (COX)-2 activity, although the effects of COX-2 in the colonic mucosa and in colorectal cancer have not been determined. Ki-67 immunoreactivity in cancers is also attracting attention, as Ki-67 reflects cell proliferation, while p53 immunoreactivity is also of interest, as it reflects the malignancy of colorectal lesions. Accordingly, to determine these correlation, we investigated the distribution and intensity of COX-2, p53 and Ki-67 expression in both cancerous and non-cancerous tissues from patients with sporadic and ulcerative colitis (UC)-associated colorectal cancer. We selected 21 colorectal cancer specimens, obtained by surgical resection or colonoscopic biopsy, from 21 patients, including 3 with UC (13 men and 8 women; aged 42-78 years). Histological examination of hematoxylin and eosin-stained specimens revealed that 9 were well differentiated; 11. moderately differentiated: and 1 was a poorly differentiated adenocarcinoma. We used anti-COX-2, p53, and Ki-67 antisera to perform immunohistochemical staining by the labelled streptavidin biotin method and then assessed and graded the staining intensity and distribution. COX-2 staining was more intense in cancer tissue than in non-cancerous areas. Colorectal cancers associated with UC were not stained intensely. COX-2, p53, and Ki-67 positivity rates in were 38.1%, 38.1%, and 47.6%, respectively. There were no relationships among the distributions or intensities of COX-2, p53, and Ki-67 expression. Our results indicate that colorectal cancer tissues overexpress COX-2, but that there are no relationships between COX-2, p53, and Ki-67 expression, suggesting that COX-2 expression may not be related to cell proliferation or to the grade of malignancy. However, it is necessary to determine whether COX-2 in cancer tissue is involved in carcinogenesis or whether it is simply a product of cancer.

Adult↗
PubMed1999

Immunoblastic lymphadenopathy-like T-cell lymphoma complicated by multiple gastrointestinal involvement.

We report a rare case of immunoblastic lymphadenopathy (IBL)-like T-cell lymphoma complicated by multiple gastrointestinal involvement, which appeared to be ameliorated by chemotherapy but resulted in perforative peritonitis. A 66-year-old Japanese woman who had generalized lymphadenopathy and eruptions was admitted to our hospital because of bloody stool. Colonoscopic examination revealed hemorrhagic ulcers in the terminal ileum and a saucer-like ulcer in the cecum. Gastrointestinal endoscopy revealed several ulcerative or elevated lesions in stomach and duodenum. Biopsy specimens of these lesions and of a lymph node showed characteristic histological features of IBL-like T-cell lymphoma. The initial treatment with prednisolone (PSL) and cyclophosphamide (CPA) was effective. Six months after the treatment, however, she developed bloody stool again caused by multiple ulcerative lesions in the large intestine. The recurrence of the disease was determined histologically, and four courses of CPA, PSL, vinblastine sulfate and doxorubicin hydrochloride (CHOP) therapy were administered. One month after completing the CHOP therapy, she developed intestinal obstruction and then acute peritonitis resulting from perforation at an ulcer scar in the jejunum. Surgical treatment was successful, and histological examination demonstrated no lymphoma cells in the resected specimen. A gastrointestinal perforation should be recognized as a potential complication of IBL-like T-cell lymphoma, even during remission.

Aged↗
PubMed2000

MRI facilitated a diagnosis of endometriosis of the rectum.

A 51-year-old pre-menopausal Japanese woman suffering from chronic lower abdominal pain was referred to our hospital. A barium enema showed a stenotic lesion in the recto-sigmoid region, and a pelvic computed axial tomography (CAT) scan revealed a thickened rectal wall. A colonoscopic examination showed the rectum to be constrictive, but the mucosa appeared to be intact. Magnetic resonance imaging (MRI) with T1 high-intensity revealed a cystic lesion in the thickened wall of the rectum, which led us to suspect possible bowel endometriosis. Part of the biopsy specimen showed endometrial epithelium within the interstitial layer of histologically normal mucosa; finally, endometriosis of the rectum was diagnosed. The patient became asymptomatic after the initiation of hormonal treatment and later experienced spontaneous menopause. MRI was effective for diagnosis and the patient did not undergo unnecessary laparotomy. Although bowel endometriosis is generally diagnosed by means of resected specimens, in our patient, diagnosis was made using MRI and biopsy, and hormonal therapy had an effective role as a bridge to menopause.

Biopsy↗
PubMed2000

Intra-abdominal desmoplastic small round cell tumor (IDSRT).

Intra-abdominal desmoplastic small round cell tumor (IDSRT) is a rare neoplasm that develops in the abdominal cavity in young people. We experienced a 27-year-old man who visited with ascites of unknown cause. Compression of the colon was found by barium enema examination. On colonoscopic examination, diffuse white elevated lesions, about 5 mm in diameter, surrounded by rubedo, so-called aphthoid lesions, were also observed. IDSRT was diagnosed by biopsy at laparotomy, and chemotherapy with cyclophosphamide, etoposide, doxorubicin, and cisplatin was performed. The tumors shrank temporarily (partial response), but subsequently grew in size again. The patient died during the second course of chemotherapy after relapse. We present one case report, together with a review of the literature.

Abdominal Neoplasms↗
PubMed2001

Microscopic polyangiitis complicated with massive intestinal bleeding.

Microscopic polyangiitis (MPA) is associated with renal dysfunction, in most cases, and occasionally with pulmonary hemorrhage. However, massive intestinal bleeding is a rare manifestation. We report a case of MPA in a man who developed arterial bleeding in the small intestine. A 74-year-old man was admitted after enduring a fever for 4 weeks. Laboratory examination revealed leucocytosis with neutrophil predominance, and renal dysfunction was noted. He did not respond to treatment with antibiotics, and the worsened renal function soon required hemodialysis. On the seventh hospital day, he suddenly developed massive melena. A colonoscopic examination suggested bleeding in the small intestine, and abdominal angiography demonstrated that the bleeding originated in a branch of the ileal artery. Hemostasis was achieved by transarterial embolization (TAE), but the patient suffered a massive pulmonary hemorrhage 2 days after the TAE. Although he responded well to a combination treatment with corticosteroid and cyclophosphamide, recurrence of pulmonary hemorrhage led to death, on the 87th hospital day. MPA in this patient was associated with three serious complications; deteriorating renal function, massive melena, and pulmonary hemorrhage. Of the various manifestations associated with MPA, arterial bleeding in the gastrointestinal tract, although rare, should be considered as one of the serious complications in MPA.

Aged↗
PubMed2001

Superficial depressed early carcinoma that developed into protuberant advanced carcinoma in the transverse colon.

A screening colonoscopic examination in a 70-year-old man revealed a nonpolypoid type superficial depressed early carcinoma, about 2cm in diameter, in the transverse colon. The lesion was not resected and was observed because of coexisting nonresectable hepatocellular carcinoma (HCC). Fifteen months later, follow-up examinations revealed a polypoid type protuberant advanced carcinoma, about 6 cm in diameter, at the same site. Because complete response of the HCC had been induced by transarterial embolization, the colon carcinoma was operatively resected. There is an indefinite concept that colorectal carcinomas develop without substantial morphological changes, and no superficial depressed carcinoma that developed into a protuberant type advanced carcinoma has been reported. The case reported here provides evidence that some polypoid carcinomas arise from superficial depressed precursors. There is some intermingling between the two postulated colorectal carcinogenic pathways, the conventional polypoid pathway named the "adenoma-carcinoma sequence", and the nonpolypoid pathway, including so-called "de-novo" carcinogenesis.

Aged↗
PubMed2002

Cap polyposis cured by Helicobacter pylori eradication therapy.

The pathogenesis of cap polyposis remains unknown. Here, we report a patient with cap polyposis that developed simultaneously in the colon and stomach, and which regressed after Helicobacter pylori eradication. A 63-year-old man was diagnosed as having cap polyposis with mucoid stool, diarrhea, and bleeding on defecation. Following 5 weeks of total parenteral nutrition, his symptoms and hypoproteinemia improved and he was discharged, although follow-up colonoscopic findings revealed no improvement. Subsequent gastroscopy revealed diffusely erosive polyps with cap-like "fur" from the angle to the antrum of the stomach, similar to the lesions observed in the colon. Because H. pylori infection was demonstrated in the stomach, eradication therapy was administered. After this treatment, his symptoms immediately disappeared, and the polypoid lesions in the colon and stomach had completely disappeared 8 months later. Because there have been no previous reports of a relationship between H. pylori and cap polyposis, this case is of great interest.

Colonic Polyps↗
PubMed2004

Heterotopic ossification of rectal adenocarcinoma: report of a case.

Heterotopic ossification of gastrointestinal tract tumors is rare. We report the case of a 67-year-old man with heterotopic ossification of a rectal adenocarcinoma. The patient presented with intermittent abdominal pain and frequent diarrhea, and colonoscopic examination showed a large polypoid tumor partially obstructing the rectal lumen. Abdominal computed tomography (CT) revealed a large tumor in the rectal lumen with calcified spots. We performed low anterior resection of the rectum, and histologic examination showed a well-differentiated adenocarcinoma with heterotopic ossification infiltrating the full thickness of the rectum. Local recurrence and liver metastases were found 2 months after surgery, and the patient died 3 months later. Such a rapidly progressive course of rectal adenocarcinoma with heterotopic ossification is very unusual.

Abdominal Pain↗
PubMed1998

Arteriovenous malformation of the rectum: report of a case.

We report herein the case of a 38-year-old man found to have a rectal arteriovenous malformation (AVM). The patient was admitted to our hospital for investigation of fresh anal bleeding and general malaise. Barium-enema examination showed a slightly elevated lesion in the rectum, and a selective superior rectal angiogram subsequently revealed an AVM in the peripheral region of the superior rectal artery, which was presumed to be the cause of the anal bleeding. Colonoscopic examination disclosed a submucosal tumor-like lesion in the left posterior wall of the rectum, 3cm above the anal verge. After marking the boundaries by clipping, transanal resection of the lesion was performed. Histological examination revealed an irregularly expanded arteriovenous aggregation in the submucosal layer. The patient had a favorable postoperative course, and no residual AVM was seen on a postoperative selective inferior mesenteric arteriogram. There have been no signs of recurrence in the 2 years since his operation.

Adult↗
PubMed2001

Colovesical fistula due to a lost gallstone following laparoscopic cholecystectomy: report of a case.

We report the case of a 74-year-old man with a colovesical fistula caused by a gallstone that was lost during a laparoscopic cholecystectomy 7 months earlier. The patient was cured after undergoing colonoscopic removal of the stone. To our knowledge this is the first case report of such a complication in the English literature. The report reviews the outcome and complications of retained intraperitoneal gallstones.

Aged↗
PubMed1999

Burkitt's lymphoma presenting as ileocaecal intussusception in systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) are reported to have an increased risk of malignancy, especially lymphoproliferative disorders. We decribe the occurrence of ileocaecal intussusception secondary to Burkitt's lymphoma in a patient with SLE. A 23-year-old woman, who had been diagnosed with SLE 2 years ago, developed intermittent abdominal pain with a palpable mass. Computed tomography and a double-contrast barium enema showed a lobulated mass with intussusception at the ileocaecal junction. Right hemicolectomy and splenectomy was performed after histopathological examinations on colonoscopic biopsy revealed Burkitt's lymphoma. Fourteen months after chemotherapy, there is no evidence of recurrence of the Burkitt's lymphoma. When a patient with SLE has abdominal complaints, besides serositis, lupus enteritis such as peptic ulcer disease, mesenteric vasculitis with or without complications and pancreatitis, we have to consider intussusception secondary to gastrointestinal lymphoma as one of the differential diagnoses. Therefore, we should thoroughly investigate patients with SLE presenting with abdominal pain and not simply consider it afeature of lupus enteritis until other causes have been ruled out.

Adult↗