[Study on the efficacy and complications of patients undergoing radical surgery and radical radiotherapy for localized prostate cancer]

OBJECTIVE

To compare the efficacy and complications of radical surgery (RP) and radical radiotherapy (RRT).

METHODS

The clinical data of patients diagnosed with localized prostate cancer in General Hospital of Eastern Theater Command with RP and RRT from January 2015 to December 2019, Observed and recorded patient preoperative and postoperative PSA levels, biochemical Relapse-free Survival and clinical Relapse-free Survival,and the occurrence of hematuria, urinary incontinence, erectile dysfunction, ankylurethria, diarrhea, hemoproctia and radiocystitis.

RESULTS

A total of 150 patients with localized prostate cancer were included in this study, including 105 patients with RP and 45 patients undergoing RRT. There was no significant difference between the complication rates of hematuria, urinary incontinence, erectile dysfunction and ankylurethria(P>0.05).Patients in the RRT group had higher rates of diarrhea(20.00% vs 2.86%), hemoproctia(15.56% vs 1.90%) and radiocystitis(13.33% vs 0%) than those in the RP group, with significant differences (P<0.05). The 5-year bRFS was lower than that in the RP group (95.1% vs 90.7%), with no statistical significance (P=0.832); the 5-year cRFS in the RP group was lower than that in the RRT group (91.2% vs 89.6%), with no significant difference (P=0.971).

CONCLUSION

The incidence of diarrhea, hemoproctia and radiocystitis was lower in the RP group than in the RRT group, and the recurrence-free survival was not significantly different between the two groups.

Effectiveness of preserved vagal nerve in totally laparoscopy radical distal gastrectomy: a matched-paired cohort analysis

BACKGROUND

The aim of this retrospective matched-paired cohort study was to clarify the effectiveness of preserving the vagus nerve in totally laparoscopic radical distal gastrectomy (TLDG).

METHODS

One hundred eighty-three patients with gastric cancer who underwent TLDG between February 2020 and March 2022 were included and followed up. Sixty-one patients with preservation of the vagal nerve (VPG) in the same period were matched (1:2) to conventional sacrificed (CG) cases for demographics, tumor characteristics, and tumor node metastasis stage. The evaluated variables included intraoperative and postoperative indices, symptoms, nutritional status, and gallstone formation at 1 year after gastrectomy between the two groups.

RESULTS

Although the operation time was significantly increased in the VPG compared with the CG (198.0 ± 35.2 vs. 176.2 ± 35.2 min, P < 0.001), the mean time of gas passage in the VPG was significantly lower than that in the CG (68.1 ± 21.7 h vs. 75.4 ± 22.6 h, P = 0.038). The overall postoperative complication rate was similar between the two groups (P = 0.794). There was no statistically significant difference between the two groups hospital stay, total number of harvested lymph nodes, and mean number of examined lymph nodes at each station. During follow-up, the morbidity of gallstones or cholecystitis (8.2% vs. 20.5%, P = 0.036), chronic diarrhea (3.3% vs. 14.8%, P = 0.022), and constipation (4.9% vs. 16.4%, P = 0.032) were significantly lower in the VPG than in the CG in this study. Moreover, injury to the vagus nerve was found to be an independent risk factor for gallstone formation or cholecystitis and chronic diarrhea in univariate analysis and multivariate analysis.

CONCLUSION

The vagus nerve plays an imperative role in gastrointestinal motility, and hepatic and celiac branch preservation mainly exerts efficacy and safety in patients who undergo TLDG.

Colchicine usage for prevention of post atrial fibrillation ablation pericarditis in patients undergoing high-power short-duration ablation

INTRODUCTION

Radiofrequency ablation (RFA) for atrial fibrillation (AF) has been associated with variable incidence (0.88%-10%) of pericarditis manifested as chest pain, possibly more prevalent with the advent of high-power short-duration (HPSD) ablation. This has led to the widespread use of colchicine in preventative protocols for postablation pericarditis. However, the efficacy of preventative colchicine has not been validated yet.

OBJECTIVE

To evaluate the efficacy of a routine postoperative colchicine regimen (0.6 mg twice a day for 14 days post-AF ablation) for prevention of postablation pericarditis in patients undergoing HPSD ablation.

METHOD

We retrospectively evaluated consecutive single-operator HPSD AF ablation procedures at our institution from June 2019 to July 2022. A colchicine protocol was introduced in June 2021 for the prevention of postablation pericarditis. All ablations were performed with 50 watts. Patients were divided into colchicine and noncolchicine groups. We recorded incidence of postablation chest pain, emergency room (ER) visit for chest pain, pericardial effusion, pericardiocentesis, any ER visit, hospitalization, AF recurrence, and cardioversion for AF within the first 30 days following ablation. We also recorded colchicine-related side effects and medication compliance.

RESULTS

Two hundred and ninety-four consecutive HPSD AF ablation patients were screened for the study. After implementing the prespecified exclusion criteria, a total of 205 patients were included in the final analysis, yielding 101 patients in the colchicine group and 104 patients in the noncolchicine group. Both groups were well-matched for demographic and procedural parameters. There was no significant difference in postablation chest pain (9.9% vs. 8.6%, p = .7), pericardial effusion (2.9% vs. 0.9%, p = .1), ER visits (11.9% vs. 12.5%, p = .2), 30-day hospitalization for AF recurrence (0.9% vs. 0.96%, p = .3), and 30-day need for cardioversion for AF (3.9% vs. 5.7%, p = .2). Fifteen (15) patients had severe colchicine-related diarrhea, out of which 12 discontinued it prematurely. There were no major procedural complications in either group.

CONCLUSION

In this single-operator retrospective analysis, prophylactic colchicine was not associated with significant reduction in the incidence of postablation chest pain, pericarditis, 30 day hospitalization, ER visits, or AF recurrence or need of cardioversion within first 30 days after HPSD ablation for AF. However, its usage was associated with significant diarrhea. This study concludes no additional advantage of prophylactic use of colchicine after HPSD AF ablation.

Chronic abdominal pain and diarrhea

Pigmented macules on the patient's oral mucosa provided an important clue to the diagnosis.

[A man with abdominal pain, diarrhoea and rectal bleeding]

A 49-year-old man came to the emergency room with abdominal pain, vomiting, diarrhoea and rectal bleeding. Both colonoscopy and CT of the abdomen showed cecocolic intussusception caused by an appendiceal mucocele. An ileocecal resection was performed via a laparoscopic approach and microscopy of the tissue showed a low-grade mucinous neoplasm.

Immunodeficiency due to chylous dysplasia: diagnostic and therapeutic considerations

Among primary immunodeficiencies, common variable immunodeficiency (CVID) is defined by an impaired production of immunoglobulins characterized by low levels of plasma immunoglobulins and an altered antibody response. The case reported here was initially interpreted as a CVID. A 20 year old male suffered from diarrhea, weight loss, and malnutrition. Accurate diagnostic assessment uncovered a protein-losing enteropathy. Conventional oil contrast lymphangiography accurately documented the underlying problem and established the appropriate therapeutic approach. The operation consisted of multiple antigravitational ligatures of dilated and incompetent chylous vessels and chylous vessel-mesenteric vein microanastomoses. Serum albumin and leukocyte counts normalized by 1 week after operation and remained stable with time. There were no more episodes of diarrhea, and the patient regained weight. Accurate diagnostic assessment and particularly lymphangiography may be necessary to properly define difficult cases of immunodeficiency due to intestinal protein loss and to plan a corrective therapeutic functional approach.

[Surgical management of persistent diarrhea]

An 82-year-old patient presented with a cervical lesion and refractory diarrhea of many years' standing. Surgical therapy of a medullary thyroid carcinoma had been performed 16 years previously. Appropriate tumor follow-up had not been carried out hitherto. Significantly high levels of calcitonin as well as a suspicious octreotide scan indicated late recurrence of the disease. Diarrhea ceased following redo surgery.

Colonoscopic findings in Peruvian patients with chronic diarrhea

OBJECTIVE

To report the colonoscopic and pathological findings in patients with chronic diarrhea from a gastroenterology unit during approximately 3 years in a general teaching hospital located in Lima-Peru.

MATERIALS AND METHODS

Patients with chronic diarrhea as the motive for colonoscopy from March 2008 to December 2010 were selected from the colonoscopy report computerized database. Colonoscopic findings were registered. Biopsies taken during the procedure were prospectively reviewed.

RESULTS

226 patients were included, of which 162 (71.7%) had a colon biopsy available. The average age of the patients was 53.6±16.36. 85.8% of patients were reported to have a normal colon. 14.8% of patients were found to have a normal colonic mucosa or mucosal edema, 35.8% of patients had lymphocytic colitis and 28.4% had paucicelular colitis.

CONCLUSIONS

The majority of colonoscopies were reported with unremarkable macroscopic findings. Lymphocytic colitis was unusually frequent compared to previous reports.

Granulomatous inflammatory response in a case of typhoid fever

OBJECTIVE

To present a case of culture-proven typhoid fever in which granulomas were demonstrated histologically in the ileum and mesenteric lymph nodes.

CLINICAL PRESENTATION AND INTERVENTION

A 47-year-old Pakistani man underwent emergency hemicolectomy for severe bleeding per rectum associated with diarrhea. Two large ulcers in the ileum, near the ileocolic junction, as well as mesenteric lymph nodes showed both necrotizing and non-necrotizing granulomas in addition to mixed inflammatory infiltrate on histology.

CONCLUSION

Typhoid fever may be considered as one of the causes of the differential diagnoses of granulomatous inflammation of the small intestine.

Ileojejunal transposition delays gastric emptying and decreases fecal water content in dogs with total colectomy

PURPOSE

The aim of the study was to investigate the effect of ileojejunal transposition, in which the distal ileum is interposed isoperistaltically into the proximal jejunum, on gastric emptying, gastrointestinal motility, and fecal water content in dogs with total colectomy.

METHODS

Dogs were divided into three groups: dogs with intact colons (control), total colectomy alone (sham operated group), or total colectomy and ileojejunal transposition group. The alimentary tract was reconstructed by ileal J-pouch-rectal anastomosis. Gastric emptying was measured by a validated freeze-drying method, and gastrointestinal motility was measured by strain gauge force transducers. Plasma peptide YY was measured by specific radioimmunoassay. Fecal water content was measured in dogs with total colectomy.

RESULTS

Gastric emptying of solids in the ileojejunal transposition group was delayed longer than 120 minutes after meal ingestion compared with that in the sham operated group. The duration of the digestive state was prolonged in the ileojejunal transposition group, only when compared with the control group. Plasma peptide YY was increased in the ileojejunal transposition group compared with the sham operated group. Fecal water content was decreased in the ileojejunal transposition group compared with the sham operated group.

CONCLUSIONS

Ileojejunal transposition delays gastric emptying of solids and decreases fecal water content in dogs with total colectomy, indicating that ileojejunal transposition might be able to improve intractable watery diarrhea after total colectomy.

Pancreatic vasoactive intestinal polypeptide-oma as a cause of secretory diarrhoea

A 42-year-old woman presented with a 4-year history of worsening diarrhoea that was watery, profuse and confirmed to be secretory in nature. She had tested positive for phenolphthalein on urinary laxative screening but continued to deny laxative usage. Her vasoactive intestinal polypeptide (VIP) level was subsequently found to be markedly elevated. Despite a normal abdominal ultrasound, a computed tomography scan revealed a 5-cm pancreatic tail mass. Octreotide scanning was used to exclude metastatic disease and she went on to have surgical removal of a localized pancreatic vasoactive intestinal polypeptide-oma which resulted in the complete resolution of her diarrhoea.

Transposition of the anorectum to the abdominal wall

A unique procedure is described in which the anorectum is mobilized on the inferior mesenteric vascular pedicle and transposed to the anterior abdominal wall. The aim is to preserve maximal intestinal length in patients with short bowel syndrome and intractable diarrhoea. Unique physiological data provided by the second case demonstrate that the specialized sensory functions of the rectum reside in the rectal wall and are subserved by an autonomic nervous supply that is independent of the pudendal nerves.

[The pathogenesis, diagnosis and treatment of postvagotomy diarrhea]

The article deals with questions of pathogenesis, diagnostics and treatment of postvagotomy diarrhea which was found in 6 (3.5%) of 174 patients with postvagotomy syndromes. The leading place in the development of diarrhea belongs to the disturbed regulatory function of the pyloric sphincter after vagotomy with pyloroplasty. In 3 patients with the II-III degree diarrhea medicamentous treatment was not effective and the patients were operated on. A new original method of surgical treatment of postvagotomy diarrhea is described. For the first time in the world the author has performed plasty of the vagus nerve with the help of epineural sutures in combination with true pyloroplasty with a good outcome.

Intractable diarrhea and melena in an AIDS patient

A young Arab male, clinically suspected to have ulcerative colitis, was operated upon for fulminant intractable diarrhea with melena. The colon showed severe necrotizing and hemorrhagic colitis which was attributed to an opportunistic infection, viz cytomegalovirus infection. The patient's immunocompromised state was a consequence of AIDS, proved by ELISA and Western Blot test. He subsequently developed multiple brain abscesses and succumbed to uncontrolled infection.

Role of rat large intestine in reducing diarrhea after 50% or 80% distal small bowel resection

The effects of intestinal resection on several intestinal parameters have been studied in the large intestine of rats one month after the surgical operation. The results show that both 50% and 80% distal small bowel resection increased net fluid absorption and mucosal permeability and caused expansion of the intercellular spaces of the large intestine. The increase in net fluid absorption was dependent upon the extent of the intestine removed. The cAMP and cGMP content of cecal and colonic mucosa were significantly reduced after jejunoilectomy. Changes in nucleotide levels were dependent on the length of the intestine resected. On the other hand, mucosa Na,K-ATPase specific activity was only increased in the cecum after 80% intestinal resection. The results are discussed in terms of adaptation to prevent diarrhea.

Surgical management of postvagotomy syndrome

The purpose of the present report is to demonstrate the results of conservative surgical treatment in twelve patients with postvagotomy syndrome (PVS). The reconstructive operation performed in each case depended on the preexisting drainage procedure. Out of eight patients who had undergone vagotomy and gastrojejunostomy (GJ) four suffered from bile reflux and vomiting, four from dumping (DU) and four had diarrhea. All underwent closure of GJ and two of them duodenoplasty for coexisting duodenal stenosis. The results were very good (Visick grade I and II) in all patients except for one complete failure. Out of four patients who had undergone vagotomy and pyloroplasty, three had DU, two diarrhea and two bile reflux and vomiting. Pyloric reconstruction was performed in all subjects. Symptoms were relieved in all cases. In one patient radioisotopic control showed mild G/O and D/G reflux. Conservative surgical operations give satisfactory results in the treatment of PVS. Furthermore they have lower morbidity and mortality than radical surgery.

Surgical management of severe intractable postvagotomy diarrhoea

Experience with the surgical management of 23 patients with postvagotomy diarrhoea is outlined. The most common pre-operative abnormalities are rapid gastric emptying (14/23) and fast small bowel transit (23/23). Three patients were found to have steatorrhoea due to organic disease. Peptic ulcer surgery performed at a young age (means = 29 years, range 21-37) appears to be the only identifiable risk factor. The results of medical treatment with bile salt binding agents were disappointing in the long term. In 10 out of 13 patients treated with antiperistaltic segments, the procedure had to be reversed because of episodes of severe postprandial colic, intestinal obstruction and bacterial overgrowth. A good result with relief of the explosive diarrhoea was obtained by the distal onlay reversed ileal graft in six out of seven patients. This procedure creates a passive non-propulsive segment, and has no undesirable sequelae. It should be considered in those patients in whom the diarrhoea is not controlled by conservative measures.

Pyloric reconstruction

Fourteen patients with persistent and severe postcibal symptoms following vagotomy and pyloroplasty for duodenal ulcer had the pylorus reconstructed. A dumping provocation test was useful in patient selection and evaluation of results. When assessed between 6 months and 3 years after operation, nine patients had an excellent or good result and three were improved. Surgical technique is relatively simple and the operation should be considered and practised more often than it seems to be from documented experience.

Effect of metoclopramide on gastric stasis after reversed jejunal loop for postvagotomy diarrhea

The effect of metoclopramide on gastric emptying in a patient with an antiperistaltic jejunal loop interposed between the stomach and duodenum because of postvagotomy dumping symdrome is studied. Solid particle emptying by 99mTc-labeled chicken liver revealed profound gastric stasis with resultant bezoar formation. Orally administered metoclopramide resulted in correction of the gastric emptying rate and dramatic symptomatic relief. The possible use of metoclopramide in patients with stasis following surgical intervention to correct postvagotomy dumping is suggested.

Reversed ileal segment for treatment of ileostomy dysfunction. Clinical application

Persistent, profuse ileostomy diarrhea developed gradually in a patient over a 12-hour period after proctocolectomy for ulcerative colitis. There was no evidence of ileostomy stenosis or dilation of the ileum proximal to the stoma. He was successfully treated with a reverse ileal segment of 10 cm, and gained 14 to 18 kg. ileostomy output became semisolid and decreased from 1,000 to 2,000 ml/day to 600 ml/day. The transit time changed from 12 minutes to 2 1/2 hours. Antiperistaltic segments of intestine prolong transit time and allow for greater absorption. While most patients with ileostomies are not troubled by severe diarrhea, the small proportion who are may be candidates for a reversed ileal segment.

Revision of intestinal bypass procedures

The results of jejunoileal bypass have been satisfactory in 80 per cent of the patients. In the remaining 20 per cent, one or more problems eventually may require revision of the bypass. These problems fall into four categories: inadequate weight loss; excessive weight loss; persistent uncontrollable diarrhea or associated severe anorectal problems, or both, and severe unmanageable electrolyte and metabolic imbalance with or without liver failure. In our series, 108 patients were observed for one to five years, and ten patients required revision, one revision for every 12 bypass operations performed. The preoperative evaluation and management and the options available to the surgeon in correcting the abnormalities are evaluated. The results of ten patients who underwent revision of the bypass and the rationale for the revision are outlined. Criteria for an ideal operation have not as yet been attained.

Surgical treatment of late postgastrectomy syndromes

An analysis of the experience at the University of California Hospital, San Francisco, with the diagnosis and treatment of fifty-nine postgastrectomy syndromes shows that stomal obstruction (sixteen patients), the most common syndrome, was best treated by total reconstruction rather than stomal revision. Disappointment with the results of other procedures for the dumping syndrome (50 per cent improvement) has convinced us of the need to adopt the use of reversed jejunal interposition for surgical treatment of this condition. Because a precise etiologic diagnosis of bilious vomiting is often elusive, the preferred procedure is isoperistaltic jejunal interposition, since it eliminates the afferent loop and prevents bile from entering the stomach. All five patients with malabsorption were improved by conversion from BII to BI. Four of five patients with diarrhea were improved by various procedures (not including a reversed segment of intestine in the midjejunum). Three patients with reflux alkaline gastritis were improved by Roux-en-Y gastrojejunostomy or isoperistaltic jejunal interposition. Either is effective. Thus, in our experience if an unquestionable diagnosis of stomal obstruction, malabsorption, or reflux alkaline gastritis can be established, there is ample justification for an optimistic outlook regarding surgical therapy.

A new operation for the dumping syndrome and post-vagotomy diarrhea

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Subcutaneous lateral internal anal sphincterotomy for anal fissure

This paper describes a method of lateral internal sphincterotomy for anal fissure entirely by palpation, a technique which gives results similar to those performed under direct vision, and is superior to posterior sphincterotomy and stretching of the sphincter. It has been employed in patients with episodic and chronic diarrhoea with equally satisfactory results. Lateral sphincterotomy preserves the external anal sphincter and it is suggested that this is the main reason for the low incidence of defects of anal continence as compared with other procedures.