乙状结肠癌经腹膜内造瘘与经腹膜外造瘘的临床疗效及并发症的预防

目的:探讨乙状结肠经腹膜内造瘘与经腹膜外造瘘的对比分析及造口并发症的预防。方法:选取我院收治的行肛管直肠下段恶性肿瘤切除术的患者127例,根据造瘘方式不同将患者分为两组,实验组72例予以经腹膜外造瘘,对照组55例予经腹膜内造口术,观察并比较两组患者的术中情况,术后并发症,以及术后排便功能,来评价两种造瘘方法的效果。结果:与对照组比较,实验组术中、术后并发症均降低,术后排便功能改善显著,差异均有统计学意义(P0.05)。结论:经腹膜外乙状结肠造口较经腹膜内乙状结肠造口的术中情况明显改善,且并发症减少,能够较好的控便和排便,值得临床推广使用。     

Hospital Topics: Examination of the Whole Colon with the Fibreoptic Colonoscope

During examination of the intact colon with the Olympus CF LB 185-cm colonoscope it has proved possible to reach the caecum or terminal ileum in 47 out of 50 cases (94%). Careful bowel preparation, moderately heavy sedation, and some x-ray screening are necessary for the procedure, but it was well tolerated by all patients and there was no morbidity. The average time taken to the caecum was 40 minutes and the average time to completion of examination 90 minutes. The long colonoscope was as convenient to use as the fibresigmoidoscope in examinations confined to the sigmoid colon or in patients with a colostomy, ileostomy, or ileorectal anastomosis. Of the two, the long colonoscope is the instrument of choice for clinical use.Because of the expense, time, and equipment involved colonoscopy appears to be best offered as a specialist service after x-ray studies. There is alo a limited place for colonoscopy during abdominal surgery, when it is technically an easier procedure. In this series 10 patients were saved exploratory laparotomy by examination with the colonocope, and we also diagnosed four resectable carcinomas not seen on double-contrast barium-enema studies. The colonoscope provides an effective new means of diagnosis of lesions throughout the colon.     

Effect of Colostomy on the Circadian Rhythm in DNA Synthesis in the Rat Colon

Synthesis of DNA and mitosis in gut epithelium are not constant or random events but rather are characterized by circadian rhythmicity, which we reported persists even in fasted rats. Others suggest that rhythms persist because rats anticipate food, causing nerve impulses to propagate caudally in the gut at usual meal times, or that digestive products from previous feedings cause rhythms in the lower tract. We studied colonic DNA synthesis in rats that had been given colostomies. In one study, the distal colon was isolated neurally from proximal gut by means of an end colostomy. In a second study, rats were subjected to loop colostomy; some intrinsic innervation of the gut wall remained intact. Sprague-Dawley male rats, 8 weeks old, were acclimated to a 12:12 light-dark cycle. Colostomies were performed after a 48-h fast. The rats were fed ad libitum for 4 weeks after surgery. Operated rats and an equal number (n = 30) of control rats (unoper-ated) were divided into four subgroups that were killed at 07:00,13:00,19:00, and 01:00 h. Each rat was injected with tritiated thymidine 30 min before it was killed. Proximal and distal colon were analyzed for incorporation of radioactivity (DNA synthesis). Results are reported as counts per minute per microgram of DNA and were analyzed using analysis of variance and the t test. Significant daily variation was found in proximal colon, both from control and operated rats. Rhythms were still present in colon distal to loop colostomy but were lost in the distal stump in rats that received an end colostomy. The mammalian “biological clock” regulates most circadian rhythms by neurohumoral mechanisms; however, our results suggest that the intrinsic enteric nervous system is important in the propagation of a signal that causes rhythmic cell proliferation in the gut in the intact animal.     

Risks associated with environmental enrichment: intestinal obstruction caused by foraging substrate

Questions are occasionally asked about the safety of enrichment techniques, considering that many novel ways are frequently employed to ensure environmental complexity. A juvenile male vervet monkey was found with a phytobezoar of straw obstructing the sigmoid colon. The straw was foraging substrate, which is used in communal cages. Due to the extent of the resulting necrosis in the sigmoid and descending colon, the monkey had to be killed. This is the only individual to have suffered a harmful effect from the foraging substrate from amongst 120 vervet monkeys, which have been permanently housed on straw for over 5 years.     

Impact of colostomy on intestinal microflora and bacterial translocation in young rats fed with heat-killed Lactobacillus acidophilus strain LB

A rat animal model of left colostomy was found to significantly impair the growth curve of rats. Assessment of the intestinal flora showed that colostomy mostly affects the cecal but not colonic microflora. Generally, the number of enterococci was increased in both ileum and cecum; cecal lactobacilli also rose, accounting for a promotion of lactic acid bacteria in colostomised rats. No significant differences between colostomised, laparotomised and control rats could be observed for the translocation of intestinal bacteria to internal organs of rats (i.e. spleen, kidneys, lungs or liver), whatever their diet. Heat-killed Lactobacillus acidophilus strain LB administration (dead probiotic bacteria) tended to exhibit a stimulatory effect on bifidobacteria, probably affecting the culture-medium fermentation substances included in the pharmaceutical product. This effect was abolished by laparotomy and colostomy. A trend towards a probiotic-like effect, not susceptible to colostomy, was also witnessed as counts of lactobacilli tended to increase in both cecum and colon of all animals fed with L. acidophilus LB.     

Chronic diarrhea due to metastatic breast cancer

We report the case of a patient with chronic diarrhea due to infiltrative cancer to the colon from the breast. A 49-year-old woman with a history of metastatic breast cancer to the bones was admitted to hospital with 4 weeks of watery diarrhea. Computed tomography (CT) scan of the abdomen showed pancolitis. Colonoscopy showed patchy subepithelial hemorrhages, most prominently in the ascending colon and sigmoid colon, but no mass lesion. Random biopsies taken throughout the colon showed infiltrative adenocarcinoma of breast origin in multiple specimens. Infectious work-up was negative.     

Massive gastrointestinal bleeding and obstruction of the ureter caused by the migration of a swallowed toothpick from the sigmoid colon--a case report

In this study, a case of an ingested toothpick partially migrating from the sigmoid colon, causing massive lower gastrointestinal bleeding due to arterial-colic fistula, and stricture of the left ureter is presented. A 70-year-old male was admitted to the emergency department after having feces mixed with fresh and coagulated blood for the past two days. Computed tomography and retrograde ureteropyelography showed the stricture of the left ureter, 1.5 cm below the branching of iliac artery, without any signs of malignancy. Colonoscopy showed fresh blood in the rectum and sigmoid colon up to the neoplasm like granulation tissue mixed with fresh and coagulated blood, which almost obstructed the lumen. Explorative laparotomy showed a foreign body (toothpick) perforating the sigmoid colon through the mesenterial wall, and being stocked with one-third into the left internal iliac artery, causing arterial-colic fistula. The remaining part of the toothpick was surrounded by granulation tissue and chronic inflammatory process, pressing on the distal third of the left ureter. We conclude that a swallowed toothpick may cause a significant gastrointestinal injury with a wide variety of clinical manifestations, and it must be treated with caution. The imaging studies are often inadequate in detecting toothpicks, and thus, we insist on a physical examination, as the best indicator of injury.     

Morphometric findings in the microcirculatory bed of the sigmoid serosa during the fetal period in man

During fetal life, formation and arrangement of the microcirculatory bed in the serous membrane of the sigmoid colon correspond to the growth and functioning of the latter at different stages of ontogenesis. Two periods in the development of the microcirculatory bed of the serous membrane of the sigmoid colon are revealed: the first period coincides with the first half of the fetal development when capillary growth is considerable, i.e. with the growth of metabolic part in the microcirculatory bed; the second period coincides with the second half of the fetal development when intensified growth of the sigmoid portion of the large intenstine and its transport sections in the microcirculatory bed (arterioles, precapillaries, postcapillaries, venules) are observed.     

Formation of the microcirculatory bed of the muscle coat of the wall of the sigmoid colon during human fetal development]

During intrauterine life microcirculatory bed of the muscular coat is forming and developing in accordance with its differentiation, growth and functional changes at various steps of its ontogenesis. This step-like differentiation in the parts composing the microcirculatory bed and the whole microcirculatory network of longitudinal and circulatory layers of the muscular coat is genetically connected with differentiation taking place in the wall of the sigmoid colon during the developmental period studied and, in the end, reflects morphological maturation of the sigmoid colon at different stages of its individual ontogenesis.     

Current x-ray studies in the diagnosis of colorectal metastases to the liver

Computed tomography was made in 90 patients to reveal the specific features of images of hepatic metastatic foci of colorectal cancer of various sites. All the patients were divided into three groups. Group 1 included patients with rectal cancer; Group 2 comprised patients with sigmoid cancer, and Group 3 consisted of those with transverse colon cancer. The study was performed in native, arterial, and venous, and delayed phases. The number of foci, their localization, sizes, and shape were analyzed. In addition, the density of a focus, its homogeneity, the presence of a cancer rim, inclusion of calcium salts, and outline sharpness were determined. Computed tomography revealed no substantial differences in the image of foci of hepatic metastases from rectal, sigmoid, and transverse colon cancers.     

Recurrent sigmoid volvulus in young people: a missed diagnosis.

In nine young patients with recurrent attacks of sigmoid volvulus there was a long delay before a correct diagnosis was made, yet volvulus was indicated in most of them by a well-taken history. All were treated successfully by excision of the redundant colon. This condition is not as uncommon in young people as was thought.     

Anaerobic bacterial populations on normal and diseased human biopsy tissue obtained at colonoscopy.

Human epithelium was cultured to characterize differences in microbial populations between regions of normal colon and between polyps, inflammatory bowel disease, and cancer and their respective adjacent normal mucosa. Twenty-one patients (12 polyps, 5 inflammatory bowel disease, 4 cancer) underwent colonoscopy with anaerobic culture of mucosal biopsies from normal and diseased ascending, transverse, descending, and sigmoid colon. No differences for total number of organisms and recovery of species between ascending colon and other normal regions were seen except for sigmoid colon. Significant differences between polyps and adjacent normal tissue were seen for total number of organisms and recovery of genera and species. No significant differences in total number of organisms and recovery of genera were seen between cancer and inflammatory bowel disease and their respective adjacent normal tissue. The recovery of genera from polyps and normal tissue was Bacteroides greater than Fusobacterium greater than Clostridium greater than Eubacterium greater than Peptostreptococcus. These data suggest that (i) the total number of anaerobic organisms and species remained relatively constant, except for lower numbers in normal distal colon which were probably a result of the preparation for colonoscopy; (ii) polyp formation favored increased microbial colonization; and (iii) the increased number of organisms generally reflected those genera and species seen on adjacent normal mucosa.     

War injuries of colon and rectum--results after 10 years

The aim of our study is to evaluate results of treating war injuries of colon and rectum, after 10 years. During the war in Croatia, 21 wounded, with colon (19) and rectum (2) injuries, were treated in the Department of Surgery at Nova Gradiska General Hospital from August 1991 to April 1992. Bullet wounds accounted for 57% of the injuries. All patients had other associated injuries. Primary repair and proximal derivation was possible in 2 cases (9.5%), while primary resection with intraperitoneal anastomosis was performed in 3 (14.3%) patients. In 2 (9.5%) patients sustained intraperitoneal and extraperitoneal rectal penetrating injury rectum was resected and closed performing temporary sigmoidostomy. When multiple perforations or crush injury of the colon were found, in 8 (38.1%) injured persons resection of the involved segment was combined with proximal end colostomy and aboral mucous fistula. Exteriorization of injured segment of the colon and creating colostomy incorporating the injured colon as the stoma was performed in 6 (28.5%) wounded patients. Four of the wounded (19.0%) died two of them during the operative procedure due to hemorrhagic shock. One injured died after eight days due to pulmonary embolism, and one patient died after thirty days due to sepsis. Reoperation was necessary in two (9.5%) injured due to bowel obstruction four days following initial surgery because of adhesions. Three (14.3%) of the injured had wound infection, one of them died 30 days after injury due to sepsis, and two (9.5%) consequently developed ventral hernia that was operated after 4 and 5 years respectively. Four (19.0%) of the injured are still occasionally experiencing occasional abdominal pain.     

Strangulated diaphragmatic hernia in a patient with osteogenesis imperfecta.

Hernias are common in patients with osteogenesis imperfecta, but to our knowledge there have been no reports of diaphragmatic hernias in such patients. We describe a patient with osteogenesis imperfecta in whom a diaphragmatic hernia contained a strangulated segment of the splenic flexure of the colon. Resection of the necrotic tissue and transverse colostomy resulted in an uneventful recovery.     

Evidence of regio-specific glycosylation in human intestinal mucins: presence of an acidic gradient along the intestinal tract

Mucin glycans were isolated from different regions of the normal human intestine (ileum, cecum, transverse and sigmoid colon, and rectum) of two individuals with ALeb blood group. A systematic study of the monosaccharides and oligosaccharide alditols released by reductive beta-elimination from mucins was performed using gas chromatography, matrix-assisted laser desorption ionization time-of-flight mass spectrometry, and nuclear magnetic resonance spectroscopy techniques. Important variations were observed in the mucin-associated oligosaccharide content with an increasing gradient of sialic acid from the ileum to the colon associated with a reverse gradient of fucose. Moreover, a comparative study of the Sda/Cad and ABH blood group determinants along the gastrointestinal tract showed the same reverse distribution in the two kinds of antigens. In addition, besides their heterogeneity, sialic acids presented considerable variations in the degree of O-acetylation in relation to glycan sialylation level. These data are discussed in view of recent concepts suggesting that the oligosaccharide composition of the gut constitutes a varied ecosystem for microorganisms that are susceptible to adapt there and possess the specific adhesion system and specific enzymes able to provide a carbohydrate nutrient.     

Mineralocorticoid receptors in the epithelial cells of human colon and ileum

Specific binding of [3H]aldosterone to the cytosolic fraction of epithelial cells was studied in the human colon and terminal ileum. Analysis of [3H]aldosterone binding to the epithelial cells of ascending colon, caecum and ileum as a function of [3H]aldosterone concentration revealed only one class of specific receptors with an affinity constant of about 2 nmol/l. [3H]aldosterone binding was approximately the same in the sigmoid, descending and transverse colon and in the caecum, but slightly lower in the ascending colon and ileum. The specificity of the [3H]aldosterone binding was the same along the colon. The relative order of potency in inhibiting [3H]aldosterone binding was: aldosterone = SC 26304 = dexamethasone much greater than dihydrotestosterone greater than estradiol = RU 26988.     

Expression of the histone H3 gene in the evaluation of cellular proliferation in colitis ulcerosa

A comparison of the number of mRNA molecules of histone H3 in 1 microg total RNA extracted from colon sections sampled during colonoscopy was used to evaluate cellular proliferation activity in the rectum and sigmoid, in normal tissue and in colitis ulcerosa. Samples with similar intensity of the disease were selected for the study. Statistically significant differences between both groups of rectal sections were found in the expression of histone H3 encoding genes. The statistically significant result (p = 0.0485) indicates a more active division of cells in the healthy rectum, with no statistically significant differences in the sigmoid (p=0.9575).     

Effects of oral supplement of L-glutamine on diverted colon wall

Diverted colorectal segments can present trophic and inflammatory changes. These alterations are of special importance in the patients whose colostomy becomes permanent, as well as in the differential diagnosis with other inflammatory diseases. This study was accomplished to quantify these alterations and to determine if oral supplement of L-glutamine would avoid them. Twenty-six adult male Wistar rats were distributed in three groups: control, colostomized and colostomized+L-glutamine. The colostomized group received a loop colostomy. The colostomized+L-glutamine group received a colostomy similar to the previous group and oral supplement of L-glutamine. Partial volumes of all layers of the colonic wall were measured by image analysis stereology. The diversion caused a decrease of partial volumes of the mucosa and the epithelium as well, and also of the height of the intestinal crypts ( p <0.05). There was an increase of partial volumes of the lamina propria, of the submucosa and of the muscularis mucosae vs controls ( p <0.05). The partial volume of the muscularis propria didn't show significant alteration. The supplementation of L-glutamine was effective in preventing the atrophy of mucosa and epithelium ( p <0.05), also avoiding the increase of partial volumes of the submucosa and lamina propria ( p <0.05). This supplement didn't change significantly the muscular layers. In conclusion, colostomy causes the atrophy of the colon wall, mainly due to the atrophy of the epithelium. The supplementation of L-glutamine is able to avoid these changes.     

Isolated colostomy site recurrence in rectal cancer-two cases with review of literature

Background

Colostomy site carcinomas are rare with only eight cases reported in the world literature. Various etiological factors like adenoma-cancer sequence, bile acids, recurrent and persistent physical damage at the colostomy site by faecal matter due to associated stomal stenosis have been considered responsible. Two such cases are being reported and in both cases there was no evidence of any local recurrence in the pelvis or liver and distant metastasis. Both patients had received adjuvant chemotherapy following surgery.

Case presentation

First case was a 30-year-old male that had reported with large bowel obstruction due to an obstructing ulcero-proliferative growth (poorly differentiated adenocarcinoma) at the colostomy site after abdomino-perineal resection, performed for low rectal cancer six years previously. Wide local excision with microscopically free margins was performed with a satisfactory outcome. Four years later he presented with massive malignant ascites, cachexia and multiple liver metastasis and succumbed to his disease.Second case was a 47-year-old male that presented with acute large bowel obstruction due to an annular growth (well differentiated adenocarcinoma) in the upper rectum. He was managed by Hartmann's operation and the sigmoid colostomy was closed six months later. Five years following closure of colostomy, he presented with two parietal masses at the previous colostomy site scar, which, on fine needle aspiration cytology were found to be well-differentiated adenocarcinomas of colorectal type. Surgery in the form of wide local resection with free margins was performed. He presented again after five years with recurrence along the previous surgery scar and an incisional hernia and was managed by wide local excision along with hernioplasty. Follow-up of nine years following first surgery is satisfactory.

Conclusion

Colostomy site/scar recurrence of rectal carcinoma is rare and could be due to various etiological factors, although the exact causative mechanism is not known. Surgery with microscopically free margins is recommended in the absence of metastatic disease. Stenosis of the stoma is considered as one of the most important contributory factors and should be followed carefully.