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Purpose: Acute diffuse peritonitis (ADP) is an important surgical complication associated with high morbidity and mortality; however, the risk factors associated with a poor outcome have remained controversial. This study aimed in collecting integrated data using a web-based national database system to build a risk model for mortality after surgery for ADP., Methods: We included cases registered in the National Clinical Database in Japan. After data cleanup, 8,482 surgical cases of ADP from 1,285 hospitals treated between January 1 and December 31, 2011 were analyzed., Results: The raw 30-day and surgical mortality rates were 9.0 and 14.1 %, respectively. The odds ratios (>2.0) for 30-day mortality were as follows: American Society of Anesthesiologists (ASA) class 3, 2.69; ASA class 4, 4.28; ASA class 5, 8.65; previous percutaneous coronary intervention (PCI), 2.05; previous surgery for peripheral vascular disease (PVD), 2.45 and disseminated cancer, 2.16. The odds ratios (>2.0) for surgical mortality were as follows: ASA class 3, 2.27; ASA class 4, 4.67; ASA class 5, 6.54, and disseminated cancer, 2.09. The C-indices of 30-day and surgical mortality were 0.851 and 0.852, respectively., Conclusion: This is the first report of risk stratification after surgery for ADP using a nationwide surgical database. This system could be useful to predict the outcome of surgery for ADP and for evaluations and benchmark performance studies.

Background: Right hemicolectomy is a very common procedure throughout the world, although this procedure is known to carry substantial surgical risks. The present study aimed to develop a risk model for right hemicolectomy outcomes based on a nationwide internet-based database., Methods: The National Clinical Database (NCD) collected records on over 1,200,000 surgical cases from 3,500 Japanese hospitals in 2011. After data cleanup, we analyzed 19,070 records regarding right hemicolectomy performed between January 2011 and December 2011., Results: The 30-day and operative mortality rates were 1.1 and 2.3 %, respectively. The 30-day mortality rates of patients after elective and emergency surgery were 0.7 and 6.0 %, respectively (P < 0.001). The odds ratios of preoperative risk factors for 30-day mortality were: platelet <50,000/μl, 5.6; ASA grade 4 or 5, 4.0; acute renal failure, 3.2; total bilirubin over 3 mg/dl, 3.1; and AST over 35 U/l, 3.1. The odds ratios for operative mortality were: previous peripheral vascular disease, 3.1; cancer with multiple metastases, 3.1; and ASA grade 4 or 5, 2.9. Sixteen and 26 factors were selected for risk models of 30-day and operative mortality, respectively. The c-index of both models was 0.903 [95 % confidence interval (CI) 0.877-0.928; P < 0.001] and 0.891 (95 % CI 0.873-0.908; P < 0.001), respectively., Conclusion: We performed the first reported risk stratification study for right hemicolectomy based on a nationwide internet-based database. The outcomes of right hemicolectomy in the nationwide population were satisfactory. The risk models developed in this study will help to improve the quality of surgical practice.

Morphologically, liver metastases from colorectal carcinoma usually form as nodular tumor masses, whereas intraductal papillary growth in the bile duct is rare. A 65-year-old man underwent right hemicolectomy for advanced colon carcinoma, and histology of the primary carcinoma confirmed moderately differentiated adenocarcinoma with subserosal invasion, no vascular infiltration, and no lymph node metastasis. A liver tumor was found in the right paramedian Glisson pedicle and intraductal growth of cholangiocarcinoma was seen on imaging. We performed right hepatectomy and macroscopically, the resected specimen contained a growth in the bile duct lumen similar to cholangiocarcinoma. Histological examination revealed intraductal papillary proliferation of well-differentiated adenocarcinoma without vascular infiltration or lymph node metastasis in the hepatic hilum. Immunohistochemical staining revealed that the tumor cells were negative for cytokeratin-7 and positive for cytokeratin-20. Based on these findings, liver metastasis from colon carcinoma was diagnosed. Liver metastasis from colorectal carcinoma rarely arises as intraductal papillary growth in the bile duct, but the possibility of liver metastases with unusual morphology must be borne in mind for patients with a history of carcinoma in the digestive tract.

Background: Photodynamic therapy (PDT) is a new palliative option in patients with non-resectable bile duct carcinoma (BDC). Here, we assessed the efficacy of adjuvant photodynamic therapy in eight patients with BDC who underwent surgical resection., Methods: Five patients had extrahepatic BDC, two had intrahepatic cholangiocarcinoma, and one had ampullary carcinoma. Cancer cells were microscopically detected in the stump of the hepatic duct in six patients, and biliary stenosis caused by remnant tumor was observed in one patient. One patient had tumor recurrence with occlusion of the bile duct. At 48 h prior to PDT, porfimer sodium was injected intravenously. A pulse laser by an eximer dye laser (50-100 J/cm2) with a wavelength of 630 microm was applied through an endoscope to the hepatic stump or tumor lesion., Results: Marked destruction of the tumor and ductal epithelium was observed on day 1 after PDT. After PDT, four patients developed mild dermatitis, but no severe morbidity or mortality was noted. In patients who underwent PDT for the stump, one patient showed distant metastasis at 31 months, and four patients did not show tumor recurrence at 17, 12, 12, and 6 months, respectively. However, one of the eight patients died at 2 months, of an unrelated cause. In two patients with occlusion caused by tumor growth, resolution of bile duct stenosis was noted on day 7. These patients showed re-occlusion by tumor at 20 and 8 months., Conclusions: Adjuvant PDT is a safe and useful option for a better survival benefit in patients with BDC undergoing surgical resection.

Purpose: We report our experience of using the minimally invasive minilaparotomy approach to resect colonic laterally spreading tumors (LSTs) that could not be removed by colonoscopic snare polypectomy., Methods: We prospectively examined 17 patients who underwent a minilaparotomy, defined as an incision less than 7 cm long, between 1997 and 2001, for a collective 19 colonic LSTs., Results: Complete en bloc resection of the LSTs was successfully performed in all 17 patients. The resections included colotomy and polypectomy in four patients (four LSTs), limited colectomy in seven patients (nine LSTs), and colectomy with regional lymph node dissection in six patients (six LSTs). There was no mortality or morbidity. The mean +/- standard deviation (SD) length of the minilaparotomy was 6.7 (+/-0.8) cm, and the mean (+/-SD) operating time and blood loss were 139 (+/-39) min and 27 (+/-15) ml, respectively. Histology revealed 2 adenomas, 16 Tis carcinomas, and 1 T1 carcinoma. None of the patients had lymph node metastasis or positive resection margins. There have been no signs of tumor recurrence after a median follow-up period of 30.4 months., Conclusions: The minilaparotomy approach is appropriate for resecting LSTs that cannot be removed by colonoscopic snare polypectomy, and provides a minimally invasive alternative to conventional laparotomy.

Purpose: We evaluated the efficiency of measuring hyaluronic acid (HA) levels preoperatively in patients with injured liver disease as a predictor of complications after hepatectomy., Methods: We examined patients who underwent hepatectomy for liver tumors secondary to chronic viral liver diseases or obstructive jaundice., Results: The preoperative HA level correlated significantly with the indocyanine green retention rate at 15 min, liver activity at 15 min by technetium-99m galactosyl human serum albumin scientigraphy, and the histopathological activity index. It was also significantly elevated in patients with severe fibrosis caused by cirrhosis. After hepatectomy, the HA level was increased on postoperative day (PODS) 7, but had normalized by POD 28. The preoperative HA level tended to correlate with the regeneration rate on POD 28, and was significantly higher in patients with prolonged ascites or hepatic failure postoperatively. Multivariate analysis identified a serum HA level above 200 or 150 ng/ml as the only significant predictor of postoperative hepatic failure or long-term ascites, respectively (P < 0.05)., Conclusion: Our findings indicate that the preoperative serum HA level is a good predictor of postoperative complications in patients who undergo hepatectomy for injured liver disease.

A minimally invasive surgical approach should be employed to resect symptomatic colonic lipomas whenever possible. We report two cases of large colonic lipomas that were successfully removed using a minimally invasive minilaparotomy approach. Patient 1 was a 53-year-old man with a 3.8-cm symptomatic submucosal lipoma in the ascending colon and patient 2 was a 57-year-old woman with a 4.2-cm symptomatic submucosal lipoma in the transverse colon. Both lipomas were successfully removed through a 5-7-cm minilaparotomy. Normal bowel function returned quickly without any postoperative complications. These case reports demonstrate that the minilaparotomy approach is a suitable alternative to conventional laparotomy to remove a large colonic lipoma.

Background: The relationship between patient prognosis and various tumor biological factors has been reported previously, and prognostic factors of tumor biology may improve predictions of prognosis after hepatectomy for hepatocellular carcinoma (HCC) and may contribute to a new staging classification. This study was designed to provide an immunohistochemical analysis of tumor biological factors in patients who underwent hepatectomy for HCC., Methods: Factors analyzed included p53 overexpression, microvessel counts, proliferating cell nuclear antigen, and expression of nm23. We examined 81 HCCs from patients with chronic liver diseases., Results: In patients who underwent chemoembolization before surgery, or those a who had confluent multinodular tumor, p53 expression tended to be higher than in patients without chemoembolization (33% vs 11%) or those with a simple nodular tumor (28% vs 10%), but the difference was not statistically significant ( P = 0.051 and P = 0.092, respectively). A lower tumor microvessel count and negative nm23 expression were significantly associated with poor disease-free survival by univariate analysis ( P < 0.01 and P < 0.05, respectively). A lower tumor microvessel count was found to be a significant prognostic factor for disease-free and overall survivals (risk ratios, 2.44 and 3.13, respectively; P << 0.05), in addition to tumor size, vascular invasion, and longterm ascites, by Cox's multivariate analysis., Conclusions: Tumor microvessel count appears to be a useful prognostic marker for predicting HCC recurrence and patient survival.

Purpose: The purpose of this study was to determine whether the type of operation [sphincter-saving resection (SSR) or abdominoperineal resection (APR)] for primary adenocarcinoma of the rectum at or below the peritoneal reflection affects survival and recurrence after curative surgery., Methods: This retrospective study included 184 patients who underwent curative surgery achieved by the following two types of operation between 1989 and 1998: (1) SSR ( n = 116 patients) including a low anterior resection with either double-stapling technique ( n = 86) or transanal coloanal anastomosis ( n = 30); (2) APR ( n = 91). The outcome factors evaluated were survival and tumor recurrence. Both univariate and corrected (multivariate Cox's and logistic regression) analyses were used to evaluate the data. The median follow-up was 47.4 months for patients alive at study conclusion., Results: Disease-free and disease-specific survivals, and the frequency and location of recurrence after surgery did not differ between the two types of operations. Multivariate analyses showed that the type of operation was not a significant independent variable in predicting disease-free survival or in the development of both local and distant recurrences after surgery. In addition, tumor-related factors (stage or histologic grade) were significant predictors of the outcome after surgery., Conclusions: The type of operation (SSR or APR) did not affect the survival or recurrence after a curative resection for adenocarcinoma of the rectum at or below the peritoneal reflection.

This study compares surgical outcomes for local resection of rectal tumors by two approaches: (1) gasless, video-endoscopic transanal-rectal tumor excision (gasless VTEM); and (2) a conventional posterior approach. Gasless VTEM involves a modification of transanal endoscopic microsurgery (TEM) that incorporates a standard laparoscopic video camera without a CO(2) insufflation system. A series of 42 patients with 45 rectal tumors (9 adenomas, 36 adenocarcinomas) who underwent gasless VTEM between 1993 and 2000 were studied prospectively. The control group consisted of 26 similar patients who underwent conventional surgery (transsacral or transsphincteric approach) between 1985 and 1993. Age, gender ratio, tumor localization, maximum tumor diameter, and histology for the cases and the controls were similar, whereas operating time and blood loss were significantly greater in the control group (p < 0.001 and p < 0.001, respectively). The postoperative intervals until able to walk, urinary catheter removal, solid food intake, and discharge from hospital were significantly shorter in the gasless VTEM group (p < 0.001, p = 0.002, p < 0.001, and p < 0.001, respectively); analgesic requirements were significantly less (p < 0.001). There was no operative mortality in either group. Postoperative complications developed significantly less frequently in the gasless VTEM group than in the control group (7.1% vs. 38.5%; p = 0.003). During the median follow-up length of 73.3 months, no patient developed tumor recurrence in the gasless VTEM group, whereas one patient did in the control group. In conclusion, gasless VTEM is less invasive and allows shorter hospitalizations and reduced complications than the conventional posterior approach, thereby providing an attractive alternative for selected patients.

Genetic aberrations in radiation-associated colorectal cancer have not been studied in detail. We analyzed genetic aberrations in five rectal cancers that developed long after radiotherapy had been performed for cervical cancer. Microsatellite instability (MSI) in tumors was examined at five loci: D2S123, D3S966, TP53, DCC, and BAT26. Mutation of simple repeat sequences within the hMSH3, BAX, and transforming growth factor Beta type II receptor ( TGFBetaRII) genes was examined by polymerase chain reaction and single-strand conformation polymorphism (PCR-SSCP). Mutation of p53 exons 5-8 was examined by PCR-SSP and direct sequencing. Mutations of the K- ras gene were analyzed by two-step PCR. No MSI was found in tumor specimens at any of the loci examined, and no mutations in the target genes were observed. K- ras mutation was detected in two carcinomas, but not in their irradiated normal mucosa, while p53 mutation was observed in another two carcinomas, but not in their irradiated normal mucosa. Our results suggest that the radiation-associated rectal carcinomas examined in this study did not develop through the mutator phenotype pathway; rather, tumorigenesis was probably mediated through the multistep carcinogenesis pathway.

Extraintestinal manifestations of ulcerative colitis (UC) are well known, but immunologically mediated hematological diseases are relatively rare. We describe two cases of immune thrombocytopenic purpura (ITP) associated with preexisting UC. Our patients had typical symptoms of UC, and endoscopy showed pancolitis. During treatment with 5-aminosalicylic acid and steroids, severe thrombocytopenia was noted. ITP was diagnosed based on a normal to high number of megakaryocytes in the bone marrow, positive autoantibody to platelet membrane antigen, and absence of splenomegaly. Medical treatment, including increased dosage of steroids, failed to control UC and ITP in both patients. In the first patient, the platelet count recovered after colectomy, while the second patient died of a cerebral hemorrhage. We stress that a diagnosis of ITP should be considered for thrombocytopenia in patients with UC, especially those showing extensive and significant colonic inflammation, and that colectomy of UC might resolve resistant ITP.

A duodenal fistula complicated with Crohn's disease may present a difficult management problem. We herein report the case of a 22-year-old woman who developed a colo-ileo-duodenocutaneous fistula with recurrent disease at the ileotransverse anastomosis. The patient had previously undergone an ileoascending colectomy for Crohn's disease. Preoperative colonoscopy did not reveal any evidence of intrinsic duodenal Crohn's disease. Symptomatology was obstructive and a consequence of associated ileocolic lesions. The patient underwent a resection of the diseased bowel including the duodenal component of the fistula. Surgery included a simple closure of the duodenal defect with both omental pedicle graft wrapping and decompression of the duodenum via a gastrostomy tube. The patient had an uneventful postoperative course. The duodenal fistula was successfully cured. Our experience demonstrates that duodenal fistulas may be successfully treated when the duodenum is not involved with intrinsic Crohn's disease. Such treatment consists of a resection of the diseased bowel segment and a primary simple closure of the duodenal defect.

The feasibility and safety of a minilaparotomy approach to terminal ileal Crohn's disease have not been fully elucidated. The purpose of this study was to compare early outcomes utilizing this technique as an alternative to conventional approaches. Nine patients with terminal ileal Crohn's disease (but no complicating enteric fistulas) who underwent minilaparotomy between January 1998 and September 2000 were studied prospectively. The minilaparotomy approach entails a complete surgical procedure performed through a skin incision of less than 7 cm. Ten similar patients who underwent conventional laparotomy between January 1995 and December 1997 served as the control group. Age, gender, body weight, height, body mass index, number of prior laparotomies, operating times, operative blood loss, and types of operative procedure were similar for cases and controls. The length of the laparotomy incision in the minilaparotomy approach group was significantly shorter than that in the conventional approach group (median length 6.0 vs. 16.5 cm; p <0.05). Postoperative intervals until initial standing and walking were significantly shorter for minilaparotomy patients than conventional surgery patients (p <0.05 and p <0.05, respectively), whereas postoperative intervals until passing flatus, urinary catheter removal, and tolerance of liquids and solids did not differ for the two groups, nor did the analgesic requirement or postoperative hospital stay. Postoperative complications developed in two conventional-group patients; none was noted with the minilaparotomy approach. Our data suggest that the minilaparotomy approach to terminal ileal Crohn's disease without an enteric fistula is feasible, safe, and less invasive than the conventional approach.

Background: Macroscopic classification of metastatic liver tumors has been recommended to predict patient prognosis., Methods: We examined the morphological analysis of metastatic colorectal cancer in 64 patients who underwent hepatic resection and the relationship with clinicopathologic factors. To identify the irregularity of the tumor, we calculated three formulas: (1) actual area of representative cut surface of tumor/circular length of tumor margin, (2) actual area of representative cut surface of tumor/elliptic area, defined by the major and minor axes, and (3) deviation of radius of marginal curvature., Results: Following Yasui's macroscopic classification, the values of formulas (1) and (2) in confluent nodules were significantly lower than those in simple nodules ( P < 0.05), while the value of formula (3) in confluent nodules was significantly greater than that in simple nodules ( P< 0.05). Only a lower value of formula (1) (less than 0.19) was significantly associated with postoperative recurrence ( P< 0.05) and a lower value tended to be associated with a shorter disease-free survival after hepatectomy, but not significantly ( P= 0.09). However, most values were not associated with any clinicopathologic factors or postoperative survival., Conclusions: We conclude that differences in the morphological irregularity of liver tumors in metastatic colorectal cancer do not have clinical significance.

Purpose/background: Increased numbers of argyrophilic nucleolar organizer region (AgNOR) dots reflect higher proliferating activity of malignant cells., Methods: To determine whether AgNOR staining is suitable for cytology of bile in biliary diseases as an ancillary diagnostic method, we examined the mean number of AgNOR dots (MNA) in cells of both bile smear and tissue sections in 14 benign biliary diseases and 25 malignancies of the biliary tract. The malignant diseases consisted of 11 gallbladder cancers, 10 bile duct cancers, and 4 ampulla cancers in patients who underwent surgical resection. Results of AgNOR staining were available in 15 min, and the MNA in the nucleus was counted in 50 cells/specimen., Results: The MNAs in malignant cells in bile smear (9.6 +/- 3.8) and tissue sections (9.2 +/- 3.5) were significantly higher than those in the corresponding cells in benign biliary diseases (4.1 +/- 1.0 and 2.9 +/- 0.8, respectively; P< 0.01). The MNA of bile smear for both benign and malignant cells correlated significantly with that of tissue sections ( r= 0.915; P< 0.0001). When the cutoff value of MNA for bile smear was set at 7.0, benign diseases could be discriminated from malignancy, and the MNA of 20 (80%) malignant specimens was higher than this value., Conclusions: Our results suggest that the AgNOR dot count of cells in bile smears would be a useful diagnostic tool, in combination with conventional cytological diagnosis, before and during surgery.