Faculty Bibliography

BACKGROUND/AIMS/OBJECTIVE:To evaluate the efficacy of the jejunal pouch reconstruction following subtotal proximal and distal gastrectomy, a retrospective study examining the postoperative condition of patients who underwent different methods of reconstruction after gastrectomy for cancer was undertaken. METHODOLOGY/METHODS:Various parameters indicative of postoperative function were evaluated at one year postoperatively, and two major groups were examined. The "proximal gastrectomy" group was composed of patients who underwent either 1) proximal gastrectomy with an interposed jejunal pouch (PG-pouch), 2) proximal gastrectomy with simple jejunal interposition (PG-inter), or 3) total gastrectomy with simple jejunal interposition (TG). The "distal gastrectomy" group was composed of patients who underwent either 4) distal gastrectomy with an interposed jejunal pouch (DG-pouch), 5) distal gastrectomy with simple jejunal interposition (DG-inter), or 6) distal gastrectomy with Billroth 1 reconstruction (B-1). RESULTS:Volume of meal intake was better preserved and the incidence of abdominal symptoms were less frequent in the PG-pouch and DG-pouch groups. In the PG-inter, DG-inter and DG-pouch groups, none of the patients experienced heartburn or had endoscopic findings consistent with reflux esophagitis, while 2 patients (20.0%) in the PG-pouch group complained of heartburn with evidence of reflux esophagitis on endoscopy. Increase in blood acetaminophen level was milder in both the PG-pouch and DG-pouch groups, signifying improved gastric emptying. CONCLUSIONS:The jejunal pouch interposition following proximal and distal gastrectomy seems to confer clinical benefit in terms of postoperative function, especially in the form of meal intake, abdominal symptoms, and gastric emptying. The side effect of an improved reservoir may be the incidence of reflux esophagitis seen in 2 patients in the PG-pouch group.

The use of laparoscopic techniques when surgical therapy is required for the treatment of mucosal ulcerative colitis has been slow to develop; the surgery is extensive, and the instruments are limited. The often urgent nature of the surgery, along with the fragile inflamed colon, have contributed to the limited development of this surgical approach. Yet there is a paradox, as these patients have often anticipated surgery and thus are extremely frightened about it, or must undergo a major operation under urgent circumstances. In this setting, it would seem that a minimally invasive surgical approach would make sense if safe and reasonable, because healing, scarring, and patient fears can be minimized. We are encouraged by the experience we have gained over the past several years in performing these complex laparoscopic cases. The development of some of the newer surgical technologies has shortened operative times. Several recent studies have demonstrated short-term advantages with the laparoscopic approach compared with standard open operations for mucosal ulcerative colitis. Thus, this new approach is a viable and valuable option that may be offered to some patients with mucosal ulcerative colitis.

PURPOSE/OBJECTIVE:The endorectal advancement flap is a surgical procedure used in the treatment of anorectal and rectovaginal fistulas. There is a wide range of success rates published in the literature. This study was undertaken to examine the success rate of primary endorectal advancement flap in our own institution. We attempted to identify factors that influence the rate of healing. METHODS:A retrospective review was performed on 105 patients (43 males) who underwent their first endorectal advancement flap at our institution between January 1, 1994, and June 30, 1999. Ninety-nine patients were available for follow-up. Sixty-two patients had anorectal and 37 had rectovaginal fistulas. The causes of fistula included cryptoglandular (48 patients), Crohn's disease (44), obstetric injury (5), trauma (1), and other (1). RESULTS:The median follow-up was 17.1 (range, 0.4-66.9) months. The median age was 42 (range, 16-78) years. Recurrence was seen in 36 patients (36.4 percent); thus, the primary rate of healing was 63.6 percent. Factors that were associated with higher rates of success were increased age (P = 0.011), greater body surface area (P = 0.012), history of incision and drainage of a perianal abscess preceding advancement flap (P = 0.010), previous placement of a seton drain (P = 0.025), and short duration of fistula (P = 0.003). Factors that negatively influenced the healing rate of the flap were the diagnoses of Crohn's disease (P = 0.027) and rectovaginal fistula (P = 0.002). Length of hospitalization, discharge on oral antibiotics, and the presence of a diverting stoma did not influence the rate of healing. Prednisone was associated with a distinct trend toward failure, with none of the patients on high-dose prednisone (greater than 20 mg/day) having achieved long-term healing. No fistulas recurred after a period of 15 months. CONCLUSION/CONCLUSIONS:The endorectal advancement flap is an effective method of repair for both anorectal and rectovaginal fistulas, even though the success rate may not be as optimistic as in some other published studies. Patient selection is imperative, realizing that a higher rate of failure may be present in Crohn's disease and rectovaginal fistulas. Control of sepsis before endorectal advancement flap with drainage of a perianal abscess and/or seton placement, whenever possible, is indicated.

PURPOSE/OBJECTIVE:There is significant concern in the current literature over the safety of laparoscopic techniques in removal of the entire colon and rectum. The purpose of this study was to examine the results of a one-stage laparoscopic-assisted restorative proctocolectomy in patients with mucosal ulcerative colitis and familial adenomatous polyposis in a single institution experience. METHODS:All patients who underwent laparoscopic-assisted one-stage restorative proctocolectomy (29 mucosal ulcerative colitis; 3 familial adenomatous polyposis) over a 24-month period were followed up prospectively for short-term and long-term complications and functional outcome. RESULTS:There were 32 patients (17 males), with a median age of 32 years (range, 16-29 years). There were no conversions to open surgery. There were two intraoperative complications, an inconsequential rectal perforation during mobilization and one staple line misfire. There were 11 postoperative complications: 3 obstruction/ileus, 2 pouchitis, 2 wound infections, 2 strictures, 1 pelvic abscess, and 1 pouch leak (at the top of the "J"). Three patients required reoperation (1 temporary ileostomy, 1 lysis of adhesions, and 1 transpouch drainage). The median number of bowel movements was seven per day (range, 2-15). CONCLUSION/CONCLUSIONS:A one-stage laparoscopic-assisted restorative proctocolectomy can be performed effectively and safely. Given that techniques in laparoscopic large-bowel surgery are still evolving rapidly, the role of this operation in the surgical treatment of patients with mucosal ulcerative colitis and familial adenomatous polyposis is likely to expand in the near future.

BACKGROUND:Amplification of the human epidermal growth factor receptor 2 (HER2) gene and overexpression of the HER2 protein have been associated with an unfavorable prognosis. We determined the efficacy of an anti-HER2 immunotoxin, erb-38 [e23(dsFv)PE38], against human gastric cancer cells. METHODS:Immunotoxin was made by fusing the disulfide-stabilized Fv fragments (dsFv) of a monoclonal antibody e23 to a truncated mutant of M(r) 38 Pseudomonas exotoxin (PE38) that lacks its cell-binding domain. RESULTS:The immunotoxin-mediated cytotoxicity directly correlated with the expression levels of the HER2 gene and protein in human gastric cancer cells. Interestingly, MKN-45P cells, a variant line of MKN-45 producing peritoneal dissemination and ascites in vivo, expressed a higher level of HER2 and were more sensitive to erb-38 than MKN-45 cells. RFB-4, a control anti-CD22 immunotoxin, was cytotoxic against none of the tested human gastric cancer cells, also suggesting that the lysis mediated by erb-38 was specific for HER2 expression. Three consecutive iv injections of erb-38 at doses of 0.5 or 5 microg/body eradicated experimental liver metastases and peritoneal disseminations produced by MKN-45P in a dose-dependent manner. CONCLUSIONS:We conclude that an erb-38 anti-HER2 immunotoxin has specific antitumor activities against human gastric cancer cells overexpressing HER2.