During the past 27 years, after resction and reconstruction 53 patients with thoracic esophageal cancer required reanastomosis between the cervical esophagus and the prosthesis. Reanastomosis was performed against leakage (L group) in 32 cases and for stenosis (S group) in 21 cases. Primary closure had been performed in 47 cases, and reconstruction with a local skin flap in 3, with pedunculated jejunal interposition in one and with free jejunal transplantation in two. Releakage after the reanastomosis occurred in 53% and became major leakage in 21%. Releakage occurred significantly more frequent in the L group (66%) than in the S group (33%), and was more frequent when reconstruction was by the antesternal route (59%) than by the retrosternal route (43%). Prognostic nutritional index was significantly deteriorated in the former cases. Primary closure with local mobilization for patients who had an anastomotic portion smaller than 1/3 of the circumference, and primary closure with wide mobilization for the patients who had an anastomotic portion between 1/3 and 2/3 of the circumference are adequate methods of reanastomosis. However the incidence of releakage after primary closure or reconstruction by skin or jejunum for patients who had an anastomotic portion larger than 2/3 of the circumference was extremly high. Careful management is recommended for patients who had a preoperative risk factor.

View full abstract

The results of surgical treatment of lower thoracic esopageal cancer were studied by comparison of 19 patients who received a lower esophageal resection and intrathoracic esophago-gastrostomy (Group A) and 21 patients who received a subtotal esophagectomy and cervical esohago-gastrostomy (Group B). The effect of lymphadenectomy in the cervical and upper mediastinal regions was retrospectively evaluated. Abdominal lymph node (LN) metastasis was observed most frequently. The rate of metastasis in the upper thoracic paraesophageal LN was 21% and it was 5% in the paratracheal LN in group B. The postoperative 5-year survival rate was better in Group B than in Group A (47% vs 21% overall, and 33.3% vs 14.3% in patients in stage III and IV). In Group B, the cumulative 5-year survival rates were 59.9% and 49.9% for patients with n (-)-n₂ (+) and those with n_3-4 (+) respectively. These results suggest that upper mediastinal lymphadenectomy is very important in cases of lower thoracic esophageal cancer. Liver metastasis was the most frequent site of recurrence. Cervical LN metastasis was observed in a few cases, but we concluded that cervical lymphadenectomy is indicated even for patients suspected of having cervical LN metastasis by preoperative examination or who have upper mediastinal LN metastasis detected during surgery.

View full abstract

For evaluating preoperative selective celiac and superior mesenteric arteriography to determine the stage of gastric cancer, we analyzed the vascular pictures of 380 patients who had undergone angiography before primary operations for gastric cancer, compared them with operative and histopathological findings and calculated the “coincidence rates” (compared with operative findings), “correct rates” (compared with histopathological findings) and rates of false-positive and false-negative angiographic diagnoses, concerning the factors of disseminating peritoneal metastasis, liver metastasis, lymph node metastasis and serosal invasion. The overall coincidence rate for the presence of disseminating peritoneal metastasis was 93.4% and that of liver metastasis was 96.3% but the ability to diagnose comparatively small liver metastases was not good; the rate of H₁ and H₂ was 16.7% and 66.7% respectively. The overall correct rate for the presence of lymph node metastasis was 51.4% and the false-negative rate was high, 47.8%. Lymph node metastasis was, in most cases, detected by tumor staining of lymph nodes and the tumor stain was frequently seen in the cases of histologically well-differentiated type. The overall correct rate for the presence of serosal invasion was 81.6%, and 43 cases of S₃ such as pancreaic invasion were diagnosed by angiography. Angiography was considered to be one of the most useful methods for preoperative diagnosis of to stage of gastric cancer, particularly of disseminating peritoneal metastasis, liver metastasis and S3 of pancreatic invasion.

View full abstract

To clarify the exocrine pancreatic function after hepatectomy, changes in amylase secretion in response to caerulein were investigated in 70% hepatectomized rats. In the early state (4 days) after hepatectomy, in-vivo caeruelin stimulated amylase output was significantly higher than in sham-operated and normal rats. In the recovering stage (7 days) after hepatectomy, amylase output was also significantly increased. In the in-vitro incubation system, the caerulein concentration for the maximum amylase output was 10^-10M 7 days after hepatectomy and shifted to a lower concentration than in the sham-operated or normal rats. The amylase content was significantly higher both 4 and 7 days in rats of hepatectomy than in the sham-operated and normal rats. These findings suggest that an increase in amylase synthesis and in sensitivity of acinar cells to caerulein occur in the pancreas after hepatectomy.

View full abstract

Fifty-five patients with recurrence of surgically resected hepatocellular carcinoma were assesed for clinical outcome in reference to type of recurrence, time of recurrence and therapy. Patients with a single intrahepatic recurrence had a better survival rate two years after recurrence than those with multiple intrahepatic or extrahepatic recurrence; 87.5% with single (n=11), 40.1% with multiple (n=30) and 13.4% with extrahepatic (n=14) metastatic lesions. In 30 cases of multiple intrahepatic recurrence, death within a year after recurrence occurred in 8 of 15 patients (53.3%) with recurrence within a year after hepatectomy, wereas it occurred in only one of 15 patients (6.7%) with recurrence more than one year after hepatectomy. In regard to treatment for recurrence, survival rate two years after recurrence was 34.3% of 10 patients treated by reoperation [OP group], 64.9% of 27 patients treated by transcatheter arterial embolizatin [TAE (+) group], and 6.9% of 18 patients treated by chemotherapy alone [TAE (-) group]. The outcome in the TAE (-) group was poorer, but no significant difference was observed between the OP group and the TAE (+) group.

View full abstract

Fifty-three patients who had received gastrectomies were studied by gallstone classificatin, bile culture and bile analysis to determine the factors affecting gallstone formation after gastrectomy. Black stones were found most frequently (43.4%), and the results of bile analysis showed that the concentration of total bile acid and phospholipid decreased in 9 patients with black stones after gastrectomy compared with those of 15 black stone paients without prior gastrectomy, while the ionized calcium concentration increased in those post-gastrectmy patients. The excess of ionized calcium in the bile of these patients was thought to be the result of the decreased concentration of bile acid and phospholipid, and it is suggested that the increased level of ionized calcium in bile promotes black stone formation after gastrectomy. In patients who underwent gastric resection with duodenal diversion such as the Billroth-II method, black stones were found in 43.6%, calcium bilirubinate stones were frequent (33.3%) and positive bile culture was at high rate (71.0%). It is suggested that, after such reconstruction procedures, absence of gastric acid in the duodenum induces a change in the bacterial flora in the excluded loop resulting in bile duct infection and may eventually induce calcium bilirubinate stone formation

View full abstract

We analyzed the magnetic resonance (MR) images of pancreaic carcinoma in contrast to operative findings, appearance of the cut surface of the removed tumor, pathohistological findings, and MR images of the resected specimen. Seventeen patients with pancreatic carcinoma who underwent surgery were studied. We divided the MR images into four types. The first type was that in which carcinoma showed apparently different signal intensity from that of the surrounding pancreaic tissue. The second type was that in which carcinoma was recognized as the tumor protruded from the pancreatic tissue. The third type was that in which carcinoma was recognized only by the finding of vessel deformity. The fourth type was that in which MR images showed no abnormal findings. In the first type, many tumors appeared nodular on gross examination, and microscopically appeared medually in inerstitional tissue; degeneration of the distal pancreatic tissue was relatively slight. In the third and fourth types, many tumors appeared infiltrative on gross examination, and microscopically appeared scirrous in interstitional tissue; degeneration of the distal pancreatic tissue was severe. The MR imaging of pancreatic carcinoma indicated the nature of the tumors and the surrounding pancreatic tissue so well that it might be useful for preoperative diagnosis of pancreatic carcinoma.

View full abstract

The prognostic factors of primary malignant lymphoma of the gastrointestinal (GI) tract were analyzed in 17 operated patients with using Naqvi's classification that is mainly based on lymph node involvement and depth of tumor invasion. The group of earlier clinical stages, or stage-I and-II (n=11), had 74.1% of 5 year survival rate, while advanced groups, or stage-III and-IV (n=6), had 33.3% (p<0.05). It is therefore indicated that lymph node involvement more than n2 and tumor exposure to the serosal surface were probably definitive prognistic factors. The groups of curative and non-curative operation had 80.0% (n=8) and 42.9% (n=9) of 5 year survival, respectively. The groups with and without adjuvant chemotherapy had 74.0% (n=11) and 33.3% (n=6) of 5 year survival, respectively. As indicated above, curability of operation and adjuvant chemotherapy also significantly influenced on the prognosis. The present study suggested that Naqvi's classification is a useful tool to predict the prognosis of the primary malignant lymphoma of the GI tract.

View full abstract

From January 1969 through April 1989, 384 patients with colorectal cancer were operated on in our department. In 21 cases (group A) the cancers were associated with multiple primary malignant tumors and clinical studies were carried out on these cases and compared with the 363 cases (group B) without other malignant tumors. Group A had the following features. The male/female ratio was 3.2 to 1; the mean age was 61.7 years, about 4 years older than that of group B; and the rate of multiple colorectal cancers was 28.6%. The cancers tended to be located in the right side colon (the cecum, ascending colon and transverse colon) in contrast to group B. A family history of cancer was noted in 55.6% of the members of group A. The other primary malignant tumors frequently originated in the stomach or urinary bladder. After treating the other malignant tumors, early detection of colorectal cancer must be attempted to improve the prognosis of multiple primary malignant tumors associated with colorectal cancer. Special attention must be paid not to overlook new malignant tumors of other organs, especialy in cases of multiple colorectal cancers, old age, cancer family history, or carcinoma of the right side colon.

View full abstract

A 49-year-old woman presented with stage N esophageal cancer in August 1986. She underwent total resection of the intrathoracic esophagus with esohageal replacement via the retrosternal route by means of a gastric tube and pyloroplasty. Post-operative radiation was given and the subsequent post-operative course was satisfactory. One year and 8 months after esophagectomy, she consulted us again in a state of shock, complaining hematemesis and melena. Emergency endoscopic examination revealed a deeply ulcerative lesion on the posterior wall of the gastric tube with massive blood coaglation. She suddenly developed cardiac arrest and apnea during an endoscopic examination, and massive fountain-like hematemesis appeared. An immediate emergency operation was performed, during which resuscitative measures were undertaken. A median sternotomy was made, and the ulceration was seen to have perforated the anterior wall of the aortic arch. We were able to stop the bleeding by directly suturing the bleeding point, and she was rescued. Reports of ulcerrative lesions developing in a gastric tube used for esophageal replacement are rare, with only 5 cases reported in Japan. No cases have been reported in which perforation into the aortic arch was successfully treated.

View full abstract

This is a report of a case of gastric duplication discovered in a 4Z-year-old woman by ultrasound examination. A clearly bounded cubic cyst was found along the lesser curvature of the stomach under the left lobe of the liver close to the lasser curvature by ultasound examination and computed tomographic scanning.An upper GI series and endoscopic examination disclosed a protrusion in the lesser curvature near the cardia. There was no communication between the gastric lumen and the extragastic mass. However, surgery confirmed continuation between the mass and the lesser curvature of the stomach. The mass was resected with the involved portion of the gastric wall. The resected mass was a cyst 4 cm in diameter totally filled with fluid similar to pus. Histopathological studies revealed the strata of the mucous membrane, muscular layer and serous membrane. The mucous membrane showed a pseudostratified columnar epithelium containing goblet cells. Part of the muscular layer communicated with the muscular layer of the gastric wall, but not with the gastric lumen. We must keep this unusual case in mind when we detect peritoneal cyst by ultrasound and, /or CT examination

View full abstract

A case of alpha-fetoprotein (AFP) producing pm gastric cancer without liver and lymph node metastasis is reported. The paient was a 69-year-old male whose serum AFP level was abnormallv high, 1086 ng/ml. X-ray and endoscopic examination revealed a tumor (Borrmann type 2) at the body of the stomach. It was confirmed as Group V by biopsy and the pyloric side of the stomach was resected and R₂ curettage was performd. Histopathological examination disclosed poorly differentiated adenocarcinoma admixed with relatively differentiated areas, limited to the tunica muscularis propria without lymph node metastasis. Immunohistochemically, the less differentiated and medullary areas were strongly positive and the relatively differentiated areas were weakly positive for AFP. The serum AFP level became normal after the operation and no recurrence was observd 1 year and 5 months later.

View full abstract

A 50 year-old man, who had been aware of general fatigue, nausea after meal and tarry stools for past two years, was admitted to our hospital for further examination of a polypoid lesion of stomach. Upper GI X-rays showed a large gastric pedicled tumor prolapsing into the duodenal bulbus. Endoscopy revealed two gastric pedicled tumors on the anterior and posterior wall of the antrum and the larger one, on the posterior wall, partially prolapsed into the duodenal bulbus. Biopsies of both tumors revealed histolqgically tubular adenoma with slight atypia of the nucleus. The stomach was surgically resected with tymph node cleanings under the diagnosis of a carcinoma in adenoma of the stomach prolapsing into the duodenal bulbus. The tumors on the posterior wall was L2.5×3×2.5 cm in size and on the anterior wall was 2.5×1.5×2.5 cm in size. Grossly, both tumors were pedicled with nodular surface. Histologically, each polypoid tumor was composed of several nodular masses with elevation of the muscular mucosa along an axis. Most nodular masses were diagnosed as adenoma (papillotubular type, colonic type), but some areas which revealed severe cellular and structural atypia with a clear border with the adenoma were diagnosed as well differentiated adenocarcinoma.

View full abstract

Two cases of hepatic infarction as a postoperative complication after hepato-biliary surgery are reported. Case 1: A 62-year-old man was admitted to our hospital with cholangiocarcinoma of the portal hepatis, for which left hepatic lobecotmy coupled with resection of the portal vein was undertaken. Postoperatively, however, he had a massive hepatic infarction (S_a) and consequently died. Autopsy revealed that ligation of the right anterior hepatic artery had led to an extensive infarction of the liver, although the portal vein was patent. Case 2: A 46-year-old man was admitted with a recurrence of gastric cancer. Pancreatoduodenectomy coupled with resection of the portal vein and the hepatic artery was performed. When a retrograde transhepatic biliary drainage tube was inserted into the liver for bile drainnage, an intrahepatic vessle was injured and subsequently hepatic infarction occurred in the peripheral area supplied but this damaged vessel.

View full abstract

There are no reports on a liver abscess caused by Lactobacillus in the literature. Therefore we report a rare case of this phenomenon. A 68-year-old woman who had subtotal gastrectomy and cholecystectomy four months before was admitted to our hospital because of high fever and right chest pain. A chest roentgenogram showed right pleural effusion. Abdominal ultrasonography revealed a hypoechoic mass in the posterior segment of the liver. A computed tomography revealed a heterogeneous low density mass in the liver. The diagnosis was liver abscess. We treated the patient with antibiotics, but the symptoms became worse and worse. On the 6th drainage contents were milky pus. The causative organism was identified as Lactobacillus catenaforme.

View full abstract

A case of emphysematous cholecystitis due to Aeromonas hydrophilia is reported. A 79-year-old woman was admitted to our hospital with mild right hypochondral pain. Abdominal computed tomography (CT) on admission revealed that fundus of the gallbladder was filled with measuring about 3×3 cm in size gallstones and contained a gas shadow. Another abdominal CT, on the 21th hospital day, revealed that the size and location of the gas shadow was unchanged compared with the prior gas shadow. On the 24th hospital day the patient underwent a cholecystectomy and choledochotomy under the diagnosis of emphysemaous cholecystitis with gallstones. Histological examination of the gallbladder revealed gangrenous cholecystitis with multiple ulcers. Aerobic bil and gallstone cultures fielded an oxidase positive, gram negative rod identified as A hydrophilia. Cholecystitis associated with A hydrophilia infection has been noted in three previous cases, but emphysematous cholecystitis due to A hydrophilia has never been reported. Therefore our case is thought to be the first one of this condition.

View full abstract

Not much is known about the orgin and growth of cholangiocarcinoma. We report two cases of cholangiocarcinoma which show rare growth patterns. The first patient is 73 years old male complained of jaundice, and percutaneous transhepatic cholangiography (PTC) revealed obstruction of the hepatic duct. An excised specimen contained two independent stalk-shaped cholangiocarcinomas in the hepatic duct. The second patient 69 years old male complained of fever and lower abdominal pain. PTC revealed cystic dilatation of the left hepatic duct and a vague defect on the cholangiogram, and millet jelly-like mucus was aspirated. An excised specimen contained mucin-producing cholangiocarcinoma cells in the lining of the hepatic duct. In the first patient, tumor remained in the mucosal layer, a rare growth pattern which is the so-called carcinoma in adenoma. The second patient showed a mucinous type of papillary adenocarcinoma located in the mucosa. These two cases showed unusual growth patterns, and led us to take a deep interest in the mechanism of carcinogenesis.

View full abstract

Insulinoma is generally an indication for surgery, but it is sometimes multiple in origin, making exact resection difficult. We have recently experienced a case of multiple insulinoma appearing in different locations according to various examinations. The patient is a 26-year-old woman who presented with Whipple's triad, suggesting an insulinoma. Its location was shown to be at the body of the pancreas by celiac arteriography, and at the head of the pancreas by ultrasonograpy and ultraendoscopy. Ca²⁺-loading percutaneous transhepatic portal venous sampling (Ca²⁺-PTPVS) gave results suggestive of its presence at both the head and the body of the pancreas. At laparotomy, tumors were found in both of these regions, and they were resected. Histological examination confirmed that both tumors were insulinomas, and the one at the body was rich in vessels, in contrast to the one at the head which showed strong vitreous degeneration. The different image diagnoses obtained before and after the operation seem to have been responsible for this histological difference.

View full abstract

We found a giant splenic aneurysm at the time of angiography for cirrhosis, and succeeded in preventing rupture of the aneurysm by using steel coils. The patient was a 40-year-old man in whom celiac angiography revealed a splenic artery aneurysm whose diameter is 3 cm at the root of the splenic artery. To prevent rupture of the aneurysm, we embolized the splenic artery. Embolization was achieved after placing angiocoils^®with a diameter of 8 mm in the proximal and distal portions of the aneurysm by using an angiography-cather, thus completely occluding the blood supply to the aneurysm. No complication were noted after embolization.

View full abstract

Superior mesenteric artery occlusion is treated by resection of the infarcted bowel in almost all cases. Recently we encountered a patient suffering from a superior mesenteric artery embolus. The patient was a 51 year old man in whom had been pointed out hypertension, diabees mellitus and an old myocardial infarction. The onset was abrupt with severe abdominal pain. Although melena occurred post admission, endoscopy revealed no evidence of bleeding from the stomach, duodenum or colon. Ultrasonography revealed a cardiac aneurysm. The physical findings and symptoms suggested the exsistence of obstruction of mesenteric vessels. On superior mesenteric angiographic examination, a shadow defect appearance was noted. Urokinase was infused continiously for 24 hours (10, 000 U/hr) by an arterial infusion pump through selected catheterization to the SMA. Repeated angiography showed persistent occlusion. Then surgery was performed. After embolectomy using a Fogarty's balloon catheter, a striking improvement in bowel color and marginal pulsation took place. Bowel resection was not necessary.

View full abstract

Mesenteric cysts are uncommon. An adult case of mesenteric cyst is presented. The patient was a 21-year-old woman, who was admitted complaining of lower abdominal pain and abdominal distension, under suspician of an ovarian cyst. Since abdominal pain and abdominal distension abruptly became severe a week after admission, an emergency operation was performed. The origin of the cyst was the mesentery of the transverse colon. Since adhesion between the cyst and the transverse coln was very tight, partial resection of the colon was necessary. Histologically the cyst consisted of two parts, enteric cyst and pseudocyst without epithelium. The preoperative diagnosis of mesenteric cyst is difficult because of its rarity and lack of specific symptoms. It is important to differentiate it from cysts of the ovary, the urinary system, the liver or the pancreas on diagnosis. As a surgical treatment, excision of the cyst is satisfactory, but sometimes tight adhesion between the cyst and the adjacent bowel necessitates resection of the bowel.

View full abstract

Recently, owing to progress in endoscopy, the number of reported cases of gastric ulcer of Dieulafoy type has increased. However, this ulcer is very rarely reported in other locations. We encountered a paient wih hemorrhage from a ulcer of Dieulafoy tye of the jejunum which was treated surgically. A 68-year-old man was admitted to our hospital becourse of a cerebral infarct and received conservative treatment and rehabilitation. A large volume of tarry stool was suddenly discharged and he was transferred to the emergency department. The systolic blood pressure was 70 mmHg and the pulse rate was 108 per minute. The hematocrit value was 17.6%. No cause for the hemorrhage was found in the upper gastrointestinal tract. Scintigraphhy (^99mTc-RBC) was performed and accumlation was noted in the left eigastric region. Accordingly, angiography of the superior mesenteric artery was performed, and extravasation in the jejunum was noted. An emergency operation was carried uot, and about 15 cm of the jejunum was excised. On opening it, a small exposed vessel was seen. There was no ulcers or other abnormal findings, and rupture of a persistent caliber artery was diagnosed histologically. Only two cases of Dieulafoy type ulcer in the small intestine have been reported, by Matuchansky, as for as we know.

View full abstract

We present 8 patients with primary tumors of the small intestine during the eleven year period from 1977 to 1987, and discuss about autopsy cases in Japan during the five year perid from 1981 to 1985. Eight cases were diagnosed by histological examination as follow: three cases of malignant lymphomas, one case of leiomyosarcoma and anaplastic carcinoma, two cases of lipomas and one leiomyoma. The symptoms of each cases were as follows: two cases of lipomas complained of abdominal fullness and slight low abdominal pain. A case of leiomyoma comlained of bloody stool. One case of anaplastic carcinoma complained of nausea, vomiting and severe abdominal pain. The diagnosis was established by radiological examination (Barium contrast study) 4 times. In 4 cases laparotomy was the diagnostic method because of acute abdomen. The tumor was almost located at the terminal ileum and at upper jejunal loop. A primary small intestinal tumor was rare, with a frequency of only 0.2-0.4% of all the autopsy cases. In the autopsy cases the most frequent malignant tumors of the small intestine were adenocarcinoma, malignant lymphomas and leiomyosarcoma.

View full abstract

To prevent local recurrence after rectal amputation, we performed intra-operative pelvic hyperthermochemotherapy (IPHC) for 13 patients with rectal cancer soon after surgery. After rectal removal, the open deperitonized pelvic cavity was filled with saline containing 40 μg of mitomicin C per ml, warmed in advance. Then, an apparatus we devised was submerged in the pelvic cavity to warm the saline and was maintained at 45°C for 90 minutes. Within the same period of time, 10 patients with rectal cancer served as controls. Throughout this IPHC treatment, the mean temperature of the esophagus was 37.2°C. An indwelling drainage tube in the pelvic cavity was removed later in the IPHC group and the drainage exudate increased in the IPHC group. Local recurrence was experienced by 2 of the controls, whereas in the IPHC group, lcal failure was nil. This IPHC is a safe, reliable treatment for preventing the development of local recurrence from residual cancer cells on the pelvic wall.

View full abstract

Sixty-three patients with an esophagogastric junctional lesion, esecially reflux espagitis, were examined in our instiute by our original methods to analyze the electromyogram, internal pressure and pH simultaneously through an endoscopic guide. When there is some kind of system of monitoring the acidity in the esophageal mucosa, analysis of the electromyogram shows that the washing out function of the esohaus against acid is present not only in the normal esophagus but also even in the case of esophagitis when it is mild type. However, in the case of moderae or severe esohagitis, the function is resumed to be lost. There are many factors which need further investigation in relation to whether the function is reversible or not once it has disappeared. The answer to this argument should give a dear indication regarding surgical treament for reflux esophagitis.

View full abstract

Endoscopic and manometric studies were undertaken to determine the incidence of hiatus hernia and the functional changes in the cardia in post-gastrectomy patients. One hundred and four post-gastrectomy patients and 399 non-gastrectomy patients were subjected to endoscopic study for obsrving the cardia. Manometric study was also carried out on 56 patients with gastric carcinoma and 19 patiens with gall stones, by an intraluminal transducer technique. Loweresohageal sphincter pressures (LESP) were measured with a catheter-tip pressure transducer, by both the slow pull-through technique (SPT) and the rapid pull-through technique (RPT), before and 6 months after surgery. Hiatus hernia was observed in 37.5% of the post-gastrectomy patients, which was significantly higher than 19.3% of the non-gastrectomy patients (p<0.01). In the post-gastrectomy patients, reflux esophagitis was observed in 20.2%. There were no significant differences between the patients receiving Billroth 1 and Billroth 2 gastrectomy and bewteen the patients with and without a hernia. The manometric study revealed that LESP was not changed by cholecystectomy but was significantly decreased after distal gastrectomy. LESP measured by SPT were 10.8±4.3 mmHg before and 8.2±3.2 mmHg after distal gastrectomy (p<0.01), while those measured by RPT were 14.3±5.6 mmHg before and 12.2 ±5.4 mmHg after distal gasrectomy (p<0.05). The decrease rate in LESP in the patients receiving Billroth 2 gastrectomy were higher than those in the patients receiving Billroth 1 gastrectomy. LESP in the patients with regurgitation symptms after distal gastrectomy were significantly lower than those without regurgitation symptoms. LESP was significantly decreased after total gastrectomy but was not related to regurgitation symptoms.

View full abstract

Between 1975 and 1989, 50 proximal gastrectomies (PG) and 55 esophageal transections (TR) were performed in our hospital. More than 5 years after PG, 6 patients had incurable anastomotic ulcers with bleeding. To determine the causes, the lower esophageal motor function and esophageal mucosal blood flow in 6 PG patients and 16 TR patients were investigated. In patients without reflux esopagitis who underwent TR, the swallowing contraction wave (31.9 mmHg) was higher than in patients with reflex esophagitis (14.0 mmHg). The esopageal motor functions did not differe significantly between the PG and TR groups. The index of mucosal blood volume in TR patients (99.1) was significantly (p<0.05) higher than in PG patients (84.3), but the index of estimated oxygen saturation of the Hb was not different in these two groups. In conclusion, the results suggest that the reflux esophagitis after TR is due to the decrease in clearance in the lower esophagus, and that the decrease in the lower esophageal blood flow significantly contributes to formation of an incurable anastomotic ulcer after PG.

View full abstract

Motility function of patients with hiatal hernia and achalasia as a common motor disorder at the esophagogastric junction was studied by perfusion manometry and the results before and after surgery were compared. Fifteen (46.9%) of 32 patients with hiatal hernia had an intragastric pressure ≥10 mmHg and 25 (78.1%) impaired peristalsis in the distal esophagus. This study shows that the coexistence of high gastric pressure and peristaltic disturbance has the most serious affect on reflux esophagitis. Surgical repair had a good effect on the pressure and length of the lower esopageal pressure (LES), but failed to improve the complete peak contractile pressure and peristaltic velocity. In patients with stenotic esohagitis, degeneration of the myenteric plexus was demonstrated along with remarked fibrosis. When fundoplication was used in the management of peptic stricture, difficulty in swallowing could not be reversed completely, because of persistence of peristaltic failure. Postoperative manometric study in patients with achalasia demonstrated an improvement in LES function. Relaxation of LES reappeared in 76.9% of the 13 patients, but normal peristalsis was not restored. Histologic abnormality of this disease was seen in nerve fibers or axons without disintegration of ganglion cells of Aurebach's plexus. This observation suggests that there may be a variety of pathologic changes according to advance in the stages of achalasia.

View full abstract

From 1986, we treated 26 cases of achalasia by modified Jekler's operation (long myotomy + partial fundopexy + posterior fixatin) based on intraoperative manometry and obtained satisfactory results (Excellent 96.8%). The lower esophageal high pressure zone (HPZ) value during laparotomy was almost the same as the preoperative levels and the intraoperative lower esophageal sphincter pressure (LESP) decreased to 38% of the preoperative level after long myotomy + manipulation of the submucosal ablation. The length of HPZ was increased to about 150% of the preoperative length by fundopexy + posterior fixation. Postoperative esophageal manometry and 24-hr pH monitoring data reveal that the occurrence of postoperative reflux esophagitis is related to the short length, rather than to the new low LESP, and posterior fixation of Hill's procedure is useful for producing a long streched abdominal esophagus and prevent postoerative reflex esophagitis. The modified Jekler's method is applicable to any stage of achalasia for simplicity and safety and shows better results than those of former methods. Intraoperative manometry in achalasia is effective for improving postoperative long-term results.

View full abstract

Among the components of the antireflux of the cardia in dogs, the lower esohageal sphincter (LES) is the most important and Willis' oblique muscle is next. In a comparison of 5 kinds of hiatal herniorrhaphies in dogs, LES pressure (LESP) increased after the operation in the following order; Nissen, Belsey Mark N, Stensrud, Hill and Harrington methods. Responses to tetragastrin tended to increase after the Nissen and Belsey Mark N procedures. No recurrences and no complications, such as fundoplication disruption, dysphagia and gas bloat syndrome, occurred in the 23 patients who undergone modified Nissen fundoplication at our clinic. The mean LESP increased from 27.2±2.8 cm H₂O preoperatively to 37.5±3.6 cm H₂O postoperatively. The effect of gastrointestinal hormones such as gastrin, secretin, VIP and substance P on LES were investigated in normal dogs, dogs with phenol-injected achalasia, normal patient and achalasia patients. Increase in the LESP response to tetragastrin injection was statistically greater in the achalasia dogs than in normal dogs. Increase in LESP response to tetragastrin was inhibited by previous injection of secretin in both normal and achalasia dogs. Radioimmunoassay revealed a decrease in VIP and substance P concentrations in the lower esophageal muscular layer in both achalasia dogs and patients. In patients with achalasia, the LESP increased significantly after intramuscular injection of tetragastrin at a dose of 5 μg/kg. The Jekler and Lhotka method with long myectomy proved to be an excellent surgical procedure for achalasia of the esophagus because disturbance in passage was improved and then suitable high pressure zone to prevent postoperative reflux esophgitis was recostructed at the gastroesophageal junction.

View full abstract

Manometrsic studies on the esophagus were conducted in patients with achalasia. Deglutitive relaxation in the lower esophageal sphincter (LES) could not be detected in 80.8% of the patients and primary peristaltic waves of the esophagus disappeared in 93.1%. However incomplete deglutitive relaxation in LES and primary peristaltic waves were detected in several patients with achalasia. High LES pressure was found in 66.7% high resting pressure in the esophagus in 83.3% and abnormal contraction in 59.3% of the patients. These are secondary findings on esophago-gastric function in ahalasia. The treatment of first choice for achalasia is balloon dilation. Surgery should be used for the patients with sigmoid type or marked dilation, in addition to the patients in whom is not very effective balloon dilation. Medication should be considered when the dysphagia is made worse by emotional conflicts. We have performed the Heller's long myectomy together with fundapplication of 2/3 the circumference of the esophagus, and Hill's posterior fundopexy in 10 patients. All of them had good passage of food without regurgitation after the operation.

View full abstract

The pathophysiologic state of 29 patients with reflux esohagitis including 8 post-gastrectomy patients and 14 patients with achalasia was evaluated manometrically, and operative indications for them are discussed. Conservative treatment for patients with longitudinal type reflux esophagitis was more effective than for patients with the marginal type, and the manometric findings suggest that the derangement in the motility was limited to the area of definite esophagitis. Roentgenologic and manometric study revealed the grade of disorder in achalasia, and intraoperative manometric study revealed the meaning of each surgical procedure. Eight patients with reflux esophagitis were treated by Nissen's procedure, and 13 patients with achalasia were operated on by a modified Jekler-Lhotka method. Good clinical results were obtained with improvement of function of the esophagogastric junction. Surgicaltreatment should be considered in cases of these diseases that are poorly controlled with conservative therapy, because the surgical treatment is safe and reliable, and the effect of the operation is continuous.

View full abstract

Patients with achalasia and reflux esophagitis have dysfunction of the esophagogastric junction. We investigated the normal function of the esophagogastric junction and functional reconstruction of the region in patients with these diseases. The results and conclusions were as follows. 1. Eleven patients with achalasia and ten patients with reflux esophagitis received functional surgical reconstruction of this region. All patients have achieved a satisfactory status after surgery. 2. The fact that surgical treatment of patients with achalasia and reflux esophagitis having hiatus hernia may be performed so effectively and safely indicates that early surgical intervention is feasible for these patients. 3. The idea of “physiological sphincter” must be broadened and take into account the crura of the diaphragm.

View full abstract

Surgical treatment of hepatocellular carcinoma (HCC) is limited because of its association with liver cirrhosis in most cases. Our criteria for indication of surgical resection of nodular HCC, less than 3 cm in diameter, are the presence of a single nodule, located at the surface of the liver and liver cirrhosis classified as Child A. Patients for whom surgical resection was not indicated, were treated with US-guided percutaneous ethanol injection therapy (PEIT). We had 160 cases of nodular HCC, less than 3 cm in diameter, during the past last five years, 124 patients (single nodule: 40.3%) were treaed with PEIT and 36 patients (single nodule: 91.7%) by surgical resection. The 5-year survival of all patients was 48% and no difference was statistically noted in 5-year survival between surgical resection and PEIT. Analysis of PEIT revealed a 5 year-survival of 85% in patients with tumors 2 cm or less in diameter and Child A liver cirrhosis, and 95% in patients with very well differentiated (Edmondson's class I or I-II) tumors 1.5 cm or less in diameter. These findings indicate that the prognosis of such small HCC depends on the size of the tumor, histological atypism and severity of the associated liver cirrhosis.

View full abstract

This report describes a contribution of surgical therapy in the treatment of hepatocellular carcinomas. The 589 patients who had surgical therapies during 1973 and Dec. 1989 consituted the present study. Hepatic resection should be the first option for patients with potential curability in view of the fact that the curative resection group achieved a 5 year survival rate of 60% in contrast to 6% in the non-curative group. Especially tumors with desired conditions such as no vascular invasion, no daughter lesion and a tumor size of less than 5 cm must be subjected to resection with which a 5 year survival of 91% can be expocted. In terms of indication of hepatectomy for advanced cancers untreatable with non-resection therapy as embolization or ethanol injection, a biological aspect of tumor nuclear DNA content is an useful guiding factor. When tumors are determined to be a diploid DNA pattern reductive resection combined with non-resection therapy is recommended. On the contrary it is not recommended for advanced cancers with an aneuploid pattern because of very limited prognosis. Determination of DNA ploidy pattern using needle biopsy specimen has made it possible to select treatable patients prior to surgery. In conclusion resection should be indicated under the consideration of curability and tumor DNA content.

View full abstract

Our policy for treatment of hepatocellular carcinoma is to perform extended resection. When curability can be expected, one segment-additive resection would be ideal. Another purpose of extended resection is to enable effective multimodality therapies by the surgical approach, such as removing a tumor thrombus in the portal vein, NC etc. Extended resection of the liver requires precise judgment of the hepatic functional capacity, and measurement of the blood ketone body ratio is very useful for this. The liver function deteriorates during hepatectomy, as expressed by a prolonged decrease in the blood ketone body ratio. One of the most helpful methods to minimize the extent and duration of the decrease in the intraoperative blood ketone body ratio is to use a Bio-Pump (R) by which portal congestion can be completely avoided.

View full abstract