Akihiro Yasui

Relation of adenoma to carcinoma in the gallbladder

In order to clarify the relation of adenoma to carcinoma in the gallbladder, histopathologic examination was made on surgical specimens of 1605 cholecystectomies. Among them, 11 benign adenomas, seven adenomas with malignant change, and 79 invasive carcinomas were found. All of the benign adenomas were 12 mm or less in diameter (average diameter, 5.5 ± 3.1 mm), while the adenomas having cancerous foci were 12 mm or more in diameter (average diameter, 17.6 ± 4.4 mm). Most invasive carcinomas were more than 30 mm in diameter. The average patient age was 50.5 ± 16.3 years for benign adenomas, 58.3 ± 12.6 years for adenomas with malignant change, and 64.8 ± 9.6 years for invasive carcinomas. Transition of benign adenoma into carcinoma was histologically traceable. Adenomatous residue was found in 15 (19.0%) of 79 cases of invasive carcinoma.

Value of percutaneous transhepatic cholangioscopy (PTCS)

SummarySince July 1975, percutaneous transhepatic biliary drainage (PTBD) has been performed in 533 cases, and since April 1977 we have developed percutaneous transhepatic cholangioscopy (PTCS) as a diagnostic and therapeutic endoscopical tool in 198 cases of malignant disease and 195 benign cases. After dilating the sinus tract of PTBD using a 15-Fr catheter about 2 weeks after PTBD, PTCS was carried out through the sinus tract. PTCS has diagnostic advantages: the lesion can be accurately diagnosed histologically and the extent of cancer in the biliary tract can be assessed by taking biopsy specimens before the operation. PTCS has been applied for cholangioscopic lithotripsy in 145 cases of gallstone disease. In 44 cases, the Nd-YAG laser and/or electrohydraulic shock wave has been used to break up the stones. The PTCS morbidity was 6% and mortality was 0.3%.

Sphincter of Oddi motility in patients with bile duct stones. A comparative study using percutaneous transhepatic manometry.

The motility of the sphincter of Oddi was measured by percutaneous transhepatic manometry of the sphincter of Oddi (PTMSO) in three groups of 57 patients with bile duct stones. The three groups were: (1) cholecystectomy group (N=10)—patients with common bile duct stones (CBDS) who had already undergone cholecystectomy; (2) noncholecystectomy group (N=37)—patients with CBDS who had not undergone cholecystectomy; and (3) intrahepatic stone (IHS) group (N=10). The basal pressure, amplitude, frequency, and propagation direction of contraction waves and the response to cerulein injection or dried egg yolk ingestion were analyzed and compared among these groups. No significant differences in the basal pressure, amplitude, frequency, and propagation direction of the contraction waves were found among the three groups. There were also no differences in the response to cerulein or dried egg yolk ingestion. The frequency and duration of the burst contractions occurring in duodenal phase III of the migrating motor complex were significantly higher (P<0.05) in the cholecystectomy group than in the other two groups. These two differences in the burst contractions may be ascribed to the absence of the gallbladder.

Paradoxical response to cerulein on sphincter of Oddi in the patient with gastrectomy

Sphincter of Oddi motility was measured in 55 gallstone patients either through the sinus tract of percutaneous transhepatic biliary drainage or through the T tube. The influence of cholecystectomy and gastrectomy on the sphincter of Oddi was analyzed by comparing responses in patients with or without surgery to the administration of cerulein and the ingestion of dry egg yolk. When comparing cholecystectomized patients to nonsurgical subjects, cholecystectomy revealed no influence on the response to cerulein and feeding. Both groups showed relaxation of contraction waves after provocations. On the other hand, two thirds of the postgastrectomy patients showed an acceleration in the contractions of the sphincter of Oddi after provocations (one third showed no change), while all of the nongastrectomy group saw the disappearance of the wave after cerulein administration and 83% revealed complete suppression of the wave after feeding. It is suspected that this paradoxical response to CCK on the sphincter of Oddi is a lithogenic factor after gastrectomy.

Clinicopathological features of superficial spreading and nonspreading squamous cell carcinoma of the esophagus

OBJECTIVES:Superficially spreading carcinoma of the esophagus, consisting mainly of intraepithelial carcinoma, is not as rare as was previously thought. Despite the surgical significance of this entity, no general definition has been established, and the clinical features of this disease remain to be clarified.METHODS:A total of 54 patients with superficial carcinoma of the esophagus (defined as carcinoma limited to the epithelium or superficially invading the lamina propria or submucosa) were classified into two groups according to the longitudinal extent of the lesion. A total of 13 patients with superficially spreading carcinoma (defined as a superficial carcinoma measuring >5 cm and consisting mainly of intraepithelial carcinoma) were compared to 41 patients with nonspreading esophageal carcinoma.RESULTS:One patient with superficially spreading carcinoma had a positive resection margin because of multiple cancerous lesions. The only significant difference in the clinical and pathological features of the two groups was a higher prevalence of associated multiple cancerous lesions in patients with the superficially spreading type.CONCLUSIONS:Superficially spreading carcinoma of the esophagus is often associated with multiple cancerous lesions. For endoscopists and esophageal surgeons, it is important to define the proximal extent of intraepithelial cancer and the presence of multiple cancerous lesions to perform curative resection.

Percutaneous transhepatic manometry of sphincter of Oddi

A nonoperative examination of the function of the sphincter of Oddi, involving percutaneous transhepatic manometry via the percutaneous transhepatic biliary drainage tract, was developed and clinically applied in 23 patients with biliary disease. Long-term recording of sphincter of Oddi motility, which was impossible using conventional intraoperative or endoscopic manometry, was made possible by means of this method and revealed various changes of sphincter of Oddi motility. The mean recording time was 131.33±9.77 min. The frequency of contractions of the sphincter of Oddi in basal fasting conditions varied from 0 to 13/min and high-frequency contractions (frequency 9.49±0.35/min, duration 5.77±0.54 min) were observed in 12 patients on a total of 19 occasions. In five patients, high-frequency contractions were observed twice during one session of continuous recording and the interval between burst contractions was 85.4±13.3 min. Long-term continuous recording is advantageous for the evaluation of the function of the sphincter of Oddi and short-term manometry may not be representative of overall sphincter of Oddi motility.

Evaluation of gastroesophageal reflux disease following various reconstructive procedures for a distal gastrectomy

Background and aimsSome patients develop gastroesophageal reflux disease (GERD) after a distal gastrectomy. In these patients, the evaluation of GERD with 24-h pH monitoring could be difficult because they may have an insufficient amount of gastric acid.Patients and methodsTo evaluate GERD following a distal gastrectomy, we retrospectively evaluated 38 patients postoperatively with an acid reflux test (ART), a barium study, endoscopy, and esophageal manometry. Three reconstructive procedures, Billrothxa0I (B-I group: 14 patients), Billrothxa0II (B-II group: 11 patients), and jejunal interposition (interposition group: 13 patients) were compared with respect to GERD and short- term operation results.ResultsOperation time and postoperative hospital stay were longest in the interposition group. Reflux symptoms were present in ten patients (26%). The ART, barium study and endoscopy demonstrated evidence of GERD in 22 (58%), 10 (26%) and 4 (11%) of the 38 patients, respectively. The frequency of a positive ART in the interposition group was significantly lower than in both the B-I and the B-II groups. The abdominal length of the lower esophageal sphincter in the interposition group was higher than that in the B-II group (P<0.05).ConclusionAlthough jejunal interposition required longer operation time and hospital stay, the lower esophageal sphincter function following jejunal interposition appears to be superior to that following a Billroth-I or Billroth-II procedure.

Changes in Hepatic Hemodynamics and Oxygen Consumption after Partial Hepatic Congestion in Dogs

The effects of 66% hepatic congestion (group 2, n = 6) on liver blood flow and hepatic oxygen metabolism were investigated in anesthetized dogs using an ultrasonic transit time flowmeter. The results were compared with those for control dogs (group 1, n = 6) and for 60% hepatectomized dogs (group 3, n = 6) wherein almost the same amount of hepatic parenchyma was removed as was congested in group 2. Portal blood flow (PVF) in group 2 and group 3 decreased similarly to 60 and 63% of the baseline values, respectively (p less than 0.05). Cardiac output (CO) in group 2 and group 3 also decreased significantly in proportion to the decrease in PVF. Among the dogs in group 2, hepatic arterial blood flow (HAF) was fairly well maintained at 86% of the baseline value, despite the decrease of cardiac output, whereas the HAF in group 3 decreased to 49% of the baseline value at 1 h after hepatectomy. The calculated hepatic arterial resistance (HAR) in group 3 increased significantly due to the 60% loss of the hepatic arterial vascular bed. The HAR in group 2, by contrast, became lower than that in group 1, suggesting a compensatory decrease of HAR for the obstructed portal flow to the congested area. These results were well consistent with our angiographic findings (n = 3) that the portal flow to the congested segments was completely obstructed and the congested segments received only an arterial blood supply. The centrilobular hepatocytes of the congested segments showed marked vacuolar degeneration and the total hepatic oxygen consumption in group 2 was reduced (p less than 0.05). However, the decrease in oxygen consumption in group 2 was not so severe as in group 3 (p less than 0.05). These data suggest that some parts of the preserved congested segments were still viable and had the capacity of aerobic metabolism even 4 h after the ligation of the drainage vein of those segments. In this study, the importance of the hepatic arterial flow to the congested segment has been demonstrated. When the congested hepatic segment is to be preserved intraoperatively, care must be taken to maintain the hepatic arterial blood flow during the perioperative period.

Recovery of portal blood flow after percutaneous transhepatic biliary drainage in patients with obstructive jaundice

Using an ultrasonic Doppler system, we prospectively studied the changes in portal venous flow (PVF) following percutaneous transhepatic biliary drainage (PTBD) and evaluated the correlation between PVF and liver function in 10 patients with obstructive jaundice. The patients were divided into two groups according to their rate of decrease in serum bilirubin (“b”). Group A comprised 5 patients with a “b” of less than −0.1, while group B consisted of 5 patients who did not meet this criterion. The mean PVF increased following PTBD (P<0.01). The increase in PVF was due to an increase in the maximum velocity of the portal vein (Vmax). The rate of increase in the Vmax in group A was significantly higher than that in group B on both the 7th and 14th postdrainage days (P<0.05). The rate of increase in the Vmax correlated significantly with the rate of decrease in the serum bilirubin concentration (P<0.01). Based on the above findings, we conclude that measuring the Vmax by Doppler ultrasonography is useful in evaluating the liver function in patients with obstructive jaundice.

Acid Reflux Test for Gastroesophageal Reflux After Distal Gastrectomy: Diagnosis and Clinical Effect of Cisapride

Gastroesophageal reflux (GER) and reflux esophagitis (RE) are common complications after gastrectomy. Reflux of the gastroduodenal contents into the esophagus elicits the same set of symptoms: heartburn, regurgitation, and anterior chest pain. It has been recognized that not all patients with RE have symptoms of reflux and not all patients with reflux symptoms have RE. 1-3 The diagnostic modalities used to evaluate GER include barium study, 4 endoscopy, 5 ambulatory pH monitoring, 6 and acid perfusion, 7 acid reflux, 8 and acid clearance 9 testing. After gastrectomy, however, the postoperative gastric pH is closer to the esophageal or intestinal pH because gastric secretion is decreased. Also, some patients with some reflux symptoms may not be diagnosed by endoscopic examination because no mucosal changes are observed in the esophagus. Diagnostic testing is necessary to determine whether GER is present in a patient who underwent gastrectomy. In this study we compared the acid reflux test with the acid clearance test, barium esophagram, and endoscopy for diagnosis of GER and RE in patients after gastrectomy and to select patients for medical therapy. METHODS Patients. This study included 46 consecutive patients who had undergone Billroth I reconstruction (16 men and 10 women, aged 38‐71 years) or Billroth II reconstruction (15 men and 5 women, aged 39‐74 years) after partial gastrectomy with lymph node resection and truncal vagotomy for gastric cancer. All patients provided informed consent. They all had been outpatients for longer than 4 months (postoperative average, 15 months). Patients showing any evidence of cancer recurrence or stenosis of anastomosis were not included in this study. All patients had undergone preoperative 24-hour esophageal