Fumihiko Kito

Comparison of Surgical Results of D2 Versus D3 Gastrectomy (Para-Aortic Lymph Node Dissection) for Advanced Gastric Carcinoma: A Multi-Institutional Study

Curative gastrectomy is a promising approach for the treatment of gastric cancer; however, the optimal extent of lymph node dissection for advanced cancer remains controversial. The aim of this multi-institutional study was to evaluate the feasibility of D3 gastrectomy (para-aortic lymph node dissection) for advanced gastric cancer. The surgical results of D2 and D3 gastrectomy (para-aortic lymph node dissection) were retrospectively compared. A series of 580 advanced gastric cancer patients were registered between 1992 and 2000. Of these, 430 underwent D2 gastrectomy and 150 underwent D3 gastrectomy. Survival time, prognostic factors, postoperative morbidity/mortality, and pattern of recurrence were compared. There was no significant difference in survival time between D2 and D3 patients. However, the survival times of D3 patients with tumor diameters measuring 50 to 100 mm or with pN1 disease were significantly longer than those of the corresponding D2 patients. Analysis of the survival of patients with tumor diameters measuring 50 to 100 mm revealed that D3 gastrectomy conferred a survival advantage only to patients with pN2 disease. The incidence of lymphatic recurrence was lower in D3 patients with 50- to 100-mm tumors than in the corresponding D2 patients. D3 gastrectomy might be beneficial in patients with advanced pN2 gastric cancer within the group with tumors measuring 50 to 100 mm. A randomized controlled trial of patients with 50- to 100-mm tumors should be performed to test the validity of this preliminary result.BackgroundCurative gastrectomy is a promising approach for the treatment of gastric cancer; however, the optimal extent of lymph node dissection for advanced cancer remains controversial. The aim of this multi-institutional study was to evaluate the feasibility of D3 gastrectomy (para-aortic lymph node dissection) for advanced gastric cancer. The surgical results of D2 and D3 gastrectomy (para-aortic lymph node dissection) were retrospectively compared.MethodsA series of 580 advanced gastric cancer patients were registered between 1992 and 2000. Of these, 430 underwent D2 gastrectomy and 150 underwent D3 gastrectomy. Survival time, prognostic factors, postoperative morbidity/mortality, and pattern of recurrence were compared.ResultsThere was no significant difference in survival time between D2 and D3 patients. However, the survival times of D3 patients with tumor diameters measuring 50 to 100 mm or with pN1 disease were significantly longer than those of the corresponding D2 patients. Analysis of the survival of patients with tumor diameters measuring 50 to 100 mm revealed that D3 gastrectomy conferred a survival advantage only to patients with pN2 disease. The incidence of lymphatic recurrence was lower in D3 patients with 50- to 100-mm tumors than in the corresponding D2 patients.ConclusionsD3 gastrectomy might be beneficial in patients with advanced pN2 gastric cancer within the group with tumors measuring 50 to 100 mm. A randomized controlled trial of patients with 50- to 100-mm tumors should be performed to test the validity of this preliminary result.

Significance of long-term follow-up of early gastric cancer.

BackgroundTherapeutic outcomes for most patients with early gastric cancer are favorable. However, mortality among these patients remains a concern. Improvements in therapeutic outcomes are being sought by studying the timing and causes of death. Here, the results of surgery were evaluated to assess the appropriate treatment and follow-up schedule for early gastric cancer.MethodsA total of 1169 patients with early gastric cancer underwent curative gastrectomy between 1992 and 1999. Survival time, prognostic factors, cause of death, and time of death were evaluated retrospectively.ResultsMultivariate analysis of disease-specific survival identified lymph node metastasis as an independent prognostic factor. The anatomical extent of lymph node metastasis and the number of metastatic lymph nodes influenced the rate of recurrence. Multivariate analysis of overall survival identified age as a prognostic factor. A total of 91 patients (7.8%) from the study group died: 56 from comorbid diseases, 21 from gastric cancer, and 14 from other second primary cancers. Death from gastric cancer was frequently observed within 5 years of surgical resection, whereas death from other diseases usually occurred after 5 years. Patients who died as a result of diseases other than gastric cancer tended to be older.ConclusionsAppropriate lymph node dissection is necessary for patients with early gastric cancer, particularly those with risk factors associated with lymph node metastasis. Meticulous follow-up protocols that can detect second primary cancers, together with the development of treatments for comorbid diseases, are required to improve survival.

Clinical Significance of the Metastatic Lymph-Node Ratio in Early Gastric Cancer

The metastatic lymph-node ratio has important prognostic value in gastric cancer; this study focused on its significance in early gastric cancer. In total, 1,472 patients with early gastric cancer underwent curative gastrectomy between 1992 and 2001. Of these, 166 (11.3%) had histologically proven lymph-node metastasis. Prognostic factors were identified by univariate and multivariate analyses. Metastasis was evaluated using the Japanese Classification of Gastric Carcinoma (JGC) and the Union Internationale Contre le Cancer/Tumor, Node, Metastasis (UICC/TNM) Classification. The metastatic lymph-node ratio was calculated using the hazard ratio. The cut-off values for the metastatic lymph-node ratio were set at 0, <0.15, ≥0.15 to <0.30, and ≥0.30. The numbers of dissected and metastatic lymph nodes were correlated, but the number of dissected lymph nodes and the metastatic lymph-node ratio was not related. The JGC and UICC/TNM classification demonstrated stage migration and heterogeneous stratification for disease-specific survival. The metastatic lymph-node ratio showed less stage migration and homogenous stratification. The metastatic lymph-node ratio may be a superior method of classification, which provides also accurate prognostic stratification for early gastric cancer patients.

Clinicopathological Features of Gastric Carcinoma in Younger and Middle-Aged Patients: A Comparative Study

Gastric carcinoma is relatively rare in patients under the age of 40. This study was undertaken to clarify the clinicopathological characteristics and surgical outcomes of gastric carcinoma in younger patients compared with those of middle-aged patients. The surgical results from 131 younger patients (aged ⩽40 years) and 918 middle-aged patients (aged 55–65 years) were compared retrospectively. Female gender, undifferentiated tumor type and lymphatic invasion were significantly more common in the younger patients. Survival time did not differ between the two groups. The depth of tumor invasion was the only prognostic factor in younger patients, whereas macroscopic appearance, tumor diameter, depth of invasion, lymph node metastasis, and venous invasion were all significant prognostic factors in middle-aged patients. Peritoneal recurrence was significantly more common in younger patients. A family history of gastric adenocarcinoma was observed in 25.9% of younger patients, but this did not affect survival outcomes. As depth of invasion affects prognosis independently, and peritoneal metastasis is the predominant pattern of recurrence, it is essential to establish an optimal prophylactic treatment for peritoneal metastasis to improve surgical outcomes in younger patients with advanced gastric cancer.

Restorative proctocolectomy for pediatric patients with ulcerative colitis.

PurposeA restorative proctocolectomy has become an elective surgical treatment for patients with ulcerative colitis (UC). In children with UC, however, the role of this procedure has not yet been well evaluated. We investigated the postoperative status of pediatric patients with UC regarding the side effects of steroids, postoperative complications, and growth.MethodsThe medical records of 15 patients with UC who underwent a restorative proctocolectomy between August 1993 and October 2003 were retrospectively reviewed.ResultsTheir mean age was 12.6 ± 3.4 years (range 5.7–15.7; boys: 9, girls: 6). All patients had total colitis, except for one who had left-sided colitis. The mean cumulative dose of preoperative prednisolone was 6201 ± 7980 mg (mean ± SD). The operative indications were an unsuccessful response to medical treatments in 12 patients (80%) and severe colitis in 3 patients (20%). Surgery was performed in one stage in 6 patients and in two stages in 9 patients. Seven patients (47%) demonstrated growth retardation at the time of operation. Steroid-related complications were seen in 3 cases, i.e., steroid myopathy, glaucoma, and cataracts, respectively. As early postoperative complications, an intestinal obstruction was seen in 2 patients, peritonitis in 1, and pancreatitis in 1. As late complications, anastomotic stenosis was observed in 5 patients, pouchitis in 4, residual proctitis in 3, and anal or proctovaginal fistula in 2. An intestinal obstruction, peristomal pyoderma gangrenosum, and dehydration each was seen in 1 patient. A growth “catch-up” was obtained for all but one patient. All patients became free of corticosteroids.ConclusionA restorative proctocolectomy was found to be an effective treatment alternative even in children with UC when conservative therapy proves to be ineffective.

Lymph node status in patients with submucosal gastric cancer.

BackgroundThe aim of this study was to clarify the lymph node status in patients with submucosal gastric cancer.MethodsBetween April 1994 and December 1999, 615 patients with histologically proven submucosal gastric cancer who underwent curative resection were included in this study. The results of the surgery and predictive factors for lymph node metastasis were evaluated by univariate and multivariate analyses. The accuracy of the predictive factors was assessed in a second population of a further 186 patients.ResultsLymph node metastasis was observed in 119 patients (19.3%). Multivariate analysis showed that pathologic tumor diameter (≥20 mm) and lymphatic invasion were independent predictive factors for lymph node metastasis. The incidence of lymph node metastasis without these 2 predictive factors was 1.8% (2 of 113), and it was 51.2% (85 of 166) with the 2 predictive factors, 9.5% (14 of 148) in tumors <20 mm in diameter, and 5.3% (22 of 414) in tumors without lymphatic invasion. Among patients with a tumor <20 mm in diameter, the incidence of lymph node metastasis was significantly reduced in those with a differentiated tumor: 4.2% (4 of 95). These results were almost identical to those observed in the second population.ConclusionsLymph node status can be accurately predicted on the basis of pathologic tumor diameter <20 mm, lymphatic invasion (absence), and histological type (differentiated) in patients with submucosal gastric cancer. Less extensive surgery for these patients might be reconsidered after confirmation of the reproducibility of the results of this study by an appropriately designed prospective clinical trial.

Extraction of retained gallstones using a fiber-choledochoscope through a PTC-drainage fistula

After unsuccessful attempts to completely remove gallstones, endoscopic papillotomy was carried out to remove the stones after closure of the T-tube tract. We treated two patients with successful extraction of retained gallstones using a fiber-choledochoscope through a percutaneous transhepatic cholangio-drainage (PTCD) fistula. This technique can be applied in cases when endoscopic papillotomy cannot be performed or for patients who are poor risks for repeat surgery.

Intestinal responses to hyperosmolar glucose infusion in dogs.

SummaryPhysiological and morphological changes of small intestine after hyperosmolar glucose infusion into canine jejunum were studied using in vivo perfusion model.Infusion of 40 ml of 50% and 20% glucose solution into the jejunal loops induced biphasic osmolar degression in the lumen. Osmolarity of jejunal venous blood was rapidly increased and maintained the maximal level (approximately 320 mOM/L).Blood flow to the jejunal loop was significantly increased after 50% glucose infusion compared to 5% glucose infusion.Most characteristic electron microscopic change of jejunal epithelial cell was pseudo-pod like process projected into the jejunal lumen, which was very similar to that of cholera.

Glucose tolerance and hepatic regulation of insulin in obstructive jaundice

閉塞性黄疸38例(対照12例)に経口的GTTをおこない,耐糖能とインシュリン反応を調べた.黄疸例には耐糖能低下とインシュリン低反応が認められた.閉塞性黄疸におけるインシュリン動態を調べる目的で,2週間前に総胆管結紮を施行した閉塞性黄疸犬9頭(対照犬7頭)を用いて,ブドウ糖投与時の門脈血と末梢静脈血のインシュリンを測定した.黄疸犬の門脈血インシュリンは糖投与後初期の反応が乏しく,漸次上昇型を示したが,後期には絶対量として対照犬より優位なものもあった.しかし末梢静脈血インシュリン反応はほとんど認められなかったことから,黄疸犬においては,インシュリンの肝extractionが亢進していることが示唆された.すなわち黄疸例においては,門脈血インシュリンが末梢静脈血に現われにくくなるよう肝によって調節されている一方,hepatotrophic facterとして利用されている可能性があると思われた.

INCIDENCE OF ACUTE CHOLANGITIS IN OBSTRUCTIVE JAUNDICE

閉塞性黄疸60例について, 胆管閉塞解除前および解除後1ヵ月以内の急性胆管炎発生を胆汁細菌培養成績と対比して検討した.38℃ 以上の発熱と10,000以上の白血球増多を示したものを急性胆管炎とし, 菌血症, エンドトキシン血症, ショックを伴ったものを重症例とした.閉塞解除前の急性胆管炎発生率 (以下発生率) は53.3% (重症6.7%) であり, 良悪性疾患別, 胆のう胆管交通の有無, 左右肝管交通の有無で発生率の差はなかった.PTCとERCP検査後は20.4%の発生率を有し, これらは全発生例の約1/3を占めた.解除時の胆汁細菌培養陽性率は36.7%であり, グラム陰性桿菌が85.7%を占めた.陽性例は陰性例に比べて発生率 (77.3%) は高く, 逆に黄疸は低かった.解除後の発生率は45.8% (重症13.6%) であり, 解除法別では胆道外瘻48例 (PTC-ドレナージ13例を含む) の発生率は52.1%, 内瘻11例のそれは18.2%であった.PTC-ドレナージ直後の発生例はすべて重症例であった.解除後の胆細菌培養は, 解除時陽性例は100%に, 陰性例も87.9%に陽性となり, 外瘻を介して体外からの細菌浸入が示唆された.解除時胆汁細菌の有無と解除後の発生率との関連はなく, 外瘻からの直接胆道造影による発生率は約20%で, 全発生例の約1/3を占めた.解除後1ヵ月以内の合併症発生率と死亡率はそれぞれ45.8%, 20.3%であり, このうち急性胆管炎に関連したものは約112を占めており, 閉塞性黄疸における胆道感染の重要性が再認識された.