Gen Naritomi

Pancreatic head resection with and without preservation of the duodenum : Different postoperative gastric motility

BACKGROUND Early gastric stasis is a unique complication of pylorus-preserving pancreatoduodenectomy. Because the duodenum proved to be important in the initiation and consolidation of phase III activity of the migrating motor complex of the stomach, the absence of the duodenum and hence gastric phase III may be a cause of gastric stasis. METHODS Postoperative gastrointestinal motility was measured with a pneumohydraulic capillary infusion system in nine patients who had undergone pylorus-preserving pancreatoduodenectomy through an indwelling tube assembly placed at operation, and compared with that in six patients who had undergone duodenum-preserving pancreatic head resection. Plasma motilin concentrations were measured by radioimmunoassay. RESULTS The mean period until the first occurrence of gastric phase III was significantly longer in patients who had undergone a pylorus-preserving pancreatoduodenectomy (40.6 +/- 4.6 days or more) than in patients who had undergone a duodenum-preserving pancreatic head resection (18.8 +/- 4.3 days; p < 0.05). On the day of the first observation of gastric phase III, the plasma concentration of motilin at proximal jejunal phase III in patients who underwent a pylorus-preserving pancreatoduodenectomy (50.2 +/- 9.8 pg/ml) was significantly lower than that at duodenal phase III in patients who underwent a duodenum-preserving pancreatic head resection (184.6 +/- 48.6 pg/ml; p < 0.05). CONCLUSIONS Gastric stasis after a pylorus-preserving pancreatoduodenectomy may be in part attributable to the low concentration of plasma motilin caused by the resection of the duodenum.

Biliary motility. Changes in detailed characteristics correlated to duodenal migrating motor complex and effects of morphine and motilin in dogs.

The temporal relationship of biliary motility to the duodenal migrating motor complex and effects of morphine and motilin were studied in five dogs prepared with a duodenal cannula. Common bile duct, sphincter of Oddi, and duodenal manometry were performed awake. Sphincter of Oddi phasic contractions occurred even during the quiescent period of duodenal phase I and its activity increased from phase II to III. Minimum basal pressure of sphincter of Oddi and common bile duct pressure decreased from phase I to phase III. Both morphine and motilin induced premature phase III in the sphincter of Oddi and duodenum. Latencies of the effect were 0.2 min for morphine and 3.2 min for motilin (P<0.01). After morphine, vigorous continuous contractions with high basal pressure occurred, being interrupted by brief and repeated inactive periods, similar to spontaneous phase III. Motilin-induced phase III appeared indistinguishable from spontaneous phase III. Although both agents induced phase III in the sphincter of Oddi, differences in the latency and contraction pattern suggest different mechanisms of action of these agents on the sphincter of Oddi.

Manometric Evidence of Improved Early Gastric Stasis by Erythromycin after Pylorus-preserving Pancreatoduodenectomy

Abstract. Gastric stasis is a frequent complication of pylorus-preserving pancreatoduodenectomy (PPPD). We demonstrated that it might be attributable to delayed recovery of phase III activity of the gastric migrating motor complex due to low concentrations of plasma motilin caused by resection of the duodenum. Leucine 13-motilin is effective for treating gastric stasis, but it is not yet available for clinical use. Whether erythromycin would improve early gastric stasis after PPPD was tested clinically and by manometry. A manometric tube assembly and a gastrostomy tube were inserted in the stomach of 10 patients at PPPD for pressure recording from the gastric antrum and jejunum and for gastric juice drainage, respectively. After baseline recording, erythromycin 5 mg/kg was given intravenously on day 14 and saline as a placebo on day 17 every 4 hours four times a day. The daily volume of gastric juice output and the gastric motility index were measured. The mean period until the return of gastric phase III was 31 ± 1 days. Erythromycin significantly increased the gastric motility index from 7.9 ± 1.3 mmHg to 15.7 ± 1.8 mmHg (p= 0.0005), whereas saline did not (7.2 ± 1.6 mmHg to 6.5 ± 1.2 mmHg; p= 0.21). Erythromycin significantly decreased the gastric juice output from 1080 ± 190 ml to 738 ± 199 ml (p < 0.0001), but the saline injections did not (1064 ± 174 ml to 1115 ± 189 ml; p= 0.35). Erythromycin, a universally available motilin agonist, is a safe, effective, potent drug for the treatment of early gastric stasis after PPPD.

Reappraisal of safety of endoscopic sphincterotomy for common bile duct stones in the Elderly

BACKGROUND Endoscopic sphincterotomy is the method of choice for elderly patients with common bile duct stones, even though these patients are poor operative risks. We undertook this study to analyze the operative risk factors for this age group. METHODS We compared specific problems of 182 patients aged 80 years or older and 921 younger patients who underwent endoscopic sphincterotomy for common bile duct stones. RESULTS Despite a higher frequency of periampullary diverticula in the elderly than in the younger patients (54% versus 36%, P < 0.001), the success rates of sphincterotomy were not different. The elderly patients required lithotripsy more often than did the younger ones (15% versus 4%, P < 0.001), and the necessity of stenting or nasobiliary drainage was greater in this group (9%) than in the younger group (5%, P < 0.05). This difference in the tactics between the older and younger groups was due to the greater number and size of stones, longer period of time for complete clearance of the common bile duct (13.5 versus 6.0 days, P < 0.01), and a greater percentage of patients with operative risks (55% versus 36%, P < 0.001). The elderly also had significantly greater overall morbidity compared with the younger patients (13% versus 7%, P < 0.005), frequency of acute cholangitis (8% versus 2%, P < 0.001), and mortality (1% versus 0%). CONCLUSION These results suggest that frequent stenting or nasobiliary drainage to prevent cholangitis or prompt stone removal by lithotripsy would be necessary in this group of patients.

Comparison of Routine and Selective Endoscopic Retrograde Cholangiography before Laparoscopic Cholecystectomy

Abstract. To evaluate the role of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy, we compared the frequency of concomitant common bile duct stones, their clinical outcome, and the frequency of bile duct injury between a group of 128 patients with routine preoperative ERC (group A) and 1010 patients with selective ERC (group B). Overall, 48 patients (4.2%) had duct stones, but the predictive signs were absent in six of them (12.5%). The stones were demonstrated by ERC and removed by sphincterotomy in all 11 patients in group A. Of 37 patients in group B, 22 were diagnosed by selective ERC and underwent endoscopic removal. Of four patients whose stones were found by operative cholangiography, one had immediate open surgery, another passed a stone spontaneously, and the other two underwent postoperative sphincterotomy, which failed in one. The stones were not recognized until pain recurred in the remaining 11 patients. Sphincterotomy was successful in nine patients but failed in the other two. Thus postoperative sphincterotomy failed in 3 of 13 patients (23%), necessitating open surgery. Forty-two patients overall (3.7%) had aberrant biliary tract anatomy, which did not lead to bile duct injury in any of the patients. Morbidity of routine ERC (3.1%) was lower than that of selective ERC (7.4%) (p < 0.05). It should be noted that a certain proportion of duct stones may be missed by selective ERC, necessitating laparotomy when sphincterotomy fails. The routine use of preoperative ERC may be justified at institutions where the expertise is available, at least until laparoscopic lithotomy becomes easy.

Pancreatic tumor formed by infiltration of adult T-cell leukemia cells

SummaryConclusionWe have described a case of pancreatic tumor formed by adult T-cell leukemia (ATL) cell infiltration.BackgroundThe patient was diagnosed as chronic ATL hematologically with the findings of increased number of atypical lymphocytes, ATL cells in the peripheral blood, and positive human T-cell leukemia virus type I (HTLV-I) antibody in the serum. The pancreatic tumor was identified by ultrasonography and computed tomography as a diffusely swollen tumor from the body to the tail of the pancreas. Biopsy specimen confirmed the ATL cell infiltration into the pancreas immunohistochemically, and Southern blot analysis showed the integration of HTLV-I proviral DNA both in the pancreas and in the peripheral blood.ResultsThe pancreatic tumor diminished spontaneously without chemotherapy when ATL cells in the peripheral blood disappeared by spontaneous regression.

Intraoperative endoscopic electrohydraulic lithotripsy of pancreatic stones

SummaryTwo male patients with complications associated with chronic pancreatitis are described. In each patient, preoperative examinations revealed a large stone obstructing the main duct in the head of the pancreas. Lateral pancreaticojejunostomy was performed to relieve pain and prevent further attacks of pancreatitis. During each operation, the stone was fragmented under direct visual control with the use of a flexible choledochoscope and a contact electrohydraulic lithotriptor. The stone was removed and ductal flow through the head of the pancreas was reestablished. Our experience shows that endoscopie electrohydraulic lithotripsy facilitates operative removal of pancreatic stones deeply located in the head of the pancreas.

Single oral dose of cisapride accelerates gastric antral emptying in healthy humans: An ultrasonographic study

An ultrasonographic study of ten healthy volunteers was carried out to evaluate the effect of cisapride on gastric antral emptying. More than 1 week after the measurement of the baseline emptying rate, cisapride was given at a single oral dose of 5 mg 30 minutes before intake of a balanced liquid test meal (5 ml/kg body weight). To determine the time to half emptying (T1/2), an exponential curve was extrapolated for the elimination phase of the gastroantral sagittal cross-sectional area plotted against time. The T1/2 was reduced by 18.5% after cisapride, from 62.6±4.3 to 51.0±4.4 min (P=0.0284). We conclude that a single oral dose of 5mg of cisapride significantly accelerates the gastric antral emptying rate in healthy humans.

MULTISEPTATE GALLBLADDER : BILIARY MANOMETRY AND SCINTIGRAPHY

A 30-year-old man with multiseptate gallbladder, a very rare congenital anomaly, is presented. His presenting symptom was epigastric pain. A hypoplastic gallbladder with multiple septa was demonstrated by ultrasonography and endoscopic retrograde cholangiography. An injection of cerulein reproduced pain, and simultaneous biliary manometry and scintigraphy showed impairment of gallbladder filling and emptying. Laparoscopic cholecystectomy resulted in complete relief of the pain. Biliary manometry and scintigraphy are useful to determine the operative indication in a symptomatic patient with this entity.

Effects of intraduodenal air insufflation on sphincter of Oddi motility in conscious dogs.

To investigate effects of intraduodenal air insufflation on sphincter of Oddi motility, manometric recordings were obtained during fasting from the sphincter and duodenum in four conscious dogs with duodenal cannula. At 40% of the mean cycle length of the migrating motor complex predetermined from baseline recording, 160 ml of air was injected into the duodenum. In both the sphincter and duodenum, air insufflation produced premature phase III-like activity in seven of 20 experiments (35%) or nonspecific excitatory reaction in eight (40%). In the remaining five experiments (25%), the sphincter exhibited a transient inhibitory response, while the duodenum showed the nonspecific excitatory reaction. Basal pressure of the sphincter increased immediately after air insufflation in 90% of the 20 experiments. The mean basal pressure increased from 12.3±1.6 mm Hg to 22.4±2.1 mm Hg (P<0.0001) and minimum basal pressure from 2.9±0.9 mm Hg to 4.7±0.8 mm Hg (P<0.001). These results indicate that intraduodenal air insufflation does affect motility of the sphincter of Oddi and duodenum in conscious dogs.