Hidenori Tsumura

Hepatic resection using the harmonic scalpel.

We describe herein our technique of performing extensive resection of the liver by blunt dissection in combination with excision using a harmonic scalpel. A ball coagulator was inserted at 3-cm intervals along the proposed cutting line in the liver, and the liver parenchyma between these holes was then cut using coagulation shears. Regardless of the condition of the liver, good coagulation and cutting were achieved using the harmonic scalpel without vascular occlusion when dividing the shallow layer of the liver, and no complications in association with the harmonic scalpel, such as postoperative bleeding, bile leakage, or abscess formation at the cut margins, occurred. In the deep layer below the main trunk of the hepatic vein, blunt dissection was used, since it was difficult to achieve sufficient control of bleeding from large vessels using the harmonic scalpel alone. Therefore, when used in combination with other techniques, the harmonic scalpel appears to be an effective device for liver surgery that minimizes bleeding and decreases the vascular clamping time.

Laparoscopic Resection of Schwannoma of the Ascending Colon

Schwannomas of the colon are rare and difficult to diagnose preoperatively. We report a case of schwannoma of the ascending colon that was resected laparoscopically. A 64-year-old woman was referred to our hospital by her local clinic for further evaluation and management of a submucosal tumor of the ascending colon. A definitive preoperative diagnosis could not be reached despite examinations. Gastrointestinal stromal tumor, leiomyoma and lymphoma were the differential diagnoses. We performed a laparoscopic right hemicolectomy with D2 lymph node dissection. Histological findings with hematoxylin-eosin staining revealed spindle-like tumor cells, and immunohistochemical analysis showed that the tumor was positive for S-100 but negative for c-kit, CD34, smooth muscle actin and desmin, with a Ki-67 index of <5%. Thus, the diagnosis in this case was benign schwannoma of the ascending colon.

Report of a case: Retroperitoneal mucinous cystadenocarcinoma with rapid progression

Highlights • A very rare case of large retroperitoneal mucinous cystadenocarcinoma and little-known clinical course of the disease is reported.• The disease took unexpectedly aggressive progression despite the small portion of adenocarcinoma for the multiple and large cysts.• Informative findings in imaging of primary retroperitoneal mucinous cyst adenocarcinoma, and impressive imaging after recurrence are presented.

Effect of continuous intravenous infusion of secretin preparation secrepan in patients with hemorrhage from chronic peptic ulcer and acute gastric mucosal lesion (AGML)

SummaryThe purpose of the present study was to investigate the hemostatic effect of continuous intravenous infusion of secrepan (secretin preparation, Eisai Company Ltd. Tokyo) on gastroduodenal hemorrhage in patients with chronic peptic ulcer and AGML (acute gastric mucosal lesion). The patients consisted of 37 cases of bleeding ulcer (13 cases of chronic peptic ulcer and 24 cases of AGML). Secrepan was infused at a rate of 2 U/kg/hr for the first 3 days and 0.5 U/kg/hr for the next 4 days. The cumulative hemostatic rate in the chronic peptic ulcer group was 53.9% after 36 hours, and 76.9% after 48 hours of infusion, but no significant change in rate was observed thereafter. The cumulative hemostatic rate in the AGML group was 52.2% after 36 hours, and 95.7% after 72 hours of infusion. The hemostatic rate in chronic peptic ulcer and AGML cases with only slight or moderate bleeding was 100%, and no recurrent hemorrhaging was observed. The hemostatic rate in chronic peptic ulcer cases with severe bleeding was 62.5% and in AGML cases with severe bleeding was 93.3%, and 7 of 15 cases showed recurrent hemorrhage. Our findings indicated that continuous intravenous infusion of secrepan had more favorable effects on AGML cases, than on chronic peptic ulcer cases.

Gastric emptying after pancreatoduodenectomy with total stomach preservation and selective proximal vagotomy.

This study evaluates postoperative gastric emptying following a new method of pancreatoduodenectomy with total stomach preservation and selective proximal vagotomy performed on 10 patients with diseases affecting the head of the pancreas, 7 being malignant and 3 benign. Reconstruction was carried out using the Billroth I and Billroth II techniques in 5 patients each, respectively. Early postoperative gastric emptying was evaluated by the time before intragastric tube removal and the resumption of oral intake, as well as by barium gastric radiography, while late postoperative gastric emptying was evaluated by the acetaminophen method. No difference was seen in early postoperative gastric emptying between the two surgical techniques, the mean time which elapsed before intragastric tube removal being 4.4 days for the Billroth I and 4.5 days for the Billroth II patients, and the mean time until the resumption of oral intake being 6.8 days for the Billroth I and 7.0 days for the Billroth II patients. A significant delay in gastric emptying was seen in the Billroth II patients compared to a normal control group, 30 and 45 min after acetaminophen administration, but the difference in gastric emptying between the Billroth I and II patients was not significant. Moreover, both techniques impaired gastric emptying much less than Traversos pylorus-preserving pancreatoduodenectomy.

Effect of continuous intravenous infusion of secretin preparation (secrepan) in patients with hemorrhage from chronic peptic ulcer and AGML

SummaryThis study was conducted to evaluate the hemostatic effect of continuous intravenous infusion of secrepan (secretin preparation, Eisai Company Ltd. Tokyo) on gastroduodenal hemorrhage in patients with chronic peptic ulcer and AGML(acute gastric mucosal lesion). The patients consisted of 37 cases of bleeding ulcer (13 cases of chronic peptic ulcer and 24 cases of AGML). Secrepan was infused at a rate of 2U/kg/hr for the first 3 days and 0.5U/kg/hr for the next 4 days. The cumulative hemostatic rate in the chronic peptic ulcer group was 53.9% after 36 hours, and 76.9% after 48 hours of infusion, but no significant change in rate was observed thereafter. The cumulative hemostatic rate in the AGML group was 52.2% after 36 hours, and 95.7% after 72 hours of infusion. The hemostatic rate in chronic peptic ulcer and AGML cases with only slight or moderate bleeding was 100%, and no recurrent hemorrhaging was observed. The hemostatic rate in chronic peptic ulcer cases with severe bleeding was 62.5% and in AGML cases with severe bleeding was 93.3%, and 7 of 15 cases showed recurrent hemorrhage. Our findings indicated that continuous intravenous infusion of secrepan had more favorable effects on AGML cases, than on chronic peptic ulcer cases.

A Case of Congenital Esophageal Stenosis Operated on at the Age of 23.

症例は23歳の女性で, 離乳食開始時より食後の嘔吐を認められていた. 徐々に嚥下困難が進行し, 6歳時に先天性食道狭窄症と診断されたが, 合併奇形は認められていない. 以後, 近医で内視鏡検査, 食道造影にて経過観察をし, 時にbougieを行っていた. 22歳時の検査にて内視鏡ファイバーが通過困難となり, 手術目的にて当院外科入院となった. 当院での内視鏡検査にて切歯より約30cmと40cmの部位2か所に狭窄が認められた. 平成10年11月12日, 右開胸開腹食道亜全摘, 胸腔内胃管食道吻合, 胆摘, 幽門形成が施行された. 病理組織診断にて2か所の狭窄とも筋性線維性食道狭窄症と診断された. 本症例は狭窄部が2か所認められたこと, 保存的治療が無効であったことより食道亜全摘術が施行された. 成人例の先天性食道狭窄症の報告は少なく, また, 2か所に狭窄を有した筋性線維性狭窄は本邦での報告がなくまれな症例である.

Long Term Follow-up Study of Selective Vagotomy with Pyloroplasty. Physiological and Morphological Studies of Gastric Endo and Exocrine System.

選択的迷走神経切離術兼幽門形成術後20年以上経過症例について, 胃内外分泌能の生理学的および形態学的変化を検討した.基礎および最高酸分泌量の減酸率はそれぞれ78.2%, 75.8%と, 術後早期と同じように良好に保たれていた.空腹時および肉汁エキス刺激時のガストリン値は, 術前と比較し有意に高値を示し, 高ガストリン血症を呈する症例が多く認められた.高酸群の壁細胞は術前と同じく, 細胞内分泌細管の内腔開大は認められず, microvilliの長さと数も保たれていた.これに対して, 低酸群では細胞内分泌細管の内腔開大, microvilliの長さと数の減少および配列の乱れが目立った.電顕および免疫染色によるガストリン細胞の観察ではG-cell hyperplasiaが認められ, また肉汁エキス刺激では, 基底側細胞膜にΩ 型開口分泌像を示し, 術後20年以上経過してもその反応性が十分保たれていることがわかった.

Clinical Study on Perforated Peptic Ulcers in the Elderly.

本論文の目的は, 70歳以上の消化性潰瘍穿孔例を詳細に分析し, その臨床的特徴を明らかにすることにある.対象は1966年から1990年までに, 順天堂大学で手術が施行された消化性潰瘍穿孔192例で, うち70歳以上の高齢者は20例であった.方法は全例を年代別, 年齢別に検討し70歳以上の症例については, 患者背景, 術前併存疾患, 臨床所見, 治療, 病理学的所見および死亡例について検討した.最近の10年間で70歳以上の症例は有意に増加し, 穿孔症例の年代別平均年齢は年々高くなっている.70歳以上の穿孔例20例のうち十二指腸潰瘍は16例と多くを占めていた.潰瘍の既往歴の無い例は14例で, 術前併存疾患合併率は85%であった.病理学的には急性潰瘍型が11例であった. 手術は単純閉鎖術が2例のみで他は根治手術が行われ, 手術死亡は4例であった.高齢老の穿孔例は, 既往歴の無い例が多く, 病状が刻々変化するので, 画像診断を駆使して早期に診断すべきである.

Postoperative Nutritional Status after Pancreatoduodenectomy with Total Stomach Preservation and Selective Proximal Vagotomy or Whipple's Procedure.

われわれは, 膵頭部領域疾患に対して選択的近位迷走神経切離術兼全胃温存膵十二指腸切除術 (全胃温存術) を行っているが, 術後の栄養評価をWhipple式膵十二指腸切除術 (Whipple術) と対比して検討した.対象は手術後1年以上経過した全胃温存術8例, Whipple術8例の計16例である.方法は身体計測指標, 生化学的指標 (血漿タンパク, 脂肪, ビタミン・微量元素, ホルモン) および免疫学的指標を測定した.またこれらを総合して栄養評価指数を算出した.その結果両術式間で有意差あるいは有意の傾向がみられたのは, 現在体重に対する手術前体重および標準体重比, プレアルブミン, レチノール結合タンパク, 血中亜鉛, 血中T3, PHAリンパ幼若化試験および栄養評価指数などで, いずれも全胃温存術の方が優れた成績であった.以上の成績から全胃温存術は栄養評価の面でWhipple術より優れていることが分かった.