Hirofumi Harada

Is D2 Lymphadenectomy in Gastrectomy Safe with Regard to the Skill of the Operator

Background/Aims: D2 gastrectomy has been regarded as an inconvenient procedure with high morbidity and no survival benefit in the West. Recent western studies, however, especially from specialist centers, have shown a survival benefit and the safety of D2 gastrectomy. The aim of this study is to clarify the safety of D2 gastrectomy (defined by the Japanese Research Society for the Study of Gastric Cancer), even if carried out by a junior surgeon, and to show that it is not a particularly difficult or special procedure. Methods: Patients who underwent a typical distal gastrectomy (DG) with D2 resection (n = 344) and total gastrectomy (TG) with D2 resection (n = 111) were analyzed. The subjects were divided into 3 groups according to the postgraduate year of the operator (group I = the surgeon’s postgraduate experience was less than 5 years; group II = surgeons with more than 5 years and less than 10 years postgraduate experience; group III = surgeons with more than 10 years postgraduate experience). The rate of postoperative complications and the 5-year survival rate were compared among the 3 groups. Results: The overall operative mortality rate, hospital death rate and the overall rate of postoperative complications were 1.2, 2.0 and 10.2% in DG patients, and 14.4, 0 and 1.8% in TG patients, respectively. There was no significant difference in the operative blood loss, the rate of operative mortality, hospital death rate and postoperative complications among the 3 groups. There was no significant difference in the 5-year survival rate among the 3 groups in each stage. Conclusion: The postoperative mortality rate, morbidity rate and 5-year survival rate after a typical D2 gastrectomy were independent of the experience of the operator. It is considered to be a safe and useful procedure in view of the rate of postoperative complications and the long-term survival rate, even if performed by a junior trainee under the supervision of experienced surgeons in a nonspecialized hospital.

Seton treatment for perianal Crohn's fistulas

In this study, we evaluated the efficacy of long-term seton drainage in the management of 13 patients with severe perianal Crohns fistulas which had proven to be intractable to conventional therapy. After adequate curettage of the fistulous tracts and infected tissue, either a Penrose drain or a fine polyethylene catheter was inserted to encircle the tracts and tied. Patients were followed up for a mean period of 12.1 months. Perianal pain disappeared or improved in all 13 patients, while the body temperature of all 7 with pyrexia dropped to within the normal range. Discharge disappeared or diminished in 77% (10/13) and tenderness disappeared or improved in 77% (10/13). Induration disappeared or improved in 69% (9/13). Overall, good results were achieved in 10 patients, although 3 required redrainage. In one of these patients, a good result was achieved after colostomy was performed for active intestinal disease. Nevertheless, 2 patients did not improve, one of whom required lay-open surgery after seton treatment. In 8 of the 13 patients, some seton drains were able to be removed, and none of the patients experienced any soiling or leakage. Thus, we conclude that seton treatment is worthwhile in the management of perianal Crohns fistulas as it alleviats the symptoms and simplifies multiple tracts. Moreover, it preserves sphincter function, is less invasive, and can be managed easily.

Cystic mesothelioma of the peritoneum

We report a case of cystic mesothelioma of the peritoneum (CMP), a rare tumor. The magnetic resonance imaging (MRI) findings and the histochemical features were studied. The patient was an 18-year-old woman who presented with upper abdominal pain. Abdominal ultrasonography and computed tomography showed a well defined cystic mass with a solid papillary projection in its lumen. MRI of the cyst showed high intensity on T2- and proton weighted images and low intensity on T1-weighted images, and the solid projection showed low intensity on T2- and proton-weighted images and slight low intensity on T1-weighted images, on which it was well enhanced. The lesion was suspected to be a benign cyst, such as a hemangioma, lymphangioma, or a splenic or pancreatic cyst. Complete surgical resection was performed. The resected specimen consisted of a unilocular cystic mass, with a solid projection, weighing 260g and measuring 10 cm in diameter. The final diagnosis, arrived at by histopathological examination, was low-grade malignant CMP. The tumor cells were strongly positive for keratin, weakly positive for vimentin, and negative for epithelial membranous antigen. The patient is now well and symptom-free with no recurrence 19 months after operation. CMP is a rare tumor; only 12 cases have previously been reported in Japan.

The Effect of Surgical Treatment of Growth Retardation in Children with Ulcerative Colitis.

横浜市大第2外科で治療した若年者の潰瘍性大腸炎25例中, 成長障害の合併は5例であり, それらに対して手術の効果を検討した.全例, 全大腸炎型で男女比は4: 1であった.手術適応は重症発作が2例, 難治例が3例であり, 3例に回腸直腸吻合術, 2例に回腸肛門吻合術を行った.手術時の平均年齢は14歳 (13～15歳), 発症より手術までの病悩期間は平均3.8年 (4か月～10年2か月) で, prednisolone投与量は平均10,066mg (1, 560～23,375mg) と多量であった.成長障害は身長, 体重を指標に.手術前と手術後平均3.8年後 (2～6年) とを比較した.手術前の身長は全例-1SD以下であったが, 手術後は3例が-1SD以内に改善し, 改善度は平均+0.8SDであった.手術前の体重は4例で-1SD以下であったが.手術後は3例が一1SD以内に改善し, 改善度は平均+0.9SDであった.重症例やステロイドを長期投与された成長障害をもつ若年者は術後に改善がみられ, 手術治療が有効であった.