Hiroyuki Sahara

Reflux of duodenal or gastro‐duodenal contents induces esophageal carcinoma in rats

Esophageal adenocarcinoma arises from Barretts esophagus, which is induced by gastro‐esophageal reflux. This refluxate often contains duodenal contents, whose backflow triggers gastric carcinoma, suggesting the hypothesis that refluxed duodenal contents cause esophageal carcinoma. This study examines the role of duodenal and gastric reflux in the absence of exogenous carcinogens in esophageal carcinogenesis. Wistar male rats, 120 in all, each weighing approximately 250 g, were used. Three experimental procedures were performed to produce gastro‐duodeno‐esophageal reflux, duodeno‐esophageal reflux and gastro‐esophageal reflux, for comparison with 2 control procedures, Roux‐en‐Y reconstruction and a sham operation. The animals were fed a standard diet and were examined 50 weeks after surgery. While no carcinoma was found among the 16 gastro‐esophageal‐reflux, 11 Roux‐en‐Y and 12 sham‐operation animals, 10 of the 12 animals with gastro‐duodeno‐esophageal reflux (83%) and 10 of the 13 with duodeno‐esophageal reflux (77%) developed esophageal carcinoma. The difference between groups was significant (p < 0.001). Two animals with gastro‐duodeno‐esophageal reflux had esophageal double and triple carcinomas respectively. Of the 23 carcinomas, 16 were adenocarcinoma, 4 adenosquamous carcinoma, and 3 squamous‐cell carcinoma. Adenocarcinoma developed from the columnar‐lined epithelium near the esophago‐jejunostoma, while adenosquamous and squamous‐cell carcinoma arose from the squamous esophagitis. These observations demonstrate that refluxed duodenal contents per se are responsible for esophageal carcinogenesis.

Status asthmaticus complicated by atelectasis in a child

A case of an 11-year-old boy who was admitted for severe status asthmaticus complicated by extensive atelectasis is reported. Atelectasis involved all left lobes and the right upper lobe of the lung. Although the patient was refractory to maximal medical therapy and continued to deteriorate after intubation, he responded dramatically to the administration of isoflurane. Atelectasis was reduced immediately after fiberoptic bronchial lavage and the use of high frequency ventilation, with a marked improvement in blood gases. Isoflurane provided sedation during prolonged mechanical ventilation without significant adverse effects, aiding the care of this pediatric patient who ultimately recovered.

Preoperative Prediction of Gastric Cancer Extension by in Vitro Labelling Index of Bromodeoxyuridine

In vitro labelling index(L.I.) of BrdU was evaluated as a preoperaitve predictor of gastric cancer extension. Biopsy specimens were obtained preoperatively and labelled by BrdU. BrdU were stained immunohistochemically and labelling index was calculated. Patients with L.I. more than 10% had a significantly higher risk of node involvement and venous invasion. Patients with L.I. omre than 20% had a significantly higher risk of liver metastasis. Patients with L.I. more than 25% had a significantly higher risk of submucosal invasion. In conclusion, in vitro BrdU labelling is an available technique as a preoperative predictor of node involvement, venous invasion, submucosal invasion and prognosis in gastric cancer.

Evaluation of Jejunal Pouch Interposition for Subtotal Gastrectomy.

胃癌手術後の残胃十二指腸間にpouchを形成した空腸を間置する再建 (JPI法) を評価した. 術後の胸やけや下痢の出現頻度は, JPI法による再建例で, 従来のBillroth法による再建と比較して低率であった. 残胃からの食物排泄を核医学的に観察すると, JPI法では食物は残胃およびpouchに貯留し, 緩徐に十二指腸へと流出するのが認められ, 残胃からの排泄時間T1/2は, Billroth I法の29±6分, Billroth II法の50±37分に対し, JPI法では104±45分と有意に延長していた. 残胃内への胆汁逆流はBillroth法では全例に認められたが, JPI法では15%にみられるのみであり, 胆汁と食物の混和異常も, Billroth法に比較してJPI法では低率であった. 以上より, JPI法は従来のBillroth法よりも術後愁訴の少ない, より生理的な状態が得られる再建法と考えられた.

Effect of Surgical Treatment and Continuous Hyperthermic Peritoneal Perfusion for Borrman Type 4 Gastric Cancer.

Borrmann 4型 (以下, B4と略記) 胃癌61例における手術療法, 持続温熱腹膜灌流 (continuous hyperthermic peritoneal perfusion: 以下, CHPPと略記) の治療成績について検討した. 根治度別の1, 3年生存率は根治度A 94, 60%, B 56, 11%, C 46, 0%, 非切除0, 0%とAが良好であった (p<0.01). 漿膜因子陽性のP0,1胃癌で, 根治度A, Bの切除が行われた症例に対して腹膜播種再発の予防の目的で予防的CHPPを施行した.CHPP施行群の2, 4年生存率は90, 56%と非施行群の67, 27%に比較して良好であった (p=0.02).P2,3の高度の播種を有する症例に対する治療的CHPPでは施行群の1, 2年生存率は50, 25%で, 非施行群の10, 0%に比較して予後は良好であった (p=0.04) が, 3年生存者はなかった.以上よりB4胃癌の治療は治癒手術が可能な場合は積極的な根治手術を行い, 腹膜播種の予防のためにCHPPを施行する.しかし著明な播種を有する場合はneoadjuvant chemotherapyなどの新たな治療方法の開発が必要と思われた.

Continuous Hyperthermic and Normothermic Peritoneal Perfusion for the Prevention of Peritoneal Recurrence of Gastric Cancer — A Randomized Control Study

We had reported advantage of continuous hyperthermic peritoneal perfusion (CHPP) for the prevention of peritoneal recurrence after surgery for gastric cancer in a historical control study. We performed CHPP (CHPP group, n=22) or continuous normothermic peritoneal perfusion (CNPP group, n=18) combined with cisplatin and mitomycin C for the prevention of peritoneal recurrence. The survival curve of the CHPP group was significantly better than of the CNPP group in log-rank test (p<0.01). This fact showed that not only intraperitoneal perfusion combined with chemotherapy (CNPP) but also intraperitoneal hyperthermia(CHPP) are effective procedures for prevention of peritoneal recurrence.

A Clinicopathological Study on Surgical Cases with Bile Duct Cancer in Middle and Distal Portions.

過去16年間に経験した中下部胆管 (Bm, Bi) 癌手術症例49例につき, 臨床病理学的所見, 予後に関し検討した. 全症例における切除率は91.8%, 切除例の5年生存率は31.2%であり, 7例の5年生存例 (長期生存例) を得た. Stage分類では, Stage III, IV症例が過半数を占め, Stageの進行とともに生存率の低下を認めた. 肝転移例は8.2%, 腹膜播種例は4.1%, リンパ節転移 (n) 例は37.8%であり, リンパ節転移陽性例の生存率は陰性例に比べ有意に低かった. Bi癌, Bm癌とも高頻度に膵臓浸潤 (panc), 十二指腸浸潤 (d) を認めたが, 浸潤の有無において予後に差は認められなかった. 組織学的には, 高頻度にリンパ管浸潤 (ly), 神経周囲浸潤 (pn) を認めたが, 浸潤陰性例の予後は良好であった. 長期生存例からみた場合, 予後規定因子としてn, ly, pn因子が重要であり, panc, d因子は予後規定因子とはなりえず, 取扱い規約におけるStage分類を再考する必要性が示唆された.

Clinical Significances of External Biliary Drainage before Pancreatoduodenectomy in Patients with Obstructive Jaundice.

従来より閉塞性黄疸患者の外科的治療に当たっては, まず術前PTCDを行って, 肝機能の改善を計ってから行うべきといわれている.そこでわれわれは, 閉塞性黄疸に対する術前PTCDの意義を探るべく検討した.163例の膵頭十二指腸切除例を術前総ビリルビン3.0mg/dl以上の黄疸群 (83例), 3.0mg/dl未満の非黄疸群 (80例) に分け, 黄疸群をさらにPTCDを行ったPTCD群 (65例) とPTCDを行わなかった非PTCD群 (18例) に分け, 3群間で治療成績を比較検討した.その結果, 黄疸群, 非黄疸群の間には手術時間, 術中出血, 術後入院日数, 術後合併症のいずれにおいても差はみられなかった.ただPTCD群は非PTCD群に比べ, 術前の入院日数が有意に長かった.以上より手術手技や術中, 術後の患者の管理が向上した今日では, 閉塞性黄疸患者には血清ビリルビン値のいかんにかかわらず, 術前PTCDを行うことなしに1期的に根治術を行うことは可能と考えられた.