Jinichi Soeda

Clinical and Biochemical Aspects of Thiamine Treatment for Metabolic Acidosis During Total Parenteral Nutrition

We encountered six cases of total parenteral nutrition (TPN)-associated lactic acidosis during the 6-y period of 1988-1993. The patients were characterized by severe disease of the digestive organs, minimal food intake before surgery, and postoperative TPN with no food intake and with no vitamin supplements. Within 4 wk of TPN, they developed hypotension (< or = 80/60 mmHg), Kussmauls respiration, and clouding of consciousness, as well as abdominal pain not directly related to the underlying disease. Routine laboratory examinations revealed no acute aggravation in hepatic, renal, or pancreatic functions. Arterial blood gas analysis showed pH < or = 7.134 and base excess < or = -17.5 mmol/L. Additional laboratory examinations revealed serum lactate > or = 10.9 mmol/L, serum pyruvate > or = 159 mumol/L, and lactate/pyruvate ratio > or = 0.029. None of the patients responded to sodium bicarbonate or other conventional emergency treatments for shock and lactic acidosis. After the first case, we suspected that thiamine deficiency might be responsible for this pathologic condition, Serum thiamine was proved to be < or = 196 nmol/L in 5 patients. Thiamine replenishment at intravenous doses of 100 mg every 12 h resolved lactic acidosis and improved the clinical condition in 3 patients. This article includes a review of 11 relevant reports published from 1982-1992 and a discussion of the biochemical mechanism of onset of thiamine deficiency-associated lactic acidosis. We emphasize the needs (1) to supplement TPN with thiamine-containing vitamins for the patients whose food intake does not meet nutritional requirements; (2) to monitor the patients routinely measuring serum thiamine concentration and erythrocyte transketolase activity during TPN; and (3) to intravenously replenish using high-dose thiamine simultaneously with the manifestation of signs and symptoms of lactic acidosis.

Small cell neuroendocrine carcinoma of the rectum

Poorly differentiated small cell neuroendocrine (NE) carcinoma of the colon and rectum is a rare primaty epithelial malignancy at this location. A case of a highly aggressive NE tumor of small cell type, combined with non‐invasive well‐differentiated papillary adenocarcinoma in villous adenoma is reported. The patient died rapidly with massive and progressive liver metastasis. The tumor cells were argyrophilic and diffusely immunoreactive for neuron‐specific enolase and synaptophysin. Ultrastructural analysis disclosed NE‐type cored granules in most of the small tumor cells. NE tumors of the colon and rectum are briefly reviewed.

Focus on the Conditions of Resection and Reconstruction in Gastric Cancer

To assess the roles of the extent of gastric resection and duodenal food passage reconstruction in gastric cancer, we examined a consecutive series of 1,061 patients who underwent total or partial (proximal and distal) gastrectomies with or without duodenal food passage reconstruction between August of 1974 and January of 2002, and received gastrectomies with D2–3 lymph node dissection. Patients who underwent distal or proximal gastrectomy were found to have significantly better survival rates than those who underwent total gastrectomy in stages 1A (10-year survival: 86.6 and 78.9 vs. 61.6%), 2 (56.5 and 65.6 vs. 34.4%), 3A (45.9 and 33.3 vs. 15.2%), and 4 (5-year survival rates: 23.7 and 50.0 vs. 7.1%). Additionally, patients with duodenal food passage reconstruction or double tract reconstruction also showed significantly better survival rates than those without duodenal food reconstruction in stages 1A (10-year survival: 86.4 and 82.5 vs. 61.7%), 1B (69.9 and 90.6 vs. 54.1%), 2 (60.5 and 63.3 vs. 16.5%), and 3A (39.9 and 47.4 vs. 23.1%). In multivariate analysis, the independent prognostic factors were age at operation, depth of tumor, duodenal food passage reconstruction, and lymph node metastasis. Our results indicate that both the extent of gastric resection and duodenal food passage reconstruction were important factors in the outcome of gastric cancer patients, and that surgeons should perform minimal gastric resection with preservation of the duodenal food passage when the gastric stump is tumor-free.

The strategy to treat disseminated neuroblastoma utilizing bone marrow transplantation: What is the surgeon's role?

The current role of surgery was evaluated in seven consecutive patients with high-risk neuroblastoma (six stage 4 patients and one stage 3, abdominal origin, and all over 12 months of age at diagnosis) treated with new modalities utilizing bone marrow transplantation (BMT). In six of these seven patients, a grossly complete excision of the primary tumor was achieved, and four have survived for 133, 69, 39, and 28 months with no further evidence of disease. The remaining patient with celiac neuroblastoma only underwent a biopsy during a second-look laparotomy after chemoradiotherapy, and thereafter developed local and distant recurrences and ultimately succumbed to the tumor. The timing of surgical intervention varied, either before or after chemotherapy, and did not appear to affect the ultimate survival. Although surgical excision of the primary tumor remains a very high priority in the overall treatment scheme, the most important factor remains the eradication of the tumor by well-planned courses of intensive chemotherapy (e.g., Al Protocol of the Study Group of Japan). Thus, after having induced complete remission, for consolidation, it is necessary to kill all remaining tumor cells by giving supralethal doses of chemotherapy including total body irradiation (TBI) assisted by BMT.

Granular-cell tumorlike Schwann cell degeneration in the anal sphincter of an infant suspected of having ultrashort Hirschsprung's disease

A 19-month-old girl who had a history of constipation since birth and suspected cytomegalovirus (CMV) infection was admitted. Barium enema revealed no caliber change in the colon, anorectal manometry failed to show sphincter relaxation on rectal distension, and biopsied rectal specimens contained ganglion cells. She underwent rectal myectomy, after which her symptoms improved significantly. Morphologic studies, including electron micrographs of the muscle, demonstrated nerve plexuses with degenerative Schwann cells containing abundant eosinphilic cytoplasmic granules that resembled those of a granular-cell tumor. Granular-cell tumorlike change of the plexus is an unprecedented finding in any form of Hirschsprungs disease or its allied disorders, but appears to have been responsible for her symptoms. CMV as a causative agent is also discussed with a review of the literature.