Keiji Mashita

A bacteriological study of perforated duodenal ulcers

Peritoneal fluid sampling and bacteriological examination were performed in 63 patients with perforated duodenal ulcers, and the results compared with those in 175 patients with other perforations. Bacterial culture was positive in 100 per cent of the patients whose perforations occurred in the colon, whereas it was positive in only 44.4 per cent of those with duodenal perforations, being negative in many cases when the interval from perforation to surgery was short. A mixed contamination with both aerobes and anaerobes was usually found in the cases of lower digestive tract perforation, and the isolates from duodenal perforations were uniquely aerobes in most cases. It is suggested that bacteria play a minor role in the pathogenesis of early stage duodenal perforation, which supports the technique of primary closure without indwelling drainage tubes during early stage operations following sufficient peritoneal lavage. Moreover, if the stomach is empty at the time of perforation and the peritonitis is localized, even conservative therapy seems possible, provided it is begun shortly after the perforation.

The relationship between juxtapapillary duodenal diverticula and the presence of bacteria in the bile

A total of 432 patients with gallstone disease were studied with respect to the existence of juxtapapillary duodenal diverticula and their relationship to the presence of bacteria in the bile. A total of 63 patients were found to have diverticula with an incidence of 14.6 per cent, being significantly higher in the elderly group aged 60 years or older (p<0.01), and no sex difference was noted. Among the patients with diverticula, positive bacterial cultures of bile were recognized at a significantly higher frequency, being found in 49 of the 63 patients (77.8 per cent; p<0.01), and the probability of bilirubinate stones was also higher, being found in 35 of 37 patients (94.6 per cent; p<0.01). The presence of a diverticulum bore significant relation to a higher positive bile bacterial culture (p<0.05), dilatation of the common bile duct (p<0.05), and elevation of the bile duct pressure (p<0.05), even when the conditions were divided into cholecystolithiasis or choledocholithiasis. It was suggested that the presence of a diverticulum affected the flow in the bile duct by narrowing it from the outside and chronically stimulating the papilla, inducing biliary tract infection and/or the formation of gallstones. As the surgical procedures for juxtapapillary duodenal diverticula, including its indications, have not been established, long term follow up investigations seem necessary.

Pancreatectomy for Small Carcinoma of the Head of the Pancreas

The clinical and pathological characteristics of 25 small carcinomas (less than 2 cm in diameter) in the head of the pancreas are reviewed. At the time of initial surgery, lymph node metastases were found in 32% of the cases, capsular invasion in 20%, retroperitoneal invasion in 24%, and portal system involvement in 28%. Nine patients had Stage I disease, three had Stage II, seven had Stage III, and six had Stage IV. Pancreaticoduodenectomy or total pancreatectomy with or without combined resection of the portal vein and/or hepatic artery was performed. The cumulative 5year survival rate for all patients was 28%. For nine Stage I patients, the 5-year survival rate was 56%. With the other stages there were no survivors after 4 years. The main recurrence sites in patients who died of carcinomas after surgery were the liver, peritonium, and local region. From the present findings we conclude that small, localized lesions, without any extratumoral extension, can be resected with a reasonable chance of a cure.

The operative risk factors of cholelithiasis in the elderly

A total 725 patients with cholelithiasis were divided into three groups according to age, and the risk factors and morbidity rates compared. Group 1 consisted of those aged younger than 49 years, group 2 of those aged between 50 to 69 years, and group 3 of those aged over 70 years. In group 3, the incidence of caliculi in the common bile duct was significantly higher than in the other two groups (p<0.05), and therefore, choledochotomy accompanying cholecystectomy was performed more often in this group (p<0.01). The rate of complications related to calculi and the presence of underlying disease were also higher in this group than in the two younger groups (p<0.05), as were preoperative abnormal liver or renal function tests, anemia and hypoproteinemia (p<0.05). The rate of positive bile cultures in group 3 was 75.6 per cent which was again significantly higher than in groups 1 and 2 (p<0.01). Postoperative complications appeared in 14.3 per cent of the group 3 patients, which was not statistically higher than in group 2 (9.7 per cent), but the percentages of both groups 2 and 3 were high compared to the 4.3 per cent of group 1 (p<0.01). The rates of complications directly attributable to the surgical procedures were 2.0 per cent in group 1, 4.8 per cent in group 2, and 5.1 per cent in group 3 with no significant differences between the three groups. There was no increase in the technical problems associated with the surgical procedures performed on the elderly patients and thus, if the operative risks are precisely evaluated and treated cautiously elderly patients should tolerate surgery for cholelithiasis well.

Postoperative infection prophylaxis for upper gastrointestinal tract surgery—A prospective and comparative randomized study of cefoxitin and ceftizozime

A prospective and randomized clinical study was conducted in order to compare cefoxitin (CFX) and ceftizoxime (CZX) as prophylactic antibiotics. Two hundred and three consecutive cases of elective upper gastrointestinal tract surgery, performed at our institute between January, 1983, and March, 1986, were entered in the trial. The patients were assigned randomly, before surgery, to the CFX or to the CZX group. Two grams of the assigned antibiotic was first administered during surgery and then continued at a dose of 1 gram, every 8 hrs for a total of 4 days. One patient was withdrawn from the study due to an allergic reaction. Both groups were comparable in sex, age, underlying disease, diagnosis, operation, and preoperative laboratory data. There were 18 infections related to the operation in the CFX group, while there were only 3 in the CZX group (p<0.001). The number of unrelated infections in each group was 6 and 6 respectively (NS). No special differences were found between the two groups regarding the kinds of microorganisms isolated, and no significant differences were seen in the adverse effects of either antibiotic. Our study demonstrated that ceftizoxime was more efficient than cefoxitin in preventing postoperative infection, following upper gastrointestinal tract surgery.

A questionnaire survey on the theory of postoperative infection prophylaxis in gynecology

A questionnaire survey on the theory of postoperative infection prophylaxis was conducted to obtain the consensus on perioperative antimicrobial use among gynecologists in Japan in the period from April to July 2000. Fifty-six of the 83 gynecologists replied, and the following consensus was obtained. An antimicrobial prophylaxis (AMP) agent should be chosen based on their efficacy against the pathogens expected to be contaminants, such as Staphylococcus spp., Escherichia coli and Bacteroides fragilis group. Use an AMP agent that archives a bactericidal concentrations in both the serum and operating site. Use an AMP agent that has little unfavourable side effects. The newer agents should be considered as a therapeutics for postoperative infections. The therapeutic antimicrobial agents having no cross-resistance to the AMP agents should be used, if postoperative infection is suspected or developed. The most commonly used agent for clean operations are cefazolin (CEZ), followed by cefotiam (CTM) and cefmetazole (CMZ). The most commonly used agent for clean-contaminated operations where low grade level of bacterial invasion expected is CTM, followed by CEZ and CMZ, where as operations where mild grade level of bacterial invasion expected is flomxef (FMOX), followed by CTM and other cephalosporins.

Bacteriological study of peritonitis due to perforated duodenal ulcer.

十二指腸潰瘍穿孔例 (63例) について, 手術時採取腹水の細菌学的検討を行い, その他の部位の穿孔例 (175例) と比較した. 腹水中細菌の陽性率は, 結腸穿孔 (陽性率100%) などの下部消化管穿孔と比較し, 十二指腸潰瘍穿孔では44.4%と低く, さらに穿孔より手術までの時間の短いものでは菌陰性例が多かった. 腹水から好気性菌と嫌気性菌が混合で分離される症例は下部消化管穿孔に多く, 十二指腸潰瘍穿孔では好気性菌の単独分離が多かった. 十二指腸潰瘍穿孔の早期手術例では, その病態に細菌が関与することは少ないと考えられた.