Kenji Tsutsumi

Large-Scale Investigation into Dumping Syndrome after Gastrectomy for Gastric Cancer

BACKGROUND The aim of this study was to investigate early and late dumping syndromes in a large number of patients after gastrectomy for gastric cancer. STUDY DESIGN Responses to questions on a visual analogue scale survey completed by 1,153 gastrectomy patients were analyzed for associations between clinical factors and occurrence of dumping syndrome. Types of gastrectomy included distal gastrectomy with Billroth I or with Roux-Y reconstruction, pylorus preserving gastrectomy, proximal gastrectomy, and total gastrectomy. RESULTS Based on the visual analogue scale rating of symptomatic discomfort, patients were categorized into 1 of 2 groups: symptom-free or symptomatic. Incidences of early or late dumping syndrome in all patients were 67.6% and 38.4%, respectively. Patients in whom early dumping syndrome developed were significantly more likely to experience late dumping syndrome than those in whom it did not develop (p < 0.001). According to multivariate analyses, factors that decreased the risk for developing early dumping syndrome were reduced weight loss (p < 0.01), old age (p < 0.01), pylorus preserving gastrectomy (p < 0.01), distal gastrectomy with Roux-Y reconstruction (p < 0.01), and distal gastrectomy with Billroth I (p = 0.019). In addition, factors that decreased the risk of developing late dumping syndrome were reduced weight loss (p = 0.03), being male (p < 0.01), pylorus preserving gastrectomy (p < 0.01), and distal gastrectomy with Roux-Y reconstruction (p < 0.01). No other clinical factors (lymph node dissection, vagal nerve preservation, and postoperative period) showed a substantial association with the occurrence of dumping syndrome in multivariate analyses. CONCLUSIONS Substantially more patients suffered from early dumping syndrome than late dumping syndrome after gastrectomy. Two clinical factors, surgical procedures and amount of body weight loss, associated significantly with the occurrence of both early and late dumping syndrome.

Prognostic factors in adenocarcinoma of the gastric cardia: pathologic stage analysis and multivariate regression analysis.

PURPOSE To clarify the pathologic stages of adenocarcinoma of the gastric cardia in which the prognosis is worse than in adenocarcinoma of the middle or distal part of the stomach, and to determine prognostic factors in these stages by multivariate analysis. PATIENTS AND METHODS We analyzed 2,536 cases of surgically resected gastric adenocarcinoma of all pathologic stages. Four hundred seventy-two cases of gastric carcinoma, in which cumulative survival of gastric cardia was poor, were subjected to Cox regression analysis for prognostic factors, and to logistic regression analysis for factors influencing venous or lymphatic invasion. RESULTS The prognosis of adenocarcinoma of the gastric cardia was inferior when compared with similarly staged carcinomas of the middle or lower part of the stomach when there was invasion of proper muscle layer or subserosal layer, with no lymph node metastasis or with only adjacent (group 1) lymph nodes metastases (T2N0 or T2N1, according to the Japanese classification). In these stages, the prognostic factors were age, histologic type, venous invasion, and location of the tumor in the upper part of the stomach. Tumor location in the upper stomach was also a predictor for the presence of venous invasion. CONCLUSION The prognosis of adenocarcinoma of the gastric cardia is poor in patients with T2 tumors with no or few lymph node metastases. Additional treatment after surgery may be necessary to improve the survival of this population.

Colon Interposition After Esophagectomy With Extended Lymphadenectomy for Esophageal Cancer

BACKGROUND The purpose of this retrospective study was to investigate the feasibility of colon interposition procedures after esophagectomy with extended lymphadenectomy. METHODS Between 1990 and 2008, 95 consecutive patients underwent colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer in our Institution. We reviewed clinical data and long-term survival, and also investigated the association between anastomotic leakage and clinicopathologic findings. RESULTS We applied three-field lymphadenectomy to 71 patients and two-field to 24 patients, by a right thoracotomy. Ninety-two patients underwent reconstruction by a retrosternal route, and a posterior mediastinal route was applied to only three patients. We performed hand-sewn anastomosis in the neck in all cases. Three patients required microvascular surgery. Sixty-one patients (64%) experienced postoperative morbidity, most commonly pulmonary complications. Anastomotic leakage occurred in 12 patients (13%). No colon conduit necrosis was detected. Overall mortality, including hospital mortality, was 5.3%. Dysphagia (39%) and diarrhea (38%) were common and stricture was low (6%) after discharge. The overall 5-year survival rate was 43%. During the latter period (1998 to 2008), when ileocolon grafts evolved as the primary choice for interposition, the rate of leakage decreased from 17% (1990 to 1997) to 5.4%. No mortality was recorded during the latter period. CONCLUSIONS Results from this study demonstrate that colon interposition after esophagectomy with extended lymphadenectomy is feasible and can have a favorable outcome.

Cologastric fistula and colonic perforation as a complication of percutaneous endoscopic gastrostomy.

Cologastric fistula has rarely been reported as a complication of percutaneous endoscopic gastrostomy (PEG). We encountered a patient in whom this problem went unrecognized for 2 years. After the initial PEG tube was changed, the second PEG tube was advanced into the colon, causing severe diarrhea. When a third PEG tube was inserted, acute peritonitis occurred because of colonic perforation. We discuss the mechanism of this complication and technical points related to its prevention.

Pulmonary Thromboembolism After Surgery for Esophageal Cancer : Its Features and Prophylaxis

We attempt to clarify the problems of pulmonary thromboembolism (PTE), which occurs less frequently in Japan than in the West, regarding its special perioperative management and prophylaxis for PTE after esophagectomy. We studied 26 patients with PTE following esophagectomy among 1023 patients with esophageal cancer between 1984 and 1997. The presence of embolism was confirmed by pulmonary perfusion scintigraphy. The incidence, diagnosis, and other issues of PTE were all reviewed. The incidence of PTE was 2.5%, with patients showing a biphasic early and late onset. The main symptoms were dyspnea in 19 patients and tachycardia in 17. Scintigraphy demonstrated 154 lesions, 35.7% of which were located in the left lower lobe and 25.3% in the right lower lobe. Treatment mainly consisted of the administration of heparin and urokinase. Four of the 26 patients died. Intermittent pneumatic compression (IPC) with the administration of heparin has been used in our department since 1994 to prevent PTE and this has also helped to decrease the incidence from 3.2% to 0.7%. Because the incidence of PTE following esophagectomy is higher than expected, PTE should be considered whenever hypoxemia of some unknown cause is found. Both early diagnosis and treatment are essential. It is also important to prevent PTE by the use of IPC.

Case Report: Gastrointestinal bleeding from a hepatocellular carcinoma invading the transverse colon

A 72‐year‐old woman with cirrhosis of the liver was treated repeatedly by transcatheter arterial embolization for multifocal hepatocellular carcinomas. She developed gastrointestinal bleeding secondary to direct invasion of the wall of the transverse colon. The diagnosis was made pre‐operatively by colonoscopy and the patient was treated successfully. This rare complication of hepatocellular carcinoma was due to the protrusive type of growth exhibited by this tumour and may have been affected by the transcatheter arterial embolization.

CASE REPORT: Rupture of a gastric varix in liver cirrhosis associated with glycogen storage disease type III

Glycogen storage disease type III, or Coris disease, is caused by a deficiency of amylo‐1,6‐glucosidase (debranching enzyme), which leads to the storage of an abnormal glycogen in the liver and in skeletal and heart muscle. Glycogen storage disease type III is usually characterized by hepatic symptoms, growth failure and myopathy. Even though liver cirrhosis is reported, portal hypertension is a rare complication of this disease. We describe the case of a glycogen storage disease type III patient who was diagnosed at 3 years of age and developed complications (liver cirrhosis and rupture of a gastric varix) at 31 years of age. We discuss the histological progression to cirrhosis of the liver and describe the liver enzyme profile at 3 and 31 years of age.

Modified Dor fundoplication technique following diverticulectomy and myotomy for epiphrenic diverticulum combined with esophageal motility disorders: prevention of esophageal leak at the diverticulectomy staple line

Surgery is the standard treatment for patients with pulmonary or incapacitating symptoms related to an epiphrenic diverticulum combined with esophageal motility disorders. Leakage from the staple line at the diverticulectomy site is a severe complication because of the lack of proper esophageal muscle. When the staple line that lacks the proper muscle is wider than expected, interrupted suturing may cause the muscle to tear because of the lack of adventitia of the esophagus, or esophageal stenosis may occur as the result of a tight suture. We propose that an antireflux wrap should be used to cover over the staple line to prevent esophageal leaks. Even if a staple line leak occurred, a major leak and mediastinitis can be avoided when the muscle defect is completely covered by a fundus.

Surgical repair of refractory strictures of esophagogastric anastomoses caused by leakage following esophagectomy

Refractory strictures of esophagogastric anastomosis caused by leakage following an esophagectomy are a severe complication, for which either repeated balloon dilations or bougies are not necessarily effective. In such a case, surgical repair is quite difficult because the esophageal substitute such as the stomach or colon is usually located in the mediastinum and severely adhesive to the neighboring organs. Furthermore, in case the resected stricture is too long for direct re-anastomosis to be performed, a free jejunal graft or a new esophageal substitute should be prepared. This paper proposes a procedure for the re-reconstruction of refractory stricture in the case of a retrosternal reconstruction with a gastric conduit, which frequently employs pull-up route. The anterior plate of the manubrium was divided medially from the notch to the symphysis with the sternal saw. The manubrium is then removed, bite by bite, like breaking up rocks, with a bone rongeur forceps, starting with the anterior plate, then the posterior plate, from upper median part to the lower and lateral part of the sternum until it reaches the symphysis and the sternoclavicular and the sternocostal joints. It is safer to destroy the manubrium little by little from the anterior side so that the posterior periosteum, which is likely to adhere tightly to the gastric conduit, can be preserved. After the manubrium is almost completely resected and the posterior periosteum of the manubrium is preserved, a median longitudinal incision is carefully made on the periosteum so as not to damage the gastric conduit that may be adhesive to the periosteum. The periosteum was gradually opened bilaterally separating the periostium and the gastric conduit. Although gastroenterological surgeons may hesitate to remove the manubrium, removing the manubrium and preserving the posterior periosteum make it possible to avoid injuring the gastric conduit and to provide a wide view around the stenosis for safely resecting the anastomotic stricture. Furthermore, this procedure allows direct re-anastomosis between the cervical esophagus and the gastric conduit without a complicated reconstruction such as a free jejunal graft. This procedure is strongly recommended as an alternative option so that a second reconstruction can be performed both safely and steadily.

Surgical treatment of superficial esophageal cancer, its result and perspective

BackgroundOur objective was to review the results of surgical treatment for superficial esophageal cancer to obtain the proper indications for the recently proposed esophagus-preserving strategies.MethodsThe clinicopathological data of 290 consecutive patients with superficial thoracic or abdominal esophageal cancer who underwent esophagectomy with radical lymph node dissection without preoperative adjuvant treatment from 1984 to 2005 were examined in terms of tumor depth (ep, lpm, mm, sm1, sm2, sm3) and TNM pStage. The category sm1 was subclassified into sm1(0–200): lesions with 200 μm or less vertical tumor invasion depth in the submucosal layer, and sm1(200-): deeper sm1, to make our results referable to endoscopically resected lesions.ResultsAbout 8% of the patients with mm or deeper tumors were classified as TNM pStage IV. Around 20% of mm and sm1(0–200) tumors were associated with lymph node involvement. The 5-year survival rate of the 211sm cancers was 74.8% ± 3.3%; the mean survival time was 11.47 ± 0.68 years. The survival of TNM pStage IV patients was no worse than that of pStage IIB patients.ConclusionsEndoscopic mucosal resection/endoscopic submucosal dissection (EMR/ESD) is definitely indicated for ep or lpm lesions. Any tumors with deeper invasion including mm and sm1(0–200) should be regarded as potentially lymph node positive, and the most reliable treatment is still radical esophagectomy. Recent attempts to treat superficial esophageal cancer while preserving the esophagus should be performed with caution and with informed consent. A randomized controlled trial is necessary to compare the results of the recent esophagus-preserving strategies to the results of radical esophagectomy.