Kiyosi Ohsumi

Density of Helicobacter pylori Infection in Patients with Peptic Ulcer Perforation

BACKGROUND A lack of change in prevalence of severe ulcer complications requiring emergency operation has been reported, despite the common use of histamine-2 (H2)-receptor antagonists and proton pump inhibitors. This may be attributable to use of ulcerogenic drugs or Helicobacter pylori (HP) infection, or both. In this study, HP infection was evaluated semiquantitatively in patients with peptic ulcer who required surgery, and the severity of histologic change was investigated. METHODS We reviewed a total of 113 consecutive patients (98 men and 15 women) operated on for perforation, hemorrhage, or stenosis of gastroduodenal ulcer between January 1986 and December 1995. Detection of HP was carried out by immunohistochemical staining. We graded the density of HP infection according to the number of individual HP bacteria counted in a highly magnified visual field (x 1,000 of light microscopy). The grade of HP infection was defined as follows: (0) = 0; (1+) = 1-9; (2+) = 10-29; (3+) = 30-99; (4+) > or = 100. The severity of gastritis was evaluated by histologic examination using the criteria of Rauws. RESULTS Although the number of operations for gastroduodenal ulcer declined significantly, the rate of emergency operation for gastroduodenal ulcer increased from 60% to 90%, with the result that the frequency of operations for perforation or bleeding remained virtually constant and that for stenosis significantly decreased. HP infection was more prevalent in perforated ulcer (92%) than hemorrhagic ulcer (55%) or stenotic ulcer (45%). The grades of HP infection were 3.0 +/- 0.14 (mean +/- SEM) in perforated ulcer, 2.3 +/- 0.34 in hemorrhagic ulcer, and 2.5 +/- 0.22 in stenotic ulcer. Perforated ulcer was associated with significantly more severe HP infection and gastritis changes than hemorrhagic ulcer or stenotic ulcer. CONCLUSIONS This study indicates that patients with perforated ulcer were infected with HP more severely than those with hemorrhagic ulcer or stenotic ulcer at the time of surgery. A close relationship was observed between the perforated ulcer and the density of HP infection determined semiquantitatively using immunohistochemical stain.

Spontaneous perforation of the rectum with possible stercoral etiology: Report of a case and review of the literature

Stercoral perforation of the colon or rectum is a rare cause of acute abdomen, with fewer than 70 cases documented in the literature. We report herein the case of a 60-year-old man who presented with anuria and epigastric pain with physical signs of peritonitis. An abdominal X-ray showed bilateral subphrenic free air accumulation, and an emergency laparotomy subsequently revealed perforation of the rectum, suggestive of a stercoral cause, which was treated by simple closure after debridement. Following an uneventful postoperative course, he was discharged from the hospital 3 weeks after his operation and is now doing well without having suffered any further gastrointestinal problems. The clinical features, diagnosis, and treatment of the disease are reviewed following the presentation of this case. Surgeons should be aware of the possibility of this fatal disease, despite its rare incidence. Furthermore, it is important to recognize the condition at an early stage because it has a significantly high mortality if not treated early. Conversely, the surgical outcome is satisfactory provided surgery is performed in due time.

Density of Helicobacter pylori infection evaluated semiquantitatively in gastric cancer

Helicobacter pylori infection may play a role in the development of gastric cancer; however, a quantitative evaluation of the density of H. pylori infection has not been reported previously in relation to the histologic stage and type of cancer. This study was designed to compare the density of H. pylori infection to the histologic stage and type of gastric cancer. Between March 1996 and March 1998, surgical resection of primary lesion was performed in 50 patients with gastric cancer (39 men and 11 women with a mean age of 67 years) at our institution. Using immunohistochemical stains, the density of H. pylori infection was evaluated semiquantitatively at cancer site as well as noncancerous mucosa adjacent to cancer. This density was compared with the histologic stage and the type of gastric cancer. The severity of the mucosal atrophy was evaluated using the updated Sydney System. The prevalences and density of H. pylori infection decreased in proportion to advances in the cancer stage and the mucosal atrophy. In early cancer of the intestinal-and diffuse-type, the prevalence of H. pylori in adjacent sites was almost 90% and was significantly higher (p < 0.01) than that seen in the advanced cancer lesions. In the intestinal-type early cancer, the prevalence and density of infection was higher (p < 0.05) in the adjacent mucosa than in the cancer site, whereas in the diffuse-type early cancer, H. pylori was found in all cases at the cancer site and the adjacent site. In advanced cancer, the prevalence of H. pylori was about 40% in the adjacent site and about 10% in the cancer site in both histologic types. These figures were significantly lower (p < 0.01) than in the early cancers. The prevalence and density of infection did not differ in the intestinal-and diffuse-type gastric cancers, but did decrease with more advanced cancer stages. The changes in local environment of the advanced cancer may not be conducive to the survival of H. pylori. Thus, the prevalence of H. pylori may be affected by the histologic stage rather than the histologic type of gastric cancer, and the organism may play a similar role, but through different pathways, in the pathogenesis of both types of cancer.

Jejunal pouch to avoid stricture after esophagojejunostomy with circular stapler.

BACKGROUND Anastomotic stricture is one of the most common problems in esophagojejunostomy using the end-to-end anastomosing (EEA) instrument (Auto Suture Co, Norwalk, CT) after total gastrectomy. To alleviate the stricture, several methods, such as incision to the scar, balloon dilatation, and steroid injection are available. To avoid stricture, the jejunal pouch may allow use of a larger EEA than Roux-en-Y (ReY) reconstruction does. STUDY DESIGN A total of 45 patients underwent curative total gastrectomy and esophagojejunostomy with jejunal pouch construction (27 patients) or ReY (18 patients), using the EEA. The effects of jejunal pouch construction with a large EEA on avoidance of stricture and benefit to nutritional status were investigated by comparing it with the ReY in terms of postoperative morbidity, postprandial symptoms, and nutritional parameters (serum protein, serum albumin, body weight). RESULTS EEA28 or larger could be used in 25 patients in the pouch group and 8 patients in the ReY group (p < 0.05). Stricture developed in one patient in the pouch group and in four patients in the ReY group (p < 0.05). Postprandial symptoms were experienced less frequently (p < 0.05) in the pouch group than in the ReY group. When stricture and symptoms were analyzed according to the size of EEA, they occurred more frequently (p < 0.05) in the patients with EEA25 than those with EEA28 or EEA31. No significant differences were evident in nutritional parameters. CONCLUSIONS The choice of jejunal pouch technique allowed the use of a larger EEA than that of ReY reconstruction, resulting in avoidance of anastomotic stricture and postprandial symptoms, though little benefit in nutritional status was evident to the patients after total gastrectomy.

Effects of Closed-SystemDrain in Surgery:Focus on Methicillin-ResistantStaphylococcus aureus

Objective: The emergence of methicillin-resistant Staphylococcus aureus (MRSA) has made a strong impact on the strategy of peri-operative antibiotic prophylaxis, since MRSA has become one of the most common causative organisms of nosocomial infection in recent years. In this study, we conducted a bacteriological evaluation of surgical drains before and after introducing strategies to decrease MRSA infection rates. Design and Patients: Between January 1987 and December 1994, we performed a total of 2,755 surgical operations on inpatients, including 1,635 major and 1,120 minor operations. Almost all surgical drains were examined bacteriologically when they were removed. The number of drains examined was 460 ± 47 (mean ± SEM) per year. Since the increased incidence of MRSA infection, we started exclusively using a closed drainage system and first-generation cephalosporins in 1991. The strategy was evaluated by comparing the positive rates of drain cultures, changes in bacteriological features, and incidence of MRSA infection for the 4-year periods before and after 1991. Results: The positive rate of bacteria in the drains decreased significantly (p < 0.01) from 25 ± 2 to 16 ± 1%. Bacteriologically, the positive rate of Staphylococcus spp. decreased significantly (p < 0.05) from 7 ± 2 to 3 ± 0.3%. Positive rates of MRSA decreased significantly (p < 0.05) from 2.1 ± 0.3 to 1.3 ± 0.3%. Streptococcus declined dramatically from 3.0 ± 0.3 to 0.3 ± 0.1%. Of gram-negative strains, Pseudomonas and Escherichia coli were most often isolated. They showed no significant difference in positive rates between the terms. Conclusion: A closed drainage system and thorough use of the first-generation cephalosporins for prophylaxis were effective in decreasing positive bacterial culture of drains and reducing the incidence of MRSA on drains after surgery.

Postsurgical sequential methotrexate, fluorouracil, and leucovorin for stages 3 and 4 gastric carcinoma: A preliminary study.

The present study compared the effects of sequential methotrexate and fluorouracil followed by leucovorin rescue (MFL), as an adjuvant chemotherapy vs. UFT (a combination of uracil and tegafur), on patient survival and recurrence following surgery for advanced gastric carcinoma.

Postsurgical sequential methotrexate, fluorouracil, and leucovorin for advanced colorectal carcinoma: A preliminary study

The present study compared the effects of sequential methotrexate and fluorouracil followed by leucovorin rescue (MFL), as an adjuvant chemotherapy versus a combination of tegafur (UFT) and mitomycin C (MMC), on patient survival and recurrence after surgery for colorectal carcinoma.

A case of hepatic metastasis of colon carcinoma, treated by arterial infusion of methotrexate, fluorouracil, and leucovorin

A 56-year-old man was admitted to hospital due to ileus resulting from advanced colon carcinoma with multiple liver metastases. He underwent right hemicolectomy, and was treated by sequential, hepatic arterial infusions of methotrexate and 5-fluorouracil, followed by leucovorin rescue as a postoperative chemotherapy, using a subcutaneously implantable drug delivery system. The catheter was placed into the hepatic artery, via the gastroduodenal artery, at surgery. Chemotherapy consisted of methotrexate (50 mg/body) bolus arterial infusion and 5-fluorouracil (500 mg/body) arterial infusion, for 2 hours at hour 24 after methotrexate, followed by oral leucovorin (15 mg/body), started at hour 30 after methotrexate, 6 times, at intervals of 6 hours. Methotrexate-5-fluorouracil-leucovorin was administered almost every week for 5 months, and every other week thereafter, at an outpatient clinic. After 5 months, carcinoembryonic antigen and carbohydrate antigen 19–9 levels had declined markedly from 3365 to 58 ng/mL and 1047 to 436 U/mL, respectively. Abdominal CT showed significant remission (70% in area) of the hepatic metastases. Performance status of the patient was improved from grade 3 to grade 0, and he has been alive and well for 15 months. This case clearly demonstrates the feasibility of methotrexate-5-fluorouracil-leucovorin, administered via hepatic arterial infusion, in managing multiple liver metastases from colorectal carcinoma.