Masamitsu Harada

Changes in surgical strategies for peptic ulcers before and after the introduction of H2-receptor antagonists and endoscopic hemostasis.

A total of 902 surgical patients with peptic ulcer disease were evaluated to clarify the effects of H2-receptor antagonists and endoscopic hemostasis on surgical treatment. Following the introduction of these treatments to our institute in 1982, the number of operations performed annually decreased by 40%, or 36 cases per year. However, a remarkable increase in the frequency of surgical emergency intervention since 1982 was concurrently observed, with the ratio of emergency procedures to the total number of operated cases increasing to 72.5% in the last 5 years of the study. Moreover, intractability as an indication for surgery decreased to 34.1%, compared with an increase in the number of patients with bleeding and perforated ulcers requiring operation. There were 13 postoperative deaths recorded (1.4%). All of the deaths were in patients who had undergone emergency surgery in poor health. Of these 13 patients, 10 had bleeding ulcers. A study of bleeding ulcers for which endoscopic hemostasis had been unsuccessful revealed that shock on admission and a concomitant medical condition had been evident in all the patients who died, and in 52.2% and 30.4% of the survivors, respectively. The current study suggests that the frequency of high-risk patients requiring surgery is increasing since the introduction of H2-receptor antagonists and endoscopic hemostasis, and thus, prompt surgical treatment and intensive management for such patients is essential.

Clinical relevance of antibiotic-induced endotoxin release in patients undergoing hepatic resection.

It has been proved that antibiotics binding to penicillin-binding protein 3 (PBP3) are associated with the greater release of endotoxin than those that bind to PBP2 in both in vitro and animal models. The aim of this study is to evaluate the potential clinical implications of antibiotic-induced endotoxin release after hepatic resection. Forty-five patients who underwent hepatic resection in our clinic were enrolled. The patients were divided into two groups. Group A (n = 26): antibiotics that bind primarily to PBP3, including cefmetazole (CMZ), latamoxef (LMOX), flomoxef (FMOX), were used. Group B (n = 19); antibiotics that bind to both PBP2 and PBP3, including cefazolin (CEZ), cefoperazone (CPZ), cefotiam (CTM). Postoperative complications, liver functional tests, and chemical mediators [endotoxin, interleukins (IL-6, IL-8), tumor necrosis factor alpha (TNFalpha), granulocyte colony-stimulating factor (G-CSF), hepatotrophic growth factor (HGF) were examined after hepatic resection. There were no significant differences in the backgrounds of the two groups. Eight patients in each group developed postoperative complications; in particular, 9 of 13 patients with biliary tract carcinoma developed postoperative complications. No significant elevation of peripheral blood endotoxin was noted by the endospecy method, in any of the patients, although six died following sepsis. Pre- and postoperative levels of cytokines showed no significant difference between the two groups. Our data suggest that clinical antibiotic-induced endotoxin release would not occur after hepatic resection regardless of the antibiotic, probably owing to continuous scavenging of endotoxin from peripheral blood.

Middle-preserving pancreatectomy for multifocal intraductal papillary mucinous neoplasms of the pancreas: report of a case.

Abstract Multifocal or continuous pancreatic lesion is identified frequently but finding an appropriate surgical approach is quite challenging. Total pancreatectomy is a useful procedure. However, postoperative endocrine and exocrine disturbance is inevitable. Recently, the safety and feasibility of parenchyma preserving pancreatectomy, including middle-preserving pancreatectomy (MPP), have been reported. MPP is a combined procedure of pancreaticoduodenectomy and distal pancreatectomy, while preserving the body of the pancreas, for cases of multifocal pancreatic lesions. So far, there have only been a few reports that have described MPP. We report a case of MPP for multifocal intraductal papillary mucinous neoplasms of the pancreas, describe the surgical procedure, and discuss the feasibility of MPP as parenchyma-preserving pancreatectomy with reference to the literature.

Functional assessment of liver for extended hepatic resection in patients with obstructive jaundice

We studied whether the maximal excretion rate of indocyanine green (ICG Bmax) and the 2-h ICG excretion rate in the bile could be used to estimate the separate functions of the left and right liver in 20 patients with biliary obstruction at the hepatic hilus. ICG Bmax was measured after biliary decompression. An operative procedure that preserved the side of the liver with a positive ICG Bmax value was selected. Eighteen patients tolerated extensive hepatic resection, such as right trisegmentectomy, extended right lobectomy, extended left lobectomy, or left lobectomy. However, prolonged jaundice was observed postoperatively in five of the six patients with 2-h excretion rates of less than 25% and who had undergone extended right lobectomy. One patient on whom extended right lobectomy had been performed died because of postoperative hepatic failure. His ICG Bmax value was +0.6 and his 2-h excretion rate was very low (3%). ICG Bmax and the 2-h excretion rate in the bile reflected well the degree of separate hepatic dysfunction in patients with biliary obstruction at the hepatic confluence. If ICG Bmax value is more than +1.0, resection of more than two segments, such as trisegmentectomy or extended hepatic lobectomy, may be tolerated, and if the ICG Bmax value is positive, hepatic lobectomy may be tolerated. ICG Bmax and 2-h excretion rate in bile are useful indicators of hepatic functional reserve of the separate lobes of the liver in patients with biliary obstruction at the hepatic hilus.

Effect of previous abdominal surgery on short-term outcomes following laparoscopic colorectal surgery.

653 Background: The impact of previous abdominal surgeries on the need for conversion to open surgery and on short-term outcomes during/after laparoscopic colorectal surgery was retrospectively investigated. This retrospective cohort study was conducted from May 2004 through October 2012. This study was conducted at Tokushima University Hospital and Ehime Prefectural Central Hospital. Methods: A total of 145 consecutive patients who had undergone laparoscopic resection of the sigmoid colon and upper rectum were classified as not having previous abdominal surgery (NPAS group, n = 123) or as having previous abdominal surgery (PAS group, n = 22). Short-term outcomes were assessed between the two groups. Results: The population of previous abdominal surgery consisted of 6 appendectomy, 3 gastrectomy for gastric ulcer, 2 nephrectomy, 2 peritonitis and 11 others (2 duplication). There were no significant differences in age, gender, BMI, tumor location, tumor size, Stage, operating time, blood loss and number of...

Transmission or 'occult' hepatitis B infection after living-related liver transplantation

Abstract A 22-year-old female with origin unknown liver cirrhosis in the absence of serological markers for hepatitis B (HBV) except for HBV-DNA developed fulminant hepatitis with HBV after liver transplantation. The donor was her father with Gilbert’s syndrome who showed anti-HBs and low titer anti-HBc positive. Severe hepatitis developed in the grafted liver due to HBV at 11 months postoperatively. HBsAg and HBeAg became positive, while anti-HBs, anti-HBe, anti-HBc, and hepatitis C were negative. After hepatitis B infection was confirmed by a liver biopsy, treatment with HB immunoglobulin and prostaglandin E1 were initiated. Despite intensive-care support including frequent plasma exchange and continuous hemofiltration, the patient died at 16 months postoperatively. Pre-transplant serum HBV-DNA was positive in the recipient but negative in the donor, while immunopathologic studies for HBsAg and HBV-DNA were negative in the liver of both the recipient and donor. Therefore, acquisition of HBV in the recipient would be due to occult pre-transplant infection. In conclusion, the pre-transplant evaluation of HBV-DNA in the liver tissue and serum should be examined when liver transplantation is attempted in patients with origin unknown liver cirrhosis.

Successful resection of cholangiocellular carcinoma with tumor thrombus in the main trunk of the portal vein

A space-occupying lesion in the right hepatic lobe, with dilated peripheral bile ducts, was observed by ultrasonography and computed tomography in a 50-year-old man with right upper quadrant abdominal pain. One month later, this lesion evidenced rapid growth and a tumor thrombus, which completely occluded the main trunk and the left primary branch of the portal vein, had developed. The tumor was diagnosed as a cholangiocellular carcinoma with an unusual pattern of intravascular extension. The primary tumor and the portal tumor thrombus were resected via a right hepatic trisegmentectomy combined with resection of the portal vein and extrahepatic bile duct, using a superior mesenteric vein—left femoral vein catheter bypass (SMV—FV bypass). The SMV—FV bypass was found to effectively reduce intraoperative hemorrhage.

An Experimental Study on Gastric Secretion Following Proximal Massive Small Bowel Resection.

小腸近位側2/3切除術後の胃酸分泌動態を分泌促進系因子面から検討するため, 実験犬を用い酸分泌能, 右胃大網静脈 (RGEV) 血漿ガストリン値とヒスタミン値, 幽門洞G細胞数, 壁細胞数を経時的に測定した.1) 術後3～4週: BAO, MAO (mEq/h), 壁細胞数 (個/0.2mm幅垂直切片柱) はそれぞれ48.5%, 28.2%, 16.4%増加し, RGEV血漿ガストリン値 (pg/ml), ヒスタミン値 (nM), G細胞数 (個/mm幅垂直切片柱) はそれぞれ57.8%, 32.2%, 10.9%減少した.2) 術後11～12週: BAOは術前値にほぼ回復したが, MAOは減少傾向を示すものの高値を持続した.RGEV血漿ガストリン値とヒスタミン値は増加し術前値に回復する傾向を示した.壁細胞数はやや減少したのに対しG細胞数は増加した.以上から, 術後の胃酸分泌能の亢進は壁細胞数の増加と機能亢進が直接関与しており, RGEV血漿ガストリンおよびヒスタミンの変動は,酸分泌量の増減に伴うfeedback作用の結果であると考えられた.