Masao Tanaka

A model of port-site metastases of gallbladder cancer: the influence of peritoneal injury and its repair on abdominal wall metastases.

BACKGROUNDnRecent surgical literature contains several reports of wound metastases of unexpected gallbladder cancer after laparoscopic cholecystectomy. We hypothesized that peritoneal injury caused by trocar insertion potentiates wound metastases. This study was designed to determine the effect of peritoneal injury on tumor implantation.nnnMETHODSnCultured human gallbladder cancer cells were injected into the peritoneal cavity of mice immediately after surgical procedures. In a peritoneal injury group muscle and the peritoneum were perforated; in a peritoneal injury and repair group each muscle and peritoneal wound was sutured carefully; in a laparoscopic model group animals underwent peritoneal insufflation with carbon dioxide gas and tumor cell injection and then the abdominal wall was perforated. Some mice (controls) were not subjected to any surgical procedure. All mice (n = 178) were killed 2 weeks after tumor cell injection and were examined for tumor implantation.nnnRESULTSnAlthough no control mice showed intraperitoneal tumor, all mice in the peritoneal injury group showed tumors at the injured sites. In the laparoscopic model group, 90% of injured sites had tumors. The traumatized site-specific implantation rate in the peritoneal injury and repair group was only 40%, whereas it was 100% in the peritoneal injury group (P < .001).nnnCONCLUSIONSnPeritoneal injury enhances peritoneal implantation of carcinoma cells. Repair of injured peritoneum at trocar sites may reduce the frequency of wound metastases in laparoscopic surgery for unexpected gallbladder carcinoma.

Relationship of biliary pressure to cholangiovenous reflux during endoscopic retrograde balloon catheter cholangiography.

In 32 patients undergoing endoscopic retrograde cholangiography with a balloon catheter, culture of bile, biliary pressure at maximal visualization of the biliary tract with iodinated contrast medium, serum iodine concentrations, and blood cultures before and after the procedure were obtained. There was a significant increase in the serum iodine concentration in five of nine patients (55.6%) with pressure between 22 cm H2O and 30 cm H2O and in nine of 13 patients (69.2%) with pressure above 30 cm H2O, while it remained low in 10 patients with pressure below 22 cm H2O. Two patients showed positive blood culture after the procedure, which yielded the same organisms as found in the bile. The biliary pressures in these two patients were 30.4 cm H2O and 38.0 cm H2O. These data suggest that during retrograde balloon catheter cholangiography: (1) cholangiovenous reflux of contrast medium develops with biliary pressure higher than 22 cm H2O, (2) the indicence of the cholangiovenous reflux increases as the pressure is elevated, and (3) regurgitation of bacteria occurs with pressure greater than 30 cm H2O. These findings are noteworthy because the number of patients who need direct cholangiography is increasing.

Cholangiography of intrahepatic bile ducts in hepatolithiasis by endoscopic placement of an indwelling balloon catheter

To improve the diagnostic yield and safety of endoscopic retrograde balloon catheter cholangiography, two technical refinements were added: (1) intraductal retention of a balloon catheter allowing injection of a contrast medium in the supine position; and (2) slow, constant injection of the contrast medium with a heavy-duty infusion pump. Maximum filling of intrahepatic branches was attempted by both the original balloon method and the new method in seven hepatolithiasis patients. The new method was superior for visualization of the right intrahepatic ducts. Although there were no significant differences in the amount of filling of the left intrahepatic ducts, the new method provided an unobstructed view since the endoscope was out of the way. Harmful rapid increase of intraductal pressure and excessive injection of contrast medium were avoided by fluoroscopically controlled infusion. No serious complications were encountered.

Is peripapillary choledochoduodenal fistula an indication for endoscopic sphincterotomy

BACKGROUNDnMost patients with a peripapillary choledochoduodenal fistula undergo fistulotomy by endoscopic sphincterotomy for the treatment of bile duct stones. However, whether sphincterotomy should be performed in patients with the fistula but without stones is controversial.nnnMETHODSnAmong 165 patients in whom a benign peripapillary choledochoduodenal fistula was diagnosed at ERCP, the clinical outcome was retrospectively analyzed and compared between those who underwent fistulotomy by endoscopic sphincterotomy (group 1) and those whose fistula was left untreated (group 2). All patients with hepatolithiasis, residual stones, biliary diversion, or transduodenal papilloplasty were excluded (32, leaving 133). Fistulas were divided into types I and II according to the location of the fistula (Ikeda classification).nnnRESULTSnFollow-up data collected during a median period of 124 months were available for 127 of 133 patients (95%), 76 in group 1 and 53 in group 2. Late complications were bile duct stone recurrence (17 patients), acute cholangitis (7 patients), and biliary carcinoma (2 patients). The incidence of stone recurrence was not significantly different between the 2 groups (p = 0.1). In group 2, 4 patients (8%) with an untreated type II fistula had 1 to 3 episodes of presumed reflux cholangitis, which resolved quickly with conservative treatment.nnnCONCLUSIONSnEndoscopic sphincterotomy is not always necessary for peripapillary choledochoduodenal fistulas if bile duct stones are absent because reflux cholangitis is a relatively rare complication that can be easily managed.

Health-related quality of life in a randomised phase III study of gemcitabine plus S-1, S-1 alone and gemcitabine alone for locally advanced or metastatic pancreatic cancer: GEST study

Objective: This study was performed to compare health-related quality of life (HRQOL) of gemcitabine plus S-1 (GS), S-1 alone and gemcitabine alone as first-line chemotherapy for locally advanced or metastatic pancreatic cancer in the GEST (Gemcitabine and TS-1 Trial) study and to assess the impacts of adverse events and tumour response on HRQOL. Methods: Patients were randomly assigned to receive gemcitabine alone (1000u2009mg/m2 weekly for 3 of 4 weeks), S-1 alone (80, 100 or 120u2009mg/day twice daily for 4 of 6 weeks) or GS (gemcitabine at 1000u2009mg/m2 weekly plus S-1 at 60, 80 or 100u2009mg/day twice daily for 2 of 3 weeks). HRQOL was assessed using the EuroQoL-5D (EQ-5D) questionnaire at baseline and weeks 6, 12, 24, 48 and 72. EQ-5D scores, quality-adjusted life months (QALMs), quality-adjusted progression-free months (QAPFMs) and time until definitive HRQOL deterioration (TUDD) were compared among the three groups. The impacts of adverse events and tumour response on EQ-5D scores were analysed. Results: Including EQ-5D scores after death as 0, the mean profile was significantly better in the GS than gemcitabine group (difference, 0.069; p=0.003), but not the S-1 group (difference, −0.011; p=0.613). The mean profiles until death were similar in the three groups. QALMs, QAPFMs and TUDD were significantly longer in the GS than gemcitabine group (p<0.001, p<0.001 and p=0.004, respectively), but not the S-1 group (p=0.563, p=0.741 and p=0.701, respectively). Fatigue, anorexia and tumour response were significantly associated with changes in EQ-5D scores. Conclusions: GS achieved better HRQOL than gemcitabine alone, resulting a good balance between overall survival and HRQOL benefits. S-1 alone provides HRQOL similar to that provided by gemcitabine alone. Preventing fatigue and anorexia and maintaining better response would improve HRQOL.

Methicillin-resistant Staphylococcus aureus Disappeared in the Gastroenterologic Surgery. A 2-year Study.

本邦の大病院ではメチシリン耐性黄色ブドウ球菌 (MRSA) が蔓延している. 当科では基本的な感染対策を行っているので, 94年1月から95年12月まで消化器外科の患者から得られた細菌1,408株を対象に解析した. その間術前1週間はヨード剤による含嗽と鼻前庭除菌を行い, 回診順序は術後観察室→ 一般病室→MRSAの隔離室の順とした. 統計学的にMRSA, カンジダ属, 緑膿菌および腸球菌の陽性者数を折れ線回帰分析した. その結果, 95年1月からカンジタ属は増加したが, MRSA, 縁膿菌, 腸球菌は減少した. MRSAの計55株は94年全株 (n=908) のうち6.1%, 95年 (n=500) では皆無だったが, カンジタ属は5.0% (45株) から5.8% (29株) へ増加した. 当科のMRSA検出ゼロ化には, 術前の上気道に対する処置などの基本的な感染症対策が功を奏していると思われる.