Masayoshi Nagayama

Postoperative total parenteral nutrition in patients with liver disorders

Sixty-one patients with liver disorders receiving total parenteral nutrition (TPN) for about 14 postoperative days were divided into three groups based on the parenteral nutritional regimen. The influence of these TPN solutions on the liver function tests and the nutritional assessments, and the availability of the specially formulated amino acid solution were studied. Glucose alone as energy source was infused in Group Ia. The mixture of glucose and fructose was infused in Group Ib. In these patients (Group I), a commercially available amino acid solution was administered simultaneously. A specially formulated amino acid, rich in branched-chain amino acids but poor in aromatic amino acids was infused with the mixture of glucose and fructose in Group II. There was no remarkable elevation of blood glucose and lactate levels in all patients. Blood glucose levels in Group Ib were maintained lower than that in Group Ia. Except for serum alkaline phosphatase, no remarkable abnormality was observed in liver function tests. Body weight changes were less than 5% in each group. Average nitrogen balances were -44.5 mg/kg/day in Group Ia, -5.5 mg/kg/day in Group Ib, -51.5 mg/kg/day in Group II. While the abnormalities in serum amino acid pattern and molar ratio of leucine, isoleucine, and valine to phenylalanine and tyrosine tend to be more enhanced in Group I, these abnormalities returned to near normal in Group II during TPN. By multiple linear regression analyses, 45 kcal/kg/day of energy intake would be required to maintain nitrogen equilibrium and zero body weight change. And when nitrogen intakes were 159 mg/kg/day in Group Ia, 114 mg/kg/day in Group Ib, and 189 mg/kg/day in Group II at 45 kcal/kg/day in energy intake, nitrogen balances were expected to be equivalent. These results suggest that postoperative TPN is good for nutritional support in patients with liver disorders. And also, the combination of glucose and fructose has better effect on nitrogen balance. The postoperative TPN with a specially formulated amino acid solution may be a valuable way of maintaining the nutritional status as well as normal serum amino acid pattern in patients with liver disorders.

Fat emulsion in surgical patients with liver disorders.

Total parenteral nutrition (TPN) with fat emulsion was evaluated in 68 patients with liver disorders who were admitted to the First Department of Surgery, Osaka City University Medical School. All patients received transabdominal direct operation for esophageal varices. Immediately after their operations, 28 received TPN with carbohydrate and fat emulsion as an energy source (FAT group), and 40 received TPN with only carbohydrate as an energy source (non-FAT group). Liver function tests, blood glucose levels, intravenous fat tolerance tests, serum lipid levels, fatty acid composition of serum total lipids, and nitrogen balance of the two groups were compared during postoperative TPN. The administration of fat emulsion during postoperative TPN in patients with liver disorders did not worsen the results of liver function tests and the relatively low levels of blood glucose were retained, thereby correcting the abnormalities in the fatty acid composition of serum total lipids. Rates of clearance of fat emulsion during postoperative TPN were significantly higher than in the preoperative period, and changes in serum lipid levels revealed no tendency toward retention of fat emulsion administered intravenously. Nitrogen balance and change in body weight during postoperative TPN were similar in both groups. These results suggest that for patients with liver disorders, the administration of fat emulsion is useful during postoperative TPN.

Nonfunctioning islet cell carcinoma presenting bleeding gastric varices and splenomegaly

This is a report of a 63-year-old Japanese woman with a nonfunctioning islet cell carcinoma of the pancreas presenting bleeding gastric varices and splenomegaly. These manifestations are extremely rare in patients with nonfunctioning islet cell tumor. The tumor originated in the tail of the pancreas and grew mainly within the spleen. The gastric varices due to increased blood flow to the tumor and arteriovenous fistuals within the tumor were confirmed by angiography and operation. The tumor was resected and she is in a good health for 14-months after the operation.

Serum fatty acid concentrations in patients on postoperative parenteral nutrition with and without fat

To examine changes in fatty acid composition of serum lipids, sixteen patients with gastric cancer were maintained on total parenteral nutrition (TPN) or intravenous feeding immediately after total gastrectomy. Subjects receiving no fat showed decreases in linoleic acid, linolenic acid and arachidonic acid and increases in palmitoleic acid and oleic acid, whereas those receiving fat emulsion showed no detectable changes. Decrease in the linoleic acid content was greater in subjects on a higher carbohydrate intake, but less in those on a higher fat intake. Multiple regression analysis of the relationships among carbohydrate intake (X1) and fat intake (X2) and changes in the linoelic acid percentage of total serum fatty acids (Y) in each case yielded an equation: Y=−4.75 X1+69.0 X2−27.9 (R=0.885, p<0.05). Approximately 1 g/kg/day of fat provided in 40–50 kcal/kg/day of nonprotein energy intake was estimated to prevent decrease in the linoleic acid content in the serum fatty acid pattern during the postoperative catabolic stage.

Laparoscopic cholecystectomy for cholelithiasis in patients with liver cirrhosis.

We performed laparoscopic cholecystectomy for symptomatic cholelithiasis on four patients with cirrhosis of the liver, two of whom had clinical portal hypertension and splenomegaly. Preoperative examination disclosed hypersplenism in one patient, while mild thrombocytopenia and decreased prothrombin concentration were noted in three patients. However, no remarkable bleeding tendency was recognized clinically in any of the patients. Preoperatively, by Child-Pughs criteria, three patients had class B disease and one class A disease. Intraoperatively, remarkable inflammatory change or fibrotic change of the gallbladder wall and Calots triangle was observed in two cases, and collateral veins and lymphangial congestion were observed in all four cases. In the first case, extreme bleeding and lymphorrhea from dissected sites were observed, and a 1.5 unit of transfusion of whole blood was required during operation. Postoperatively, increase in ascites which was controlled with diuretics was recognized in one case. However, the postoperative course was uneventful in all cases, and no serious complications were recognized. That laparoscopic cholecystectomy can be safely performed in patients with cirrhosis if careful and appropriate management of bleeding and lymphorrhea from sites of dissection is ensured, is encouraging.

A Retrospective Study of Laparoscopic Versus Open Cholecystectomy.

最近2年2か月間の胆襲摘出術症例120例を腹腔鏡下胆菱摘出術が施行された78例 (LC群) と開腹下胆襲摘出術が施行された42例 (OC群) の2群に分け, 術前所見, 手術成績および手術前後の検査値の変動などについて比較検討した. 術前所見では胆襲造影陰性例, 急性胆嚢炎および開腹術の既往は両群間に差はなく, 併存疾患の合併率はLC群で多かった. 手術成績では, LC群ではOC群に比べ手術時間の延長がみられるものの出血量は有意に減少した. またLC群では発熱の頻度および程度が軽減し, 術後白血球数, CRPの増多および術後疼痛がより軽度で, 経口開始日数および入院日数の短縮もみられた. 術後の肝あるいは腎機能におよばす影響も少なかった. これらのことから, LCでは手術侵襲はOCに比べより軽微であると考えられ, また, 手術時間は延長する傾向があるものの重篤な合併症もみられず, 胆襲輸出術の標準術式と考えてよいと思われた.

Endoscopic treatment for esophageal stomal stricture.

1983年から1988年までの6年間に当科で内視鏡的拡張術を施行した食道吻合部狭窄31例を対象として, 10回以上の拡張術を必要としたり, 拡張術施行後早期に再狭窄をきたした難治群5例と数回の拡張術により狭窄症状の軽快した良好群26例について比較検討した.その結果, 術後合併症としては縫合不全の有無およびその程症, 内視鏡的には拡張術1～2週間後の吻合口短径・長径比の測定, X線学的には拡張術前の狭窄部の長さの測定が狭窄の予後判定に有用であると考えられた.また治療に難渋する症例では吻合部での癌の再発に留意し, また狭窄部の極めて長い症例では外科的治療を含めた他の治療法を考慮すべきであると考えられた.

Surgical treatment for Crohn's disease.

当科で外科的治療が行われたCrohn病9例の手術適応および手術成績について検討した, 病型分類は小腸型3例, 小腸大腸型5例, 大腸型1例であり, 手術適応は穿孔2例, 瘻孔2例, 難治性狭穿2例, S状結腸癌疑診1例, 盲腸単純性潰瘍1例, 内科的治療抵抗1例であった, 手術術式は全例に主病巣の腸管切除がなされた. 穿孔2例はともに術前1ヵ月以上におよぶtotal parenteral nutritionを受けていたが, 病態の改善をみることなく穿孔した. 瘻孔2例は1例が回腸臍瘻であり, 1例が回腸S状結腸瘻および回腸膀胱瘻であった. 痔瘻を有する症例では再発率, 再手術を要する率が高かった. 術後は7例においてほぼ満足する社会生活を営んでいた.

Clinical and histopathological study on colorectal carcinoma in young adults.

当教室で最近13年間に経験した大腸単発癌手術施行例570例を対象とし, 39歳以下の若年者大腸癌の臨床病理学的所見ならびに手術成績について検討した.若年者大腸癌は570例中57例 (10.0%) であり, 女性が多かった.若年者大腸癌では, 組織型は粘液癌が多く, 壁深達度, リンパ節転移率, 腹膜播種, 組織学的進行程度において進行度の進んだ症例が有意に多かった.若年者の全手術例の累積5年率は41.0%と非若年者とくらべ有意に低率であったが, 治癒切除例の累積5年率は71.6%と非若年者の76.3%とくらべ有意差はなかった.若年者における大腸癌の早期診断ならびに治癒手術への努力が重要であると思われた.