Naruo Kawasaki

Laparoscopic Heller myotomy and Dor fundoplication for the treatment of achalasia. Assessment in relation to morphologic type

BackgroundThe significance of laparoscopic Heller myotomy and Dor fundoplication (LHD) for the treatment of achalasia in relation to the severity of the lesion has not been sufficiently assessed.MethodsOf patients who were diagnosed with achalasia from August 1994 to February 2004, 55 individuals who underwent LHD served as subjects. The therapeutic effects of LHD were assessed in terms of operation time, intraoperative complications, postoperative hospital stay, and symptom improvement in relation to morphologic type (spindle type, Sp; flask type, Fk; and sigmoid type, Sig). Degree of symptomatic improvement was classified into four grades: excellent, good, fair, and poor.ResultsBreakdown of morphologic type was as follows: Sp, n = 29; Fk, n = 18; and Sig, n = 8. Excluding one patient for whom conversion to open surgery was required, median average operation time for 54 patients was 160 min. As to intraoperative complications, esophageal mucosal perforation was seen in nine of the 55 patients (16%); however, conversion to open surgery could be avoided by suturing the affected area. Moreover, intraoperative bleeding of at least 100 g was seen in five of the 55 patients (9%), with one Fk patient requiring conversion to open surgery and transfusion. Median postoperative hospital stay was 8 days. Degree of dysphagia relief was excellent in 45 patients (83%), good in eight patients (15%), and fair in one patient (2%). Excellent improvement was obtained in 90%, 88%, and 50% in Sp, Fk, and Sig patients, respectively. Reflux esophagitis was seen in two patients, and was treated with a proton pump inhibitor.ConclusionsThe results of the present study suggest that classification of morphologic type is a useful parameter in predicting postoperative outcome in achalasia. In order to achieve excellent symptomatic relief, surgery for achalasia should be recommended for but not limited to Sp and Fk types.

Effect of Dai-kenchu-to on Gastrointestinal Motility Based on Differences in the Site and Timing of Administration

The purpose of this study was to investigate the effects of the herbal medicine dai-kenchu-to on gastrointestinal motility based on differences in the administration site and timing. We sutured strain-gauge transducers to the stomach (three), duodenum (one), jejunum (one), ileum (one), and colon (two) and inserted indwelling tubes into the stomach, jejunum, and proximal colon of beagles. Dai-kenchu-to was administered to each site during the fasting or fed state. During the fasting state, the prokinetic effects of dai-kenchu-to were evident at all administration sites. The effects were attenuated during the fed state. With intracolonic administration, a contraction similar to the giant migrating contraction-like contraction was induced during the fasting and the fed state, and defecation occurred. Despite the differences in administration site and timing, no contraction complex appeared orad to the administration sites. These results indicate that the prokinetic effects of dai-kenchu-to differ with the site or timing of administration.

Alendronate improves vitamin d-resistant osteopenia triggered by gastrectomy in patients with gastric cancer followed long term

Gastrectomy/gastric bypass has been used for patients with gastric cancer, and its application is now expanding to treating patients with morbid obesity, the prevalence of which is increasing worldwide. It is well known that gastrectomy leads to osteopenia, but the underlying pathophysiology and optimum treatments for this disorder have not been delineated. We followed 13 patients who showed progressive osteopenia (bone mineral density T-score <-2.4 SD) after gastrectomy/gastric bypass due to gastric cancer and who were resistant to long-term treatment (mean, 6 years) of active vitamin D3 and prospectively studied the effects of alendronate, a bisphosphonate, on osteopenia-related parameters for 2 years. Oral administration of alendronate in addition to vitamin D3 led to remarkable improvement within 2 years, not only in clinical symptoms, such as radial bone fractures and lumbar pain, but also in parameters for osteopenia, including decreased bone mineral density of the lumbar spine (P < 0.01), decreased concentrations of calcium (P < 0.05), increased urine levels of deoxypyridinoline (P < 0.01), increased serum levels of bone-specific alkaline phosphatase (P < 0.01), increased serum levels of osteocalcin (P < 0.01), and increased serum levels of intact parathyroid hormone (P < 0.05), although body weight did not alter. These results suggest that bisphosphonate may improve osteopenia after gastrectomy/gastric bypass.

Preoperative dilatation does not affect the surgical outcome of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia.

Background Laparoscopic Heller myotomy and Dor fundoplication are now widely performed for achalasia. In patients who have had dilatation in the past, inflammation between the esophageal mucosal and muscular layers may make it difficult to perform myotomy. Purpose We investigated the effects of preoperative dilatation on the surgical outcomes. Method : One hundred and twelve patients were divided into 2 groups: 37 patients with a past history of preoperative dilatation and 75 patients who had no history of preoperative dilatation. The operating time, intraoperative blood loss, days required to resume postoperative oral intake, postoperative hospital stay, improvement in dysphagia, and incidence of postoperative esophagitis were compared. Results The operating time, intraoperative blood loss, postoperative hospital stay, and improvement of dysphagia were no significant differences between these groups. Furthermore, there were no significant differences in the incidence of postoperative esophagiatis. Conclusions The therapeutic outcome of laparoscopic Heller myotomy and Dor fundoplication is not affected by preoperative pneumatic dilatation.

Early postoperative enteral nutrition is useful for recovering gastrointestinal motility and maintaining the nutritional status

PurposeThe efficacy of enteral nutrition in postoperative nutritional management is known, but the effects on gastrointestinal motility and nutrition have not yet been elucidated. The purpose of this study was to compare the effects of enteral and parenteral nutrition soon after open abdominal surgery on gastrointestinal motility and nutritional status.MethodsA partial resection of rectum models was prepared to compare two types of nutrient administration: enteral nutrition and total parenteral nutrition. The differences between the effects of nutrition types in terms of gastrointestinal motility and nutritional status were investigated.ResultsEnteral nutrition contributed to recovery of gastrointestinal motility and maintenance of nutritional status.ConclusionEnteral nutrition should therefore be initiated soon after surgery if the gastrointestinal tract is available.

Therapeutic Effects of a Laparoscopic Heller Myotomy and Dor Fundoplication on the Chest Pain Associated with Achalasia

PurposeThe therapeutic effects of a laparoscopic Heller myotomy and Dor fundoplication (LHD) on the chest pain associated with achalasia were investigated.MethodsSixty-six patients who were diagnosed to have achalasia underwent LHD. The degree of dilatation was assessed based on the maximum horizontal diameter of the esophagus (Grades I–III). The type of dilatation was assessed based on the shape of the distal esophagus, namely, spindle type (Sp), flask type (Fk), and sigmoid type (Sig). The degree of improvement was classified into three grades as follows: A (complete disappearance), B (partial response), and C (unchanged).ResultsChest pain improved (A or B) in 22 patients (92%). The statistical results revealed that the improvement of postoperative A or B was significantly better in patients with Sp than in those with Fk or Sig (P = 0.0213). In addition, the results revealed that the improvement of postoperative A or B was significantly better in patients with grade I and grade II than in those with grade III (P = 0.004).ConclusionLHD is an effective therapeutic technique for the treatment of chest pain associated with achalasia. These results suggest that both the morphological type and esophageal dilatation are useful predictors for the improvement of chest pain after surgical therapy.

Epidural Administration of Morphine Facilitates Time of Appearance of First Gastric Interdigestive Migrating Complex in Dogs with Paralytic Ileus After Open Abdominal Surgery

Morphine is known to delay gastric emptying and intestinal transit, although epidural morphine is believed to decrease postoperative complications. However, these findings are still controversial and based only on clinical observations. We investigated the effects of epidural morphine administration on gut motility by measuring interdigestive migrating complex after open surgery in dogs. Twenty-eight beagles were divided into four groups (n = 7 each) to receive epidural saline (control group), epidural morphine, epidural ropivacaine, or low-dose continuous intravenous morphine. Strain gauge force transducers were sutured under open operation to the serosal surface of the stomach, duodenum, jejunum, and ileum to monitor gut motility. Time of appearance of first interdigestive migrating complex from the stomach propagated to the distal intestine was significantly shorter in the group that received epidural morphine compared with the other three groups. These results suggest that epidural administration of morphine may facilitate recovery from paralytic ileus after open abdominal surgery, perhaps through its effects on the central nervous system.

Covering the percutaneous endoscopic gastrostomy (PEG) tube prevents peristomal infection.

BackgroundBecause oropharyngeal bacteria can be brought through the abdominal wall during percutaneous endoscopic gastrostomy (PEG), peristomal infection is one of the most frequent complications in patients who undergo the procedure. This study aimed to determine whether covering the PEG tube with a sheath that could be detached in the stomach could help prevent peristomal infection.MethodsIn three community hospitals in Japan, data from 449 patients with swallowing dysfunction were prospectively collected between March 2000 and February 2002 for non-covered PEG (n = 206) and between March 2002 and February 2004 for covered PEG (n = 243).ResultsAfter adjusting for hospital, age, gender, and underlying diseases, covering the PEG significantly reduced peristomal purulent infection compared with non-covered PEG (odds ratio: 0.05; 95% confidence interval: 0.02–0.13). Body temperature, white blood cell count, and C-reactive protein at day 3 after PEG placement, as well as duration of antibiotics usage, were significantly lower or shorter in patients treated with covered PEG than non-covered PEG. In spite of the same frequencies in the two groups of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa in oropharyngeal cultures before PEG placement, these organisms were detected significantly less frequently in peristomal lesions of patients who underwent covered PEG. Moreover, 28 patients treated with covered PEG received no antibiotic therapy, and 27 of them had no signs of peristomal infection.ConclusionsThese results suggest that covering the PEG tube, with or without providing antibiotic therapy, may prevent peristomal infection in spite of the presence of oropharyngeal bacterial flora after percutaneous endoscopic gastrostomy.

Prediction of recurrence after laparoscopic fundoplication for erosive reflux esophagitis based on anatomy-function-pathology (AFP) classification

BackgroundThe usefulness of the anatomy–function–pathology (AFP) score was examined to evaluate its prediction of recurrence after laparoscopic fundoplication for erosive reflux esophagitis.MethodsOf the patients undergoing laparoscopic fundoplication for erosive reflux esophagitis of Los Angeles classification grade A or higher from December 1994 to December 2004, 107 who underwent preoperative barium esophagogram, pH monitoring, and endoscopy were selected as subjects. The AFP score was calculated by A, F, and P factor grades of the AFP classification. By comparing patients with and without recurrence, the usefulness of the AFP score for predicting recurrence was examined.ResultsReflux esophagitis recurred in seven patients. No significant difference in age, sex, or A or F factor was observed between the groups, whereas a significant difference was observed in the P factor (p = 0.008). On the other hand, the mean AFP score in the recurrence group was 16.9 ± 5.3, whereas that in the nonrecurrence group was 8.9 ± 5.3 (p = 0.0021). Among the patients with a score of 17 points or more (n = 23), recurrence was found in 6 patients (26%). On the other hand, among the patients with a score lower than 17 points (n = 84), recurrence was found in 1 patient, but not in the remaining 83 patients (1%). Sensitivity was thus 85.7% (95% confidence interval [CI], 42.1–99.6), and specificity was 83% (95% CI, 74.2–89.8). The positive predictive value was 26.1% (95% CI, 10.2–48.4), and the negative predictive value was 98.8% (95% CI, 93.5–99.9). Multiple logistic regression analysis was performed, and receiver operating characteristics curves were obtained. The area under the curve for the AFP score was 0.8457, whereas that for the P factor was 0.7907 (p = 0.0045), suggesting that the AFP score may more accurately predict recurrence than the P factor.ConclusionThe AFP score may be useful for predicting postoperative recurrence. If surgery is performed when the AFP score is lower than 17 points, the likelihood of postoperative recurrence is expected to be very low.

Laparoscopic Collis gastroplasty and Nissen fundoplication for reflux esophagitis with shortened esophagus in Japanese patients.

Background There is an extremely small number of surgical cases of laparoscopic Collis gastroplasty and Nissen fundoplication (LCN procedure) in Japan, and it is a fact that the surgical results are not thoroughly examined. Purpose To investigate the results of LCN procedure for shortened esophagus. Patients and Methods The subjects consisted of 11 patients who underwent LCN procedure for shortened esophagus and followed for at least 2 years after surgery. The group of subjects consisted of 3 men and 8 women with an average age of 65.0±11.6 years, and an average follow-up period of 40.7±14.4 months. Esophagography, pH monitoring, and endoscopy were performed to assess preoperative conditions. Symptoms were clarified into 5 grades between 0 and 4 points, whereas patient satisfaction was assessed in 4 grades. The use of postoperative acid-reducing medication and the recurrence of esophagitis were also investigated. Results None of the patients experienced intraoperative complications, received transfusions, required conversion to open surgery, or died postoperatively. The average preoperative heartburn, regurgitation, and dysphagia scores were 2.36±1.29, 2.27±1.19, and 1.82±1.78 points, respectively. These scores improved after surgery to 0.55±1.21 (P=0.0063), 0.55±1.21 (P=0.0094), and 1.0±1.18 (P=0.1236) points, respectively. All patients had esophagitis preoperatively, which recurred in 3 patients (27%). In these 3 patients, acid-secreting mucosa was confirmed on the oral side of the wrap, by positive Congo-red staining. Hiatal hernia recurred in one patient, who also experienced recurrent esophagitis. Five patients received acid-reducing medication postoperatively. The degree of satisfaction was excellent in 2, good in 6 patients, fair in 2, and poor in 1 patient(s). Conclusions Although the LCN procedure can be performed safely, the outcome was not necessarily satisfactory. The LCN procedure requires avoidance of residual acid-secreting mucosa on the oral side of the wrapped neoesophagus. If acid-secreting mucosa remains, continuous acid suppression therapy should be employed postoperatively.