Nobuhiro Koyanagi

Endoscopic classification of gastric varices

Endoscopic observations of gastric varices in 124 patients were classified according to form, location, and color. Form was classified into three types: tortuous (F1), nodular (F2), and tumorous (F3). Location was classified into five types: anterior (La), posterior (Lp), lesser (Ll) and greater curvature (Lg) of the cardia, and fundic area (Lf). Color was white (Cw) or red (Cr). Glossy, thin-walled focal redness on the varix was defined as red color spot (RC spot). Stepwise logistic regression analysis for multivariate adjustments was performed for all of the endoscopic covariates, and four risk factors (La, Lg, F2, RC spot) that affect bleeding from gastric varices were independently identified. This classification should aid in assessing gastric varices observed by fiberoptic endoscopy and help design appropriate treatment.

Exclusion of nonisolated splenic vein in distal splenorenal shunt for prevention of portal malcirculation.

In an attempt to prevent portoprival malcirculation after distal splenorenal shunt (DSRS), a splenic hilar renal shunt (HRS) with proximal flush ligation of splenic vein was designed. To accomplish this procedure, two methods were compared: HRS alone (Group A) and HRS plus proximal flush ligation of the splenic vein (Group B). In Group A, which included 20 cirrhotic patients with esophageal varices, angiographic as well as pulsed Doppler flowmetric follow-up study revealed a portal thrombosis in two patients and severe narrowing of a portal vein in another two. Considerable stealing flow was observed in these four patients. In the Group B series, which included 33 cirrhotic patients, there were no gross changes in the portal hemodynamics. Normal prograde portal flow was confirmed by Doppler flowmeter in this series including 14 patients of more than 8 months after surgery. When the amount of nonisolated splenic vein embedded in the pancreas is minimized, portal malcirculation after distal splenorenal shunt can, to a great extent, be prevented.

Mucosal Blood Flow and Modified Vascular Responses to Norepinephrine in the Stomach of Rats with Liver Cirrhosis

To observe changes in hemodynamics and vascular responses to norepinephrine in cases of liver cirrhosis, male WKA rats were given CCl4 subcutaneously. The portal venous pressure of these so-induced cirrhotic rats was significantly higher than that of the controls. There was an increase of mucosal blood flow and a lowering of peripheral vascular resistance of the stomach. After norepinephrine infusion, the gastric mucosal blood flow increased significantly in cirrhotic rats, whereas there was no significant change in controls. The aorta and the portal vein showed no difference in the vascular response to either norepinephrine or [K+].0. These results suggest that in cirrhotic rats there is an increase in blood flow and a lowering of peripheral vascular resistance in the gastric mucosa and that these hemodynamic changes may be derived from alteration in the vascular response to norepinephrine in gastric microcirculation.

Prognostic Value of Combination Assays for CEA and CA 19–9 in Gastric Cancer

Preoperative serum CEA and CA 19-9 levels in 158 patients with gastric cancer were analyzed with respect to prognostic factors, using univariate and multivariate analysis. The incidence of high preoperative levels of both CEA and CA 19-9 was 10.1% (16/158). 13.9% (22/158) showed high CEA levels and normal CA 19-9 levels, whereas the reverse was true in 16.5% (26/158). Neither marker showed a high level in 59.5% (94/158). The multivariate analysis showed that in addition to tumor stage, the depth of invasion, liver metastasis and peritoneal dissemination, combination assays of preoperative serum CEA and CA 19-9 levels were an independent prognostic factor. Combination assays of preoperative serum CEA and CA 19-9 will allow us to conduct a more careful postoperative follow-up of high-risk patients, and also help determine the optimum adjuvant chemotherapy.

Increased incidence of proximal colon cancer in the elderly.

To define the characteristics of colorectal cancer with regard to site distribution, age, and sex, due to the significantly increased incidence of colorectal cancer in Japan, we investigated 1,205 Japanese patients with colorectal cancer between 1975 and 1994. When we compared site distribution for age and sex in the entire 20-year period, tumors in the proximal colon were more frequent in elderly patients than in young ones (p < 0.05); this tendency was true only for females (p < 0.01), but not for males. The increased incidence of proximal colon cancer in elderly patients was also found in the second 10-year period (p < 0.05). Because elderly patients are characterized by an increasingly high incidence of proximal colon cancer in recent years, more concerted efforts for the early detection of proximal colon cancer, particularly in the elderly, are called for.

Anatomie resection for severe blunt liver trauma in 100 patients: Significant differences between young and elderly

The liver is the organ most commonly injured during blunt abdominal trauma. As our society ages, emergency surgery for active elderly patients increases, but data on aggressive emergency hepatic resection remain scarce in the literature. The purpose of this study was to determine whether the elderly (70 years of age or older) can tolerate major liver injury and subsequent hepatic resection. We investigated 100 patients who were treated by an anatomic resection for severe blunt liver trauma (29 elderly patients who were 70 years of age or older and 71 young patients who were younger than 70 years of age) in a retrospective study. The elderly patients were more severely injured as demonstrated by a higher Injury Severity Score, a lower Glascow Coma Scale, and lower survival (80.3% vs. 65.5%; p<0.05). The total number of associated injuries was greater in elderly patients. Motor vehicle accidents were responsible for 71.8% of the injuries in the young group, and the predominant mechanism in the elderly patients was also motor vehicle accidents (51.7%). The 71 anatomic hepatic resections performed on the young patients included right hemihepatectomy (n=45), left lateral segment resection (n=14), bisegmentectomy (n=5), and others. The 29 anatomic hepatic resections performed for the elderly patients were right hemihepatectomy (n=15), left lateral segment resection (n=5), left hemihepatectomy (n=4), and others. Pneumonia, subphrenic abscess, and urosepsis occurred at a significantly higher frequency in elderly patients than in young patients. Our data clearly indicated that (1) the mechanism of injury, grade of associated intraabdominal injuries, distribution of surgical procedures, and complications differ significantly between young and elderly patients; and (2) the survival rate (65.5%) in elderly patients may be sufficient to consider anatomic hepatic resection to be a useful, safe procedure.RésuméLe foie est l’organe le plus souvent lésé lors des traumatismes fermés de l’abdomen. En raison du vieillissement de notre société, le besoin d’envisager une chirurgie d’urgence pour les gens âgés augmente. Cependant, les données dans la littérature sur les résections hépatiques agressives en urgence sont très rares. Le but de cette étude a été de déterminer comment le sujet âgé de 70 ans ou plus supporte des lésions hépatiques majeures et ensuite comment il supporte une résection hépatique en conséquence. Nous avons revu rétrospectivement les dossiers de 100 patients traités par résection réglée pour traumatisme fermé sévère du foie (29 patients âgés qui avaient 70 ans ou plus, et 71 patients plus jeunes, moins de 70 ans). Les patients âgés de 70 ans ou plus avaient des lésions plus graves comme on pouvait le constater par un score ISS plus élevé, un score de Glasgow plus bas, et un taux de survie plus bas (80.3 vs. 65.5%, p<0.05). Le nombre total de lésions associées était plus élevé chez les patients plus âgés. Les accidents de voitures étaient responsables de 71.8% des lésions chez les plus jeunes; ils étaient également la cause principale chez les personnes âgées (51.7%). Parmi les 71 résections hépatiques réglées chez le sujet jeune, on note, parmi les interventions principales, l’hémihépatectomie droite (n=45), la résection segmentaire latérale gauche (n=14) et la bisegmentectomie (n=5). Parmi les 29 résections hépatiques réglées chez les sujets plus âgés, on note principalement l’hémi hépatectomie droite (n=15), la résection segmentaire latérale gauche (n=5) et l’hémihépatectomie gauche (n=4). On a noté plus de complications comme l’infection pulmonaire, les abcès sous-phréniques et les infections urinaires chez les patients plus âgés que chez le patient plus jeune. Nos données indiquent clairement que: (1) le mécanisme des lésions, le degré des lésions intra-abdominales associées et les complications diffèrent significativement entre les patients ages et jeunes, et (2) le taux de survie (65.5%) chez les patients plus âgés est une preuve que la résection hépatique réglée chez le sujet est utile et sure.ResumenEl hígado es la víscera que con más frecuencia se lesiona en los traumatismos cerrados de abdomen. Dado que nuestra sociedad envejece más, la cirugía de urgencia en pacientes añosos es cada vez más frecuente. Sin embargo, la bibliografía sobre las resecciones hepáticas urgentes es escasa. El objetivo del trabajo fue averiguar si los viejos (de 70 o más años) pueden o no soportar traumatismos hepáticos mayores, así como la subsiguiente resección hepática. Se estudiaron retrospectivamente 100 pacientes que por grave traumatismo cerrado de hígado requirieron una resección hepática anatómica (29 tenÍan 70 o más años y 71 menos de 70 años). Los pacientes añosos presentaron traumatismos más graves como demostraba su alta puntuación en la escala ISS, la baja puntuación en la GCS y la escasa supervivencia (80.3 vs 65.5%, p<0.05). El número total de traumatismos asociados fue mayor en los pacientes añosos. Los accidentes viarios fueron la causa etiológica más frecuente tanto en los traumatizados jóvenes (71.8%) como en los viejos (51.7%). En pacientes jóvenes se practicaron 71 hepatectomías anatómicas que comprendieron: hemihepatectomía derecha (n=45), resección segmenteria lateral izquierda (n=14), bisegmentectomía (n=5) y otros tipos de resección. En ancianos, se realizaron 29 resecciones hepáticas anatómicas: hemihepatectomía derecha (n=15), resección segmentaria lateral izquierda (n=5), hemihepatectomía izquierda (n=4) y otros tipos de resecciones. Complicaciones tales como pneumonías, abscesos subfrénicos, urosepsis, fueron mucho más frecuentes en los pacientes añosos. Nuestros hallazgos demuestran: (1) que el mecanismo del trauma, el número de lesiones traumáticas asociadas intraabdominales, el tipo de intervención quirúrgica y las complicaciones son totalmente diferentes en pacientes jóvenes que en los viejos y (2) que la supervivencia (65.5%) en los pacientes añosos es alta, por lo que la resección hepática anatómica puede considerarse un procedimiento útil y seguro.

A comparison of an open and laparoscopic appendectomy for patients with liver cirrhosis.

Liver cirrhosis is a critical factor contributing to morbidity and mortality in abdominal surgery, because patients with cirrhosis have a particularly high risk of developing bleeding, infection, and ascites. Laparoscopic appendectomy (LA) recently has gained a lot of attention around the world; however, comparisons between the benefits of LA and those of conventional open appendectomy (OA) for patients with liver cirrhosis have yet to be sufficiently compiled. In the present retrospective study, 40 patients with liver cirrhosis who were diagnosed with acute appendicitis before surgery underwent an appendectomy (OA in 25 patients and LA in 15 patients). This study focused on the operative time, amount of postoperative pain, use of analgesics, the restart of a normal diet, number of complications, length of hospital stay, and cost-effectiveness of the procedure in such patients. The amount of postoperative pain and the length of hospital stay were significantly smaller in the LA group. The mean values of the serum C-reactive protein on postoperative days 1, 3, and 7 were significantly less in the LA group. The number of wound infections and wound bleeding was also less in the LA group. The difference in the total cost of hospitalization was not significant. The cost of the operation was greater in the LA group than in the OA group, whereas the hospitalization cost in the LA group was less than that in the OA group. The results of this study suggest that LA may be superior to OA for the treatment of postoperative pain and postoperative complications for patients with liver cirrhosis. Long-term follow-up studies are still necessary, however, to determine any possible decrease in the number of late complications.

Hemodynamic and Morphological Changes in the Stomach of Portal Hypertensive Rats

To determine hemodynamic and morphological changes in the stomach of portal hypertensive rats, male WKA rats were given CCl4 subcutaneously in order to induce liver cirrhosis. The portal venous pressure of cirrhotic rats was significantly higher (17.7 cm H2O) than that of controls (10.5 cm H2O). Mucosal blood flow of the stomach in the portal hypertensive rat was increased (+ 46%) compared with that of controls and the peripheral vascular resistance of the stomach was significantly low. Morphological studies revealed that capillaries, collecting, submucosal, serosal and portal veins were significantly dilated; however, there were no apparent alterations in the arterial system of the stomach of the portal hypertensive rats. These results suggest that in the stomach of the portal hypertensive rat there is an increased blood flow and decreased peripheral vascular resistance and that this hyperdynamic circulatory state may derive from the dilatation of microvascular systems.

Postoperative recurrence of solitary small hepatocellular carcinoma

The prognosis of hepatocellular carcinoma after hepatic resection remains poor. The major cause is postoperative recurrence, most frequently intrahepatic. During the past 7 years, we conducted a detailed study of recurrence after hepatectomy in 34 patients with solitary small hepatocellular carcinoma measuring no larger than 4 cm in diameter, in which 13 cases had postoperative recurrent tumors. and two cases were considered multicentric. Eighty‐five percent of recurrences were diagnosed at 6–18 months after the operation. The cumulative recurrence rates were 61% at 5 years after operation. When analyzing the factors affecting recurrence, a significant difference was observed regarding tumor diameter. After recurrence, most patients underwent percutaneous ethanol injection treatment and/or transcatheter arterial chemoembolization and lipiodolization. Four patients died of progressive disease within 1 year after recurrence; the treatment thus seemed to have no effect. The other patients with recurrence remain alive with the disease. The overall cumulative survival rates in this series were 76% at 3 years and 60% at 5 years after operation. To obtain better results after hepatectomy, even for small hepatocellular carcinoma, careful, long‐term follow‐up evaluation is therefore necessary for the multidisciplinary treatment of the postoperative recurrence, as well as the early diagnosis of tumors in high‐risk patients.

The natural history of nonalcoholic cirrhosis

SummaryTo assess the natural history of non-alcoholic liver cirrhosis, one hundred and eighty medically treated Japanese cases, including 110 accompanied by esophageal varices were investigated retrospectively. Among those patients with varices fifty-one (46.4%) bled from the upper gastrointestinal (GI) tract and thirty-two (29.1%) from esophageal varices, while GI bleeding was found in only six out of 70 patients without varices. The GI bleeding rate was the highest in patients with varices and concomitant hepatoma (76.5%). The mortality rate of the GI bleeders was 68.6% in patients with varices and 33.3% in patients without varices. The mortality on the first variceal bleeding episode was 65.6%, and another 25.0% had rebleeding from varices, resulting in a one-year survival of 9.4%. The ten-year cumulative percentage of variceal bleeding was 61.2% in patients with varices, and that of occurrence of hepatoma was 50.7% in total of 180 patients.This study revealed that the non-alcoholic cirrhotic patients have a highly rate of complication by hepatoma and that the development of hepatoma doubles the risk of varix rupture.