Satoru Miyazaki

Usefulness of an estimation of physiologic ability and surgical stress (E-PASS) scoring system to predict the incidence of postoperative complications in gastrointestinal surgery

Surgical intervention induces various host responses to maintain homeostasis. When postoperative inflammation is intense and persists for a long time, postoperative complications may occur, sometimes developing into multiple organ failure. Therefore, it is very important to assess surgical stress and predict the risk of morbidity and mortality. Using a new scoring system, an estimation of physiologic ability and surgical stress (E-PASS) scoring system, surgical stress following gastrointestinal surgery was evaluated to assess the feasibility of this scoring system. This system comprises a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) that is calculated from both the PRS and the SSS. The relationship of the E-PASS score to the incidence of morbidity and mortality was examined. The relationship between the E-PASS score and a sequential organ failure (SOFA) score was also evaluated. The CRS had a significant positive correlation between not only the incidence but also the grade of postoperative complications. Total maximum SOFA score in patients with a CRS of more than 1 was significantly higher than that in patients with a CRS of less than 1. In conclusion, the E-PASS scoring system will be useful for predicting and recognizing the risk of postoperative complications. This scoring system is brief, simple, and reproducible and can be useful in all types of hospitals.

Function of the sphincter of Oddi in patients with juxtapapillary duodenal diverticula: evaluation by intraoperative biliary manometry under a duodenal pressure load

The purpose of this study was to elucidate the function of the sphincter of Oddi (SO) in patients with juxtapapillary duodenal diverticula (JDDs). The SO function was evaluated by intraoperative biliary manometry in three groups of patients. Group 1 consisted of nine patients with JDDs and a dilated common bile duct (CBD) (diameter > 10 mm). Group 2 consisted of six patients with JDDs and a normal-sized CBD (diameter < 10 mm). Group 3 consisted of 26 patients without JDDs and with normal-sized CBDs.In the absence of a duodenal pressure load, the patients in group 1 demonstrated a lower baseline SO pressure and lower resistance of the biliary outflow than patients in group 3. They also demonstrated a lower baseline SO pressure and shorter decay time (which represented terminal biliary ductal resistance) than patients in group 2. In the presence of a duodenal pressure load of 300 mm H2O, the patients in group 1 demonstrated a lower incidence of phasic SO contractions, a higher baseline SO pressure, and a higher resistance of the biliary outflow than group 2 and group 3 patients. The decay time in group 1 and group 2 patients was higher than that of group 3 patients. Based on these findings, we conclude that the SO function in patients with JDDs is impaired owing in part to long-standing compression of the terminal biliary ductal system by a distended JDD associated with a rise in intraduodenal pressure in daily life.

A Case of Lactic Acidosis from Vitamin B1 Deficiency during Total Parenteral Nutrition.

患者は86歳, 女性の進行膵頭部癌症例.高カロリー輸液 (総合ビタミン剤非配合) 施行中に, 温熱化学療法を契機に経口摂取不良となり, 高カロリー輸液21日目に急激な意識低下 (II-20), 末梢循環不全, 呼吸促拍を認め, 腹痛を訴えた.血液ガス分析でpH7.193, Base Excess-16.6mEq/lと著明な代謝性アシドーシスを認め, 7%炭酸水素ナトリウムを計480ml投与したが改善しなかった.発症より16時間後ビタミンB1欠乏を疑い, 塩酸チアミン150mgを静注したところ, 1時間後にpH7.507, BaseExcess 3.8mEq/lとなり, 4時間後に意識レベルは1-2に改善した.発症時の血清乳酸値は119mg/dlと異常高値を示し, 血中ビタミンB1値は13ng/mlと異常低値であったがそれぞれ塩酸チアミン静注後正常化した.本症例を含めた高カロリー輸液施行中のビタミンB1欠乏による乳酸アシドーシスの報告例48例について文献的に考察した.

A Case Report of Celiac Axis Compression Syndrome Combined with Gastric Cancer. Diagnosis by Doppler Ultrasonography.

胃癌の手術を契機に超音波検査で発見された腹腔動脈起始部圧迫症候群 (celiac axis compressionsyndrome: 以下, CACSと略記) の1例を報告する.症例は50歳の男性.既往歴として幼少時より月に1～2度腹部仙痛を自覚.主訴は嚥下困難で, 噴門部癌の診断のもとに当科に紹介入院-術前の超音波検査にて, 腹腔動脈起始部の狭窄と総肝動脈の遠肝性血流を認めCACSと診断した.左開胸開腹下に胃全摘術, 摘脾術を施行した.術中に内側弓状靱帯による腹腔動脈起始部の圧迫を確認し, 靱帯を切離した.電磁流量計により測定した総肝動脈血流量は靱帯切離前後で40ml/分から115ml/分に増加した.術後に腹痛の発生を認めず, また術後の超音波ドプラ検査にて総肝動脈の求肝性血流を確認した.超音波検査はCACSの診断および治療効果判定に有用と思われた.