Shigeru Iwazaki

Results of duct-to-mucosa pancreaticojejunostomy for pancreaticoduodenectomy Billroth I type reconstruction in 100 consecutive patients.

BACKGROUND This study retrospectively analyzed 100 consecutive patients who underwent pancreaticoduodenectomy (PD) and pylorus-preserving PD (PPPD) with a Billroth I type reconstruction and pancreaticojejunostomy by duct-to-mucosal anastomosis using a continuous running suture. STUDY DESIGN Seventy patients underwent PD and 30 patients PPPD for pancreatic cancer in 33, bile duct cancer in 28, ampullary or duodenal tumor in 22, chronic pancreatitis in 8, and other gastrointestinal cancer in 9. Postoperative pancreatic anastomotic leakage was diagnosed from skin excoriation around the drain site, and was defined as a high concentration of amylase in drainage fluid or leakage demonstrated on x-ray. RESULTS The mortality rate was 2% overall (2.8% in PD, 0% in PPPD). The morbidity rate was 23% overall (12.8% in PD, 46.7% in PPPD). Pancreatic anastomotic leakage was 4.0% overall (2.8% in PD, 6.7% in PPPD).. The incidence in the ampullary or duodenal tumors was 9.1% overall (0% in PD, 14.3% in PPPD). Biliary leakage occurred in four patients, 4.0% overall (4.3% in PD, 3.3% in PPPD), intraabdominal hemorrhage in 2% (2.8% in PD, 0% in PPPD), and lethal anastomotic leakage in one patient, overall rate 1% (1.4% in PD, 0% in PPPD). Delayed gastric emptying had the highest morbidity and was seen exclusively in PPPD (39.3%). CONCLUSIONS A simple continuous running suture and parachuting for duct-to-mucosal pancreaticojejunostomy makes pancreaticoduodenectomy a safe procedure, even in a Billroth I type reconstruction.

The effect of cyclooxygenase-2 inhibitor FK3311 on ischemia-reperfusion injury in a canine total hepatic vascular exclusion model

BACKGROUND Liver grafts from non-heart-beating donors inevitably suffer from warm ischemic injury. In these grafts, large quantities of inflammatory cytokines and arachidonic acid metabolites are induced, further aggravating injury. Cyclooxygenase (COX) is an intracellular enzyme that converts arachidonic acid into prostaglandin (PG)G2 and PGH2. COX has two isoforms: constitutive COX-1 and inducible COX-2. The aim of this study was to evaluate the effects of COX-2 inhibition by FK3311 (FK) on warm ischemic injury in a canine total hepatic vascular exclusion (THVE) model. STUDY DESIGN Sixteen mongrel adult dogs were studied. The portal triad of the hilum and the inferior vena cava above and below the liver was clamped for 1 hour. Splanchnic decompression was achieved by active splenofemorojugular bypass. The animals were divided into two groups. FK (1 mg/kg) was administered in the FK group (n = 8), and saline was administered in the control group (n = 8). Hepatic venous blood was collected to measure serum alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase (LDH), and hyaluronic acid levels. Serum thromboxane (Tx)B2 and 6-keto-PGF1alpha levels were also measured. Hepatic tissue blood flow was estimated simultaneously. Liver specimens were harvested for histologic study and polymorphonuclear neutrophils were counted. RESULTS Alanine aminotransferase, aspartate aminotransferase, and hyaluronic acid 2 and 6 hours after reperfusion and LDH 30 minutes and 2 and 6 hours after reperfusion were significantly (p < 0.05) lower in the FK group than in the control group. Hepatic tissue blood flow remained significantly (p < 0.05) higher in the FK group than in the control group 1, 2, and 6 hours after reperfusion. Histologic tissue damage was mild and polymorphonuclear neutrophil infiltration was significantly lower (p < 0.05) in the FK group than in the control group 1 and 6 hours after reperfusion. Thirty minutes after reperfusion, TxB2 was significantly reduced (p < 0.05) in the FK group, and 6-keto-PGF1alpha was not significantly lower. CONCLUSIONS FK protected against hepatic warm ischemia-reperfusion injury by marked inhibition of TxA2.

Pancreaticojejunostomy-securing technique: duct-to-mucosa anastomosis by continuous running suture and parachuting using monofilament absorbable thread.

Despite reduced operative mortality and intraabdominal complications after pancreaticoduodenectomy, pancreatic fistula is a leading cause of morbidity and mortality (1-5). A number of methods have been described to deal with the pancreatic remnant, including nonanastomotic options, insertion into the je junum by a variety of techniques, and pancreaticogastrostomy (1, 6, 7). No matter which method is used, however, pancreatic fistula is most likely to occur when anastomosis involves a normal pancreas (1, 2, 8, 9). Duct-tomucosa anastomosis is important in preventing anastomotic leakage and preserving anastomotic patency and pancreatic function (2). We refined a duct-to-mucosa anastomosis that is easier, safer, and less prone to fistula formation. In this report, we describe the technique and its results.

The effect of FK409—a nitric oxide donor—on canine lung transplantation

BACKGROUND Nitric oxide (NO) is known to have beneficial effects in ischemia-reperfusion (I/R) injury through maintaining endothelial integrity, inhibiting leukocyte adhesion and platelet aggregation, and inducing vasodilation. The effect of FK409 (FK), a spontaneous NO donor, was investigated in a canine lung transplantation model. METHODS Ten pairs of weight-matched dogs were used. Five pairs were assigned to the FK group, to which FK (5 microg/kg/min) was administered intravenously from 30 minutes prior to ischemia until the induction of ischemia in the donor, and from 15 minutes prior to reperfusion until 45 minutes after reperfusion in the recipient. The others were assigned to the control group. After 8-hour preservation in 4 degrees C Euro-Collins solution, orthotopic single-lung transplantation was performed. During a 5-minute clamping test of the right pulmonary artery, left pulmonary arterial pressure (L-PAP), left pulmonary vascular resistance (L-PVR), arterial oxygen pressure (PaO(2)), and alveolar-arterial oxygen pressure difference (A-aDO(2)) were measured. The lung specimens were harvested for histologic study, and polymorphonuclear neutrophils (PMNs) were counted. Pulmonary perfusion and ventilation scintigraphy (Tc-99m-MAA and Xe-133) were performed. RESULTS PAP, L-PVR, PaO(2), and A-aDO(2) revealed significantly (p < 0.05) better function in the FK group than in the control group. Histologically, edema was more mild, and PMN infiltration was significantly (p < 0.05) lower in the FK group than in the control group. Xe-133 and Tc-99m-MAA were widely distributed throughout the graft lung in the FK group. The 2-day survival rate was 100% in the FK group, which was significantly (p < 0.05) better than the rate (40%) in the control group. CONCLUSIONS FK appears to generate a protective effect on I/R injury in lung transplantation.

FR167653 ameliorates pulmonary damage in ischemia-reperfusion injury in a canine lung transplantation model

BACKGROUND Interleukin (IL)-1 and tumor necrosis factor-alpha (TNF-alpha) are recognized as important factors in ischemia-reperfusion (I/R) injury. FR167653 has been characterized as a potent suppressant of IL-1 and TNF-alpha production. We previously reported that FR167653 suppressed the expression of IL-1 beta mRNA after reperfusion and ameliorated pulmonary I/R injury following 3-hour left lung warm ischemia in dogs. The aim of this study was to investigate the effects of FR167653 on I/R injury in a canine left, single, lung transplantation model. METHODS We used 10 pairs of weight-matched dogs. We assigned 5 pairs to the FR group, in which each animal received FR167653 (1 mg/kg/hr) IV from 30 minutes before ischemia until 2 hours after reperfusion; we treated the transplanted lungs with FR167653 after the onset of reperfusion. The others were assigned to the control group. After 8-hour preservation with 4 degrees C Euro-Collins solution, orthotopic left, single, lung transplantation was performed. During a 5-minute clamping test at the right pulmonary artery of each recipient, the left (transplanted) pulmonary arterial pressure (L-PAP), left (transplanted) pulmonary vascular resistance (L-PVR), arterial oxygen pressure (PaO(2)), and alveolar-arterial oxygen pressure difference (A-aDO(2)) were measured. We harvested transplanted lung specimens for histologic study, and we counted polymorphonuclear neutrophils (PMNs), which were identified by staining with naphthol AS-D cholroacetate esterase. Pulmonary perfusion and ventilation scintigraphy (Tc-99m-MAA and Xe-133) were performed. We observed the animals for 3 days after transplantation. RESULTS The PAP, L-PVR, PaO(2), and A-aDO(2) revealed significantly (p < 0.05) better function in the FR group than in the control group. Histologically, lung edema was milder, and PMN infiltration was significantly (p < 0.05) lower in the FR group than in the control group. Xe-133 and Tc-99m-MAA were widely distributed throughout the graft lung in the FR group. Three-day survival rates in FR and control groups were 60% and 20%, respectively. CONCLUSIONS FR167653 appears to generate a protective effect on I/R injury in lung transplantation in dogs.

FR128998 (a PAF receptor antagonist) counters the increased pulmonary vascular resistance associated with ischemia-reperfusion injury in the canine lung

Ischemia-reperfusion injury induces deterioration of pulmonary function following lung transplantation. The spiro-thiazepin derivative FR128998 (FR) is a novel PAF receptor antagonist. The effect of FR on ischemia-reperfusion injury was investigated in anin situ warm ischemia model of canine lungs. Fifteen adult mongrel dogs, weighing 6 to 12 kg, were divided into two groups. FR (1 mg/kg/hr) was administered from prior to ischemia until 2 hours after reperfusion (FR-treated group; n=8), or vehicle was injected using the same technique (Control group; n=7). Following hilar stripping of the left lung, the left pulmonary artery and veins were clamped for 3 hours to induce warm ischemia. The left main bronchus was bisected at the same time and anastomosed 3 hours later. Arterial oxygen saturation (SaO2), left pulmonary vascular resistance (L-PVR), and cardiac output (CO) were measured 30 minutes after reperfusion. The lungs were harvested for pathological study, and polymorphonuclear neutrophils (PMNs) were counted. The 2-day survival rate was also investigated. After reperfusion, SaO2 L-PVR, and CO were significantly (p<0.05) better in the FR-treated group than in the control group. Histological findings after 30 minutes of reperfusion showed alveolar damage with interstitial edema and hyaline membranes localized along the alveolar ducts in the control group, while there was only slight localized interstitial edema in the FR group. PMN infiltration was less extensive in the FR group than in the control group. FR appears to have a protective effect against lung ischemia-reperfusion injury. This might result from inhibition of the local release of PAF.

Left Colon Substitution with His’ Angle following Total Gastrectomy

To resolve the disadvantages of jejunal Roux-en-Y reconstruction following total gastrectomy, we attempted the use of left colon substitution with all anastomoses conducted using mechanical stapling devices. A His’ angle was formed to reduce regurgitation esophagitis. About 25 cm of the left colon with the ascending branch of the left colic artery with an adequate blood supply was brought up to the remnant esophagus without tension on the mesentery. The colon graft was interposed between the esophagus and duodenum in an isoperistaltic fashion. Three anastomoses, esophagocolic, duodenocolic and colocolic, were completed with a circular stapling device. An end-to-side esophagocolonostomy was positioned about 3 cm distal from the blind end of the proximal colon stump. The proximal end of the left colon was pexied to the esophagus using 3–4 stitches to make a new His’ angle. Gastrointestinal continuity was restored by a side-to-end colonoduodenostomy and an end-to-end colonocolonostomy. Fifteen gastric cancer patients underwent left colon substitution following total gastrectomy. The circular staple used for esophagocolonostomy and colonoduodenostomy was 25 mm in all patients, and for colonocolonostomy was 29 mm in 9 patients and 33 mm in 6 patients. No problems were encountered in any steps of the procedure, and faulty stapling was avoided. Neither anastomotic leakage nor necrosis of the interposed colon segment was seen, nor was late anastomotic stricture, in any patient. Barium radiograms of the interposed colon segment showed that the capacity and passage of the interposed colon were adequate, and regurgitation did not occur. Diet volume was satisfactory and weight loss minimal.

FR183998 protects against the increased microvascular permeability associated with ischemia-reperfusion injury in the canine lung

FR183998 (FR) is a Na+/H+ exchange inhibitor known to protect against cardiac ischemia-reperfusion (I/R) injury. The purpose of this study is to investigate the effects of FR on pulmonary I/R injury.Eleven adult dogs were divided into two groups. FR (1mg/kg) was administered intravenously 5 min prior to ischemia and 5 min prior to reperfusion (FR group; n=5), and a vehicle was injected in the same manner (Control group; n=6). Warm ischemia was induced for 3 hr by clamping the left pulmonary artery and veins. The lung was then reperfused and animals were observed for 2 hr. Left pulmonary vascular resistance (L-PVR), cardiac output (CO), arterial oxygen pressure (PaO2), and alveolar arterial oxygen pressure difference (A-aDO2) were measured. The lung specimens were harvested for histological study, and polymorphonuclear neutrophils (PMNs) and the wet-to-dry lung weight ratio (W/D ratio) were quantified.99mTc-diethyltriaminepentaacetic acid (DTPA)-human serum albumin (HSA) scintigraphy was performed.L-PVR, CO, PaO2, A-aDO2, and W/D ratio were maintained at significantly (p<0.05) better levels in the FR group than in the control group. Histological findings revealed alveolar damage with interstitial edema in the control group and only slight interstitial edema in the FR group. PMN infiltration was significantly (p<0.05) more severe in the control group than in the FR group. In the scintigrams,99mTc-DTPA-HSA was more accumulated in the left lung in the control group than in the FR group.FR protects against the increased microvascular permeability resulting from I/R injury.

Minutes of the 3rd General Assembly of European Digestive Surgery (EDS)

EDS Secretary M.W. Büchler gave a short report on the ongoing increasing membership of EDS. EDS presently has 1,013 members from 52 countries. He especially mentioned the following 3 countries as bringing most of the members: (1) the former Yugoslavia, with 125 members; (2) Switzerland, with 117 members, and (3) Germany, with 78 members. M.W. Büchler underlined that with over 1000 members our society has reached great importance in the field of European digestive surgeons. However, it should continue to be our aim to encourage young doctors with an interest in digestive surgery to join the society. Agenda of the EDS General Assembly

Clinicopathological studies on local recurrence of carcinoma of the rectum following abdominoperineal resection.

直腸癌 (下部直腸, 上部直腸) に対して直腸切断術を施行した治癒切除症例における局所再発17例について, 術後2年以上を経過した非再発62例と対比し, 臨床病理学的に検討した.局所再発率は16.7%であり, 再発までの期間は平均12.9か月で2年以内に88, 2%が再発した.局所再発は全例, 下部直腸 (Rb) にみられ, 肉眼型3型 (70.6%: p<0.01), 壁深達度a2 (s) ～ai (si) (70.6%: p<0.05), とくにai (si) (23.5%: p<0.01), リンパ節転移n2 (+) (64.7%: p<0.01) (うち, 側方転移41.2%: p<0.01), 剥離面の癌浸潤 (ew) 1mm以内 (52.9%: p<0.05) に高率に認められた.局所再発例の3および5年生存率はそれぞれ53.8%, 11.5%で有意に低率 (p<0.05;p<0.01) であり, 遠隔成績は不良であった.以上より, 直腸癌, とくに下部直腸 (Rb) に対する直腸切断術に際しては, 側方郭清を伴うリンパ節郭清と腫瘍よりの周囲組織を含めた十分な剥離, 切除が重要であると思われた.