Taigo Tokuhara

Chylothorax after thoracoscopic esophagectomy

Among 30 patients who underwent thoracoscopic esophagectomy with lymphadenectomy for thoracic esophageal cancer, from July 1995 to May 1997, chylothorax developed in 2 patients (7%). In Case 1, the ligation of the thoracic duct under conventional right thoracotomy was performed on the 9th day after esophagectomy. After ligation, the pleural effusion was decreased, and the patient was discharged from hospital on the 25th day after the second operation. In Case 2, massive pleural effusion developed on the 10th day after esophagectomy (at 3 days after thoracic drainage tube was removed). The thoracic duct was ligated at the level just cranial to the diaphragm thoracoscopically on the 14th day after esophagectomy. The patient was discharged from hospital on the 30th day after the second operation. Injury to the thoracic duct due to a magnification effect of the view of scopic surgery remains a pitfall in thoracoscopic esophagectomy. But thoracoscopic ligation of thoracic duct was effective and safe for these two cases of chylothorax after esophagectomy.

Changes of serum cytokine levels after thoracoscopic esophagectomy

We introduced thoracoscopic esophagectomy with extended lymphadenectomy for reduction of respiratory dysfunction and less surgical intervention in July 1995. In this study, we investigated the changes in serum interleukin-6 (IL-6) and interleukin-1 receptor antagonist (IL-1ra) levels in 8 patients (TS Group) who underwent thoracoscopic esophagectomy with extended lymphadenectomy and compared them with the changes in patients who underwent conventional thoracotomy (CT Group). The duration of the operation and intrathoracic procedure in the TS group were significantly longer than in the CT group. However, the amount of blood loss and intrathoracic blood loss of the TS group were not significantly higher than in the CT group. The number of dissected lymph nodes was not significantly larger. The serum IL-6 levels reached maximum levels 3 hours from the end of operation. In the TS group, the changes in IL-6 levels were significantly larger (p < 0.05). On the other hand, the changes in CRP levels were also significantly larger (p < 0.01). Significant correlation was observed between the duration of the intrathoracic procedure and the maximum levels of IL-6. On the other hand, serum IL-1ra levels were not significantly. At present, these results suggest that the surgical intervention of thoracoscopic esophagectomy are more larger than that of conventional thoracotomy. We think that the length of intrathoracic procedure of thoracoscopic esophagectomy may make more large surgical stress.

Three cases of synchronous laparoscopic resection for gastric and colonic cancer.

Case 1 was an 84-year-old female who suffered from a superficial elevated lesion within depressed area (0 IIc+IIa) from the lesser curvature to the posterior wall at the middle corpus of the stomach and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. Case 2 was a 70-year-old male who suffered from a superficial depressed lesion (0 IIc) at the lesser curvature of the gastric angle and a superficial elevated lesion (0 IIa) at the cecum. Case 3 was a 58-year-old male who suffered from a superficial depressed lesion (0 IIc) from the lesser curvature to the posterior wall at the middle corpus of the stomach, and an elevated lesion (type 1) and a depressed lesion with a circumferential embankment (type 2) at the sigmoid colon. In 3 cases, we first inserted 5 or 6 trocars and performed laparoscopic distal gastrectomy with groups 1 and 2 lymph node dissection according to the Japanese Classification of Gastric Carcinoma. Subsequently, in case 1, 1 additional port was inserted at the right lower quadrant for sigmoidectomy; in case 2, two trocars were added for ileocecal resection; and in case 3, one additional port was inserted at the median hypogastric region for sigmoidectomy. In cases 1 and 2, Billroth II reconstruction was performed using a laparoscopic linear stapling device (endo-GIA) and, in case 3, Roux-en-Y reconstruction was performed using endo-GIA, after distal gastrectomy. The double stapling technique using a conventional circular stapling device was performed after pulling out the specimen from the paraumbilical port after colectomy in case 1, whereas an end-to-end triangular suture using endo-GIA was used extracorporeally through the paraumbilical port in case 2 and the median hypogastric port in case 3. The operative durations of cases 1, 2, and 3 were 315, 340, and 495 minutes and the amounts of blood loss were 80, 300, and 440 mL, respectively. Except for the need to retain the drain until the tenth postoperative day because of serous discharge in case 1, no postoperative complications occurred. The postoperative commencement of oral feeding was on the fifth day in case 1 and on the third day in cases 2 and 3. All cases made a quick recovery and they were discharged from hospital on the nineteenth, thirteenth, and tenth day after operation, respectively. Double cancer patients with gastric and colonic carcinomas were thought to be very suitable for laparoscopic surgery because by avoiding a total median skin incision, there is less wound pain and quicker postoperation recovery.

ENDOBRONCHIAL STENTING AS A PALLIATION FOR ADVANCED ESOPHAGEAL CANCER

Three cases of airway invasion of esophageal cancer treated palliatively by endobronchial stenting are reported. In case 1 (a 60-year-old male) expandable metallic stents were inserted into the totally occluded left main bronchus. In case 2 (a 45-year-old male) a Dumon stent was inserted into the totally occluded left main bronchus. Both patients recovered from performance status 4 to performance status 1 or 0 and were in good condition before they died of cancer, 150 and 54 days after stenting in cases 1 and 2, respectively. In case 3, a Dumon stent was inserted into the left main bronchus before total occlusion. The patient recovered from performance status 3 or 2 to performance status 1 or 0 and survived 40 days after stenting with no signs of airway obstruction. Endobronchial stenting is a useful palliation for keeping the performance status at a good level in patients with esophageal cancer obstructing or narrowing the main airway.

Acute acalculous cholecystitis complicated by penetration into the liver after coronary artery bypass grafting

BACKGROUND Perforation or penetration due to acute acalculous cholecystitis is a rare complication after open-heart surgery. The mortality rate of this disease is high. METHODS A 71-year-old woman complained of a sudden onset of right upper abdominal pain with development of peritoneal signs at 21 days after coronary artery bypass grafting. Abdominal ultrasonography and laboratory examination performed at 1 day earlier had revealed no abnormalities. Neither anticoagulants nor antiplatelet agents were administered following the bypass operation. An exploratory laparotomy was performed to locate a presumed embolization to the superior mesenteric artery. RESULTS Laparotomy revealed acute acalculous cholecystitis complicated by penetration into the liver, causing a subserosal hematoma. The hematoma had ruptured into the abdominal cavity. A cholecystectomy was performed. The gallbladder wall which was in contact with the liver was necrotic. Most of the gallbladder mucosa was necrotic. Microscopical examination revealed atherosclerosis of the cystic artery which was partially obstructed by thrombus. CONCLUSIONS Given the atherosclerotic condition of the cystic artery, hypotension during the bypass in combination with postoperative total parenteral nutrition and hypovolemia may have induced the cystic artery thrombosis. Surgeons who manage patients with cardiovascular disease should be aware of this potentially lethal development.

A Case of Epiphrenic Esophageal Diverticulum Associated with Esophageal Dysmotility.

食道運動異常と胃食道逆流を伴う横隔膜上食道憩室に外科的な処置を加え良好な結果を得たので報告する.患者は71歳の女性で, 嚥下困難を主訴として来院.上部消化管造影で下部食道に憩室を認め, 内視鏡で憩室炎を認めた.食道内圧測定では憩室より上部の食道に嚥下に伴う正常な蠕動波が認められず, 24時間食道内pH測定では明らかな酸逆流を認めた.手術としては経胸的憩室切除術にBelseyの噴門形成術を付加した.切除標本は組織学的には炎症所見のみで悪性所見はなかった.われわれは食道憩室では食道内圧測定や24時間食道内pH測定検査を行い, 憩室切除術のみではなく病態に応じた付加治療を考慮すべきであると考える.

Experimental Study on Function of the Upper Esophageal Sphincter After Radical Operation for Esophageal Cancer

The upper esophageal sphincter (UES), located between the esophagus and the pharynx, provides a barrier against esophagopharyngeal reflux and subsequent aspiration of intraesophageal contents such as food or digestive juices. This consists of the cricopharyngeus muscle and the upper part of esophageal circular muscle. The UES is presented as a high pressure zone manometrically, with the pressure (UESP) higher than pharyngeal or esophageal pressure, i.e., around 39mmHg as reported by Tokuhara et al. [1], and the length of this high pressure zone is about 2–4 cm.

Usefulness of Posterior Mediastinal Reconstruction After Esophagectomy in Case of Esophageal Cancer with Palsy of Recurrent Laryngeal Nerve

In cases of esophageal cancer, metastasis to the lymph nodes alongside the recurrent laryngeal nerve (RLN) is found in high incidence, namely 25%. Palsy of the RLN may develop after the dissection of these nodes, even if the nerves were preserved surgically. In patients with metastasis to these nodes, the palsy of the RLN is observed before operation. Functional changes in the pharynx and cervical esophagus after the reconstruction of the intrathoracic esophagus have not yet been reported. To find an appropriate reconstructive procedure in the cases of esophageal cancer with palsy of the RLN, postoperative swallowing function was examined quantitatively by scintigraphy in the patients who had undergone a reconstruction via various routes.