Takehira Yamamura

Effect of truncal vagotomy on pancreatic polypeptide response after intravenous glucose administration.

Intravenous glucose infusion was performed in six dogs with and without truncal vagotomy, and plasma pancreatic polypeptide (PP) responses were compared before and after truncal vagotomy. Following truncal vagotomy, basal PP levels decreased significantly from 286 +/- 64 pg/ml (mean +/- S.E.) to 94 +/- 14 pg/ml (P less than 0.05). Basal plasma insulin and blood glucose levels also tended to be lower, but not significantly. During the infusion of glucose, blood glucose concentrations rose rapidly in both groups and after 15 min reached peak values which were not significantly different from each other. In the vagotomized group the plasma insulin response to intravenous glucose infusion was significantly lower than in the control group. Following intravenous glucose loading, plasma PP concentrations decreased rapidly in both groups, but the PP level in the vagotomized group was suppressed only to 77 +/- 4% of the basal level whereas in the control group it decreased by 45 +/- 8%, significantly lower than in the vagotomized group (P less than 0.01). These results suggest that basal PP is regulated by vagal tonus and that vagus controls, at least in part, suppression by intravenous glucose administration.

Possible role of the duodenum in the entero-PP axis.

The plasma pancreatic polypeptide response to a meal was compared in 6 healthy controls and 30 patients with gastric cancer who had undergone either subtotal gastrectomy or total gastrectomy with radical lymph node dissection including sympathectomy. Twelve patients were reconstructed with Billroth I, 9 patients with Billroth II, 6 patients with a double tract, and 3 patients with Roux-en-Y. Ten patients with a gastric ulcer who had undergone Billroth I gastrectomy including pyloric ring preservation also were examined. Impaired pancreatic polypeptide secretion was noted only in Billroth II and Roux-en-Y patients, where the duodenum is not affected by the passage of meals. Billroth I and double tract patients, in contrast, and an enhanced pancreatic polypeptide secretion. However, in BI patients with pyloric ring preservation the PP response to a meal was almost normal. These findings suggest an important role of the duodenum in the entero-PP axis in man.

THE EVIDENCE FOR THE REGULATORY ROLE OF ENDOGENOUS GIP AS A GLUCOSE DEPENDENT INSULINOTROPIC HORMONE IN PATIENTS WITH DUODENAL ULCER

In order to investigate the mechanism of GIP secretion and the role of endogenous GIP in the enteroinsular axis in duodenal ulcer patients, we have compared plasma GIP, insulin, and blood glucose responses to oral glucose ingestion in 10 duodenal ulcer patients, 5 patients with total gastrectomy, and 20 normal subjects. The mean basal level of plasma GIP in totally gastrectomized patients was significantly higher than in normal subjects, while in duodenal ulcer patients the value was not different from that of controls. Plasma GIP and insulin responses to oral glucose loading were significantly higher than normal in both groups. The degree of exaggerated plasma GIP and insulin secretions was more prominent and earlier in totally gastrectomized patients than in duodenal ulcer patients, and was positively correlated with the blood glucose increase during glucose ingestion. On the other hand, no significant change in GIP secretion during insulin‐induced hypoglycaemia was observed in normal subjects, duodenal ulcer patients, or patients with selective proximal vagotomy. These findings indicate that the exaggerated GIP response to oral glucose in duodenal ulcer patients may be due not to increased vagal tone, but to more rapid incoming load. We found also that the hypersecretion of GIP induced by glucose ingestion in patients with duodenal ulcer and total gastrectomy may be responsible for the hyperfunction of the enteroinsular axis in these patients.

Current Surgical Management for Ulcerative Colitis.

潰瘍性大腸炎 (UC) の外科的治療には根治性と同時に機能性が求められ, 永久的回腸人工肛門, 回腸肛門吻合術, 回腸肛門管吻合術 (回腸直腸吻合術) などの手術術式における改良と進歩があり, 今日に至っている. 私どもは3期分割手術計画を基本としたJ型回腸嚢肛門吻合術 (IAA) を行ってきたが, IAAでは体位変換を要し, 手術時間が長く, 手術侵襲も大きくなっていた. 1997年以降, 超音波駆動メス (Harmonic Scalpel) とバイポーラーシザーズ (Power Star) を導入, 術式の改良を行った結果, IAAは簡便で出血量の少ない, 安全な手術となった.さらにはUCに対する外科的治療のstrategyをも改善し, 緊急手術であっても2期分割手術で行うことが可能となっている. ただし穿孔例や, Crohn病と鑑別のつかない症例は3期分割手術とせざるを得ず, 患者のニーズに答えるためには, より的確な診断と手術時期の選択が重要であると考える.

Ultrasound measurement of contractile motility of the gallbladder after vaious gastric surgery.

過去1カ月以内に, 胃切除術を施行された患者44名 (良性疾患13名, 悪性疾患31名) を対象に, 乾燥卵黄製剤 (ダイヤン) 経口投与後の胆のう収縮運動を超音波映像下に観察した.胆のうの最大収縮率は健常者 (10名) に比べ, 悪性疾患で有意に低下し, 特にBillroth II法による再建術を受けた群で, 収縮不全が顕著であった (p<0.01).naloxone (0.4mg) の筋肉投与は胃癌手術後の収縮不全を有意に改善した (p<0.01).以上の事実より, ダイヤン投与後の胆のう収縮機能に関して, リンパ節郭清による神経の切離と, 再建術式による食物の十二指腸通過の有無が重要であり, 内因性opioidの過剰やcholecystokinin (CCK) 放出の低下が関与する可能性が示唆された.

Ultrasound measurement of contractile motility of the gallbladder after subtotal gastrectomy.

胃切除後に高頻度に発生する胆のう疾患の原因を収縮運動の面から考察する目的で, 過去1ヵ月以内に, 胃癌で胃亜全摘術を施行された患者18名を対象に, ダイヤン経口負荷後の胆のう収縮運動を, 経時的に超音波診断装置にて観察した. 胃亜全摘後には, 胆のう収縮能の低下がみられたが, 特にBillroth II法による再建術を受けた群では, Billroth I法に比べ, 空腹時胆のう面積は拡張し, ダイヤンによる収縮能も極めて不良であった. 胃癌手術時には, 胃切除に加え, リンパ節郭清に伴い, 迷走神経や交感神経の切離も施行され, これら種々の要因が術後の胆のう機能低下に関与していると考えられるが, 特に再建術式による食物の十二指腸通過の有無が重要と考えられた.