Takeyoshi Yumiba

Impact of esophageal bile exposure on the genesis of reflux esophagitis in the absence of gastric acid after total gastrectomy

OBJECTIVE:The role of duodenal contents refluxing into the esophagus in producing reflux esophagitis (RE) remains unclear. We aimed to assess the impact of esophageal bile exposure on the genesis of RE in reference to esophageal pH changes in the absence of gastric acid after total gastrectomy.METHODS:Thirty patients having undergone total gastrectomy were studied with concurrent 24-h esophageal pH and bilimetric monitoring, and were divided into two groups based on endoscopic esophageal mucosal findings: without RE, group 1 (n = 24) and with RE, group 2 (n = 6). Esophageal bile exposure was defined as bilirubin absorbance >0.14 detected in the esophagus.RESULTS:1) The percentage total time of esophageal bilirubin absorbance >0.14 was not correlated with that of esophageal pH >7.0, >7.4, and >8.0. 2) All parameters for esophageal bilirubin absorbance >0.14 in group 2 were significantly higher than those in group 1, whereas none of the parameters for esophageal pH >7.0, >7.4, and >8.0 showed a significant difference between the two groups. 3) The percentage total time of esophageal bilirubin absorbance >0.14 was over 50% in all subjects with RE, and six of seven subjects with that over 50% had RE.CONCLUSIONS:Esophageal bile exposure plays an important role in the genesis of RE in the absence of gastric acid, which is assessed better with the measurement of esophageal bilirubin absorbance than that of esophageal pH.

Is laparoscopic colorectal surgery less invasive than classical open surgery? Quantitation of physical activity using an accelerometer to assess postoperative convalescence

Background: With the technical advances of recent years, the number of operative manipulations in the abdominal cavity by laparoscopic surgery is now considered to be the same as that using classical open surgery. The question has been raised whether laparoscopic colorectal surgery with lymphadenectomy improves the recovery compared to open surgery. Methods: We compared patients’ physical activity for 7 days postoperatively as measured with an accelerometer between laparoscopic-assisted colorectal resection (LAC, n = 32) and classical open colorectal surgery (OC, n = 30). Results: Physical activity expressed as cumulative acceleration was significantly higher in the LAC than in the OC group on each postoperative day. The recovery time, defined as the day on which the cumulative acceleration recovered to 90% of the preoperative level, was significantly shorter (p < 0.05) in the LAC (3.4 ± 1.2 days) than in the OC group (6.8 ± 1.7 days). Conclusion: Our results showed that the duration of convalescence with LAC was significantly shorter than that with the OC procedure. Laparoscopic colorectal surgery appears to allow an earlier recovery after the operation than the classical open procedure, and it is less invasive as assessed by convalescence.

A New Parameter for Assessing Postoperative Recovery of Physical Activity Using an Accelerometer

AbstractPurpose. While many retrospective and prospective observational studies have shown laparoscopic surgery to be less invasive than conventional open surgery, this issue has not been evaluated by objective parameters. Currently available clinical parameters, such as the day of first ambulation, the day food intake is commenced, and the length of postoperative hospital stay, are subjective. The purpose of this study was to investigate whether measuring postoperative physical activity with an accelerometer is a useful parameter for evaluating postoperative recovery after surgical stress. Methods. The subjects included 20 patients who underwent laparoscopic partial gastrectomy (LPG group), 35 patients who underwent open distal gastrectomy (ODG group), and 20 patients who underwent open total gastrectomy (OTG group). The cumulative acceleration of voluntary movement, measured by an Active tracer AC-301 (ACT) accelerometer for 7 days postoperatively, was compared among these three groups. Results. The cumulative acceleration of physical activity for 24 h was significantly better in the LPG group than in the ODG and OTG groups on each postoperative day. The recovery time, defined as the day that cumulative acceleration had recovered to more than 90% of the preoperative level, was significantly shorter in the LPG group (2.8 ± 0.9 days) than in the ODG (6.6 ± 2.1 days) and OTG (7.8 ± 1.2 days) groups. Conclusion. These results showed that convalescence differed with the degree of surgical stress, and that measurement of the cumulative acceleration of voluntary movement by using an accelerometer could be a useful objective and quantitative parameter for evaluating postoperative recovery.

Completely Laparoscopic Total Colectomy for Chronic Constipation: Report of a Case

Laparoscopic surgery has had a remarkable impact on the practice of colorectal surgery. However, most operations are performed using a technique of laparoscopic assistance, whereby extracorporeal bowel division and anastomosis are made following laparoscopic mobilization of the bowel. To our knowledge, this is the first report to describe a case of chronic constipation managed by total colectomy with ileorectal anastomosis, performed completely laparoscopically. The diagnosis of slow transit constipation was made by a transit time study. After dissection of the entire colon, the colon to be resected was delivered through the open rectal stump and brought out transanally. The anvil of an intraluminal circular stapler was passed through the rectum into the peritoneal cavity and the end of the open distal rectum was closed with a linear cutting stapler. The anvil of the circular stapler was inserted into the end of the open terminal ileum and fixed with an Endo-Loop, following which an intracorporeal double-stapling anastomosis was performed. By 3 months following surgery, the patient was passing 3–4 stools a day. Thus, we highly recommend this technique as it eliminates the need for a small incision to deliver the resected colon, thereby minimizing the operative time and risk of wound infection.

Effect of mucosal suture on the healing of mucosal defect in laparoscopic intragastric surgery.

Background. The efficacy of mucosal suturing for the healing of a mucosal defect in laparoscopic intragastric surgery (LIGS) for gastric lesions is not yet known. Methods. We prospectively studied ten patients who underwent mucosal resection by LIGS for gastric tumors: four patients with early gastric cancer and six with gastric adenoma. Patients were randomly divided into two groups: group I (n = 5); patients who underwent mucosal resection by LIGS with mucosal defect suturing and group II (n = 5); patients who underwent mucosal resection by LIGS without mucosal defect suturing. We performed endoscopy on day 10, and 1 month, 2 months, and 3 months after the operation to observe the healing process of the mucosal defect. The ulcer stage by endoscopy was classified as active, healing, or scarring according to the classification of Sakita and colleagues. Patients were given an H2-blocker daily until the mucosal defect improved to the scarring stage. Results. There were no significant differences in sex, age, tumor location, size of mucosal resection, or the incidence of Helicobacter pylori infection between groups I and II. The ulcer stages in group I were significantly lower than those in group II on day 10, and 1 month, 2 months, and 3 months postoperation. The medication cost (H2-blocker) in group I was significantly lower than that in group II. Conclusion. Mucosal defect suturing after mucosal resection by LIGS promotes more rapid healing of mucosal defects and reduces drug costs for patients.

Jejunal Pouch Interposition with Fundic-Like Plication After Total Gastrectomy

PurposeWe developed a technique of jejunal pouch interposition with a fundic-like jejunal plication (JPI-FP) for reconstruction after total gastrectomy (TG) for gastric cancer. The aim of this study was to investigate the advantages of JPI-FP over Roux-en-Y reconstruction (R-Y).MethodsTwenty-two patients who had undergone TG more than 1 year earlier were classified into two groups according to the method of reconstruction used: Group A (n = 7) underwent R-Y, and group B (n = 15) underwent JPI-FP. Group B was subdivided into two groups to examine the usefulness of additional pylorus preservation: group B1 (n = 8), pylorus (−) and group B2 (n = 7), pylorus (+).ResultsFood intake and body weight were significantly higher in group B than in group A (P < 0.05). Reflux esophagitis was diagnosed in two of the group A patients, but in none of the group B patients. Excessive esophageal bile exposure, determined as the fraction time of esophageal bilirubin absorbance over 0.14 > 50%, was significantly higher in group A than in group B (P < 0.05). There was no significant difference in bile exposure in the jejunal pouch between groups B1 and B2.ConclusionsJPI-FP is a superior method of reconstruction after TG to prevent excessive esophageal bile reflux and from a nutritional aspect. The advantage of pylorus preservation remains unconfirmed.

Laparoscopic intragastric surgery using a radially expandable sleeve

Abstract Laparoscopic intragastric surgery (LIGS) has become more widely established in Japan as a therapy for early gastric cancers and some types of submucosal gastric tumors. However, there have been some technical difficulties with the original method of LIGS. Certain complicated procedures to access the gastric lumen are required, along with repair of the gastric wall after endoluminal procedures. Using a 5-mm radially expandable sleeve (RES) for the working ports in LIGS, it becomes easier to establish access to the gastric lumen, and repair of the port sites on the gastric wall is not required. Using RES makes LIGS a simpler, less invasive procedure.

Evaluation of QOL After Proximal Gastrectomy Using a Newly Developed Assessment Scale (PGSAS-45)

AbstractBackgroundProximal gastrectomy with esophagogastrostomy (PGEG) has been widely applied as a comparatively simple method. In this study, we used a questionnaire survey to evaluate the influence of various surgical factors on post-operative quality of life (QOL) after PGEG.MethodsIn this post-gastrectomy syndrome assessment study, we analyzed QOL in 2,368 cases. Among these, 193 had undergone proximal gastrectomy and 115 had undergone PGEG. The Post-Gastrectomy Syndrome Assessment Scale (PGSAS)-45 is a questionnaire consisting of 45 items, including the SF-8, the Gastrointestinal Symptom Rating Scale (GSRS), and other symptom items seemed to be specific to post-gastrectomy. The 23 symptom items were composed of seven symptom subscales (SS), including esophageal reflux, abdominal pain, and meal-related distress. These seven SS, total symptom score, ingested amount of food per meal, necessity for additional meals, quality of ingestion SS, ability to work, dissatisfaction with symptoms, dissatisfaction with the meal, dissatisfaction with working, dissatisfaction with daily life SS and change in body weight were evaluated as main outcome measures. In PGEG cases, we evaluated the influence on QOL of various surgical factors, such as procedures to prevent gastroesophageal regurgitation and size of the remnant stomach.Results The scores for esophageal reflux and dissatisfaction with the meal were higher in patients who had not undergone an anti-reflux procedure. In most cases, the preserved remnant stomach was more than two-thirds the size of the pre-operative stomach. When comparing patients with a remnant stomach two-thirds the pre-operative size and those with more than three-quarters, the diarrhea SS and necessity for additional meals scores were lower in the group with more than three-quarters. The indigestion, constipation, and abdominal pain subscales, and the total symptom score, were higher in patients who had not undergone pyloric bougie than in those who had.ConclusionThese results indicated that QOL was better in patients with a large remnant stomach. Procedures to prevent gastroesophageal reflux, and the use of pyloric bougie as a complementary drainage procedure, were considered effective ways to reduce the deterioration of QOL.

Significant role of intragraft lymphoid tissues in preventing insulin‐dependent diabetes mellitus recurrence in whole pancreaticoduodenal transplantation

Graft recurrence of insulin‐dependent diabetes mellitus (IDDM) was examined. Islet transplantation or pancreas‐alone transplantation excluding the duodenum and peripancreatic lymph nodes was compared with whole pancreaticoduodenal transplantation. A Wistar Furth (WF; RT1u, RT6.2) to major histocompatibility complex (MHC)‐compatible diabetes‐prone (DP; RT1u, RT6.1 gene carrier)‐biobreeding (BB) rat transplantation model was used. Only DP recipients that had been transplanted with whole pancreaticoduodenal grafts were free from IDDM recurrence (>60 days postgrafting) when treated with anti‐intercellular adhesion moluecule‐1 (ICAM)‐1/leukocyte function‐associated antigen‐1 (LFA‐1) monoclonal antibodies (mAbs). In the spleen cells of the DP rats that had accepted pancreatic grafts (60 days postgrafting), flow cytometric analysis showed that NKR‐P1+TCRαβ+ (NKT) cells had proliferated markedly, with the proportion of 12.8 ± 1.7% in the total splenic T cells, most of which (86.2%) were derived from the donor (RT6.2+). By enzyme‐linked immunonosorbent assay (ELISA), serum interferon gamma (IFN‐γ) was not detected (<13 pg/ml) in all rats. However, interleukin‐4 (IL‐4) was detected as 158.8 ± 28.0 pg/ml in the nonrecurrent DP recipients. These data suggested that to prevent IDDM recurrence in the pancreatic graft, the lymphocytes in the pancreaticoduodenal grafts are necessary. Also, the donor‐derived NKT cells might have some immunoregulatory functions with a Th2 deviation.

Simultaneous observation of endocrine and exocrine functions of the pancreas responding to somatostatin in man

Six patients who underwent segmental autotransplantation of the caudal pancreas (SAT) following total pancreatectomy for pancreatic cancer were investigated. The graft was transplanted to the left groin, and pancreatic juice was diverted outside through a polyethylene tube indwelled into the main pancreatic duct. In these SAT patients, the responses of insulin (IRIS) in terms of plasma levels and pancreatic secretion to subcutaneous injections of somatostatin octreotide (Sandostatin: SMS201-995) were simultaneously observed. Four doses (0.039, 0.156, 0.625 and 2.5 micrograms/kg) of SMS201-995 were given on separate days. As a control, saline was injected subcutaneously. Standard liquid test meal was given 1 h after the subcutaneous injection. The basal plasma IRI were significantly decreased with doses greater than 0.156 microgram/kg. The postprandial responses of IRI was also significantly suppressed with the same doses. On the other hand, the basal pancreatic exocrine secretion was significantly suppressed with doses greater than 0.625 microgram/kg. The postprandial pancreatic exocrine secretion was also significantly suppressed with doses greater than 0.625 microgram/kg. Those suppressions were dose-dependent. The postprandial CCK secretion was also significantly suppressed in dose-dependent manner with SMS201-995. The CCK suppression was significantly correlated with the suppression of pancreatic exocrine secretion. This clinical study under the setting of SAT demonstrated not only the direct inhibitory effect of somatostatin on both the islet and acinar cells but also, probably, the indirect inhibitory effect on the acinal cells via suppression of CCK release in humans.