Tsutomu Dousei

Rupture of liver metastasis of malignant melanoma —A case of hepatic resection—

A case is reported in which resection of the left lateral segment of the liver was performed for rupture of a metastatic malignant melanoma in an attempt to control hemorrhaging. The primary lesion was located in the skin of the head, and there were multiple metastases to the lung, liver and distant nodes. The patient, a 47-year-old woman, had been undergoing systemic chemotherapy for the disseminated disease, but she presented with intraabdominal bleeding from a metastatic nodule in the left lateral segment of the liver. An emergency operation was performed, and the immediate postoperative course was uneventful. She was discharged 10 days after the operation. The patient died, however, of hemorrhagic shock due to renewed intraabdominal bleeding on the 39th postoperative day. It is concluded from the above case that hepatic resection for a bleeding metastasis of malignant melanoma is a viable option even in patients with disseminated disease.

Long-term Follow-up of Gastroplasty in a Patient with Prader-Willi Syndrome

To prevent the development of metabolic disturbances caused by overeating, we performed vertical banded gastroplasty in an adult woman with Prader-Willi syndrome. Her fasting blood sugar (FBS) and urinary sugar excretion (US) decreased during 6 months after the surgery under strict dietary control in the hospital. The insulin response to oral glucose at 6 months after surgery was as good as in the normal controls. A barium meal study in the 11th postoperative month revealed that the staple line was partially ruptured. After this, FBS and US increased, and the glucose tolerance and insulin response worsened. At 24 months, US was still less than preoperative US, and the oral glucose tolerance test showed a better result than before operation. At 29 months, her condition was brought under control with use of Glibenclamide. At 60 months, her FBS and US were at the same level as before operation. She was doing a part-time job. In conclusion, the effect of gastroplasty in preventing worsening of glucose metabolism in a case of Prader-Willi syndrome lasted satisfactorily for 24 months in spite of the partial breakdown of the staple line.

Metabolic changes following gastroplasty in Prader-Willi syndrome--a case report.

A vertical banded gastroplasty was performed in an adult female patient with Prader-Willi syndrome in an attempt to prevent the metabolic deterioration caused by polyphagia. After her operation, the patient felt satiated with the scheduled amount of food and one month later, her fasting blood sugar concentration (FBS) decreased from 521 to 125 mg/dl, and her urinary sugar excretion (US) from 257 to 9g/day. Both glucose tolerance and insulin secretion were also improved. However, these parameters subsequently became worse after dietary control was lost since the surgical procedure alone was unable to continue to suppress the insatiable desire to eat food. Both her glucose tolerance and insulin secretion by the 31st postoperative month were better than before the surgery, but worse than at one month after the surgery. At the end of the 34th postoperative month, even under the temporary administration of 0.625 mg/day of glibenclamide, her FBS was 158 mg/dl and US, 38.1 g/day. Her body weight had also increased to over her preoperative value. Based on these results, we conclude that the effect of gastroplasty to prevent metabolic deterioration in our patient with Prader-Willi syndrome gradually diminishes.

Gastric neuroendocrine tumors in our institutions according to the WHO 2010 classification.

In 2010, World Health Organization classified gastric neuroendocrine tumor (NET) as follows: NET grade (G) 1, NET G2, neuroendocrine carcinoma (NEC). We reviewed 22 gastric NETs that were encountered in our institutions. Nine, 6, and 4 were NET G1, G2, and NEC, respectively. We also encountered 3 NET G3. NET G1 was treated with observation in 2 patients, endoscopic mucosal resection (EMR) in 3, and gastrectomy in 4 patients. No recurrence was experienced during a median of 53 months of follow-up. All NET G2 was treated with gastrectomy. No patient experienced recurrence during a median of 25 months of follow-up. NET G3 was treated with gastrectomy. One patient died of liver metastasis 52 months after gastrectomy. For NEC, gastrectomy was performed in 3 cases and no patients died of tumor-related death. We conclude that the prognoses of NET G1 and G2 were good. We also experienced long-term survivors of NEC. An accumulation of more patients is needed for further investigation.

Prognostic Factors for Gastrectomy in Elderly Patients

The decision to undergo surgery for gastric cancer patients aged ≥85 years should be made carefully. We retrospectively reviewed the prognostic factors of gastrectomy for 64 patients aged ≥85 years who had undergone curative gastrectomy for gastric cancer. The effects of various clinical characteristics and surgical interventions on survival were retrospectively analyzed. Univariate analysis revealed that sex (male/female; P = 0.001), the extent of gastric resection (total/distal; P = 0.028), the extent of lymph node dissection (D2/<D2; P = 0.019), and blood loss (P = 0.005) were significant prognostic factors for overall survival. Multivariate analysis demonstrated that sex was the only independent prognostic factor. For pneumonia-specific survival, sex was also the only prognostic factor by multivariate analysis.Prognoses of males aged ≥85 years after gastrectomy were significantly worse than those of females, as they were more likely to die of pneumonia.

Influence of distal pancreatectomy on insulin secretion in patients with pre-existing disorders of the pancreas

Insulin secretion was investigated by oral glucose loading before and early (mean: 8.9 weeks) after distal pancreatectomy (DP) in 9 patients with a tumor of the caudal pancreas. In 6 patients the same investigation was repeated later (mean 17.8 months). Two parameters expressing the initial and total secretion of insulin in response to elevation of the plasma level of glucose ([ΔIRI/ΔBS]30m and [ΣΔIRI/ΣΔBS]o-180min) were calculated for each individual patient for serial comparison. These parameters were significantly smaller before the operation compared with 10 normal controls. Early after DP, the parameters decreased significantly, and a further significant decrease was noted late after DP. It is concluded that distal pancreatectomy causes a progressive decrease in insulin secretion in patients with pre-existing disorders of the pancreas.

Surgical Aspect of Cancer of the Distal Pancreas

A retrospective analysis was made of 115 patients who had undergone laparotomy for ductal cell carcinoma of the pancreas. The purpose of the analysis was to analyze the surgical statistics of patients

Gastric inhibitory polypeptide secretion after gastrectomy in patients with diabetes mellitus

Gastric inhibitory polypeptide (GIP) secretion after distal gastrectomy was compared between patients with diabetes mellitus (DM-group) and patients with normal glucose tolerance (N-group). GIP secretion in the DM-group was significantly greater in the early postcibal response period, but less in the late postcibal response period after gastrectomy, the total secretion of GIP being less after gastrectomy than before in this group. In the N-group, both the early and total postcibal responses of GIP were greater after gastrectomy than before. Moreover, the early and total postcibal secretions of GIP after gastrectomy were less in the DM-group than in the N-group. These findings suggest that GIP secretion in diabetics becomes insufficient after gastrectomy.

POSTOPERATIVE GASTRIC EMPTYING AND QOL IN RECONSTRUCTION PROCEDURE USING GASTRIC TUBE AFTER PROXIMAL GASTRECTOMY FOR UPPER GASTRIC CANCER

胃上部癌に対して噴切後,食道胃管吻合を施行した15例を対象とした.年齢は47～81歳,男性12例,女性3例であった.手術適応はEC-junction近傍の早期癌やhigh risk症例でU領域を占拠する進行癌とした.リンパ節は(1), (2), (3), (7)番のみ郭清し,胃管の長さは約20～25cmとした.術後のQOLとして経口摂取量の変化,体重の推移,臨床症状の有無,内視鏡所見,排出能を検討した.退院時,経口摂取量は術前の50～85%,体重は術前の80%まで低下したが術後1年目には15例中8例が術前のレベルに回復した.食後のつかえ感は1例にみられたが,胸やけやDumping症状は認めなかった.内視鏡検査では逆流性食道炎を12例中3例に認めたが保存的に軽快した.残胃炎や胃石は認めなかった.噴切症例の排出能は墜落型のパターンを呈した.胃上部癌に対する噴切後の大彎側胃管を用いた再建法は手術手技も簡便であり,術後のQOLも良好に保たれていた.

An Adult Case of Duodenal Anomaly

A distal gastrectomy reconstruction using the Billroth II procedure was performed for epigastralgia and liver dysfunction caused by a duodenal anomaly in an adult. Hypotonic duodenography revealed the duodenum to be obliterated at the junction of the second and third portion, while the third portion was joined to the first portion. Endoscopic retrograde cholangiopancreaticography (ERCP) and ultrasonography showed a normal construction of the common bile and pancreatic ducts, as well as gallstones. To prevent ingested food from the stomach from entering the obliterated second portion, a distal gastrectomy (Billroth II) was thus performed. The patient has remained asymptomatic for 4 years since surgery. A distal gastrectomy reconstructed by a gastrojejunostomy is thus considered to be an effective method for improving the symptoms caused by food stasis in the obliterated second portion of the duodenum.