Yoshi Takeda

Proximal subtotal gastrectomy for the treatment of carcinoma of the upper third of the stomach: Its indications based on lymph node metastasis and perigastric lymphatic flow

To clarify the indications for a proximal subtotal gastrectomy in the treatment of carcinoma in the upper third of the stomach based on lymph node metastases, 1055 patients in whom either a D2 or greater lymph node removal was performed were reviewed. In the patients in which the lesion was confined to the upper stomach and did not invade beyond the muscularis propria of the stomach wall, no metastases to either the lymph nodes above and below the pylorus or the lymph nodes along the greater curvature were observed. A lymphatic flow study revealed a minimal flow to these nodes from the upper stomach in patients without lymph node metastasis, but in cases with lymph node metastases the lymphatic flow changed. The indications for a proximal subtotal gastrectomy for a carcinoma of upper third of the stomach therefore must fulfill the following two conditions: (1) The deepest layer of cancerous invasion does not extend beyond the muscularis propria of the stomach wall, and (2) No macroscopic evidence of lymph node metastasis can be detected during surgery.

Surgery for cholelithiasis in cirrhotic patients

Although biliary tract surgery for cholelithiasis is performed frequently in Japan, cirrhotic patients require special consideration. Postoperative complications after biliary tract surgery were studied in 23 patients with liver cirrhosis and associated cholelithiasis, 9 of whom had no complications, 8 had minor complications, and 6 had severe complications. Concerning the relation between Childs classification and postoperative complications, no complications were seen in four Childs type A patients, but seven of ten (70%) Childs type B patients and seven of nine (78%) Childs type C patients developed complications. Two (20%) of the Childs type B patients and four (44%) of the Childs type C were severe, and three of the latter group died. Regarding the preoperative laboratory findings, significant differences were seen between the patients without complications and those with severe complications in serum bilirubin, albumin, and ICG R15 values. Of the six patients with severe complications, five had choledocholithiasis, three of whom died of liver failure, while two developed biliary peritonitis caused by insufficient fistula formation after removal of the T-tube. Thus, for the treatment of choledocholithiasis in patients with severe cirrhosis, avoiding surgical invasion through the use of such techniques as endoscopic papillotomy is recommended whenever possible.

Significance of proliferating cell nuclear antigen (PCNA) expression in gastric cancer in relation to lymph node metastasis.

Proliferating cell nuclear antigen (PCNA) in gastric cancer was evaluated in relation to lymph node metastasis. A total of 125 gastric cancer patients who underwent gastrectomy were studied immunohistochemically. The PCNA‐positive rate of the primary lesion with lymph node metastasis (47.6%) was significantly higher than that in those without metastasis (24.3%, P < 0.0001). The PCNA‐positive rate of early gastric cancer was significantly higher in lesions with lymph node metastasis (36.9%) than in lesions without lymph node metastasis (14.7%). However, there was no significant difference between lesions with and without lymph node metastasis in advanced gastric cancer. In addition, the PCNA‐positive rate in metastatic lesions (44.6%) was significantly higher than that in the primary lesion (40.0%, P = 0.001). It is concluded that gastric cancer with higher tumor growth activity has a higher rate of lymph node metastasis. Cancer cells in the metastatic foci of lymph node have a higher proliferating activity than that in the primary lesion.

The successful surgical management of perforation after endoscopic sphincterotomy: Report of two cases

Retroperitoneal performation following endoscopic sphincterotomy (EST) is an infrequent but serious complication with a high mortality rate in patients who do not receive prompt treatment. We report herein two cases of perforation, diagnosed 3 and 7 days after EST, one of whom was treated by choledochojejunostomy (Roux-en-Y) and suturing of the perforation site with jejunal patching, and the other by pancreatoduodenectomy. Both operations were successful as emergency treatments and therefore we consider that radical surgery should be attempted for cases of perforation after endoscopic sphincterotomy with a delayed diagnosis.

SCLEROTHERAPY WITH A LIGATION OF INCOMPETENT VEINS FOR A STASIS ULCER DUE TO VARIX CRURIS: MINIMAL INVASIVE THERAPY FOR VARIX CRURIS

A retrospective analysis was performed on 11 patients (mean age 50 years), consisting of 8 men and 3 women, with a stasis ulcer due to varix cruris who underwent sclerotherapy with a ligation of incompetent veins on an outpatient basis. The follow-up ranged from 26 to 76 months (mean 53 months). The ulcers healed in 14 to 128 days (mean 41 days) after this procedure except in 1 patient. Three patients healed within 1 month and 7 others within 2 months. Only 1 patient needed over 2 months to heal. A recurrence of the ulcer was observed in 1 case 59 days after healing, and incompetent perforating veins were newly identified. This patient required an additional endoscopic subfascial division of the perforating veins and is now in the process of healing. No deterioration of the ulcer was observed. Thrombophlebitis and faintness were observed in 1 patient each. Neither pulmonary embolism nor deep venous thrombosis was observed. In conclusion, sclerotherapy with a ligation of any incompetent veins was found to be a safe and effective treatment for a stasis ulcer due to varix cruris; however, long-term observation will be required to confirm the effectiveness of this procedure. To successfully use combination therapy with less or minimally invasive procedures, a precise diagnosis of vein incompetency is crucial.

Endoscopic evaluation of the depth of invasion of the depressed type early gastric cancer and apparently early advanced cancer in cases of a peptic ulcer within the cancer lesion

SummaryDepressed-type early and apparently early advanced cancers were divided into two groups according to whether or not an associated peptic ulcer was present within the cancer lesion, and the accuracy of preoperative endoscopic diagnosis was reviewed. As a result it was found that evaluation of depth of invasion was more difficult in the ulcer [UL(+)] group than in the group without an ulcer [UL(-)]. In the UL(+) group it was difficult to identify endoscopie findings which indicate depth of invasion at the tip of the folds, the volume of cancer invasion of the deeper layers was small, and there were many cases of invasion of deeper layers in a portion of the margins of the peptic ulcers.

Diagnosis and Surgical Indications for Polypoid Lesions of the Gallbladder

To clarify the surgical indications for polypoid lesions of the gallbladder (PLG), we studied 62 patients who underwent cholecystectomy with the preoperative diagnosis of PLG. This included cholestero

Surgery for Gastric Cancer Patients Aged 75 and Over

To analyze the clinicopathological characteristics and surgical results in very elderly gastric cancer patients, we reviewed 129 patients aged 75 years and over (group 1) and 708 patients younger than 60 years (group 2) as controls. There were significant differences between group 1 and group 2 with regard to the preoperative impairment of cardiac, respiratory, liver and renal function. The maximum dimension of the tumor in group 1 was greater than that in group 2, and lymph node metastases were more common in group 1. Although reduced lymph node dissection was performed more frequently in group 1 than in group 2, the operative mortality in group 1 (8.5%) was significantly higher than that in group 2 (2.5%, p = 0.002). Among the causes of operative mortality, anastomotic leakage was the most common in the both groups (group 1 36.3%; group 2 44.4%). With regard to the long-term results, although a significant difference in the cumulative 5 -year survival rate was detected in stage I or II patients (group 1 52.2%; group 2 91.1%; p