Yoshinao Kotoura

Hepatobiliary and gastrointestinal imaging after pancreaticoduodenectomy —A comparative study on Billroth I and Billroth II reconstructions

This study was conducted to compare the passage of bile and food through the remnant alimentary tract between 2 and 6 months following pancreaticoduodenectomy in patients undergoing Billroth I (Imanaga) and Billroth II (Child) reconstructions, using dual scintigraphy. In the patients who underwent Childs operation (n=14), hepatobiliary scintigraphy showed a prominent stasis of bile tracer in the proximal jejunal loop and a significant time delay before the bile and food became mixed at the upper jejunum. On the other hand, in the patients who underwent Imanagas operation (n=9) no bile stasis in the proximal jejunal loop was found and the time taken before the two agents became mixed was similar to that of healthy controls (n=7). The time taken for the two agents to mix at the upper jejunum was 65.8±7.9 min in the patients after Childs operation, 17.3±2.5 min in those after Imanagas operation, and 18.5±2.8 min in the healthy controls, respectively. Continuous stasis of bile in the proximal loop and severe postcibal asynchronism in patients who undergo Childs operation can therefore cause reflux cholangitis and absorptive disturbances in the long postoperative term. The results of this study suggest that Imanagas reconstruction is a more physiological procedure than Childs reconstruction following pancreaticoduodenectomy.

Availability of plasma pancreatic polypeptide measurement in diagnosis of chronic pancreatitis.

Plasma pancreatic polypeptide (PP), a newly recognized pancreatic hormone, was studied in healthy subjects and patients with chronic pancreatitis. After an oral load of 50 g of meat extract, the plasma concentration of PP showed a rapid fourfold rise at 20 min in healthy controls. In contrast, the plasma PP level rose only 1.8-fold in patients with chronic pancreatitis. This difference was statistically significant (P less than 0.05). The increase rate of the PP level during the test in each subject correlated significantly (P less than 0.01) with total amylase output and maximal amylase concentration measured by the pancreozymin-secretin test. Thus, it is suggested that the measurement of the plasma PP level may be a useful tool to diagnose chronic pancreatitis.

Follow up studies on various reconstruction methods of the biliary tract including our new method (Roux Y-duodenojejunal anastomosis)

Thirty six patients with benign diseases of the biliary tract (14 patients with congenital choledochal dilatation, 15 patients with postoperative stricture and 7 patients with others) were divided into three groups: 21 patients who underwent a Roux Y (RY), 7 patients who underwent a jejunal interposition (IP) and 8 patients who underwent a side to side anastomosis between the jejunal limb of the Roux Y and the duodenum (RY-DJ). The RY-DJ was designed to decompress the Roux Y jejunal limb and to allow an inflow of bile into the duodenum. Significant complications, including cholangitis, infection, or abdominal pain, developed in 10 of the patients with RY (48 per cent), 7 of the patients with IP (100 per cent) and 1 of the patients with RY-DJ (13 per cent). None had a postoperative peptic ulcer. Simultaneous scintigraphy showed the time required for the two agents,99mTc-IDA and111In-DTPA, to mix at the upper jejunum, which revealed that the time taken by the patients with RY-DJ was similar to that of the patients with IP and to that of healthy controls. The time was markedly longer in the patients with RY, presumably due to a prominent stasis of the bile tracer in the Roux Y jejunal limb. Our new method (RY-DJ) for reconstruction of the extrahepatic biliary tract is more physiological and has less postoperative complications than other conventional methods.

Computed tomography of carcinoma in the pancreatic head

Computed tomographic findings in patients with localized and extensive pancreatic head cancer were studied. Widening of the pancreatic duct existed in both groups; mass shadow was hardly detected in localized and rather easily detected in extensive cancer; duodenal invasion and obliteration of fat planes were found only in extensive type; enlargement of the pancreas was a confusing factor of tumor detection in localized type; atrophy of the pancreatic body and tail was a most favorable indirect sign in extensive cancer.

Better control of esophageal variceal bleeding by sclerotherapy followed by surgery

This paper reports the clinical results of a retrospective study comparing endoscopic injection sclerotherapy (EIS) and back-up surgical treatment after EIS in the management of acute variceal bleeding. The 74 patients included in the study were divided into 2 groups. Group I consisted of 41 patients who received EIS over a mean period of 2.2 sessions and Group II consisted of 33 patients who underwent EIS and subsequent surgical intervention, in the form of 19 distal splenorenal shunts and 14 nonshunting procedures. The overall percentage of patients in whom initial control of variceal bleeding was achieved was 91.8 per cent. Four of the Group II patients were saved by emergency nonshunting operations. Rebleeding was experienced by 4 (28.6 per cent) of the 14 patients who underwent nonshunting surgery but by only 1 (5.3 per cent) of the 19 patients who underwent selective shunt surgery. The cumulative survival in Group II was significantly superior to that in Group I with 2 year survival being achieved in 66.7 per cent of the Group II patients but in only 23 per cent of Group I patients. Thus, the combination of initial EIS and back-up surgical intervention may be more benefical than sclerotherapy alone for patients with acute variceal bleeding, while, the distal splenorenal shunt may be a more suitable surgical technique for patients having previously EIS.

A comparison of the metabolic changes after the distal splenocaval and portacaval shunts.

The distal splenorenal shunt (DSRS) is the recommended procedure for selective variceal decompression, but its use may be limited in patients who have undergone left nephrectomy, those with an anatomically aberrant relationship between the splenic and left renal veins, and those whose preoperative angiographic findings suggest a risk of developing postoperative renal vein hypertension. For these clinical situations, the selective distal splenocaval shunt (DSCS) is a useful alternative to the DSRS. However, the metabolic consequences of the DSCS have not yet been studied in detail and therefore, using a canine model, the metabolic changes following the DSCS and the portacaval shunt (Eck) were compared. The metabolic changes observed following the Eck were hyperammonia and amino acid imbalance, while those following the DSCS were similar to those of the control dogs. In terms of the hepatic adenosine triphosphate level, which reflects hepatic mitochondrial function, the DSCS dogs were also similar to the control dogs. These data suggest that there was no metabolic disadvantage of the DSCS compared to the control.

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.