Yuzuru Sugiyama

Survival and recurrence after low anterior resection and abdominoperineal resection for rectal cancer: the results of a long-term study with a review of the literature.

Morbidity, survival, and recurrence in 203 patients treated with curative low anterior resection (LAR) were compared with those in 100 patients treated with curative abdominoperineal resection (APR). The overall 5-year survival figures for the total number of, LAR and APR patients were 75.6±5.7%, 79.8±6.4% and 67.7±9.6%, respectively. The prognosis for cancers situated low enough in the rectum to involve the anal canal was poor even when managed by APR, as evidenced by a low survival at 5 years of 59.0±9.6% and a high pelvic recurrence rate of 34%. For all except these tumors, LAR proved at least equal to, or better than APR as a curative surgical method for middle and low rectal cancers, on the basis of 5-year survival being 79.8±6.4% vs 78.7±5.2%, operative mortality being 1.5% vs 1.0%, morbidity being 39.4% vs 59.0%, and the incidence of pelvic recurrence being 8.9% vs 13.5%. When deciding upon the most appropriate surgical procedure for rectal cancer, especially for middle or low rectal lesions, the patient should not simply be condemned to a permanent colostomy. Thus, we first attempt LAR for every lesion except those which are very advanced or those with anal canal involvement, if technically feasible and suitable for the individual patient.

Regurgitant bile acids and mucosal injury of the gastric remnant after partial gastrectomy

Three groups, each consisting of seven patients who had undergone either Billroth I, Billroth II, or pylorus-preserving gastrectomies, were evaluated more than 18 months postoperatively in terms of concentration and amount of bile acids in the gastric aspirate and histologic changes in the gastric remnant mucosa. Concentrations of bile acids were determined by gas chromatography and mucosal specimens were obtained by endoscopic biopsy. The total bile acid concentration and all of the individual fractional bile acid levels, whether free or conjugated, were significantly higher in the Billroth II group than in the other two groups. The amount of gastric aspirate was also highest in the Billroth II group. Endoscopic biopsy revealed glandular dysplasia to be predominantly in the Billroth II group. The presence of bile acids in the gastric remnant may contribute to mucosal injury, possibly leading to cancer in the gastric remnant, especially after the Billroth II operation.

Altered Bile Composition in the Gallbladder and Common Bile Duct of Patients with Anomalous Pancreaticobiliary Ductal Junction

The high incidence of biliary tract carcinoma in patients with anomalous pancreaticobiliary ductal junction (APBDJ) has been well documented. Elevation of the secondary and free bile acid (FBA) concentrations is considered a risk factor for biliary carcinogenesis in these patients. Bile from the gallbladder and common bile duct in 12 patients with APBDJ was analyzed and compared with gallbladder bile from 19 patients with gastric cancer and a normal hepatobiliary tract. The concentrations of secondary bile acids were significantly lower in the APBDJ group than in the control group, and FBA concentrations were not detected in the gallbladder in either group. The lysolecithin (LL) in the phospholipid, which is produced from lecithin by activated phospholipase A2 in refluxing pancreatic juice, was significantly elevated in the APBDJ group. Elevation of the LL concentration in the bile is one of the factors for the development of biliary tract carcinoma in patients with APBDJ.

ϱ-Shaped anastomosis: A reconstruction of the alimentary tract after total gastrectomy

Abstract One hundred sixty-four patients underwent total gastrectomy with a ϱ-shaped jejunal food pouch (ϱ loop) and Roux-en-Y jejunojejunostomy. The rate of postoperative complications was very low (9.1 per cent), and the most important problem of anastomotic failure was never encountered. Only 4 of 164 patients (2.4 per cent) died within one month of surgery, and the causes of death were pneumonia (2 patients), cerebral hemorrhage (1), and ileus (1). The function of the newly constructed passage was estimated through an elaborate barium meal examination. The test revealed that the ϱ-shaped jejunal food pouch has adequate reservoir and mixing functions for ingested foodstuff. No reflux of barium meal into the esophagus was observed during the examination. In a follow-up study of the patients, only a few complained of symptoms of reflux esophagitis or dumping, but none of them needed any treatment.

Adverse Effects of Regurgitant Duodenal Content on the Mucosa of the Residual Stomach After Partial Gastrectomy

Three groups of patients partially gastrectomized by Billroth II, Billroth I or pylorus-preserving procedure were evaluated for amount of bile acids in the gastric aspirate and histologic changes in the remnant gastric mucosa. The amount of bile acids was the highest and glandular dysplasia of the mucosa most predominant in the B-II group. Rats with either gastrojejunostomy or simple gastrotomy were maintained with an usual laboratory diet. Intestinal type adenoma and carcinoma developed exclusively in the gastrojejunostomized rats. Prolonged exposure of the gastric mucosa to bilious content may result in its histological changes that possibly lead to development of carcinoma.

Increased Risk of Gallstones following Curative Gastrectomy for Cancer

The incidence of gallstones in patients who had undergone radical gastrectomy for cure of gastric cancer was 4–8 times higher than in the general population. At least two factors seem to be involved in this high incidence: one is complete vagotomy which is inevitable in gastrectomy with lymph node dissection, and the other perioperative hepatic dysfunction. One fourth of these patients with gallstones required cholecystectomy with or without T-tube drainage. The high incidence of gallstones and a rather difficult cholecystectomy we experienced forced us to perform prophylactic cholecystectomy in these gastric cancer patients diagnosed with: cirrhosis or hepatitis; hemophilia or other hematologic disorders, and the cancer lesion involving the aborad part of the stomach.

Ultrasonographic study of gallbladder motility in gastrectomized patients for gastric cancer.

胃癌に対する胃全摘および胃亜全摘後の胆嚢運動機能をより生理的な手段である超音波診断装置を用いて経時的に検討した. 対照群21例では最大収縮率62.2%を示し, 空腹時胆嚢面積は12.9cm2であった. 術後早期27例は対照群に比べ最大収縮率35.7%と有意に収縮不良であり, 空腹時胆嚢面積も15.9cm2と有意に拡張していた. 再建術式別でみるとρ吻合で収縮不良傾向が強く, 空腹時胆嚢面積も他術式より拡張していた. 術後後期34例では対照群に比べ差はなく最大収縮率64.3%と収縮良好であったが, 空腹時胆嚢面積は15.3cm2と有意に拡張していた. 再建術式別では各術式間に差はなく良好な収縮を示した. なお, 空腹時胆嚢面積はρ吻合で拡張傾向が強かった.

Effect on survival term of stage IV carcinoma of the stomach, with or without resection and its adjuvant therapies.

StageIV胃癌486例の検討において, 胃癌病巣切除例の50%生存期間は246～247日, 1年生存率は35, 5～37.0%で, 非切除の101～102日, 0.7～10.0%より有意に高い値を示した. また手術に併用した補助療法のうち化学療法には有用性が示されたが, 遺残癌病巣内OK-432大量局注および肝転移巣への動注療法では有意の延命効果がなかった. また非切除姑息術式中で空置的胃腸吻合は最も良好であったが, 50%生存期間は153日, 1年生存率もたかだか20.0%の成績に留まった. 以上よりStage IVという高度に進行した胃癌では積極的胃癌病巣切除が大切で, しかる後化学療法の併用によりさらに延命が期待できるものと判断された.

Long term observation of gastric mucosa following partial gastrectomy for benign conditions: Chronic gastritis of remnant stomach in pathogenesis of carcinoma.

胃良性疾患のため胃部分切除を施行しBillroth II法で再建した43例について術後7～21年6ヵ月経過後の胃粘膜を検討対象とした.内視鏡所見では吻合部の発赤・びらんは30.3%, ポリープ病変は11.6%にみられたが, これと胆汁逆流との因果関係は明らかでなかった.残胃生検標本において固有胃腺萎縮の程度は吻合部に最も高度で, その改築像としての偽幽門腺化, 腺管嚢胞状拡張および腺管異型の所見も同部に高頻度で出現した.しかし術後15年を境に症例を2群に区分して各組織所見の出現頻度を比較すると後半の症例で増加する傾向は認められなかった.また腸上皮化生が残胃に新生したものは4.7%と著しく低率であることを指摘した.

A study on the long-term results of eighty patients formed proximal gastrectomy

In our clinical laboratory, 3228 cases of abdominal surgery have been experienced for the past 11 years and cases of the aged (over 70 years old) have accounted for 128 cases (4%) of them. The number of male aged cases was 2.5 times as many as the female ones. 51 cases in the aged, the greater number in the various abdominal diseases were suffered from gastric cancer. In such aged cases, the increase of mortality rate was the most significant finding. In cases with ileus, mortality rate was 55.6%. One of such cases died in intestine paralysis and three in cardiac failure. The causes of death in their series were dehydration, unbalance of electrolyte and hypoproteinemia due to repeated vomitting. On the diseases of biliary tract and pancreas, mortality rate was 53.3%, the rate of which was 75% in malignant diseases and 25% in benign ones. Jaundice index was over 100 unit, except for one case, and primary radical operation, therefore, was impossible on them. On gastric cancer, the rate of Stage 3 and 4 types were 93.5% of all the aged cases. The patients of this disease complained mainly of anorexia epigastralgia and epigastric distress. 5 year survival rate was 14.3%. On the other hand, the operative death rate was 6.5%. It seems to be natural that surgical t reatment in the aged patients should be performed under the suitable management.