Sugiura procedure for management of variceal bleeding in Japan

During the last three decades the Sugiura procedure and other nonshunting operations have been widely performed as the operations of choice for bleeding esophageal varices in Japan. The Sugiura procedure (University of Tokyo method), a transthoracoabdominal esophageal transection, consists in paraesophageal devascularization, esophageal transection and reanastomosis, splenectomy, and pyloroplasty. The results have been satisfactory with low operative mortality and low rebleeding rate. The prognosis of the patients after this operation depended on the liver function at the time of operation but not on whether operation was done as an emergency, elective, or prophylactic measure. Although the Sugiura procedure has recently been performed in more selected cases with an advance in endoscopic injection sclerotherapy, this procedure remains the ultimate direct operation for portal hypertension in Japan.

Role of laparoscopic cholecystectomy in treating gallbladder polyps

Since the application of laparoscopic cholecystectomy (Lap C) to gallbladder polyps has not yet been fully evaluated, we performed Lap C on 26 patients with gallbladder polyps. Pathological examinations showed adenocarcinoma in three patients, adenoma in two, and cholesterol polyp in 21. Preoperative diagnoses of the cases with adenocarcinoma were a cholesterol polyp in one patient and an adenoma in two. Adenocarcinoma was confirmed to reside in the mucosa without any invasion of lymphatic ducts or small vessels in the three patients. This procedure was considered to be sufficient for this grade of cancer, and, therefore, no additional operations were performed. At present, our policy is to resect by Lap C a gallbladder polyp having a maximum size larger than 10 mm and a tendency to grow or presenting with suspicion of adenoma. When cancer is suspected by preoperative examinations, however, traditional surgery may be recommended.

[Gallstones in liver cirrhosis]

The prevalence of gallstones in cirrhotic patients has been found to be higher than in the general population, by at least twofold. Of this increment, the majority of stones are of the pigment type in the gallbladder. The composition of black stone is unique because of the large fraction of unconjugated bilirubin, which is present as calcium bilirubinate or in an undefined polymeric form. There is little doubt that biliary surgery is hazardous in cirrhotic patients. Elective surgery for symptomatic Child A and B patients would normally be warranted. For Child C patients with life-threatened cholecystitis or cholangitis, every type of medical treatment should be attempted. After considering the bleeding tendency or ascites, percutaneous transhepatic gallbladder drainage or endoscopic sphincterotomy is considered to be one of the treatments.

A case of an aortocolic fistula occurring 27 years after aorto-femoral bypass surgery, treated successfully by surgical management

The secondary aortoenteric fistula (AEF) is a rare but grave complication of aortic reconstructive surgery. We report herein a case of an aortocolic fistula which occurred 27 years after an aortofemoral bypass. A 69-year-old man was admitted to hospital following a sudden episode of melena. He had undergone aortofemoral bypass surgery with a prosthetic graft 27 years previously for occlusive disease of the right external iliac artery. Colonofiberscopy, CT scan, and angiography were performed, and an aortocolic fistula due to an aortic anastomotic pseudoaneurysm was diagnosed. The first-stage operation, being resection of the previously implanted graft, right hemicolectomy, and aortic stump closure were carried out with concomitant axillo-right femoral bypass. A femoro-femoral crossover bypass was performed in the second stage and the patients recovery followed uneventfully. This case constitutes the longest postoperative interval for an AEF recorded in the English literature.

Safe intraabdominal pressure of carbon dioxide pneumoperitoneum during laparoscopic surgery

BACKGROUND

The deliberate induction of carbon dioxide pneumoperitoneum during laparoscopic surgery could be a possible source of cardiovascular collapse. The effects of elevated intraabdominal pressure (IAP) on systemic hemodynamics and splanchnic blood flow created by insufflation of carbon dioxide were examined in anesthetized dogs.

METHODS

Stepwise increases in IAP of 8 (n = 7), 12 (n = 7), and 16 (n = 7) mm Hg were applied to determine the threshold pressure that had minimum influence on these hemodynamics. Hemodynamic parameters were measured at baseline and 1, 2, and 3 hours after the start of insufflation.

RESULTS

At an IAP of 16 mm Hg, cardiac output was decreased significantly by 1 hour after the start of insufflation and became progressively lower during the procedure. Systemic vascular resistance was elevated significantly in parallel with the change in cardiac output. Although hepatic arterial blood flow was not decreased significantly, portal venous and superior mesenteric arterial blood flows were diminished significantly at 16 mm Hg, resulting in a decrease in total hepatic blood flow. No significant changes were observed in these parameters at 8 or 12 mm Hg.

CONCLUSIONS

Based on these results, an IAP from 8 to 12 mm Hg is recommended for laparoscopic surgery, to avoid complications caused by hemodynamic derangements.

Changes in splanchnic blood flow and cardiovascular effects following peritoneal insufflation of carbon dioxide

Laparoscopic surgery has rapidly become a popular and widely used technique. Although this procedure has been shown to be generally safe, cardiovascular derangement related to carbon dioxide pneumoperitoneum has been reported. There are few data available on the relationship between systemic and regional hemodynamics in cases of pneumoperitoneum. Changes in splanchnic blood flow and cardiovascular effects following a moderate increase of intraabdominal pressure (IAP) to 16 mmHg during a 3-h period were analyzed in six anesthetized dogs. After insufflation, cardiac output and blood flow in the superior mesenteric artery and portal vein decreased progressively and returned to the preinsufflation values following deflation. Hepatic arterial blood flow did not change significantly, perhaps due to compensatory mechanisms for maintenance of hepatic blood flow. Mechanical compression of the splanchnic capillary beds due to the elevated IAP may possibly reflect the increase in systemic vascular resistance causing the decrease in cardiac output. To prevent this impairment, intermittent decompression of gas during surgical laparoscopy is recommended.

Localized sclerosing cholangitis in the intrapancreatic bile duct. Report of a case

A case of primary sclerosing cholangitis (PSC) localized in an isolated segment of the intrapancreatic bile duct was successfully treated by a pancreatico-duodenectomy. Although a progressively larger number of patients with PSC have recently been reported, there have been no other reports of a patient with this disease confined to the very distal part of the common bile duct. Since it is difficult to differentiate this rare disease from malignancy, surgical treatment as for a malignancy is sometimes required.

Perianastomotic findings in canine endothelial cell seeded grafts at 3 months

Endothelial cell seeding is one of the methods commonly used to prepare an antithrombogenic surface for small caliber vascular prostheses. In this study, we investigated the perianastomotic tissue reaction of seeded grafts, using a canine model. Eight dogs were used to harvest endothelial cells (ECs) enzymatically from their external jugular veins, with one dog being excluded because of infection. ECs were cultured and seeded, using a rotation method, onto a small caliber prosthesis woven with ultrafine polyester fibers. Each graft was implanted into the carotid artery of its cell donor dog, with another implanted contralaterally as a non seeded control. Two of seven seeded grafts were patent at 3 months, while all controls were occluded. Histologic examination revealed a continuous lining of ECs in the patent grafts, but thickening of the intima at the anastomoses was also observed. The occluded seeded grafts had organized hard thrombi and thick fibrosis at the perianastomotic area, however, with few thrombi in the midportion. These observations suggest that the investigation of a small caliber prosthesis with the ultimate aim of producing better patency should focus not only on antithrombogenicity of the surface of the lumen, but also on the perianastomotic biologic reaction.

Comparison between wedge and needle biopsies for evaluating the degree of cirrhosis

To examine whether the biopsy method could affect histological evaluation, the volumetric ratio of human liver parenchyma was estimated in specimens from subcapsular and intralobar areas, and also in specimens obtained by needle biopsy (Tru-Cut needle). A new method of morphometric analysis was performed using a computer-aided color image analyzer. Eighteen cirrhotic, 7 fibrotic, and 4 normal liver biopsies were taken during hepatic resection and analyzed. The parenchymal cell volume ratio in the intralobar area was significantly correlated with that in the subcapsular area, and less significantly with needle biopsy samples (r = 0.844, p < 0.001; r = 0.577, p < 0.01, respectively). Both showed one-to-one correspondence. These results suggest that both wedged and needle biopsy samples are appropriate for assessing the degree of fibrosis or cirrhosis, although the sampling variability of the latter is greater than the former.

Management of gallstones in cirrhotic patients

34 cirrhotic patients who underwent either cholecystectomy alone or in conjunction with common duct exploration were retrospectively reviewed. In Child A and B patients morbidity was low and there were no postoperative deaths. However, all patients who underwent additional cholecystectomy during the non-shunting operation for esophageal varices required blood transfusion. Cholecystectomy in Child C patients is frequently associated with considerable intraoperative bleeding and subsequent postoperative complications. In the 23 patients who were not operated upon for gallstones, no patients developed symptomatic biliary disease. Ultrasonographically, most of these gallstones were strongly suspected to be black stones. Elective surgical intervention for symptomatic Child A and B patients would normally be warranted, but hemorrhage and resulting complications due to additional cholecystectomy for asymptomatic gallstones during the non-shunting operation should be minimized. An additional cholecystectomy should be considered, provided such a cholecystectomy is thought to be easily performed judging from the degree of development of collateral circulation around the hepatoduodenal ligament and unless black stones are suspected ultrasonographically. For symptomatic gallstones in Child C patients every type of medical treatment should be attempted. After considering the bleeding tendency or ascites, percutaneous transhepatic gallbladder drainage is considered to be one of the safest treatments.

Present status of sclerotherapy and surgical treatment for esophageal varices in Japan. Japanese Research Society for Portal Hypertension and Japanese Research Society for Sclerotherapy of Esophageal Varices

A nationwide survey on the treatment for esophageal varices was performed in 1990 jointly by the Japanese Research Society for Portal Hypertension and the Japanese Research Society for Sclerotherapy of Esophageal Varices to clarify the present status and strategy of this treatment in Japan. A total of 12,675 cases, including 4,159 cases of nonshunting procedures and 7,612 cases of sclerotherapy, were collected from 101 institutions. The number of patients had greatly increased in the first half of the 1980s. With regard to the therapeutic strategy, surgical procedures were not recommended in either emergency or prophylactic cases in terms of the timing of the operation, or in Child C cases in terms of the degree of hepatic insufficiency. Endoscopic injection sclerotherapy became the leading method of treatment and in 1988 only 16% of 1,528 cases were treated by surgical procedures. The strategy for the same group of patients differed between medical and surgical institutions. With regard to sclerotherapy, repeated intravariceal injection and combined intra- and paravariceal injection were the two main techniques and 10-year cumulative survival rates were 62.8% in Child A cases, 47.7% in Child B cases, and 13.2% in Child C cases. With regard to surgical procedures, 10-year survival rates were 50.6% in esophageal transection, 42.5% in gastric transection, 53.1% in cardiectomy, and 43.0% in selective shunt procedures. We are quite convinced that this report will prove useful in determining the future strategy for treating esophageal varices.

[Operative strategy for thoracoabdominal aortic aneurysm with concomitant reconstruction of four main abdominal branches]

A thoracoabdominal aortic aneurysm (TAAA) involving major abdominal branches remains still difficult to be managed. From 1983 to 1990, we successfully operated five such cases. Our operative strategy for TAAA which necessitates concomitant reconstruction of four major abdominal branches is i) to utilize temporary bypass to maintain distal perfusion during aortic cross-clamping, ii) to reconstruct bilateral renal arteries prior to aortic clamping in order to shorten renal ischemic time as much as possible, iii) to reconstruct celiac and superior mesenteric arteries by Crawford's method, iv) to reconstruct two pairs of intercostal arteries by using diagonal anastomosis in the proximal site, and v) to divide the left renal vein temporarily for easy manipulation of renal arteries. All five cases were recovered uneventfully. This procedure, in which the renal ischemic time is saved as short as possible, is considered a safe and reasonable one for thoracoabdominal aortic aneurysms.

Esmarch's bandage technique in distal bypass surgery

Esmarch's rubber bandage technique has been applied to 49 distal bypass surgeries in 46 patients during the past ten years. The primary and secondary patency rates at 5 years after femoro-tibial bypass surgery were 82% and 92%, respectively. This technique has the following advantages: (1) it minimizes surgical injury of the arterial wall because there is less dissection around the anastomotic site; (2) it decreases scar formation in the anastomotic area after surgery; (3) it maintains abundant muscular blood flow by preserving small branches to muscles, and (4) it provides a bloodless surgical field and easy handling for fine sutures without using vascular clamps. We consider that the avoidance of long circumferential dissection of the artery may play an important role in improving long-term patency in distal bypass surgery.

[Cellular and molecular biological study of the laminin-binding protein and its clinical application]

Tumor invasion and metastasis involve the interaction between tumor cells and basement membrane, which is mediated in part by laminin receptors. To search for tumor-associated-genes which can be used as new markers in colon cancers with known poor prognosis, cDNA libraries from a colon cancer cell line and colonic tissues were constructed and screened. We selected a cDNA clone which encodes 32-kD laminin-binding protein (LBP-32), and showed increased mRNA expression of LBP-32 in colon carcinoma. This mRNA expression was also correlated with clinical tumor staging. Furthermore, to investigate the role of LBP-32 in cancer invasion and metastasis, cell adhesion assays and in vitro invasion assays were performed, using anti-sense RNA of LBP-32 to block the synthesis of LBP-32. Results showed that anti-sense RNA of LBP-32 inhibits tumor cell attachment and invasiveness in vitro in transfectants of a colon cancer cell line. These data suggest that LBP-32 may play an important role in colon cancer progression, and that LBP-32 may be used as a marker of biological aggressiveness. These findings also imply that laminin receptors may provide a target for novel therapeutic strategies: modulating LBP-32 expression by anti-sense RNA or monoclonal antibodies may have clinical application in colorectal cancer therapy.

[The current role of devascularization and transection procedures in portal hypertension]

It is not clear which theory should be used in patients with bleeding esophageal varices that are not controlled by emergency endoscopic sclerotherapy. Definitive hemostasis is the key to successful therapy of variceal bleeding. Recurrence of haemorrhage in patients with portal hypertension is the most feared life threatening complication. Based on our management of 658 patients with esophageal varices and the availability of treatment options at our institution, the strategy of management of uncontrollable variceal haemorrhage by endoscopic sclerotherapy has evolved. Bleeding was controlled in 64 liver cirrhosis (100%) by devascularization and transection procedures and 50 patients (78%) survived to leave the hospital including 43 of 64 patients (67%) with Child grade C liver cirrhosis. Cumulative rebleeding rate at 10 years following emergency surgery was 3% (2/64). It is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. We suggest that emergency transection and devascularization is an effective salvage treatment for the endoscopic sclerotherapy failed group.

[Postgraduate education in surgery and surgical specialties]

Accreditation system of postgraduate training in surgery was started by the Japan Surgical Society (JSS) in 1979, and since then more than 6,800 surgeons has been certified by examination performed by JSS in general surgery. This accreditation system has greatly contributed to the improvement of postgraduate training in general surgery in Japan; since the start of this system operative experiences of surgical residents have increased by 40% and reached to the level of 580 during the 4-year period. In order to further improve the level and quality of surgical care of the patients in Japan, it may be necessary to reform and adjust the accreditation system of postgraduate training in clinical specialties which was started quite separately by each medical specialty society. Probably, to establish a board for each medical specialties should become necessary in the near future to be officially recognized in the medical system of Japan.

Transection and devascularization procedures for bleeding from oesophagogastric varices

Transection and devascularization procedures (Sugiura procedure and transabdominal transection of oesophagus and devascularization) had been the most popular modality of treatment for oesophagogastric varices until the 1970s but the trends of treatment for varices have changed drastically during the last decade. This is partly due to the recent development of endoscopic sclerotherapy and partly due to the patient's increasing demand for less invasive treatment. Recently most patients with oesophagogastric varices are treated initially by endoscopic sclerotherapy and surgical treatment is only called for after sclerotherapy has failed.

A comparison between antipyrine and aminopyrine blood clearances

The purpose of this study was to investigate the relationship between two quantitative liver functions, that is, antipyrine blood clearance and aminopyrine blood clearance, in normal subjects and in patients with liver cirrhosis. The mean blood clearances of antipyrine and aminopyrine in cirrhotic patients (0.220 +/- 0.085 ml/min/kg and 1.13 +/- 0.56 ml/min/kg; n = 64) was 50% and 38% of that of normal subjects (0.440 +/- 0.110 ml/min/kg and 2.95 +/- 0.59 ml/min/kg; n = 11). While no significant correlation was demonstrated between these two values in normal subjects (n = 11, r = -0.107, p greater than 0.10), a strong positive correlation was observed between antipyrine and aminopyrine blood clearances in cirrhotic patients (n = 64, r = 0.846, p less than 0.001). These results suggest that both antipyrine and aminopyrine blood clearances may be valuable indicators for assessing the total hepatic functioning mass in cirrhotics.

[Mechanism of synergism and clinical results of sequential methotrexate and 5-fluorouracil in the treatment of gastric cancer]

Mechanism of synergism and clinical results of methotrexate and 5-fluorouracil (MTX/5-FU) combination therapy for gastric cancer were studied. The response rate against poorly differentiated gastric cancers was 35% in this treatment. This treatment also showed a remarkable effect against cases with pleural and abdominal effusion caused by cancerous disseminations. A promising result was obtained by this treatment as neoadjuvant and postoperative chemotherapy against Borrmann type 4 gastric cancer. A greater dependence on the de novo pathway of pyrimidine synthesis against poorly differentiated gastric carcinoma, which was estimated by the fact that the thymidylate synthetase/thymidine kinase ratio was significantly higher in poorly differentiated gastric cancer than in well differentiated cancer, may potentiate therapeutic results of this treatment.

Activities of thymidylate synthetase and thymidine kinase in gastric cancer

In a previous clinical study, sequential methotrexate and 5-fluorouracil has shown improved efficacy for treating advanced gastric cancer of the poorly differentiated type. In this study, we investigated whether difference in the levels of thymidylate synthetase (TS) and thymidine kinase (TK) activities in gastric cancer tissue account for selectivity of the treatment. Activity of TS was higher in 19 cases of the poorly differentiated type than in 16 cases of the well differentiated type (P < 0.02), whereas TK activity was lower in the poorly differentiated type than in the well differentiated type (P < 0.01). Thus, the TS/TK ratio was significantly higher in poorly differentiated gastric cancers than in well differentiated cancers (P < 0.001). These results suggest that a greater dependence upon the de novo pathway of pyrimidine synthesis in poorly differentiated gastric carcinomas may enhance the efficacy of sequential methotrexate and 5-fluorouracil treatment.

Stones in a long pancreaticobiliary common channel: a rare cause of obstructive jaundice and pancreatitis

A case of obstructive jaundice associated with acute pancreatitis is reported. The underlying cause was a dilated long pancreaticobiliary common channel impacted with stones and bile debris. There was no stone in the rest of the biliary system except for one in the lowest part of the common bile duct and the overall appearance of the stones suggested that they originated within the common channel itself. A long common channel may be an underlying cause of various pathological conditions in the pancreaticobiliary system. Early operative intervention is recommended when such a diagnosis is made.

Leiomyosarcoma of the small intestine associated with von Recklinghausen's disease: report of a case

A 54-year-old woman with intestinal multiple smooth muscle tumors including leiomyosarcoma, epithelioid leiomyoma, and leiomyomas in association with von Recklinghausen's disease is reported. Thirteen years after the excision of an intestinal leiomyosarcoma, another leiomyosarcoma arose in a different area of the jejunum and was also completely resected. Although leiomyomas are occasionally recognized in patients with von Recklinghausen's disease and a gastrointestinal neoplasm, there have been no other reports of leiomyosarcomas. Careful observation of the tumor is necessary and, if a rapid increase in tumor size is recognized, malignant tumor may have arisen and early surgical treatment is required.

False aneurysm as a late complication of division of a patent ductus arteriosus

A 58-year-old male patient who had a huge false aneurysm as a late sequela of division of patent ductus arteriosus was surgically managed with success. It is noteworthy that 24 years had elapsed from the initial operation until recognition of the aneurysm. The pathogenesis and method of the surgical treatment are discussed.