The Japanese journal of surgery最新文献

Postpneumonectomy empyema is one of the most difficult complications for the thoracic surgeon to treat. We report herein a case of a 62 year old diabetic man who developed empyema 13 years after a pneumonectomy for cancer, which was successfully treated using an omental pedicle flap. Postoperatively, the chest would healed uneventfully, however, a bowel obstruction developed which was subsequently treated by removing the remnant omentum that had adhered to the bowel.

In an attempt to define the preoperative risk factors that predictably influence mortality after aneurysmectomy, this study reviews the surgical management of abdominal aortic aneurysms in a series of 110 consecutive patients who underwent elective resection. The preoperative risks to be added to the present study included pulmonary insufficiency, renal dysfunction, advanced age of over 80 years, ischemic heart disease, and associated other diseases such as thoracic aneurysms, atherosclerosis of the limbs and malignant tumors. Forty-six patients had one of these risk factors (one-risk group), 17 had two (two-risk group), and 9 had three (three-risk group). The operative mortality rates were 4.2 per cent for the high-risk patients and 0 per cent for the patients at no risk. As the number of risk factors increased, aneurysm repair was associated with an increased operative mortality; being 2.2 per cent in the one-risk group, 5.9 per cent in the two-risk group and 11.1 per cent in the three-risk group. The common risk factor in patients who died after aneurysmectomy was pulmonary insufficiency which induced prolonged periods of assisted ventilation. Thus, the optimal management of high-risk patients, particularly those with pulmonary insufficiency, may reduce the mortality after aneurysmectomy.

Severe septic complications are the major cause of operative mortality in patients with esophageal cancer. We examined the levels of acute phase proteins together with infection-related complications after surgery in a large number of patients with esophageal cancer and compared them with a group of patients with gastric cancer and healthy controls. Elevations in alpha 1-antitrypsin, alpha 1-acidglycoprotein, haptoglobin and ceruloplasmin were evident in patients with esophageal cancer, being more predominant when compared to the findings in patients with gastric cancer. Although the mean levels of alpha 2-macroglobulin were not significantly elevated in either patients with esophageal cancer or those with gastric cancer, the average level immediately prior to surgery was higher in esophageal cancer patients with postoperative septic complications than in those without any such problems. Preoperative radiation therapy and total parenteral nutrition did not significantly alter the levels of acute phase proteins. It would thus appear that the elevation in alpha 2-macroglobulin is associated with the occurrence of infectious complications following surgery in patients with esophageal cancer.

The activation mechanism of pancreatic enzymes refluxing into the biliary tract in the anomalous arrangement of pancreaticobiliary ducts (APBD) remains unclear. In order to elucidate this activation mechanism, an immunohistochemical examination of both bile ducts and gallbladders was carried out on 20 patients with APBD to determine whether or not enterokinase (EK) producing cells exist in the biliary tract, by employing an avidin-biotin-peroxidase complex (ABC) method using a monoclonal antibody, hek-1. Immunoreactive EK was found in the metaplastic epithelium of the bile duct in 2 patients and the gallbladder in one, suggesting that EK production at the metaplastic epithelium is involved in an activation mechanism of pancreatic enzymes refluxing into the biliary tract. The same study was performed on the gallbladders of 62 patients without APBD, which revealed immunoreactive EK in some parts of the metaplastic epithelium of the gallbladder in 2 patients. Thus, in cases of pancreatic juice refluxing into the biliary tract regardless of the presence of APBD, we can not refute the possibility that refluxed pancreatic enzymes may be at least partly activated by EK produced at the metaplastic epithelium.

In order to evaluate the prognostic importance of clinical and histological node information, we made univariate and multivariate analyses of regional lymph node metastases in 223 patients with operable breast cancer who were surgically treated from 1973 to 1985. Clinical axillary node status, histological involvement of the axillary lymph nodes, their anatomical levels and numbers, and histological involvement of the internal mammary lymph nodes were selected as evaluating prognostic factors. The histological presence or absence of axillary node involvement, especially at the distal level, proved to be the most important prognostic factor. However, neither the anatomical level nor the number of histologically involved axillary lymph nodes appeared to be an important prognostic factor. On the other hand, histological involvement of the internal mammary nodes appeared to be an important and independent prognostic factor. Therefore, we concluded that axillary lymph node dissection with a biopsy of the internal mammary nodes would provide more accurate information about the prognosis of patients with operable breast cancer.

The choice remains controversial as to which surgical procedure should be selected for carcinomas situated in the esophagus at the cervicothoracic junction involving the trachea. After mediastinal tracheostomy associated with pharyngolaryngoesophagectomy and thoracic esophagectomy, numerous reports have previously described severe postoperative complications, such as tracheal necrosis and rupture of the great vessels in the neck. To prevent such complications, we have developed the procedure called "upper esophagectomy" followed by a free jejunal graft and mediastinal tracheostomy through either manuburectomy or upper median sternotomy. We have established that this procedure maintains the vascular networks between the trachea and the esophagus, avoids an occurrence of tracheal necrosis or great vessel bleeding postoperatively, and obtains an improved prognosis in the surgical treatment of esophageal carcinoma at the cervicothoracic junction.

In the process of liver regeneration, the participation of various types of growth stimulators and changes in immune responses have been reported. Here, we examined the growth of subcutaneously transplanted AH130 cells and Walker 256 cells after partial hepatectomy. In the case of tumor cells being transplanted on the same day as partial hepatectomy, the increase in tumor size in hepatectomized rats was significantly greater compared with that in non-treated rats or in those having undergone a simple laparotomy. When the transplantation of tumor cells was done on the 7th day after partial hepatectomy, however, the increase was less marked. We also examined the effect of serum obtained from rats after partial hepatectomy on the in vitro growth of these tumor cells. Growth enhancement was observed with medium containing serum drawn from rats 1 to 4 days after partial hepatectomy. These results suggest that the growth of tumor cells was stimulated during liver regeneration and that some humoral factors participated in the process. Furthermore, as the conditions of the in vitro method appear to mimic those of the in vivo method, the in vitro approach should be very useful for analysis of the factors responsible.

Severe aspiration following esophageal reconstruction is often very difficult to treat while preserving the larynx. However, we have successfully adopted a modified surgical procedure previously employed for aspiration caused by neurological diseases or head and neck cancer surgery. We report herein the use of this modified procedure against aspiration in 2 cases following esophagectomy. In the first case, a combination of cricopharyngeal myotomy, infrahyoid myotomy and laryngeal pull-up, with approximation of the thyroid cartilage against the hyoid bone and that of the hyoid bone against the mandible, were performed simultaneously with the primary esophagectomy. In the second case, cricopharyngeal myotomy, infrahyoid myotomy, laryngeal pull-up and infrafold silicone injection were performed three months after the primary operation. Good results were achieved in both cases. Thus, for any case at risk of aspiration after esophagectomy or for any case with severe aspiration following esophagectomy that does not respond to swallow therapy, these operative rehabilitation procedures should be performed before laryngectomy is considered.

A case of a 42 year old multiparous female with bilateral angiosarcoma of the breast without any evidence of dissemination, who later also developed a psammomatous meningioma, is described herein. The world literature on angiosarcoma is reviewed and a discussion presented on the incidence of bilaterality, hormonal stimulation, diagnostic difficulty, prognostic factors and treatment modalities.

A case of a superior lumbar hernia in a 50 year old woman is described herein. She presented with a 7 x 8 cm soft, nontender, smooth-surfaced mass in the left flank, and barium meal with follow through showed herniation of the descending colon. At operation, a 6 x 5 cm defect was found in the transversalis fascia, which was repaired with mattress sutures to the transversalis fascia together with suturing of the external oblique to the latissimus dorsi. This article presents the above case and reviews the published literature relating to this subject.