Teikyo University Hospital Research Articles

Laparoscopic Cholecystectomy: Treatment o Choice in Elderly Patients

Abstract: The application of laparoscopic] cholecystectomy, first reported in 1987, has grown rapidly worldwide, replacing the open cholecystectomy. This trend is attributable to the benefits of minimal surgical access, i. e. a smaller incision, less postoperative pain and faster recovery. However, doubts persist concerning the role of laparoscopic cholecystectomy in elderly patients. The purpose of this study was to assess morbidity and mortality in elderly patients who underwent laparoscopic cholecystectomy at Teikyo University Hospital at Mizonokuchi. Forty‐eight patients, 65 years or older, underwent attempted or successful laparoscopic cholecystectomy. To assess operative risk in these patients, the American Society of Anesthesiologist's Surgical Risk (A. S. A.) category was used. The risk ranged from 1 to 3 with a median of 2. Twenty‐five percent of the patients were defined as A. S. A. I, 61% as A. S. A. II and 14% as A. S. A. III. Four patients required intraoperative conversion of the procedure to open cholecystectomy (conversion rate of 8.3%). The indications for conversion in three patients were severe adhesion and thickened gallbladder wall and in the other were secondary to gallbladder bed oozing. This conversion rate is similar to that reported in other series. The conversion was not related to the surgical risk. The morbidity rate was 4.5%. the mortality rate zero. These results compared favorably with those reported for open cholecystectomy in elderly patients and with the overall published morbidity‐mortality rate of laparoscopic cholecystectomy in large series. We conclude that laparoscopic cholecystectomy is a suitable procedure for elderly patients.

Laparoscopic cholecystectomy — key technical points to prevent bile duct injury

During the period May, 1990 to the end of December, 1992, 434 patients (203 males and 231 females; aged 16–87 years; mean 49.4 years) underwent laparoscopic cholecystectomy at our Department, Teikyo University Hospital, Mizonokuchi. Eleven out of these 434 patients were converted to open cholecystectomy, due to uncontrollable bleeding from the cystic artery (n=1), venous bleeding due to portal hypertension (n=1), extensive adhesions of the omentum and the duodenum to the gallbladder (n=2), extensive adhesions around the gallbladder (n=4), and extensive adhesion between the gallbladder and the common duct (n=3). The time taken to complete the procedure ranged from 25 to 235 min, the mean being 74 min. Seventeen complications manifested intra- or postoperatively. Three cases of bile duct injury which manifested after operation required laparotomy. In 1 patient, injury to the right hemidiaphragm resulted in a right pneumothorax. One patient had periumbilical subcutaneous emphysema, 2 patients had mild bile leaks that cleared up within a few days, and 1 patient had considerable bile leaks which stopped 6 days later. Indications for laparoscopic cholecystectomy widened as our experience grew. Common bile duct stones and previous gastrectomy are no longer contraindications for this procedure. Based on our experience with laparoscopic cholecystectomy, we describe here our technique and the rules we consider important for the successful accomplishment of this procedure.

Laparoscopic cholecystectomy: a report of 409 consecutive cases and its future outlook.

A retrospective study was conducted on 409 patients who underwent laparoscopic cholecystectomy at Teikyo University Hospital between May, 1990 and October, 1992. The operation had to be converted to an open cholecystectomy in ten of these patients because of uncontrollable bleeding from the cystic artery in one, venous bleeding due to portal hypertension in one, extensive adhesions of the omentum and the duodenum to the gallbladder in two, extensive adhesions around the gallbladder in four, and extensive adhesions between the gallbladder and the common bile duct (CBD) in two. The time taken to complete the procedure ranged from 30 to 235 min, the average time being 81 min, and the postoperative hospital stay ranged from 3 to 56 days, the average stay being 6.5 days. Eleven patients developed complications intra- or postoperatively: bile duct injury which became manifest after the operation and required laparotomy in three patients; injury to the right hemidiaphragm resulting in a right pneumothorax in one; periumbilical subcutaneous emphysema in one; mild bile leaks which resolved in a few days in two; and a severe bile leak which resolved after 6 days in one. The indications for laparoscopic cholecystectomy have widened with experience and now, CBD stones and a history of previous gastrectomy are no longer contraindications for laparoscopic cholecystectomy. Thus, it seems that laparoscopic cholecystectomy can be performed as safely as a standard cholecystectomy, provided the patients are selected properly and appropriate caution is exercised.

Longitudinal studies in hearing-impaired children with Down's syndrome

Over the past twenty years hearing impairment has become widely recognized as one of the most important problems in the children with Down's syndrome. We have continued longitudinal observations of the hearing and speech development of children with Down's syndrome during the 10-year period from 1982 to 1991. One hundred ten children with Down's syndrome were examined and followed in the Department of Otolaryngology, Teikyo University Hospital. The examinations included otomicroscopy, behavioral audiometry, auditory brain stem response audiometry and tympanometry. Questionnaires were also administered to obtain information on the speech and hearing development of the children. In the present paper, we discuss assessment of hearing evaluation and the characteristics (degree, incidence, and types) of hearing impairment in Down's children. We divided the children into the following groups according to hearing acuities: 35 children with a normal hearing level (0-39 dB), 54 children with a moderately impaired hearing level (40-79 dB) and 21 children with a hearing level above 80 dB, and in 12 of these 21 children the finding was unilateral, and the 9 remaining children was bilateral. Thus the incidence of hearing impairment with a threshold higher than 40 dB was 68%. We detected otitis media with effusion (OME) in 34 (63%) of the 54 children with moderate hearing loss. Active treatment with medication or minor surgery, such as myringotomy or insertion of a ventilation tube, resulted in remarkable improvement in hearing in 26 children with OME. We used hearing aids for patients with prolonged otitis media and those with a hearing loss greater than 50 dB in both ears. When their hearing acuity improved in response to appropriate medical care and the use of hearing aids, human-relations improved and speech development accelerated. We emphasize that appropriate medical care and management of hearing impairment, including the use of hearing aids, were required for both patients' emotional and linguistic development.

Reproductive rates in schizophrenic outpatients

We investigated the marriage rates, the reproductive rates and the marital reproductivity of schizophrenic outpatients in Japan. A total of 553 patients with DSM-III-R-diagnosed schizophrenia at the Teikyo University Hospital, Tokyo, Japan were compared with age- and sex-matched outpatients at surgical clinics of the same hospital. Our findings indicate that the reproductivity of schizophrenics is reduced, even though the sample consists of outpatient population and modern operational diagnostic criteria have been used. The marriage rate and reproductive rate of the schizophrenics were reduced, especially in men. The number of married men was significantly less than that of married women and the reduced marital reproductivity was found in women but not men. These findings indicate that the reduced reproductivity of men in accounted for largely by a reduced rate of marriage, and that in women is accounted for partly by lower rate of reproductivity within marriage.

頭頚部癌における照射とシゾフィランの併用

The effect of the concurrent use of Sizofiran (SPG) and radiation therapy for head and neck cancers was evaluated by tests of cell-mediated immunity in the peripheral blood of patients. The administration of SPG was started at the beginning of radiation therapy. It was administered intramuscularly in a dose of 40 mg once a week during hospitalization and 40 mg once every 2 weeks during outpatient care. This regimen was continued for 1 yearafter the completion of basic treatment. The subjects were 39 patients with stage III or stage N head and neck cancers treated at the Department of Otolaryngology, Teikyo University Hospital between May, 1988 and April, 1991. Twenty-four of these patients received SPG plus radiotherapy (SPG group), and the remaining 15, who received only radiotherapy, were considered to be controls. The subjects were allotted to the two groups by the envelope method. 1) Cell-mediated immunity was reduced by irradiation. 2) The reduction in cell-mediated immunity after irradiation was milder in the SPG group than in the control group. 3) The recovery of cell-mediated immunity was greater in the SPG group than in the control group 1 month after the completion of the basic treatment. These findings indicate that SPG prevents the suppression of cell-mediated immunity and promotes its recovery during radiation therapy for head and neck cancer.

Molecular Mechanisms and Their Clinical Application in Malignancies

<b>Background:</b> Although recent retrospective studies suggest the possibility that peripheral blood (PB) eosinophil counts can predict the efficacy of inhaled corticosteroids (ICS) in COPD, the results are still inconsistent. In addition, the distribution of PB eosinophil counts and its relationship with prescription of ICS in real world settings has not been fully described. <b>Aim:</b> The aim of the current study is to clarify the distribution of PB eosinophil counts in real world settings in Japan. We also analyzed the relationship between eosinophil count and the serum IgE level and frequency of ICS prescription. <b>Methods:</b> The data from patients diagnosed as COPD based on GOLD document in Teikyo University hospital and followed by specialists were analyzed (n=103). Asthma patients were excluded by specialists. The PB eosinophil %, counts, serum IgE level and medications were analyzed during stable condition. <b>Results:</b> PB eosinophil (%) exceeded 2% and 5% of total white blood cell count in 72.8% and 22.3% of patients, respectively. PB eosinophil counts were more than 150/μl and 300/μl in 54.4% and 23.3% of patients, respectively. Although ICS was prescribed to 31.1% of patients, there was no significant relationship between eosinophil counts and the frequency of ICS prescription and serum IgE level. <b>Conclusion:</b> In majority of COPD patients, PB eosinophil % or counts exceeded 2% or 150/μl, respectively and did not seem to reflect the atopic status and affect the decision making for ICS prescription by specialists. Utility of PB eosinophil counts in COPD seemed to be limited and its role should be further investigated.

Methicillin-resistant Staphylococcus aureus from blood cultures--microbiological characteristics and the background of patients

Staphylococcus aureus used in this study were isolated from blood cultures of inpatients at the Central Clinical Labolatory, Teikyo University Hospital from January 1984 to April 1986. Resistant patterns to various antibiotics, phage type, coagulase type, TSST-1 productivity of these strains were investigated. In addition, background and administrated antibiotics for the patients were analyzed with Multivariate-analysis.1. In the above period, 81 strains of S. aureus were isolated and 57 strains of them (70.4%) were MRSA.2. Of this MRSA, 55 strains (96.5%) were resistant to aminoglycosides (AGs). According to previous studies in our hospital, except for production of 3'-phosphotransferase (3'-APH), AGsresistant MRSA were possible to classify into 2 groups. The one is a GM-resistant MRSA that produces bifunctional enzyme having 2′′-phosphotransferase and 6'-acetyltransferase (2′′-APH+6'-AAC) activity. The another one is a TOB-resistant MRSA that produces 4'.4′′-adenylyltransferase (4', 4′′-AAD). 8 strains that produce simultaneously bifunctional enzyme and 4', 4′′-AAD were newly found out in this studies (GMr-+TOBr--MRSA).3. GMr-+TOBr--MRSA were classified into 2 groups; 3 strains were similar to GMr--MRSA and the others were similar to TOBr--MRSA in respect to phase type, coagulase type and toxin production. From these results, it was suggested that hospitalized MRSA are changing its properties gradually.4. MRSA positive patients were classified into 3 groups;1) Age advanced patients affected to brain disorders, malignant tumor, cardiac disorder or diabetis mellitus and fell into so-called immunocompromised host.2) High risk infants such as congenital immunodeficiency syndrome and low birth weight.3) Age unrelated patients (but many cases were the twenties) encountered multiple trauma or burn.Grpoup 1 and 2 recieving radical antibiotic therapy were becoming S. aureus positive over one week hospitalization. In contrast, group 3 become S. aureus positive in a short duration without using anti-biotics.5. Significant high frequency between MRSA positive cases pre-administrated 2nd & 3rd generation cephems and unrecieved cases, was proved by statistical analysis using the Hayashi's Quantification 2.6. GMr--MRSA was isolated predominantly from the cases admitted to non-surgical wards and TOBr--MRSA was from the cases of surgical wards respectivelly. The reason why the above phenomenon observed was speculated that many cases of surgical wards were administrating various antibiotics in combination.7. Post-administrated antibiotics for MRSA infection were also used in combinations of over 2 kinds of antibiotics for almost all cases. By quantification analysis, it was suggested that some of them are effective partially. However, none of them were found to be such as clinicaly effective fully to MRSA infections. From the above findings, it was indicated that MRSA infection if occured, is very difficult to recover.

小児の言語障害の取り扱い

During the past 17 years (1971 to 1987), 7, 419 children with communicative disorders due to various causes visited our speech and hearing clinic for children at Teikyo University Hospital. These communicative disorders were classified into the following six groups according to the anatomical sites of pathology related to speech or language disorders.1) Retarded development of speech and language due to peripheral hearing loss or central auditory disorders, such as auditory agnosia or pure word deafness.2) Developmental and acquired language disorders, including mental retardation, infantile autism and aphasia.3) Developmental motor speech disorders, including specific developmental speech disorder syndrome, developmental apraxia of speech, so-called functional articulation disorders, dysarthria, etc.4) Speech disorders due to deffects of the peripheral speech organs.5) Voice disorders.6) Speech and language disorders caused by psychological or environmental problems.Although many factors influence the development of language and speech, from a therapeutic view point, it is important to pay attention to psychological and environmental factors, including intelligence, mental energy, cognitive abilities, emotional stability, parent-and-child relationship, environment surroundings, etc.My clinical and practical experience indicates that those who work for communicatively handicapped children must establish their own methodologies for understanding each child as an individual developing under the influences of many biological as well as psychological and environmental factors.

Experience with routine postoperative choledochoscopy via the T-tube sinus tract.

AbstractIn the 40‐month period from April, 1974 to July, 1977, postoperative choledochoscopy was performed 566 times in 186 patients at Teikyo University Hospital. Included in this series were 56 patients with retained common bile duct stones and 23 patients with intrahepatic stones; the stones were removed by postoperative choledochoscopy in 52 and 20 of these patients, respectively. In some patients, unsuspected stones were detected endoscopically after a completion T‐tube cholangiogram was reported as negative for stones. Our experience to date indicates that this technique is of substantial diagnostic and therapeutic value in the management of biliary calculi. Therefore, routine use of postoperative choledochoscopy as an adjunct to T‐tube cholangiography is strongly advocated. Failure of attempts to remove retained stones endoscopically and complications in this series were all attributable to inadequate insertion of the T‐tube into the common bile duct at the time of operation. To overcome this problem, a T‐tube of at least No. 18 Fr. caliber, and preferably of No. 20 Fr. caliber, should be inserted at operation into the common bile duct at a right angle, so as to avoid a tortuous sinus tract and produce a tract of sufficient caliber to permit postoperative choledochoscopy.

Biliary tract endoscopy with an improved choledochofiberscope

Over the past 3½ years 657 intra- and postoperative choledochoscopies have been performed in 200 patients at the Teikyo University Hospital. The technique of using a new, improved choledochoscope (Olympus CHF-B3) for selective cholangiography and removal of retained stones is described. Stones retained in the major bile ducts were encountered in 58 patients, and intrahepatic stones were found in 24 patients. Successful choledochoscopic removal of stones was accomplished in 56 and 21 cases, respectively. From 1 to 58 successive choledochoscopies were required to completely clear the biliary tract of stones in these 77 patients, all of whom have remained asymptomatic. Complications occurred in 8 cases (5 minor, 3 major). Choledochoscopy with guided, selective cholangiography is the preferred method of detecting retained biliary stones that can then be efficiently removed by the choledochoscopic technique.