Total Gastrectomy Patients Research Articles

Total Gastrectomy for Patients over the Age of 70 with Gastric Cancer

We analyzed data on 621 Japanese patients with gastric cancer treated with total gastrectomy, with respect to age of the patient. There were 123 patients aged 70 years and older. The mortality rate was 1.6% for the elderly patients and 1.4% for the others. In patients over the age of 70, there were fewer women and the differentiated tissue type was more common. The infiltrative Borrmann types 3 and 4 accounted for 53.6% of the elderly patients, serosal invasion was less prominent and the rate of peritoneal dissemination was lower. Extensive lymph node dissection (R2 or R3) was done for 65.9% of the elderly patients and the rate of curative resection was higher. There was no difference in survival rates among these patients. Liver metastasis, operative curability, serosal invasion, lymph node metastasis, tumor size and extensive lymph node dissection, but not age, proved to be independent prognostic factors for total gastrectomy, as determined by multivariate analysis. Thus, the outcome of surgery is good and the mortality rate is low in the elderly patients with gastric cancer undergoing total gastrectomy with lymphadenectomy and resection of adjacent organs. When considering the indications for total gastrectomy, the age of the patient should not be an untoward factor.

STUDIES OF POSTGASTRECTOMY GALLSTONE DISEASE

In 127 patients who underwent gastrectomy for gastric cancer at the department in a 5-year period (1982-1986) and were followed up by ultrasonography or CT for more than 2 years, postgastrectomy gallstone disease was investigated. The prevalance of gallstone was found in 16 patients (12.9%). Male-to-female ratio was 12:4. The duration from gastric resection to the detection of gallstone disease was within one year in 3 cases; one to 2 years in 3 cases; 2 to 3 years in 5 cases; 4 to 5 years in 2 cases; and over 5 years in 3 cases. The methods of the gastric resection included distal gastrectomy in 5 cases, total gastrectomy in 10 cases, and proxymal gastrectomy in one case. The reconstruction at the gastrectomy were made with Billroth II in 5 cases, esophagojejunostomy with Roux-en-Y in 10 cases, and esophago-gastrostomy in one case. All of them underwent lymphadenectomy at the initial operation. the gallstones were located in the gallbladder alone in 13 cases, common bile duct alone in 2 cases, and both in one case. The incidence of common bile duct stone were considered to be high. Postgastrectomy gallstone disease were predominant in males, and was more frequently found in total gastrectomy-patients with a significant difference. They occupied 23.2% of the total gastrectomy cases. Prophylactic cholecystectomy may be recommended for total gastrectomy patients.

Immediate effect of vagotomy on pancreatic insulin secretion.

The effect of vagotomy and gastric resection on insulin secretion was examined by the glucagon stimulated C-peptide test in gastrectomy patients (n = 11) without truncal vagotomy and in total gastrectomy patients (n = 10) with truncal vagotomy. The test was performed twice in each patient: 10 minutes after the midline incision was made and then 60 to 90 minutes later when gastric resection or total gastrectomy was completed, during the reconstructive phase of the operation. Gastric resection without truncal vagotomy was followed by a higher increase (48%) in serum C-peptide concentration caused by glucagon stimulation than total gastrectomy with truncal vagotomy (13%). There was a significant (p less than 0.05) increase in the glucagon stimulated glucose-related C-peptide concentration in patients without truncal vagotomy, whereas truncal vagotomy inhibited this increase. These results suggest that truncal vagotomy will produce a reduction in stimulated insulin secretion in humans.

Group I pepsinogen for early detection of gastric cancer recurrence after total gastrectomy

Group I pepsinogen (PG-I) staining was performed in the gastric carcinoma tissues of 75 patients by the peroxidase-antiperoxidase (PAP) method, 44 cases (59%) of which were positive for PG-I, suggesting that they were PG-I-producing gastric carcinomas. Type IV gastric carcinoma by the Borrmann classification and/or poorly-differentiated adenocarcinoma were positive for PG-I in high incidence. Serum and urinary levels of PG-I were determined by the Pepsinogen I Radioimmunoassay Kit in patients with gastric carcinoma who underwent total gastrectomy. The levels of PG-I declined remarkably or disappeared at 1 week after curative surgery. Changes of serum PG-I levels after total gastrectomy were observed in 9 patients with PG-I-producing gastric carcinomas, 7 of whom died of recurrence. The PG-I values became elevated with recurrence in 5 of them and the values increased with the passage of time. In contrast, no substantial changes in PG-I levels occurred in patients with no recurrence. These results suggest that PG-I is useful for the early detection of recurrent disease after total gastrectomy in patients with PG-I-producing gastric carcinomas.

STUDIES OF POSTOPERATIVE ATELECTASIS BY OPERATIVE PROCEDURES

In 255 cases of gastric, 198 of lung, 27 of esophageal cancer, and 23 of esophageal varices (a total of 503 cases), the occurrence of postoperative respiratory complication especially atelectasis has been investigated by operative procedures. Atelectasis was most frequently occurrd in elderly (over 70 years) patients with gastric and lung cancers who often developed preoperative respiratory complications, too. No significant difference between the atelectasis group and non-atelectasis group was found by diseases. When viewed by operative procedures, atelectasis was more frequently observed in lung cancer patients undergone lobectomy (upper lobe), in gastric cancer patients done total gastrectomy, and in the most patients operated on for esophageal cancer. The complications were commonly located at the upper and/or middle lobes on the open chest side in lung cancer, and at the left lower lobe in total gastrectomy and esophageal cancer patients. Most of atelectasis episodes developed on the 3rd day after operation in gastric, from the 1st to 2nd day in lung, on the 3rd day in esophageal cancers, and until the 3rd day as a whole. For a good management of postoperative atelectasis in the aged patients, we should pay careful attention for a difference of operative procedures of thoracolaparotomy during surgery, and after surgery endoscopical aspiration of sputum and alleviation of pain are needed in appropriate timing, thinking over the time after the onset of the complication developed and location of the lesion.

Bone disorder following partial and total gastrectomy with reference to bone mineral content.

To study post-gastrectomy metabolic bone disorders, we measured the radial bone mineral content (BMC), serum levels of calcium, inorganic phosphorus, alkaline phosphatase, and 25-hydroxyvitamin D(25-OH-D) in 59 patients with partial- and 39 patients with total gastrectomy. Total gastrectomy patients manifested a higher incidence of decreased BMC levels than did partial gastrectomy patients (56 per cent vs. 25 per cent). Patients subjected to the Billroth II procedure, especially females, manifested abnormally low BMC values. The decline in BMC was age-related; it was pronounced in females. At 10 years postoperatively, many of the partial gastrectomy patients manifested markedly low BMC levels; in totally gastrectomized patients this finding was made at less than 5 years postoperatively. Approximately 30 per cent of our patients showed abnormalities in serum minerals, alkaline phosphatase or 25-OH-D.

Resection of gastrinomas.

Exploratory laparotomy and a search for gastrinomas was performed in 52 patients with the Zollinger-Ellison syndrome (ZES). Gastrinoma tissue was resected in 11 patients (21%), 6 (12%) of whom appear to have been cured. After surgery, serum gastrin levels in these six patients have remained normal from 10 months to 10 years. In the 46 other patients, tumor was unresectable because of metastases or multiple primary tumors (21 patients; 40%) or inability to find the tumor at laparotomy (21 patients; 40%). Multiple pancreatic islet cell adenomata were found in six of seven patients with multiple endocrine neoplasia (MEN), indicating that patients with this condition usually have diffuse involvement of the pancreas. The results of CT scans correlated with findings at laparotomy in 13 of 16 patients. The smallest tumor detected by CT scans was 1 cm in diameter. CT technology is more accurate in finding gastrinomas now than in the past and has a useful role in preoperative evaluation. The possibility of resection should be seriously considered in every patient with Zollinger-Ellison syndrome. Abdominal CT scans, transhepatic portal venous sampling, and laparotomy should be used to find the tumor and to determine whether it is resectable. Using presently available methods, it should be possible to cure about 25% of patients with gastrinomas who do not have MEN and over 70% of those without MEN who appear to have a solitary tumor. Total pancreatectomy may be necessary to cure some patients with MEN, but that operation is rarely justified. The morbidity and mortality of surgical attempts at curing this disease have become minimal; we have had no deaths or serious complications following such operations in over 10 yrs. Total gastrectomy and indefinite use of H2-receptor blocking agents are the therapeutic options for patients with unresectable gastrinomas. Because H2-receptor blocking agents fail to control acid secretion in many patients after several yrs of therapy, total gastrectomy is indicated in a large proportion of patients whose tumors cannot be resected. Total gastrectomy in patients with ZES is also safe using current techniques; our last death following this operation for ZES occurred 15 yrs ago.

腸溶性錠剤の崩壊試験法に関する研究

In the J.P.IX disintegration test for enteric-coated tablets, the tablets are tested for 120 min in the first fluid (pH 1.2) prior to the test in the second fluid (pH 7.5). In clinical medicine, tablets are often administered to patients under fasting conditions and to partial or total gastrectomy patients. It is well known that the gastric emptying rate in these conditions is faster than in normal condition. Therefore, to clarify the effects of a shortened test period in the first fluid on entericcoated tablets disintegration time and coefficient of variation (C.V.), three different test periods (120, 30 and 0 min) were used. These tests were conducted on 17 enteric-coated tablets on the market. Two lots of these preparations failed to disintegrated completely under all of the test conditions. The disintegration time of these tablets in the second fluid obtained with the first fluid was generally faster compared to that obtained without the fluid. When the tablets were tested with the first fluid for 30 or 120 min, disintegration time was approximately constant. Moreover, in some preparations the disintegration time obtained without disks was markedly increased and they failed to disintegrate completely. The effect of test period in the first fluid on the C.V. in disintegration time was not negligible and the C.V. was changed irregularly by alterations of the test period. Usually, but not always, it was found that adherence of the test tablets to disks or test equipment tends to increase disintegration time and C.V.