改良隧道式食管胃吻合术治疗食管贲门癌96例

目的研究治疗食管贲门癌减少吻合口瘘、增强抗反流效果、防止吻合口狭窄的术式。方法对隧道式食管胃吻合术作如下改进：①在隧道下口下方１ｃｍ处另作切口进行吻合，加强吻合口后壁，使重建后的Ｈｉｓ角锐化；②隧道宽于食管横径１＿１５ｃｍ。治疗食管贲门癌９６例。男５７例，女３９例；年龄４２－７３岁；其中食管癌６４例（中段３９例，下段２５例），贲门癌３２例。结果本组９６例全部成功，皆无吻合口瘘，术后２个月钡餐Ｘ线检查无吻合口狭窄，无胃食管反流。结论改良隧道式食管胃吻合口术可增强抗反流效果，防止吻合口狭窄。     

Improved quality of life in patients with gastric cancer after esophagogastrostomy reconstruction

AIM： To compare postoperative quality of life （QOL） in patients with gastric cancer treated by esophagogastrostomy reconstruction after proximal gastrectomy. METHODS： QOL assessments that included functional outcomes （a 24-item survey about treatment- specific symptoms） and health perception （Spitzer QOL Index） were performed in 149 patients with gastric cancer in the upper third of the stomach, who had received proximal gastrectomy with additional esophagogastrostomy. RESULTS： Fifty-four patients underwent reconstruction by esophagogastric anterior wall end-to-side anastomosis combined with pyloroplasty （EA group）; 45 patients had reconstruction by esophagogastric posterior wall end-to-side anastomosis （EP group）; and 50 patients had reconstruction by esophagogastric end-to-end anastomosis （EE group）. The EA group showed the best postoperative QOL, such as recovery of body weight, less discomfort after meals, and less heart burn or belching at 6 and 24 mo postoperatively. However, the survival rates, surgical results and Spitzer QOL index were similar among the three groups. CONCLUSION： Postoperative QOL was better in the EA than EP or EE group. To improve QOL after proximal gastrectomy for upper third gastric cancer, the EA procedure using a stapler is safe and feasible for esophagogastrostomy.     

Effects of nifedipine on esophageal tone and perception of esophageal distension

The effects of nifedipine (20 mg orally) on esophageal body resting tone and perception of esophageal distension were compared with those of placebo in 10 healthy volunteers, using a double-blind crossover design. A 3-cm silicon balloon positioned 10 cm above the lower esophageal sphincter was inflated with 2–20 ml of air, in 2-ml increments. The subjects scored their chest sensations, while pressure in the balloon was continuously recorded. In each experiment three series of measurements were made, at baseline and 15 and 30 min after administration of nifedipine or placebo. Bench tests were run to determine pressure-to-volume relationships for each of the balloons used in the study. Thirty minutes after nifedipine ingestion, a significant decrease in systolic blood pressure (from 112.6±2.3 to 99.0±2.0 mm Hg) was observed. Amplitude and duration of esophageal peristaltic contractions were significantly decreased by nifedipine (from 128.1±16.7 to 98.7±10.6 mm Hg and from 3.9±0.3 to 3.3±0.2 sec, respectively). With balloon volumes of 8 ml and higher, balloon pressures were higher with the balloon in the esophagus than on the bench, the difference being determined by the compliance of the esophagus. This difference rose from 18.5±6.8 to 40.2±7.2 mm Hg (8–20 ml) with placebo and from 23.1±3.7 to 35.9±5.8 mm Hg with nifedipine. No significant differences between nifedipine and placebo were found. The esophageal sensation scores increased linearly with increasing balloon volume from 6 ml onwards. Nifedipine had no significant effect on the perception of esophageal balloon distension.     

Treatment outcomes of cervical esophageal cancer patients

Background

Although systemic therapy for esophageal carcinoma has advanced dramatically over the last several decades, the consensus of treatment for cervical esophageal carcinoma (CESCC) has yet remained controversial.

Patients and methods

We analyzed 56 CESCC patients who underwent various therapies in our hospital between January 2000 and December 2013.

Results

Thirteen cases underwent surgery without neo-adjuvant therapy (NAT), while 20 cases underwent surgery after NAT. Definitive chemo-radiotherapy (dCRT) was administered to 23 cases. Five cases underwent salvage surgery after dCRT. Three-year overall survival rates (3-year-OS) were similar between the NAT and dCRT groups (53.3 vs. 51.5 %). These cases were divided into clinical T2/T3 and T4 cases, and a differential analysis was performed. The 3-year-OS achieved by NAT in T2/T3 cases (90.9 %) tended to be better than that by dCRT (62.5 %). In contrast, the 3-year-OS achieved by NAT in T4 cases (12.5 %) tended to be worse than that by dCRT (34.2 %). The prognosis of CESCC patients undergoing salvage surgery after dCRT was very good, with 3-year-OS of 100 % in T2/T3 cases and 66.6 % in T4 cases. A comparative analysis of postoperative complications was performed between CESCC patients undergoing surgery after neo-adjuvant chemotherapy and chemo-radiotherapy to evaluate the operative risk for CESCC patients after CRT. The rates of postoperative complications were similar between these groups.

Conclusion

We analyzed the treatment outcomes of CESCC patients by dividing them according to the clinical tumor invasion depth. Salvage surgery may be an effective therapy for CESCC patients and needs to be considered.

     

Reflux esophagitis and columnar‐lined esophagus after cervical esophagogastrostomy (following esophagectomy)

Reflux esophagitis (RE) and columnar‐lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow‐up is necessary for such patients irrespective of the route of esophageal reconstruction.     

Increasing pain sensation to repeated esophageal balloon distension in patients with chest pain of undetermined etiology

Previous studies have demonstrated lowered sensory thresholds to esophageal balloon distension in patients with chest pain of undetermined etiology. Whether this finding is specific to patients with chest pain or is simply related to an underlying esophageal motility disorder is unclear. In the present study, distension-induced pain-sensation scores and the effect of repeated balloon distension were compared in patients with chest pain, dysphagia secondary to esophageal dysmotility, and healthy controls. All subjects underwent standard esophageal manometry followed by mid-esophageal balloon distension. Volumes 2.5, 5, 7.5, and 10 ml (each volume repeated three times) were applied in random order in a single-blind fashion, and the pain-sensation score was recorded after each distension. Pain-sensation scores varied directly with balloon volume. Mean pain scores were significantly higher (P<0.001) in the chest pain group than in either the controls or dysphagia group. There was no significant difference between controls and the dysphagia group, and the motor response to distension was no different between groups. In the controls and dysphagia groups, painsensation score was not significantly different between the first, second, or third distension at a given volume. However, in the chest pain group, pain-sensation scores increased significantly with the second (P=0.004) or third (P=0.002) distension using the same balloon volume. These studies suggest that abnormal esophageal nociception in patients with chest pain of undetermined etiology is not simply related to underlying esophageal motor dysfunction. In addition, chest pain patients display a conditioning phenomenon, further supporting the presence of a visceral sensory abnormality.     

Mucosal cell proliferation of the rectal stump in ulcerative colitis patients after ileorectal anastomosis

The proliferative activity and polyamine levels of the rectal epithelium in unoperated ulcerative colitis patients and in ulcerative colitis patients after total colectomy and ileorectal anastomosis were determined and compared with control subjects. Cell proliferation was evaluated in rectal biopsies by in vitro 3H thymidine incorporation by measuring the labeling index and the position of labeled cells along the crypt; polyamines were determined with a chromatographic method. In ulcerative colitis patients the labeling index was significantly increased, and labeled cells were shifted toward the upper part of the crypt when compared with controls. Ileorectal anastomosis patients showed a normalization of the labeling index and a distribution of labeled cells similar to controls. Polyamine levels were also increased in ulcerative colitis patients; in ileorectal anastomosis patients, the level of polyamines was decreased in respect to unoperated patients and return to normal values except for spermine. Because the increased proliferation and higher polyamine levels are related to increased colon cancer risk, our results confirm that ulcerative colitis is a risk factor for the development of carcinoma. Ileorectal anastomosis may reduce this risk through a normalization of mucosal cell proliferative activity and of some polyamine levels.     

Multichannel recording of cerebral potentials evoked by esophageal balloon distension in humans

In order to obtain insight in the generator localization of esophageal evoked potentials, cerebral responses were recorded from 32 scalp electrodes in five healthy volunteers (two male; three female; age 20–30 years), using series of 50 balloon inflations with 15 ml of air. Sequential topographical mapping of waveforms was performed in each subject. Biphasic waveforms were recorded. At Fpz, a positive deflection at 300 and a negative deflection at 465 msec (P300 and N465) were recorded and at Pz, N300 and P465. At Cz the first peak (N270) was slightly earlier than 300 msec. Waveforms were left to right symmetrical. At distal electrodes, biphasic waveforms were recorded (P300 and N465). In four subjects, a gradual phase shift occurred in between the waveforms at midline electrode Cz and the left and right mastoids. Brain mapping showed phase reversals between central negativity and surrounding positivity at about 300 msec, and between central positivity and surrounding negativity at 400–500 msec. Our data suggest the presence of more than one generator in the anterior and dorsal part of the insula and/or dorsal periinsular cortex.     

Provocation of transient lower esophageal sphincter relaxations during continuous gastric distension

BACKGROUND: Transient lower esophageal sphincter relaxations (TLESRs) are triggered by gastric distension. The aim of the study was to investigate TLESRs during controlled prolonged gastric distensions using the barostat technique. METHODS: Twelve healthy volunteers (4 M, 8 F, age range 19-42 years) were studied under fasting conditions with combined esophageal manometry (Dentsleeve) and gastric barostat. Randomized isobaric distensions at 0 (control), 10, 12 and 14 mmHg were performed each period for 30 min with 30-min recovery periods in between. RESULTS: The frequency of TLESR was significantly (P < 0.05) higher during all distension periods compared to control periods (4.0 +/- 0.4 TLESR/30 min versus 2.6 +/- 0.4 TLESR/30 min). The frequency of TLESR in the first 15-min period of distension was significantly (P < 0.001) higher compared to the second 15-min period pointing to adaptation (2.7 +/- 0.3 TLESR/15 min versus 1.3 +/- 0.2 TLESR/15 min, respectively). The frequency of TLESR correlated significantly with intragastric pressure (r = 0.47; P < 0.01) and wall tension (r = 0.48; P < 0.01), but not with intragastric volume. TLESR characteristics such as duration were not related to pressure or wall tension. CONCLUSIONS: Acute gastric distension increases the frequency of TLESR but adaptation occurs rapidly. The frequency of TLESR during distension is related to pressure and wall tension rather than to intragastric volume.     

Relaxatory responses of canine proximal stomach to esophageal and duodenal distension

The viscerovisceral reflex control of gastric tone remains poorly characterized. We have previously demonstrated physiological variations in gastric tone that occur during fasting and after feeding. These variations are neurally regulated. We have now compared the reflex mechanisms modulating gastric tone that are elicited by esophageal or duodenal distension in fasted, conscious dogs. To determine the pathways involved in these reflexes, we combined the technique of vagal blockade (by cooling the supradiaphragmatic vagi isolated within a surgically implanted cooling jacket) with the administration of autonomic drugs. Gastric tone was measured as the air volume within an intragastric bag maintained at a constant, low pressure by an electronic barostat. Standardized distensions were performed by means of an inflatable balloon-catheter positioned either in the mid-esophagus (in three dogs) or in the distal duodenum (in three dogs). A profound and consistent gastric relaxation was induced by distension of either the esophagus (247 ±21 ml volume, P<0.05) or the duodenum (238±29 ml, P<0.05). Supradiaphragmatic vagal cooling abolished the gastric relaxatory response to duodenal distension and significantly reduced, but did not completely suppress, the response to esophageal distension. Neither cholinergic stimulation (intravenous bethanechol) nor adrenergic blockade (combined intravenous phentolamine and propranolol) had any significant effect on either gastric relaxatory response. Combined adrenergic and cholinergic (intravenous atropine) blockade induced gastric relaxation, but failed to suppress the gastric responses. We conclude that both esophageal and duodenal distension elicit gastric relaxation by a nonadrenergic, noncholinergic vagal mechanism.This work was supported in part by grant AM-26428 from the National Institutes of Health. CLINFO Data Management System was sponsored by grant RR-00585 from the National Institutes of Health.     

Provocation of transient lower esophageal sphincter relaxations by gastric distension with air

OBJECTIVES: Transient lower esophageal sphincter relaxations (TLESRs) are the major mechanism permitting not only gastroesophageal reflux but also venting of air from the stomach. Triggering of TLESRs is provoked by gastric distension. Antireflux surgery is associated with impaired ability to belch. It is not known whether a reduced capacity to belch results from postoperative reduction in TLESRs. METHODS: We studied the occurrence of TLESRs, common cavities (indicator for gas gastroesophageal reflux), and belching after standardized acute gastric distension by air insufflation (750 ml). Control subjects (n = 10), patients with gastroesophageal reflux disease (GERD) (n = 22), and patients after fundoplication (n = 24) were studied. LES and esophageal motilities were recorded with perfusion manometry. RESULTS: Gastric distension with air significantly (p < 0.05) increased TLESR frequency in controls (1.6+/-0.3 to 3.5+/-1.0 per 20 min), GERD patients (1.2+/-0.3 to 3.1+/-0.5 per 20 min), and patients after fundoplication (0.5+/-0.1 to 1.8+/-0.6 per 20 min). Postfundoplication the number of TLESRs was significantly reduced (p < 0.05) both under fasting conditions and after air insufflation. The number of common cavities and belches after gastric air distension also was significantly reduced (p < 0.05) after fundoplication: 2.3+/-0.6 versus 4.7+/-0.4 in controls and 4.1+/-0.4 in GERD patients. About half of the common cavities occurred during TLESRs, and half during other mechanisms. An impaired ability to belch in daily life correlated with an impaired belching response during the test. An impaired ability to belch occurred only in patients with complete fundoplication and not in patients with partial fundoplication and was associated with a reduced number of common cavities after gastric air insufflation. CONCLUSIONS: Short-lasting gastric air distension 1) provokes TLESRs but does not differentiate GERD patients from controls, 2) reveals impaired belching capacity in patients after complete fundoplication, and 3) shows that common cavities do not exclusively occur during TLESRs.     

Massive pulmonary thromboembolism demonstrated at necropsy in Japanese psychiatric patients treated with neuroleptics including atypical antipsychotics.

BACKGROUND: There may be an increased risk of pulmonary thromboembolism (PTE) with antipsychotic drugs, so this association was investigated in autopsy cases of sudden unexpected death determined by the Department of Legal Medicine of a Japanese university hospital. METHODS AND RESULTS: Records of 1,125 forensic autopsies (808 males, 317 females) performed during the study period for investigation of the cause of sudden unexpected death were reviewed and a logistic regression analysis was performed to explore whether age, gender, body mass index (BMI), and antipsychotic drug use were associated with fatal PTE. Among all records, 34 (3.0%; 14 males, 20 females) indicated the use of antipsychotic drugs and 28 (2.5%; 9 males, 19 females) indicated PTE as the cause of death. Of the 28 subjects who died from PTE, 8 had taken antipsychotic drugs (29%) and all were female. Female gender and antipsychotic drug use accounted for a significantly higher risk of PTE death with an odds ratio of 4.22 (95% confidence interval (CI), 1.82-9.78; p<0.01) and 10.49 (95% CI, 3.95-27.85; p<0.01), respectively. CONCLUSIONS: Japanese women taking antipsychotic drugs may be at particular risk for PTE.