Osteoporosis after gastrectomy: bone mineral density of lumbar spine assessed by dual-energy X-ray absorptiometry.

Although osteoporosis is a common clinical disorder associated with gastric surgery, long-term effects of gastrectomy on bone metabolism are still unclear. The purpose of this study was to clarify the incidence and risk factors of osteoporosis after gastrectomy using univariate and multivariate analyses of quantitative measurements. The study included 59 patients who had undergone gastrectomy more than 5 years before. There were 38 men and 21 women, aged 37-81 years, mean 64 years. Bone mineral density (BMD) of L2-L4 spine was measured using dual-energy X-ray absorptiometry (DXA). Absolute value of BMD (g/cm2) and age- and sex-matched BMD (%) were given. The mean BMD was 0.766 g/cm2, and the incidence of osteoporosis (BMD less than 0.70 g/cm2) was 37%: 18% in men and 71% in women. The mean age- and sex-matched BMD was 85.9%: 87.5% in men and 83.1% in women. Univariate and multivariate analyses revealed that BMD was significantly associated with the age and sex of patients, but was not influenced by the type of gastrectomy (partial versus total) and years after operation (< 20 versus 20 <). Our study clarified the fact that postgastrectomy osteoporosis was frequent in the aged or female patients. BMD should be evaluated after gastrectomy, especially in the aged and in women.

Long tube for obstructing left-sided colon cancer.

BACKGROUND: Obstructing left-sided colon cancer is now managed by immediate resection and primary anastomosis using intraoperative mechanical bowel irrigation. The aim of this study was to describe our new technique using a long tube for preoperative bowel decompression and intraoperative antegrade irrigation. METHODS: A long nasointestinal tube was inserted and a balloon was inflated with distilled water. The tube gradually went forward to the ileum end by peristalsis, and the small intestine became fully decompressed. At operation, antegrade colonic irrigation with warm saline was performed through this long tube without insertion of a Foley catheter. RESULTS: Immediate colonic resection and primary end-to-end anastomosis using layer-to-layer interrupted sutures was successfully performed in 4 patients with obstructing sigmoid colon cancer. CONCLUSIONS: This method avoids opening and closure of the cecum or ileum, and minimizes bacterial contamination. The technique is simple and easy, and useful for immediate resection and primary anastomosis of obstructing left-sided colon cancer.

Clinical results and prognostic factors of radiologically node-positive gastric carcinoma.

Lymph node metastasis determined by histologic examination is an important prognostic indicator in gastric carcinoma. However, prognostic value of lymph node metastasis detected by computed tomography (CT) is unknown. The aim of this study was to evaluate clinical results and prognostic factors of patients with radiologically node-positive gastric carcinoma. The study included 78 patients with primary gastric carcinoma and lymph node metastasis confirmed by CT. The level of lymph node metastasis was simply graded as follows: level I included perigastric nodes; level II included intermediate nodes along the left gastric, common hepatic, and celiac arteries; and level III included distant nodes along the hepatoduodenal ligament, pancreas, spleen, and abdominal aorta. Sixty patients (79%) had stage IV tumors showing one or more of the following: level III lymph node metastasis in 37, pancreatic invasion in 27, peritoneal dissemination in 23, and liver metastasis in 19. Overall 1- and 5-year survival rates were 29% and 6%, respectively, and the 1-year survival rate was significantly influenced by the level of lymph node metastasis on CT (55% for level I, 27% for level II, 7% for level III, P < 0.01). In patients with gastrectomy, prognostic factors were tumor size (<10 cm versus >10 cm, P < 0.01), gross type (localized versus infiltrative, P < 0.01), histologic type (well differentiated versus poorly differentiated, P < 0.01), and curability of the disease (curative versus noncurative, P < 0.01). Our study indicates that prognosis of patients with radiologically node-positive gastric carcinoma is poor because of high frequency of extensive tumor spreads. Patients having only positive level I nodes on CT are candidates for curative gastrectomy, which may offer long-term survival.

Bone mineral density in patients taking H2-receptor antagonist.

Osteoporosis after gastrectomy is a common clinical disorder. In gastrectomized patients, decreased gastric acidity may be associated with impaired calcium absorption. This study was undertaken to determine whether patients with chronic use of H2-receptor antagonists (HRA) had demonstrable decreases in bone mineral density (BMD). Thirty-three patients taking cimetidine, ranitidine, or famotidine for more than 2 years were analyzed. We measured BMD of L2-L4 using dual energy X-ray absorptiometry (DXA). Osteoporosis (BMD less than 0.70 g/cm2) was found only in three patients (9%). As compared with healthy controls, age- and sex-matched BMD ranged from 74.4% to 132.9%, with a mean of 97.0%, and was not influenced by the period of HRA use (<5 years versus >5 years or more). Although the age- and sex-matched BMD was different among the kinds of HRA (98.6% for cimetidine, 101.3% for ranitidine, and 85.5% for famotidine), the relationship between the BMD and type of drug was not significant by multivariate analysis. These results indicate that chronic use of HRA has little influence on the degree of BMD, and suggest that decreased gastric acidity is not always associated with osteoporosis after gastrectomy.

Successful conservative treatment for esophageal perforation by a fish bone associated with mediastinitis.

A 74 year-old man presenting with esophageal perforation associated with mediastinitis due to the swallowing of a fish bone is reported herein. Conservative treatment, including starvation therapy and the injection of antibiotic drugs, proved to be successful for this patient. Although the optimal treatment for esophageal perforation remains controversial, it is important to choose the appropriate strategies when treating cases of esophageal perforation with mediastinitis.

Preoperative assessment of advanced gastric carcinoma using computed tomography.

OBJECTIVES: The role of computed tomography (CT) for the staging of gastric carcinoma is controversial. The purpose of this study was to evaluate the utility of CT in assessing the perigastric spread of advanced gastric carcinoma. METHODS: The study included 56 patients who underwent dynamic CT and laparotomy for the treatment of node-positive gastric adenocarcinoma. Preoperative CT findings were compared with surgical findings, and diagnostic accuracy was estimated. RESULTS: Sensitivity, specificity, and accuracy of preoperative CT in determining the perigastric tumor spreads were 33, 97, and 73% in pancreatic invasion, 36, 97, and 70% in level III lymph node involvement, and 89, 98, and 96% in liver metastasis. Peritoneal dissemination was not detected in 15 of 56 patients (27%), and stage IV disease was not diagnosed correctly in 18 of 40 patients (45%). CONCLUSIONS: Radiologists and surgeons must remember that pancreatic invasion, extended lymph node metastasis, and peritoneal dissemination are sometimes overlooked in CT examination in patients with advanced gastric carcinoma.

Postoperative bile peritonitis caused by division of an aberrant bile duct in the left triangular ligament of the liver.

A 61-yr-old man underwent Billroth I gastrectomy for an advanced cancer in the corpus of the stomach. On the first postoperative day, fresh bile discharged from the penrose drains, which had been placed in Winslow's foramen, and the volume of bile discharge subsequently increased. Leakage from the gastroduodenal anastomosis was excluded by gastroduodenography. Exploratory relaparotomy showed bile peritonitis with much more bile retention in the left subphrenic space. The origin of bile leakage could not be traced despite close examination of all the extrahepatic biliary tract and the liver surface. Intraoperative cholangiography through the cystic duct after cholecystectomy revealed that the bile leakage originated from an aberrant bile duct present in the free edge of the left triangular ligament (appendix fibrosa hepatis), which had been unintentionally cut at the primary operation. Knowledge of this anatomical structure is important and proper ligation is recommended when dissecting the appendix fibrosa hepatis to avoid postoperative bile peritonitis and the need for a relaparotomy.

Epstein-Barr virus-associated gastric carcinoma.

Epstein-Barr virus (EBV) is associated with certain types of gastric carcinoma. We report a case of EBV-positive undifferentiated carcinoma of the stomach in a 59-year-old woman with a well-demarcated ulcerating tumor in the gastric body. Examination of the resected stomach revealed that the tumor was undifferentiated carcinoma with lymphoid stroma, or lymphoepithelioma-like carcinoma. Tumor cells were positive for EBV by in situ hybridization. Gastroenterologists must keep in mind that localized ulcerating tumors of the stomach histologically seen as undifferentiated carcinnoma with lymphoid stroma are linked to EBV infection.

Choledochoduodenal fistula: a complication of a penetrated duodenal ulcer.

A 44 year old man who had a 5-year history of recurrent duodenal ulcer with a choledochoduodenal fistula is reported. He showed bulbar stricture and was successfully treated with an truncal vagotomy and distal gastrectomy by Billroth II method, leaving the fistula intact. Choledochoduodenal fistula is an uncommon complication of penetrated peptic duodenal ulcer. Surgical treatment for duodenal ulcer has been recommended. Medical management with the recent anti-ulcer drugs for choledochoduodenal fistula also has been reported to gain good results.