Effects of the continuous intake of a milk drink containing Lactobacillus casei strain Shirota on abdominal symptoms, fecal microbiota, and metabolites in gastrectomized subjects.

OBJECTIVE: This article is based on our previously reported results of irregular bowel movement and disturbances of the intestinal microbiota/environment in gastrectomized patients. A placebo-controlled, double-blind comparative study was carried out to evaluate the effects of a fermented milk beverage containing Lactobacillus casei strain Shirota (LcS) in such patients. The major evaluated factors of this article were "bowel movement" and "quality of life." The secondary evaluated factors were "fecal microbiota" and "enteric environment." METHODS: Of the 190 gastrectomized subjects who participated in our previously reported defecation survey, 134 subjects judged as having abnormal defecation gave consent to participate in this study. These subjects continuously ingested the test beverage containing 40 billion LcS or placebo (one bottle per day, 4 weeks). RESULTS: In the LcS-ingested group, among the 118 subjects who completed the tests, the assessments of the subjects were based on their division into groups based on their symptoms with our scoring system for constipation/diarrhea; although there was no significant ingestion effect in total, in the constipation group, LcS reduced the degree of constipation compared with that in the placebo group. In the diarrhea group, LcS ingestion improved diarrhea compared with that in the preingestion state. Fecal Staphylococcus level was decreased. CONCLUSIONS: The results suggest the possibility that the continuous consumption of LcS-fermented milk relieves irregular bowel movement in gastrectomized patients.

Irregular bowel movement in gastrectomized subjects: bowel habits, stool characteristics, fecal flora, and metabolites.

BACKGROUND: We conducted a survey regarding irregular bowel movement in gastrectomized patients. Their defecation frequency, intestinal microflora, and intestinal environment were studied and compared with those of healthy controls. METHODS: As a first step, a questionnaire survey on bowel movement, involving 769 patients and 312 healthy controls (total: 1,081 subjects), was carried out. As a second step, the defecation frequency (scoring of the survey results conducted to evaluate the state of constipation/diarrhea), intestinal microflora, and intestinal environment were evaluated in 190 gastrectomized patients with irregular bowel movement and 31 controls identified in the first survey. RESULTS: First step: Of the 769 patients, 58% complained of irregular bowel movements (constipation, diarrhea, or their alternate occurrence), and their frequency of complaints was significantly higher (p < 0.01) than that in the healthy controls (33%). Second step: The levels of the most predominant obligate anaerobe and harmful bacteria in the feces were lower and higher, respectively, the fecal pH was lower, the fecal water content was lower, and the level of putrefactive metabolites in the feces was higher in the gastrectomized patients than in the healthy controls. The intestinal flora and environment were more disrupted in the totally gastrectomized than in the partially gastrectomized patients. CONCLUSIONS: Many gastrectomized patients with irregular bowel movements exhibited significant changes showing impaired intestinal microflora and metabolite levels.

Preoperative determination of appropriate cutting line for proximal gastrectomy to avoid postoperative jejunal ulcer.

BACKGROUND/AIMS: Although proximal gastrectomy has become a procedure of choice for patients' early cancer in the upper third of stomach, no clinical guide for optimal gastric resection in order to avoid postoperative jejunal ulcer is available. The aim of this study was to investigate whether determining the distribution of parietal and chief cells of the stomach using Congo red test is clinically relevant. METHODOLOGY: The F-line was defined as a boundary line between fundic and intermediate area of the stomach according to the pathological findings in 29 patients who underwent total gastrectomy for early gastric cancer, whereas the f-line was regarded as a boundary line between intermediate and pyloric area. In the additional 6 patients undergoing vagus-preserving proximal gastrectomy with jejunal pouch interposition, endoscopic Congo red test was preoperatively performed to determine the F-f-line. RESULTS: The distances from the pyloric ring to f-line on the lesser and greater curvatures were variable. Long-term outcomes of proximal gastrectomy guided by preoperative endoscopic Congo red test were favorable. CONCLUSIONS: It is suggested that preoperative endoscopic Congo red test is useful to determine the appropriate cutting line in order to avoid postoperative jejunal ulcer after proximal gastrectomy.

[A case report of effective chemoradiation with 5'-DFUR and concomitant preoperative radiotherapy of the lower rectum].

We treated a lower rectal carcinoma patient with preoperative radiation and chemotherapy, resulting in a downstaging, and the findings are reported herein. The patient is a 55-year-old woman endoscopically diagnosed with advanced rectal carcinoma at a site 3 cm from the dental line. Preoperative radiation and chemotherapy included whole pelvis irradiation (44 Gy in total) and 800 mg/day of 5'-DFUR administered until one day before the operation. On the 20th day after completing irradiation, a low anterior resection of the rectum was conducted. During the operation, we found serositis of the small intestine and retroperitoneal fibrosis thought to be due to the irradiation. Histopathologic findings showed: invasion degree, sm2; stage I with N0; and histologic grading, Grade 2. The patient started drinking water from postoperative day 1, and was discharged on postoperative day 11. At present, in Europe and the USA, large scale studies are being conducted to evaluate preoperative radiation and chemotherapy in patients with lower rectal carcinoma. We think that this therapy is an effective treatment, since a distance (AW) from the lower margin of the tumor and the cut edge of the anal end can be established.

[A new residency program for Japanese surgical specialties].

Medical education, in general, should be a continuous and life-long persistent training for the purposes to be reached through the education of humanity and medical techniques which are the arts based on the sciences whichever originated from the western or eastern world histories. These training started from the student life through the termination of medical profession, especially in the field of surgery, the medical doctors are the only existence to be allowed to insult human body even for the purpose of treatment. These facts should be learned through well-trained experienced teachers with ethics, theories and evidence based medicine. The new training curriculum for 5 years program of the surgical specialties in Japan has built up and started just two years ago to be successful supported not only by medical teachers but also by the government and civilian economical foundations. A sort of national board of medical specialties is necessary system to develop general medical care system with effective specializations.

Postoperative long-term evaluation of interposition reconstruction compared with Roux-en-Y after total gastrectomy in gastric cancer: prospective randomized controlled trial.

BACKGROUND: The postoperative clinical superiority of the interposition of jejunum reconstruction (INT) to Roux-en-Y reconstruction (RY) after total gastrectomy has not been clarified. Postoperative quality of life (QOL) was evaluated between the 2 methods by a multi-institutional prospective randomized trial. METHODS: A total of 103 patients with gastric cancer were prospectively randomly divided into groups for RY (n = 51) or INT reconstruction (n = 52) after total gastrectomy. They were stratified by sex, age, institute, histology, and degree of lymph node dissection. Postoperatively, body mass index (BMI) and nutritional conditions were measured serially, and QOL and postoperative squalor scores were evaluated at 3, 12, and 60 months and compared between the 2 groups. RESULTS: After removing patients who did not complete the follow-up survey or censured cases, 24 patients in the RY group and 18 patients in the INT group were clinically available and their postoperative status was assessed. QOL scores were increased and complication scores were improved in the postoperative periods (P < .01). Postoperative BMI significantly deteriorated compared with preoperative BMI in each group. The postoperative QOL and complication scores at 60 months after surgery were significantly better than those at 3 months after surgery in each group (P < .01). However, there was no significant difference of QOL scores and postoperative complication scores between the 2 reconstruction groups. The nutritional condition in the INT group was nearly the same as that in the RY group. CONCLUSIONS: Although our patient sample was small and patients who did not complete the follow-up survey were present, we could not identify any clinical difference between INT and RY after total gastrectomy 60 months after surgery. The safer and simpler RY method may be a more suitable reconstruction method than INT after total gastrectomy.

A novel 3-dimensional EUS technique for real-time visualization of the volume data reconstruction process.

BACKGROUND: Three-dimensional EUS (3D-EUS) technology has facilitated spatial interpretation of US images. However, acquisition of consecutive US scans is time consuming and difficult. A new 3D-EUS system was developed that negates this problem by allowing rapid image renewal and the efficient production of consecutive US scans. METHODS: Three-dimensional images were reconstructed from a series of 2-dimensional images corresponding to the rotation angle of the echoendoscope as measured with an electromagnetic tracking system. To evaluate the technical feasibility of the system, 3-dimensional images of splenic veins in 2 patients and an esophageal submucosal tumor in a third patient were generated. RESULTS: The 3D-EUS system acquired image data at a rate of 30 frames per second and allowed visualization of these data in real-time. The area of interest was clearly and rapidly portrayed in all 3 patients. CONCLUSION: This study demonstrates the efficiency of the new 3D-EUS system described in this report. Further development of this novel 3D-EUS system may lead to new applications of this technology.