噴門切除術式の検討

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In later years the operation of resecting the lower esophagus and the cardiac portion of the stomach including the esophago-cardio junction, combined with various methods of anastomosis, has become increasingly popular as a treatment of various diseases circumscribed to that area-benign lesions such as ulcer and polyps and malignant ones such as carcinoma and sarcoma. In an effort to assess the relative values of various procedures of anastomosis, investigations were carried out in clinical cases operated on in our clinic as well as experimental animals. The methods were evaluated based on technical difficulties involved in operation, postoperative complaints (especially esophagitis due to reflux, impairment to the passage of aliment through anastomosing part and dumping syndrome), digestion and assimilation, and long-range postoperative blood picture. The procedures employed clinically were esophagogastrostomy, interposition of jejunal loop between esophagus and antrum, esophagojejunostomy with antral exclusion, and esophagojejunostomy with gastrostomy at antrum. The operations done experimentally in mature dogs were esophagogastrostomy, esophagojejunostomy with antral exclusion, and esophagojejunostomy and antrojejunostomy. 1. Esophagogastrostomy. As compared with other operations, this operation is easiest to perform, involving the least hazard. It is the best method of anastomosis from the viewpoint of physiology. The rate of digestion and assimilation was nearly normal and dumping syndrome did not occur after this operation. Some cases developed esophagitis due to reflux and impairment to the passage of aliment through anastomosing part. Measures taken conservatively to cope with esophagitis due to reflux consisted of elevation of the upper half of patient's body and administration of anti-acid agent, antiphlogistic agent and adsorbent. The use of A. C. L. has achieved good results in our clinic. Surgically, pyloroplastic surgery and the operation of forming a valve in the lower end of the esophagus were the methods of value. Interposition of jejunal loop between esophagus and antrum proved to be the best method for the prevention of esophagitis. The following caution may be of value for the prevention of stricture of anastomosing part : to be careful to secure patency of anastomosing part, to leave a vynil tube in place in anastomosing part for a certain period of time, and to transect the esophagus obliquely. A bougie or a Laminaria may be used to effect gradual dilatation in cases of a high degree of stricture. 2. Interposition of Jejunal Loop between Esophagus and Antrum. This operation did not cause esophagitis due to reflux, impediment to the passage of aliment through anastomosing part, and dumping syndrome. Though it is a method of great value, its fault lies in the fact that the technique is very complicated. 3. Esophagojejunostomy with Antral Exclusion. After this operation, stricture of anastomosing part between jejunum and esophagus rarely occurred, but the rate of digestion and assimilation showed a slight decrease below normal. Besides, there were possibilities of the development of esophagitis due to reflux. 4. Esophagojejunostomy with Gastrostomy at Antrum. This operation has the advantage of being done comparatively easily in cases of poor risk, for the gastric fistula makes food intake possible at an early postoperative date. It is also to its credit that stricture may seldom occur at anastomosing part between esophagus and jejunum. Its faults are that it may cause a slight lowering of the rate of digestion and assimilation, and that it may cause dumping syndrome to occur. 5. Esophagojejunostomy and Antrojejunostomy. This operation is easier to perform than interposition of jejunal loop. Moreover, publication of jejunal limb will lead to the maintenance of a normal process of digestion and assimilation, and to the prevention of circulus vitiosus. No anemic symptoms were noticed in all the patients and experimental animals regardless of the type of operation performed. The following conclusions have been reached : from the viewpoint of physiology, esophagogastrostomy is the operation of choice for those cases in which resection of a small portion of the cardia seems to achieve the end. Either esophagogastrostomy with antralexclusion or gastrostomy is preferable in cases of poor risk. Interposition of jejunal loop between esophagus and antrum seems to be the best method in cases of good general condition, if importance is to be attached to the prevention of postoperative complications.
千葉大学の論文
1960-11-28

噴門切除術式の検討

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