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The clinicopathological features and operative results were analyzed in 21 patients undergoing an operation for cancer of the remnant stomach between 1979 and 1997. The twenty-one patients were divided into two groups: Group A; n = 9: who had undergone a gastrectomy for benign gastric disease, Group B; n = 12: who had undergone the same operation for gastric cancer. In Group A, the interval between the first gastrectomy and the second was longer than in Group B. In both groups, a large number of advanced cancers (n = 16, 76.2%) and undifferentiated carcinomas (n = 15, 71.4%) were seen. Five-year-survival rates in Group A and Group B were 23.7%, 19.0%, respectively. The incidence of gastric stump cancer following partial gastrectomy was 80% in the patients on whom Billroth II reconstruction had been performed after gastrectomy. It is suggested that the residual stomach in the Billroth II reconstruction patients is susceptible to cancer development. Consideration of the reconstruction method and a systemic follow-up is needed to improve a prognosis.

Dumping syndrome results from a rapid passage of carbohydrate in the small intestine after gastric surgery. A 50-year-old man developed the syndrome after surgery for peptic ulcer. He often complained of burning epigastralgia after meals. Various methods of treatment had only a limited effect. Acarbose, alpha-glucosidase inhibitor, suppresses the breakdown of carbohydrates in the small intestine and consequently reduced osmolarity. The patient had a dramatic improvement in the dumping syndrome including epigastralgia, diarrhea and perspiration with an administration of acarbose 50 mg. There was no intractable side effect. Preprandial administration of acarbose is a reasonable treatment in the case of dumping syndrome.

Recently, antisecretory drugs such as H2-receptor antagonists (H2-RA) or proton pump inhibitor have been used for peptic ulcer patients widely in Japan. However, there are possibilities that long term administration of H2-RA might cause changes in intragastric environment. The present study was designed to clarify the changes of surgical treatment in Japan Surgical Society training hospitals, before and after introduction of H2-RA. Serum gastrin and antral G-cell number was measured after administration of H2-RA (1 mg/kg 14 days continuous infusion) in rat. Also, acid secretion and gastrin response stimulated by adrenalin (40 ng/kg.min) were measured in duodenal ulcer patients. 1) In the view of surgical treatment, elective operation highly decreased after the introduction of H2-receptor antagonists, and showed the increase of the rate of emergency operation up to 70%. 2) Hypergastrinemia and antral G cell hyperplasia were observed after administration of H2-RA in rats. 3) Acid secretion stimulated by adrenalin which is considered as antral G cell dependent, showed a higher response in H2-RA treated cases than in those untreated. 4) Antrectomy was carried out in 43.4% of the patients treated with H2-RA versus 18.9% to the patients untreated.

Patients with recurrent peptic ulcer undergoing surgery were reviewed at 57 institutions by the 18th meeting of the Japanese Research Society of Gastric Surgery. The factors involved in recurrence was analyzed in patients fulfilling the following criteria: the minimum follow-up period was over 5 years, the age was over 15 years, tetragastrin-stimulated acid secretion was measured before surgery, and the recurrence was confirmed by endoscopy or upper gastrointestinal radiography. In 632 patients, the recurrence rate of duodenal ulcer was significantly higher than that of gastric ulcer. However, the duodenal ulcer patients undergoing selective vagotomy and antrectomy did not develop recurrence. A significant difference in the recurrence rate was observed between selective vagotomy and antrectomy and the wide gastrectomy or selective proximal vagotomy. By analysis using the Cox proportional hazard model, the risk factors for recurrence of duodenal ulcer were the ulcer stage, the operative procedure, the location of the ulcer, and the age of the patient. Especially, recurrences in patients receiving selective proximal vagotomy depended on the location of the ulcer and the age, but the risk factors for patients undergoing wide gastrectomy were uncertain.

Recurrent peptic ulcer after gastric surgery differs from duodenal ulcer in that they usually occur with low acid output, which is sufficient to cause ulceration in predisposed stomach or anastomosis. The proton pump inhibitor (PPI), significantly more potent and long-acting than H2-blocker, is expected to be more effective for postoperative recurrent ulcers. We evaluated the efficacy of omeprazole (OPZ) on recurrent ulcers in 12 patients following either gastrectomy or vagotomy. The healing rate after 4 week treatment with OPZ was 58% and increased to 100% after 8 week. Evaluation of quick symptom relief also supported the efficacy of OPZ treatment. These findings showed that OPZ treatment resulted in a more rapid healing of recurrent ulcers compared with H2-blocker. It remains to be clarified whether quit of treatment with PPI would induce high ulcer relapse rates, and whether maintenance therapy with PPI would be the only alternative therapy for surgical intervention.

The major surgery for gastroduodenal ulcer, gastric cancer, esophageal cancer, and mediastinal tumor, were performed on 5 patients during anticoagulant therapy after prosthetic valve replacement. In the postoperative management, Dipyridamole (30 mg/day) was given in case 1, Heparin sodium (24,000 mu/day) in case 2, 3, and Gabexate Mesilate in case 4, 5. Postoperative course was uneventful in case 1, 3, 4, 5, intratracheal bleeding was recognized on the 3rd postoperative day and treated by reducing of heparin dose in case 2. Gabexate Mesilate was thought to be effective and free from complication in case 4, 5.

The plasma secretin concentration in response to a meat meal and luminal pH were investigated in patients with gastrectomy: total gastrectomy with Roux-Y anastomosis or interposed jejunal anastomosis and partial gastrectomy with Billroth I or Billroth II anastomosis. The fasting plasma secretin concentration was significantly elevated in relation to the decreases of duodenal pH in postprandial state in normal subjects. No significant response of the plasma secretin and jejunal pH were observed in patients with total gastrectomy with Roux-Y anastomosis, however total gastrectomized patients with jejunal interposition showed the peak plasma secretin response in postprandial state. In patients with Billroth I the postprandial plasma secretin concentrations were well responded when the duodenal pH was below 4.5, however it was less than that of normal subjects. In patients with Billroth II the response of plasma secretin was much less than that of Billroth I, even though the decrease of jejunal pH was as comparable as in Billroth I. These studies suggest that a Billroth I operation after subtotal gastrectomy and interposed jejunal anastomosis after total gastrectomy are better procedures than the Billroth II or Roux-Y anastomoses to obtain endogenous secretin release.

This clinical study was based on 307 peptic ulcer patients treated with gastrectomy over a 15-year period in our department. Numbers of surgical cases for peptic ulcer remarkably decreased after the introduction of cimetidine in 1980. A median age of gastric ulcer patients was in sixth decades, whereas duodenal ulcer in fifth decades. Surgical indications were 60 percent in intractable ulcer, 30 percent in complication as bleeding, stenosis and perforation, and 10 percent in suspicious malignancy. After cimetidine introduction intractable cases decreased from 63 percent to 44 percent. There was no remarkable difference in the fasting and peak plasma secretin concentrations in postprandial period between peptic ulcer patients and normal controls, however, in gastrectomized patients the plasma secretin response decreased in postprandial state. Follow up study was made on a point of postoperative recurrence and postgastrectomy syndrome. Small stomach syndromes such as insufficient food intake and body weight loss were observed in 10 and 30 percent in the gastrectomized patients, but 86 percent of the patients were satisfied with the results of operation. We concluded that gastrectomy for peptic ulcer was treatment of choice from the point of low recurrence rate and no severe postgastrectomy disorders.

Sixty-one patients with carcinoma of the remnant stomach after distal gastrectomy were admitted by the end of 1982. Twenty-six of them were gastrectomized for benign disease such as peptic ulcer and 35 for malignant disease such as gastric carcinoma. The age of the benign group was 58, and the average interval from the first operation was 19 years. The corresponding figures for the malignant group were 63 and 8 years, respectively. In the malignant group, the methods of anastomosis at the first operation were 18 cases of Billroth-I (B-I) and 17 of B-II. The lesion was located at the surgical stump in 7 patients and distant from the stump in 14 patients in this group. In the benign group, there were 10 cases of B-I and 16 of B-II, and no differences were seen in the location. Early carcinoma was noted in 11 patients, and 34 were advanced. Differentiated adenocarcinoma was observed in 25 cases and undifferentiated in 20 in the resected specimen. Although no metastases were seen in early cases, the rate of lymph node metastasis was 70%, and the five-year survival rate was 21% in advanced cases, and 80% in early cases.

To elucidate the risk factors of peptic ulcer which require surgical treatments, we examined the influences of following factors such as sex, age, smoking, and alcohol in 308 peptic ulcer patients. In the group with gastric ulcers, high age group was likely to be operated. On the contrary, young patients with duodenal ulcers were likely to be treated surgically. Sex, smoking and alcohol were not regarded as risk factors. The correlations between the degree of neurosis and the amounts of smoking and alcohol were analyzed in the cases with duodenal ulcers. In the cases treated surgically, the degree of neurosis showed no or little correlations. In the cases treated conservatively, however, the degree of neurosis showed positive correlation with the amounts of smoking and alcohol.

The secretion of gastric acid in the peptic ulcer patients were examined by the dopamine infusion test (DIT). Production of gastric acid was investigated when the patients were treated by 30-minute dopamine infusion of 2 micrograms/kg/min. According to the difference of production of gastric acid, 132 patients were categorized into three groups: 59 Cata-responders, 28 Ana-responders and 45 Non-responders. Cata-responders were the patients whose production was less than 0.2mEq/30 min, Ana-responders, greater than 0.2mEq/30 min and Non-responder less than or equal to 0.2mEq/30 min. Cata- and Ana-responders showed higher gastric acid secretion preoperatively, and higher gastric acid reduction rate after selective proximal vagotomy (SPV) than Non-responder. Cata-responder showed decreased acid output preoperatively and unchanged after SPV with DIT. Ana-responder showed increased acid output preoperatively and decreased after SPV with DIT. Non-responder showed unchanged acid output preoperatively and decreased after SPV. Cata-responder may be depending more on vagus-mediated factor and parietal cell mass. Ana-responder may be depending more on vagus-mediated factor, parietal cell mass and dopaminergic factor. Non-responder may be depending more on gastrin cell mass and less cholinergic influence. From these findings dopamine receptor may exist in the stomach, and DIT seems to be useful in studying pathogenesis of the peptic ulcer and determining treatment for patients with peptic ulcer.