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The risk factors for postoperative morbidity and mortality in elderly patients with Parkinsonism after gastrointestinal surgery were evaluated by univariate and multivariate analyses in comparison to those of patients with cerebrovascular disease and to those of patients with no comorbid condition. Data were obtained on 36 patients with Parkinsonism (PK), 77 with cerebrovascular disease (CVD) and 120 with no comorbid condition (ND). All data were adjusted for age, sex and operative procedure. The postoperative morbidity rate was highest in the PK group (77.8%), followed by the CVD group (70.1%), and both differed significantly from the rate of the ND group (32.5%). Gastrointestinal and pulmonary complications and delirium were the major postoperative complications, and were significantly more common in the PK group than in the ND group. Patients in the PK group had the longest postoperative hospital stay, followed by those in the CVD and ND groups; the differences were significant between the PK and ND groups and between CVD and ND groups. The PK group had the highest operative and hospital mortality rates, and they differed significantly from the ND group. Hayashi's second method of quantification was used to assess the risk factors for postoperative death. The highest partial correlation coefficient was that found for postoperative pulmonary complication. We conclude that we should pay close attention to postoperative respiratory management, particularly in elderly patients with Parkinsonism, to prevent pulmonary complications and reduce postoperative mortality.

In order to elucidate the correlation of gastroesophageal reflex (GER) with aspiration pneumonia after surgery, 48 patients (mean, 75.6 years) with gastric cancer treated at the hospital from March, 1994 to December, 1994 were subjected to this prospective study. The pharyngeal stimulation test, nutritional assessment, radionuclide esophageal scintigraphy (34 cases) were performed before surgery and relationship between those results and aspiration pneumonia were studied. Aspiration pneumonia occurred in 3 cases, and all of them were in, significantly, poor nutritional status, compared with other. A significant increase in the frequency of GER was observed when a naso-gastric tube (NGT) was placed, but surprisingly, all the patients with aspiration pneumonia were 3 out of 4 patients who had continuous GER without NGT. It is noteworthy, continuous GER without NGT was significantly (p

EDITORIAL COMMENT: We accepted this case report for publication to inform readers that pyometra is an entity in itself with a significance apart from that of underlying pathology such as carcinoma of the cervix or endometrium. The authors' takeaway message seems to be that a pyometra needs treatment by cervical dilatation in addition to that of associated complications including peritonitis and septicaemia as a result of perforation of the uterus. Summary: Spontaneous uterine perforation of pyometra is closely related to physiological uterine involution and requires a correct diagnosis, rapid surgical intervention and administration of antibiotics.

Gastric cancer in the elderly was evaluated with regard to age-related pathomorphological changes. Resected gastric cancer was studied with regard to location, stage, morphology and histology in male young old (65-74 years old) which were 25 cases and 31 lesions, respectively male middle old (75-84 years old); 104 cases and 120 lesions, male very old (85 years-); 96 cases and 110 lesions, female young old; 22 cases and 31 lesions, female middle old; 91 cases and 106 lesions, female very old; 51 cases and 55 lesions. Multiple gastric cancers were more frequent in female older group. In early cancer the frequency of elevated type increased significantly and that of depressed type decreased in very old group. In advanced cancer Borrmann I type was not so common in very old group. Histologically the frequency of signet ring cell cancer decreased and of tubular adenocarcinoma and of papillary adenocarcinoma increased significantly in female very old group. Hepatic metastasis increased significantly in male very old group. Lymph node metastasis and peritoneal metastasis did not show any change in age-related frequency.

Leiomyosarcoma of the esophagus is an uncommon disease of which only 97 cases including the present case have been reported in Japan. We report a case of the tumor which showed multiple hematogenous metastases after surgery. A 73-year-old male was admitted complaining of dysphagia and vomiting. Esophagography and endoscopy revealed a large protruding lesion in the lower esophagus. CT scanning revealed threefold-sized extramural mass. Boring biopsies failed to yield evidence of malignancy. However, we performed surgical treatment because of the uncommon size for a benign tumor. The excised tumor was 11 x 9 x 5 cm in size and was diagnosed histologically as leiomyosarcoma of the esophagus without any nodular involvement. Metastatic tumor in the right rib was found 14 months after the operation. Radiotherapy failed to decrease tumor size but eliminated pain. Bone metastases appeared successively and the patient died 3 years and 4 months after operation. Chemotherapy had no effect. Autopsy revealed metastases to the ribs, vertebrae, sternum, pelvic kidneys and diaphragm, but no local recurrence. There is a great need for the development of effective anti-cancer drugs for leiomyosarcomas, particularly in cases with extensive metastasis, such as presented here.

The risk factors of operative death and complications in the elderly following operations for gastric cancer were evaluated by multiple logistic model analysis. Subjects were 511 patients (a mean age of 75.6±7.9 years) operated on for gastric cancer in a past decade. The most significant risk factors for death within 50 postoperative days was (1) postoperative pulmonary complication, followed by (2) stage of cancer, (3) age, (4) postoperative hepatic injury and (5) postoperative delirium in order of standardized coefficient values. In assessing risk factors for postoperative pulmonary complications which was the major risk factor for operative death, two underlying diseases, namely, neurological disease including cerebral vascular disorder of Parkinsonism and diabetes mellitus, were statistically significant. We should pay careful attention to postoperative respiratory management to prevent the pulmonary complications, if we encounter the elderly patients with cerebral vascular disorder, Parkinsonism or diabetes mellitus.

It has common knowledge that the advent of H2-blockers has radically changed the treatment of peptic ulcer. We reviewed 26,667 endoscopic examinations, 5,800 consecutive autopsies and 134 consecutive patients operated for peptic ulcer over an 18-year period to evaluate the effects of H2-blockers on the treatment of peptic ulcer in the elderly (or = 60 years of age). The number of operations for peptic ulcer in the elderly markedly declined after H2-blocker therapy was introduced. This is mainly due to decreased operative indications for gastric bleeding as a result of conservative treatment. However, the incidence of perforating ulcers has hardly changed even after the introduction of H2-blockers. More than 90% of these cases were non-diagnosed or non-treated ulcers and 50% of them were NSAID- or steroid-treated, which is characteristic in the elderly. We conclude that patients to be treated by anti-inflammatory drugs should be screened by endoscopy, and should be given anti-ulcer drugs prophylactically if necessary.

A prospective study to examine the relationship of pre- and postoperative cellular immune responses to the postoperative MRSA infection has been conducted in the aged patients with malignant tumors. Subjects were 12 patients with stomach cancer and 9 with the colon cancer, with a men age of 76.7 years. In these 21 patients, the activities of peripheral blood T lymphocyte subsets (CD4, CD8, CD4+2H4-., CD4+2H4-) and NK cells were measured. MRSA infection occurred as a postoperative complication in 4 patients, who all had an advanced cancer. Cases complicated by infection were compared with those not complicated by infection for the cellular immune responses. The results were: 1) There was no significant difference between both groups in CD4, CD8, and CD4/CD8. 2) Preoperative helper T cell (CD4+2H4-) ratio was significantly reduced in cases complicated by MRSA infection. 3) Suppressor-inducer T cell (CD4+2H4-) ratio was significantly elevated in advanced cancers. 4) The restoration of NK cell activity was significantly delayed in cases complicated by MRSA infection. These results suggest that the postoperative development of MRSA infection in aged patients depends partly on the host immunological competence.

MRSA infection have occurred at a high rate among surgical patient at our hospital. In order to clarify substantial circumstances underlying such high incidence, we studied 51 patients complicated with MRSA infection. The patient group, with an average were age of 77.3 years, comprised 33 males and 18 females. All the 51 patients had MRSA infection after laparotomy, and accounted for 11.2% of overall surgical patients, 14.0% of those after operation for malignant tumor and 6.4% of those after operation for benign tumor, with significant differences (p

We report two cases of intestinal perforation caused by accidental swallowing of Press-Through Packages (PTP). The first case occurred in a 90-year-old woman with moderate dementia. She was admitted to our hospital because of abdominal pain and intestinal obstruction. She showed symptoms and sign of peritonitis and underwent abdominal surgery. The postoperative diagnosis was diffuse peritonitis due to a perforated rectal ulcer caused by the sharp corners of an accidentally swallowed PTP. The second case occurred in an 82-year-old woman with recurrent symptoms and signs of intestinal obstruction. She underwent abdominal surgery and the operation revealed an ileal perforation due to penetration by the sharp edge of a PTP. Both patients were discharged in good condition. PTPs are rapidly becoming popular as packaging for tablets and capsules. However, reports of accidental swallowing of PTPs have recently been increasing. In most cases, the PTPs were found in the esophagus and removed endoscopically. Progression of accidentally swallowed PTPs to the intestines is rare. However, when this occurs, the patient's condition becomes more serious. We propose that drugs should not be dispensed in PTPs but rather handed to the patients, especially to elderly patients, or when impossible, the corners of PTPs should be rounded.

Risk factors of operative death and prognosis in the elderly following operations for esophageal cancer were evaluated by multivariate analyses. Data were obtained from 45 operations over a 14-year period in patients of a mean age of 72.6 +/- 6.3 years. Using a multiple logistic model analysis, it was determined that the significant risk factor of death within 50 postoperative days was postoperative pulmonary complication. No other factors were significant as risk factors with regard to survival. Cox's proportional hazards model analysis was used to assess the prognostic factors of long-term survival following operations. Independent predictors were the stage of cancer and age. We conclude that two points are essential to improve the survival rate of elderly patients with esophageal cancer; first, postoperative special attention in order to prevent pulmonary complications and secondly, performing operations at as early a stage of cancer as possible.

The prognostic factors influencing survival after operations for gastric cancer in the elderly were evaluated by Cox's proportional hazards model analysis. Data were obtained from 511 operations over a 10-year period, in patients with a mean age of 75.6 +/- 7.9 years. The significant prognostic factors of survival out of 47 examined risk factors were, in order of standardized coefficient values, (1) stage of cancer, (2) %IBW, (3) peritoneal dissemination (P-factor), (4) multiple non-gastric cancers, (5) postoperative hepatic injury and (6) postoperative cardiac complication. No other factors, including preoperative associated diseases and postoperative pulmonary complication (the major risk factor of operative death), were significant risk factors of survival. We conclude that by giving special postoperative attention to prevent hepatic injury and cardiac complication, the length of survival of elderly patients with gastric cancer will improve.

Seven hundred and thirty seven patients over 65 years of age (mean 76 years) undergoing gastrectomies from 1979 to 1991 were reviewed to evaluate the cause of stomal stenosis in the early postoperative period. Fifty seven (7.7%) patients, 24 males (5.6%) and 33 females (10.6%), had overt stomal stenosis or obstruction documented by radiological and endoscopic findings. The incidence of stenosis in females was significantly higher than in males (p < 0.05). Complications developed in 19 (20.0%) of 95 patients after gastroduodenostomy (Billroth-I), 29 (6.2%) of 465 after gastrojejunostomy (Billroth-II and others) and 8 (5.0%) of 159 after esophagojejunostomy (total gastrectomy). The incidence of complications in the first was significantly higher than in the other two (p < 0.01). The cause of stomal stenosis was classified into three groups; (1) transient stenosis due to stomal edema in 21 patients, (2) intestinal obstruction immediately adjacent to the stoma (kinking, invagination and volvulus) in 22, (3) organic stenosis of pathological origin (stomal ulcer, anastomotic leakage and strangulation by the proliferated mesocolon) in 14. The period of recovery from postgastrectomy retention was different in each group. It was 20.7 (mean) +/- 7.7 (SD) days in group (1), 29.7 +/- 12.6 days in group (2) and 62.1 +/- 30.0 days in group (3). These mean periods were significantly different from each other (p < 0.01). Group (1) and most of group (2) responded well to conservative management consisting of decompression by nasogastric suction and parenteral feeding but a reoperation was necessary for only two patients in group (2). Half of group (3) was treated by endoscopic dilatation and one third by reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)

In order to evaluate the prognostic importance of the conditions before abdominal surgery for patients over 60 years of age. Multivariate analyses of postoperative complications were performed in 634 patients (comprising 525 cases of elective abdominal surgery and 109 cases of emergency abdominal surgery). The Mortality rate was significantly higher (p < 0.01) in the emergency group (11.9%) and relatively low among the elective abdominal surgery group (3.8%). In the emergency group, 13 patients died, and MOF (multiple organ failure) was found to be the direct cause of death in 11 (85%). Although, the majority (75%) of emergency operations were for benign disorders, the remainder (25%) had malignant tumors. It is noteworthy that among 25% of cases, obstructions and perforations due to large bowel cancers were found to be 59% and 19%, respectively. In the elective surgery group, postoperative pulmonary and cardiovascular complications were found in 11.6% and 9.6%, respectively. Death due to cardiovascular problems in rare (5%), however, postoperative pneumonia was the cause of death in 70% of all of postoperative death. Risk factors affecting postoperative pulmonary complications were malnutrition, advanced age, male sex, malignant disease, dementia, cerebrovascular disorders, impaired pulmonary function tests. Surprisingly, the risk factors were identical, except for impaired pulmonary function, for postoperative MRSA pneumonia. In our study, postoperative pulmonary death was not associated with impaired pulmonary function, and it appears to be rather affected by the presence of cerebrovascular disorders and malnutritional state. A poor nutritional states (< 40 according to Onodera's nutritional index) was present in over 50% of patients with cerbrovascular disorders and low ADL.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical records of patients over 80 years old with gastric cancer were reviewed.One hundred patients were operated on: 78 for advanced cancerand 22 for early cancer. Ninety-five (95%) had resections. Of these 28 underwent a curative operation. Eleven (11%) all with advanced cancer died due to post-operative complications, most of which were suture line failures and pulmonary complications.These patients were compared with 66 gastric cancer patients treated without surgical precedures because of multiple associated diseases, advanced age or refusal of operation. Of these, 55 (83%) died in association with cancer. Sixty-four percent (14/22) of the non-operated patients with early cancer eventually died of tumor growth.Our data suggest that surgical operation may be of great value in treating patients over 80 years with advanced cancer as well as those with early cancer.

Gallbladder bile from 24 patients (five with anaerobic biliary tract infection, 10 with aerobic biliary tract infection, and nine without biliary tract infection) was examined by thin-layer chromatography (TLC) for the presence of free bile acids. All five patients with an anaerobic biliary tract infection had small amounts of free bile acids in gallbladder bile. Seven of 10 patients with aerobic biliary tract infection and nine patients with sterile bile had no detectable free bile acids. Minute amounts of free bile acids were detectable on TLC in bile of three patients with aerobic infections. Calcium bilirubinate stones were more common in patients with free bile acids in bile.