Navigation surgery in the biliary surgery and NOTES: carbon dioxide enhanced MDCT cholangiopancreatography and image overlay surgery

The preoperative image diagnosis in the biliary disease devolved from analog imaging such as PTCD or ERCP to digital data analysis such as MDCT, MRI, DIC-CT, or MRCP. In late years synchronous visualization of the biliary tracts and associated blood vessels was enabled in fusion method or MRCPA. Carbon dioxide enhanced MDCT cholangiopancreatography depicts the biliary and pancreatic duct by the negative contrasting effect of the carbon dioxide, and is ideal for the surgical navigation. Real time correspondence to the operator's demand is important, and multidirectional observation and volume rendering method are effective for the use of it during surgery. The introduction of image analysis software OsiriX improves complexity and image construction time, and it may be practical. Image overlay surgery consisted of augmented reality and mixed reality is developing toward practical use in navigated surgery. In recent years, NOTES (Natural Orifice Translumenal Endoscopic Surgery) was developed, the support system of the navigation of such flexible endoscope is desired earnestly.     

Reconstruction methods to achieve optimal postoperative bowel function following low anterior resection for rectal cancer

After low anterior resection for rectal cancer, approximately 50% of patients experience defecatory malfunction such as multiple evacuations, urgency, and soiling. Since the neorectum is constructed with the remaining colonic segment, it can only substitute for the rectum to a limited extent. A straight anastomosis is most frequently used when the rectal remnant is sufficient, such as in high anterior resection. When the height of anastomosis is close to the anal sphincter, a J-pouch, a side-to-end, or a transverse coloplasty pouch are constructed to achieve better postoperative bowel function. The advantage of J-pouch reconstruction is not only the increased volume but also may be decreased motility when compared with straight reconstruction. In terms of postoperative function, the side-to-end and transverse coloplasty pouch have both been reported to exhibit similar functional results to J-pouch reconstruction. To obtain optimal functional results, pouch reconstruction should be considered, especially when the height of anastomosis is at the levator plane.     

Value of Multidetector-row Computed Tomography in Diagnosis of Portal Vein Invasion by Perihilar Cholangiocarcinoma

BACKGROUND: Although knowledge of cancer invasion of the portal bifurcation is vitally important in planning an operation for perihilar cholangiocarcinoma, the diagnostic capability of multidetector-row computed tomography (MDCT) for this purpose has not been assessed. We evaluated how well MDCT could identify cancer invasion of the portal bifurcation by perihilar cholangiocarcinoma. METHODS: Between April 2003 and June 2005, perihilar cholangiocarcinoma was resected in 87 patients, 83 of whom underwent MDCT within 1 month before the surgery. Three-dimensional volume-rendered (3DVR) and multiplanar reformation (MPR) images were examined for evidence of portal vein invasion. Agreement with intraoperative and pathologic findings was assessed. Portal bifurcation findings by 3DVR and MPR were classified into no portal vein stenosis, unilateral stenosis, or more extensive stenosis, and also into tumor contact with the bifurcation in no, one of two, or two projections. RESULTS: For macroscopic portal vein invasion, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were 81.5, 91.1, 81.5, 91.1, and 88.0% in 3D portography and 96.3, 92.6, 86.7, 98.1, and 94.0% in MPR, respectively. Findings by both 3DVR and MPR were significantly correlated with depth of cancer invasion (p < 0.001). CONCLUSION: MDCT is useful in assessing cancer invasion of the portal vein bifurcation by perihilar cholangiocarcinoma.     

Pediatric epidural catheterization in Japan: a postal survey of current status in university hospitals

BACKGROUND: Despite widespread use of epidural catheter for post-operative pain management in adults, its prevalence of use for pediatric patients in Japan has not been clarified. METHODS: Postal survey had been conducted of the anesthesia departments of university hospitals (105 institutions) throughout the country. Information was requested on hospital policy of indication and technique of pediatric epidural catheterization. Methods of pain management for typical pediatric surgical patients were also investigated. RESULTS: The response rate was 68.6%. Of these respondents, 36 institutions (50%) use epidural catheter for pediatric post-operative pain treatment. However, the indication and/or policy of epidural catheterization were significantly different among hospitals. The most common reason for avoiding pediatric epidural catheter placement was fear of nerve injury during epidural puncture in unconscious patients. Pain management strategies for post-operative children were also divergent. CONCLUSIONS: There was little consensus regarding pediatric epidural analgesia and post-operative pain management among anesthesiologists in Japanese university hospitals.     

A huge lymphovenous malformation in the retroperitoneum

Vascular malformations are localized or diffuse errors of embryonic development resulting in collections of abnormal vessels with normal endothelium. Many authors have pointed out the confusing terminology of vascular anomalies that has led to improper diagnosis and therapy. This still remains confused in clinical practice, especially in cases occurring at rare regions or presenting atypical radiologic findings. We present a huge retroperitoneal lymphovenous malformation, which exhibited unusual radiologic findings and was difficult to confirm the diagnosis that occurred in a 12-year-old male.     

Giant cystic meconium peritonitis associated with a cloacal anomaly: case report

This report describes a case of giant cystic meconium peritonitis (GCMP) associated with a cloacal anomaly. Antenatal ultrasonography and magnetic resonance imaging demonstrated persistent fetal ascites, bilateral hydronephrosis, and 3 pelvic cystic structures. The baby girl showed duplicated hydrocolpos and a single orifice of the cloaca with a long common channel inducing a urinary outflow obstruction. After constructing a diversion colostomy, a cutaneous vesicostomy was necessary to prevent recurrent urinary tract infections. These findings are consistent with a prenatal diagnosis of cloacal anomalies, thus suggesting an association with severe obstruction of lower urinary tract and meconium peritonitis.Most of reported cases of meconium peritonitis associated with the cloaca show fibroadhesive types with scattered intraperitoneal calcifications and adhesions. However, the present case showed a rare GCMP suggesting continuous urinary influx via the fallopian tubes until the later stage of intrauterine life.     

Rapamycin, but not cyclosporine or FK506, alters natural killer cell function

Infiltration of natural killer (NK) cells into solid organ allografts is observed in clinical and experimental transplantation. Studies suggest a role for NK cells in acute and chronic rejection of solid organ allografts; however, the effects of immunosuppressive agents on NK cells are not clearly established. Rat NK cell lines were analyzed for proliferation and cytotoxicity in the presence of cyclosporine, FK506, or rapamycin. Lewis recipients of DA liver allografts received immunosuppressive agents after transplantation. NK cells demonstrated robust function both in the absence and presence of cyclosporine and FK506. In contrast, rapamycin significantly inhibited proliferation and cytotoxicity of NK cells. NK cell numbers remained stable in graft recipients treated with cyclosporine and FK506, whereas there was a significant decrease in NK cells in rapamycin-treated recipients. These data indicate that immunosuppressive drugs have differential effects on NK cell function that may impact the immune response of transplant recipients.     

Mitral valve repair for anterior leaflet prolapse: surgical techniques review and 16-year follow-up results

Abstract   Objective: Mitral valve repair is now the surgical treatment of choice for mitral regurgitation. However, the repair of anterior leaflet prolapse due to chordal rupture or elongation remains a technically challenging procedure. Here, we review our experience and present the long-term results of mitral valve repair for mitral regurgitation due to anterior leaflet prolapse. Methods: Between January 1988 and August 2006, 210 patients with mitral regurgitation underwent mitral valve reconstruction. We performed mitral valve repair in 49 patients with mitral regurgitation due to anterior leaflet prolapse. The preoperative degree of mitral regurgitation was moderate to severe in all patients. There were 36 patients (73.5%) with degenerative, eight (16.3%) with infective endocarditis, and five (10.2%) with rheumatic. Reconstructive techniques included chordal replacement in 13 patients, chordal shortening in 14, chordal transposition in five, chordal shortening and reinforcement with artificial chordae in four, leaflet folding plasty in six, and resection-suture in four. Results: Follow-up was complete with an average of 89 ± 59 months (range 1–201 months). In the early postoperative period, transthoracic echocardiography was performed in all patients. The grade of regurgitation was trivial (Grade I) in 17 patients (34.7%) and mild (Grade II) in seven patients (14.3%). Survival rate at 10 and 15 years was 95.2% and 88.9%, respectively. Freedom from reoperation at 10 and 15 years was 95.8% and 89.0%, respectively. Conclusions: The long-term results of mitral valve repair for anterior leaflet prolapse are satisfactory, with low mortality and morbidity. In particular, chordal replacement using temporary Alfieri stitch is a simple and effective procedure.     

Unusual false aneurysm of the ascending aorta associated with ruptured acute type A aortic dissection

Abstract   False aneurysm of the thoracic aorta unrelated to trauma, or to previous aortic or cardiac surgery, is extremely rare. We encountered a case of ascending aortic false aneurysm formation associated with ruptured acute type A aortic dissection. The false aneurysm, which was contained by thin connective tissue surrounding the aortic wall, was located beside the false lumen of the dissected ascending aorta, expanding toward the transverse sinus. We immediately decided to perform an emergency operation. We noted the large entry site at the anterior wall of the dissected ascending aorta after resection of the flap. We identified the false aneurysm arising from a small tear of the false lumen. Graft replacement of the ascending aorta using a tube graft was performed. The postoperative course was satisfactory. This pathology was believed to be not only a consequence of hemostasis, but also a process of re-rupture of the dissected aorta.