A simple technique ligating the corresponding inflow and outflow vessels during anatomical left hepatectomy

Background Massive bleeding remains one of main factors of morbidity and death in liver resections. For this reason, the Pringle maneuver or total vascular exclusion is commonly used during liver resection. However, ischemic damage is still a major problem. Some surgeons used the “glissonean” approach for bleeding control, but the technique is tedious and also time consuming, with high incidence of bile leaks in the postoperative period. The aim of this paper is to describe a new bleeding control technique, rapid ligation of the corresponding inflow and outflow vessels without hilus dissection before the parenchyma transection during anatomical left liver resection and to analyze the feasibility, blood loss, transfusion requirements, and postoperative complications. Materials and methods During the past 18 years, we used the new hemorrhage control technique in left liver resection in 630 patients with malignant or benign tumors. Results The median blood loss in all 630 patients was 110 ± 250 ml (range 50–750), and no patient required blood transfusion. The median total operative time was 77 ± 35 min (range 25–155). No bile leaks and liver failure of the patients occurred postoperatively. There was no death within 30 postoperative days. Conclusion The rapid ligation of the corresponding inflow and outflow vessels without hilus dissection before the parenchyma transection is a feasible, safe, and bloodless technique during the left liver resection. A commentary on this paper is available at     

High concentrations of landiolol,a β<Subscript>1</Subscript>-adrenoceptor antagonist,stimulate smooth muscle contraction of the rat trachea through the Rho-kinase pathway

Purpose Gradually progressing contraction of airway smooth muscle is suggested to be due to the Rho-kinase signaling pathway. In our preliminary study in rat tracheas, landiolol, a β₁-adrenoceptor antagonist, at high doses caused gradually progressing contraction, and this contraction reached a plateau after 20 min. Therefore, this study was carried out to clarify whether landiolol could stimulate the Rho-kinase pathway or the phosphatidylinositol (PI) response in the rat trachea. Methods Seventy-eight male Wistar rats weighing 250–350 g were used for the experiments. Their tracheas were cut into 3-mm-wide ring segments or 1-mm-wide slices. Measurements of isometric tension and [³H] inositol monophosphate (IP₁) production were conducted, using these tracheal rings or slices. Data values are expressed as means ± SD, and statistical significance (P < 0.05) was determined using analysis of variance (ANOVA). Results Landiolol (700 μM)-induced contraction was completely inhibited by fasudil at 30 μM, while the landiolol-induced contraction was not inhibited by 4-diphenylacetoxy-N-methyl-piperidine methobromide (4-DAMP), ketanserin, or nicardipine. Landiolol did not stimulate IP₁ production. Conclusion These results suggest that high concentrations of landiolol could cause airway smooth muscle contraction through the Rho-kinase pathway, but not through the PI response coupled with muscarinic M₃ receptors, 5-HT receptors or the activation of L-type Ca²⁺ channels.     

Current status of high-intensity focused ultrasound for prostate cancer: Technology,clinical outcomes,and future

Based on a review of recently published articles, we evaluated the current status of high-intensity focused ultrasound (HIFU) as a primary treatment option for localized prostate cancer and as a salvage therapy when radiation has failed. With mid-and long-term progression-free survival rates around 70%, negative postoperative prostate biopsies almost 90%, and an excellent morbidity profile, primary HIFU appears to be a valid alternative to active surveillance protocols in low-risk patients and standard therapies in patients with life expectancies of 10 or fewer years. Moreover, HIFU has a considerable potential for local-only recurrence after radiation failure. HIFU is a recent technology, and many improvements will undoubtedly expand its future indications and use for the management of prostate cancer.     

Do Modern Techniques Improve Core Decompression Outcomes for Hip Osteonecrosis?

Core decompression procedures have been used in osteonecrosis of the femoral head to attempt to delay the joint destruction that may necessitate hip arthroplasty. The efficacy of core decompressions has been variable with many variations of technique described. To determine whether the efficacy of this procedure has improved during the last 15 years using modern techniques, we compared recently reported radiographic and clinical success rates to results of surgeries performed before 1992. Additionally, we evaluated the outcomes of our cohort of 52 patients (79 hips) who were treated with multiple small-diameter drillings. There was a decrease in the proportion of patients undergoing additional surgeries and an increase in radiographic success when comparing pre-1992 results to patients treated in the last 15 years. However, there were fewer Stage III hips in the more recent reports, suggesting that patient selection was an important reason for this improvement. The results of the small-diameter drilling cohort were similar to other recent reports. Patients who had small lesions and were Ficat Stage I had the best results with 79% showing no radiographic progression. Our study confirms core decompression is a safe and effective procedure for treating early stage femoral head osteonecrosis.     

Laparoscopic Treatment of Gastric <Emphasis Type="SmallCaps">Gist</Emphasis>: Report of 21 Cases and Literature’s Review

Background Although the feasibility of laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) has been established, various aspects are debated. This paper describes the problems of minimally invasive resection of gastric GISTs and compares this experience with an extensive literature review. Study Design Between August 2001 and December 2006, 21 consecutive patients undergoing laparoscopic resection of gastric GISTs were enrolled in a prospective study. A literature review of laparoscopic treatment was performed on Pubmed using keywords GIST and surgery. A comparison with authors’ experience with open wedge-segmental resection of GISTs (25 cases from November 1995 to December 2000) was also carried out. Statistical analysis was based on chi-squared test and t Student evaluation. Results Twenty-one patients, mean age 50.1 years (range, 34–68 years), were submitted to laparoscopic wedge- segmental gastric resections. Mean tumor size was 4.5 cm (range, 2.0–8.5 cm). Mean operative time was 151 min (range, 52–310 min), the mean blood loss was 101 mL (range, 10–250 mL), and the mean hospital stay was 4.8 days (range 3–7 days). There were no major operative complications or mortalities. All lesions had negative resection margins. At a mean follow-up of 35 months, all patients were disease-free. Morbidity, mortality, length of stay, and oncologic outcomes were comparable to the open surgery retrospective evaluation (p = not significant). Conclusions As found also in the literature review, the laparoscopic resection is safe and effective in treating gastric GISTs. Given these findings as well as the advantages afforded by laparoscopic surgery, a minimally invasive approach should be the preferred surgical treatment in patients with small- and medium-sized gastric GISTs.     

Role of Selective α and β Adrenergic Receptor Mechanisms in Rat Jejunal Longitudinal Muscle Contractility

Gut motility is modulated by adrenergic mechanisms. The aim of our study was to examine mechanisms of selective adrenergic receptors in rat jejunum. Spontaneous contractile activity of longitudinal muscle strips from rat jejunum was measured in 5-ml tissue chambers. Dose–responses (six doses, 10⁻⁷–3 × 10⁻⁵M) to norepinephrine (NE, nonspecific), phenylephrine (PH, α₁), clonidine (C, α₂), prenalterol (PR, β₁), ritodrine (RI, β₂), and ZD7714 (ZD, β₃) were evaluated with and without tetrodotoxin (TTX, nerve blocker). NE(3 × 10⁻⁵M) inhibited 74 ± 5% (mean ± SEM) of spontaneous activity. This was the maximum effect. The same dose of RI(β₂), PH(α₁), or ZD(β₃) resulted in an inhibition of only 56 ± 5, 43 ± 4, 33 ± 6, respectively. The calculated concentration to induce 50% inhibition (EC50) of ZD(β₃) was similar to NE, whereas higher concentrations of PH(α₁) or RI(β₂) were required. C(α₂) and PR(β₁) had no effect. TTX changed exclusively the EC50 of RI from 4.4 ± 0.2 to 2.7 ± 0.8% (p < 0.04). Contractility was inhibited by NE (nonspecific). PH(α₁), RI(β₂), and ZD(β₃) mimic the effect of NE. TTX reduced the inhibition by RI. Our results suggest that muscular α₁, β₂, and β₃ receptor mechanisms mediate adrenergic inhibition of contractility in rat jejunum. β₂ mechanisms seem to involve also neural pathways. Part of this work was presented as a poster at the annual meeting of the Society for Surgery of the Alimentary Tract, Orlando, FL, May 17–22, 2003, and published as an abstract in Gastroenterology 2003, 124(4):M1342.     

Early ERCP for Gallstone Pancreatitis: For Whom and When?

The indications for early endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis are unclear, and the examination is often requested or performed without substantial supporting evidence. Several trials have been performed to determine the benefit of early ERCP in pancreatitis, yet the results of these studies are inconsistent. To more closely analyze these studies, we performed an evidence-based review of the outcomes of early ERCP in gallstone pancreatitis. To obtain the best available evidence, a PubMed search using the MeSH terms “gallstones” and “pancreatitis” was performed and further refined to identify appropriate studies. We included five randomized trials, a meta-analysis, and a Cochrane Database Systematic Review in our detailed examination of the pertinent literature. Collectively, these studies suggest that early ERCP does not alter mortality in gallstone pancreatitis. In addition, few patients with mild pancreatitis benefit from the procedure, whereas some studies indicate that patients with severe pancreatitis or documented biliary obstruction may experience fewer complications if ERCP is performed. The data in the studies are confounding because of heterogeneity of the patient population and the inability to confirm gallstones in up to one third of patients. In conclusion, ERCP is not indicated for patients with mild pancreatitis. In select patients with severe disease or biliary obstruction, ERCP may be indicated. A multicenter trial designed to study the effect of early ERCP in severe pancreatitis only may provide additional useful information in patients with documented gallstones. Presented at the Postgraduate Course of the 48th Annual Meeting of The Society for Surgery of the Alimentary Tract (Digestive Disease Week 2007), Washington DC, USA, May 20, 2007.     

Right Hepatic Lobectomy Using the Staple Technique in 101 Patients

Background Application of linear stapling devices for extrahepatic vascular control in liver surgery has been well-established. However, the technique for use of stapling devices in hepatic parenchymal transection is not well defined. Purpose To describe the safety and efficacy of our technique for use of vascular stapling devices in hepatic parenchymal transection during open right hepatic lobectomy is the purpose of this study. Methodology We reviewed our experience with 101 consecutive open right hepatic lobectomies performed by a single surgeon between January 2003 and July 2006, in which vascular staplers were utilized for the parenchymal transection phase. Results Of the 101 patients who underwent resection, 53 (52%) were female. The mean age was 58 years. Malignant disease was the indication for resection in the majority of patients (88%). Of those with cancer, 78% (69 of 89) had metastatic colorectal cancer, 6% (5 of 89) had metastatic neuroendocrine tumor, 4% (4 of 89) had hepatocellular carcinoma, 4% (4 of 89) had cholangiocarcinoma, and the remaining 8% were other metastatic cancers. Twelve patients (12%) underwent resection for hepatic adenoma or symptomatic benign disease (FNH or hemangioma). Forty-eight patients (48%) underwent a major ancillary procedure at the time of hepatic resection. Thirty-nine patients (39%) had a nonanatomic wedge resection of a left lobe lesion, 27 patients (27%) had one or more lesions treated with radiofrequency ablation (RFA), and 6 patients (6%) were treated with a synchronous bowel resection. The median total operative time was 336 min (range 155–620 min). A Pringle maneuver for temporary vascular inflow occlusion was utilized in all cases, with a median time of 9 min (range 4–17 min). Ten patients (10%) required blood transfusion during surgery or in the postoperative period. The maximum transfusion was 2 U of packed red blood cells (PRBC) in seven patients and 1 U of PRBC in three patients. The mean nadir postoperative hematocrit was 28.2. All patients with malignant disease had tumor-free margins at the completion of the procedure. The average hospital length of stay was 6.0 days. One patient (1%) developed a clinically significant bile leak requiring a postoperative endoscopic retrograde cholangiography (ERCP). No patient required reoperation. The 30 and 60-day postoperative survival was 100%. Conclusion These findings indicate that application of vascular stapling devices for parenchymal transection in major hepatic resection is a safe technique, with low transfusion requirements and minimal postoperative bile leak. The technique allows for rapid transection of the entire right hepatic lobe in under 10 min. Short video clips of the technique will be demonstrated. Presented at the 2007 American Hepato–Pancreato–Biliary Association, Las Vegas, Nevada, April 19–22, 2007 (oral presentation/video presentation).     

An evaluation of quality of life of mothers of children with enuresis nocturna

The aim of this study was to evaluate the impact of enuresis nocturna on quality of life of the mothers. Mothers who have a child with monosymptomatic nocturnal enuresis (n = 28) and mothers who have a child without any health problems (n = 38) were enrolled in the study. Groups were in balance for background variables (child’s age, gender, and number of siblings; mother’s age, marital status, highest year of education completed, and occupation; presence of health insurance; and type of residence). Short-Form Health Survey (SF-36) Questionnaire, the Beck Depression Inventory (BDI), and Spielberg’s State-Trait Anxiety Inventory (STAI) were applied to all mothers. The mothers of children with enuresis had significantly lower quality-of-life scores in the SF-36 for the bodily pain (p = 0.015) and role emotional (p = 0.014) subscales. We observed significant difference between groups according to BDI; mean score was higher in mothers who have a child with enuresis nocturna (p = 0.017). There was no significant difference between groups according to the STAI. Significant differences according to bodily pain and role emotional subscales of SF-36, and the BDI scores, show that the mothers were negatively affected by having a child with monosymptomatic nocturnal enuresis.     

Clinical Application of Layered Anastomosis During Esophagogastrostomy

The aim of this study was to compare the operative results in regard to reducing anastomotic leakage and stricture formation using a newly designed layered manual esophagogastric anastomosis versus a stapler esophagogastrostomy versus the conventional hand-sewn whole-layer anastomosis after resection for esophageal or gastric cardiac carcinoma. From January 2004 to September 2006, a total of 1024 patients with esophageal or gastric cardia carcinoma underwent a layered esophagogastric anastomosis with the assistance of a three-leaf clipper in a single university medical center. The mucosal layers of the esophagus and stomach were sutured continuously with 4/0 Vicryl plus antibacterial suture (polyglyconate). From May 2002 to December 2003, there were also 170 patients and 69 patients who underwent stapler and conventional whole-layer anastomosis, respectively; they served as control groups. The results were analyzed retrospectively. The operative mortality rate was 0.7% in the layered group compared to 5.9% and 7.2% for the stapler group and the whole-layer group (p < 0.01), The anastomotic leakage rates were 0%, 3.5%, and 5.8% for the layered group, stapler group, and whole-layer group, respectively (p < 0.01). All patients were followed postoperatively. Six patients in the layered group (0.6%) developed mild stricture formation compared to 16 patients in stapled group (9.9%) and 5 patients in the conventional whole-layer group (7.8%) (p < 0.01). The application of layered esophagogastric anastomosis could reduce the incidence of anastomotic leakage and stricture after esophagectomy compared with the stapler and whole-layer manual anastomoses. It is easy to apply and could be used as an alternative for esophagogastric anastomosis after resection for esophageal or cardiac carcinoma. This abstract was accepted as a free paper and oral presentation at International Surgical Week 2007, Abstract 320, Montreal, Canada, August 2007