Prolonged peri-firing compression with a linear stapler prevents pancreatic fistula in laparoscopic distal pancreatectomy

Background  

Laparoscopic distal pancreatectomy (Lap-DP) is one of the most accepted laparoscopic procedures in the field of pancreatic surgery. However, pancreatic fistula remains a major and frequent complication in Lap-DP, as in open surgery. The aim of this retrospective study is to clarify the advantages of prolonged peri-firing compression (PFC) with a linear stapler for prevention of pancreatic fistula after laparoscopic distal pancreatectomy.     

Interface pressure and stiffness of various elastic stockings during posture changes and exercise

The importance of measuring interface pressure and stiffness to characterize the elastic properties of materials has been stressed with regard to elastic stockings and elastic bandages. The objective of this study was to compare the pressure profiles of nine different elastic stockings and to quantify the effects of posture changes and exercise on compression. Using a pressure transducer (Air Pack Type Analyzer), the interface pressure associated with nine different elastic stockings was measured at level B1 during supine resting, standing, and exercise. The elastic stockings examined could be divided into two categories according to extensibility: short stretch (< 105% extensibility) and long stretch (> 105% extensibility). Short-stretch stockings include thick round-knitted stockings, firm round-knitted stockings, and flat-knitted stockings. Short-stretch stockings showed a higher peak working pressure and a larger pressure amplitude during exercise than long-stretch stockings. Short-stretch stockings can be expected to have more pronounced benefits for augmenting muscle pumping in the same way as short-stretch bandages. In selecting suitable elastic stockings for patients, the stiffness should be taken into account in addition to interface pressure.     

Radiofrequency ablation with hand-assisted laparoscopic surgery for the treatment of hepatocellular carcinoma in the caudate lobe

OBJECTIVE: To assess the feasibility and safety of radiofrequency ablation (RFA) with hand-assisted laparoscopic surgery (HALS) for hepatocellular carcinoma (HCC) in the caudate lobe with severe liver dysfunction. SUMMARY BACKGROUND DATA: HCC in the caudate lobe remains one of the most difficult locations where various treatments tend to pose problems regarding the optimal surgical approach. The technique of HALS has thus been proposed as a useful method for performing a safe RFA therapy. For this study, we assessed the feasibility and safety of RFA with HALS for the treatment of HCC in the caudate lobe with liver dysfunction. PATIENTS AND METHODS: Between July 1999 and February 2005, 5 patients who suffered from HCC in the caudate lobe were indicated for RFA. The percutaneous puncture was difficult and all patients have severe liver dysfunction with viral chronic hepatitis. Therefore, RFA was assisted by an inserted hand through a minimal skin incision under laparoscopic inspection. An intraoperative endoscopic ultrasound examination was performed before RFA to determine the tumor region. The hand-assisted minimal dissection around the caudate lobe was required to detect tumor and avoid injuries of other tissues. RFA for HCC was performed using a cooled-tip (Radionics Inc, Burligton, MA) connected to a RF generator under the programmed cyclic impedance. RESULTS: The surgical procedures consisted of 5 RFA to tumors in the caudate lobe with HALS, which was performed safely, and a postoperative computed tomography scan revealed a sufficient ablation in all patients. There was no operative mortality but 1 patient had minor bile leakage, which was treated conservatively, and all patients recovered and thus were eventually discharged. One patient had local recurrence after 3 months, 3 patients had tumor recurrences in another segment after 6 months. At a mean follow-up 32.2 months, all patients were still alive. CONCLUSIONS: RFA with HALS is considered to be a safe and feasible technique for HCC in the caudate lobe with liver dysfunction.     

Retrorectal epidermoid cyst in an elderly woman: Report of a case

An epidermoid cyst is a common occurrence in the skin. Such a cyst occurring in the retrorectal space, however, is extremely rare. We herein present a case of retrorectal epidermal cyst in a 67-year-old Japanese woman. She reported no symptoms and a perirectal mass behind the lower rectum was accidentally detected by computed tomography (CT). Contrast CT and magnetic resonance imaging revealed a cystic mass (76 x 70 x 63 mm) with a slightly enhanced thin wall which was attached to the lower rectum. The patient underwent surgery via a posterior approach. The mass was exposed after an excision of subcutaneous fat and was firmly adhered to the anal sphincter muscle. The cystic mass was completely removed without a proctectomy. Histologically, the cyst was diagnosed to be an epidermoid cyst. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. A diagnosis of retrorectal cystic tumor is difficult, and a complete resection is necessary for the treatment of such tumors.     

Effect of sivelestat sodium on acute lung injury after acute aortic dissection

Acute lung injury is a frequent and serious complication in patients with acute aortic dissection (AAD). Elevated neutrophil elastase has been reported to be one of the major determinants occurring in AAD. On admission, we administered sivelestat sodium hydrate, a neutrophil elastase inhibitor, to 11 patients with AAD who were medically treated to prevent lung injury. We compared their clinical course with that of 12 patients of control group in which sivelestat was not used prophylacticaly. Although there were 5 patients (42%) who suffered from respiratory failure and needed mechanical ventilation in the control group, no one needed intubation in the sivelestat group. Our study suggested that sivelestat sodium hydrate could be effective in preventing intubation due to respiratory failure. Further prospective study is necessary to evaluate prophylactic administration of sivelestat sodium hydrate in AAD.     

Primary choriocarcinoma of the urinary bladder

A 72-year-old woman with asymptomatic macrohematuria was referred to our hospital. Cystoscopy revealed a 7 cm sessile tumor on the left lateral wall of the bladder. Subsequently an intravenous pyelography revealed left hydronephrosis. We performed transurethral biopsy and resection of the bladder tumor under the diagnosis of ordinary malignant bladder tumor. Histopathologically, the lesion was shown to be an undiffentiated urothelial carcinoma, G3, > or = pT2, containing syncytiotrophoblastic giant cells. The level of serum human chorionic gonadotropin-beta (hCG-beta) level was slightly elevated (0.3 ng/ml; normal value: < 0.1). Because a further examination revealed an invasion into the surrounding fat tissue of the bladder and left ureter, a total cystohysterectomy with an ileal conduit were performed. The final histopathological classification was choriocarcinoma of the urinary bladder, pT3a, pN1, pMx. An adjuvant combination chemotherapy was carried out using methotrexate, vinblastine, adriamycin and cisplatin (MVAC). After two courses of chemotherapy, the serum hCG-beta levels returned to normal. Eleven months postoperatively, however, there was evidence of multiple lung metastases. The patient died 12 months after the surgery as a result of complications caused by widespread metastases.     

Biliary complications in right lateral sector graft live donor liver transplantation.

Biliary complications remain the most challenging issue in adult living donor liver transplantation (LDLT) and to the best of our knowledge, no study has focused on the biliary complications in LDLT with right lateral sector graft (RLSG), a graft consisting of segments VI and VII according to Couinaud's nomenclature for liver segmentation. Between January 1996 and October 2006, 310 LDLTs were performed for adult recipients at our institution. Among them, 20 patients received RLSG. The incidence of biliary complications during follow-up in these patients with RLSG was retrospectively analyzed. Follow-up period after transplantation ranged from 1 to 87 months (median 58 months). The 3-year and 5-year graft survival rates following the use of RLSGs in LDLT were 90% and 90%, respectively. Biliary complications were encountered in altogether nine patients. Two patients (10%) were complicated with bile leakage requiring surgical intervention. Seven patients (35%) were complicated with bile duct stenosis, which occurred with a median interval of 26 months (range: 6-51 months) after LDLT. Four were treated surgically and the other three were treated by endoscopic approach. Outcomes of the interventions were satisfactory in all cases. The incidence and severity of biliary complications after LDLT using RLSG was within an acceptable range with excellent graft survival. Accordingly, it is concluded that RLSG is a technically feasible option that may effectively expand the donor pool. Further application of RLSG is warranted.     

The effects of transplantation of osteoblastic cells with bone morphogenetic protein (BMP)/carrier complex on bone repair

We investigated the effects of transplantation of osteoblastic cells with a bone morphogenetic protein (BMP)/carrier complex on bone repair by in vitro and in vivo experiments. Poly-D,L-lactic-co-glycolic acid/gelatin sponge (PGS) was used as a carrier for cell transplantation. In the in vitro experiments, three cell types, C3H10T1/2 cells, MC3T3-E1 cells, and primary osteoblastic cells, isolated from newborn rat calvariae (ROB cells), were cultured for 2 weeks on PGS alone or PGS containing BMP-2 (PGS/BMP). C3H10T1/2 cells cultured on PGS/BMP expressed several markers related to differentiation of both osteoblasts and chondrocytes, such as alkaline phosphatase (ALP) activity and mRNAs for osteocalcin and aggrecan, whereas the cells cultured on PGS alone expressed no such markers. MC3T3-E1 cells cultured on PGS/BMP exhibited a more ALP-positive cells than those cultured on PGS alone. PGS/BMP promoted ROB cell differentiation into both osteoblasts and chondrocytes. In the in vivo experiments, we transplanted ROB cells, which had been cultured on PGS alone or PGS/BMP in vitro for 2 weeks, into bone defects created in rat calvariae. Transplantation of ROB cells cultured on PGS alone generated little new bone. Transplantation of ROB cells cultured on PGS, which absorbed a low dose (10 ng) of rhBMP-2,; induced significantly higher bone mineral content than PGS/BMP alone, although application of a high dose (1 microg) of rhBMP-2 induced no difference in bone mineral content between transplantation of PGS/BMP with or without ROB cells. These results show that transplantation of osteoblastic cells after induction of osteoblast maturation in vitro by cultivation on PGS/BMP is a potent technique for cell therapy of bone repair.     

Use of small-bore silastic drains in general thoracic surgery.

STUDY OBJECTIVE: To evaluate the safety and efficacy of small-bore, silastic drains for patients undergoing general thoracic surgery. PATIENTS AND METHODS: Twenty-five patients who received soft, small-bore, silastic drains were compared with 17 patients who received semi-rigid double lumen (DL) tubes retrospectively. RESULTS: The pain score was significantly lower in patients who received the silastic tubes in video-assisted thoracoscopic surgery (VATS) cases on postoperative days 5 and 6 , after continuous epidural analgesia had finished (P=0.018). No specific morbidity was seen in the patients who received silastic tubes. CONCLUSION: We considered that soft, small-bore silastic drains were just as effective as traditional DL tubes, but caused less pain especially in VATS cases.     

Women with mitochondrial haplogroup N9a are protected against metabolic syndrome

To identify mitochondrial haplogroups that confer resistance against or susceptibility to metabolic syndrome, we performed a large-scale association study on 1,337 unrelated Japanese individuals, including 871 subjects with metabolic syndrome and 466 control subjects. Metabolic syndrome was diagnosed according to modified National Cholesterol Education Program Adult Treatment Panel III guidelines, using the cutoff point for obesity as a BMI of >/=25 kg/m(2) instead of waist circumference. The genotypes for 25 polymorphisms in the coding region of the mitochondrial genome were determined, and the haplotypes were classified into 10 major haplogroups, i.e., F, B, A, N9a, M7a, M7b, G1, G2, D5, and D4. Multivariate logistic regression analysis revealed that the haplogroup N9a was significantly associated with resistance against metabolic syndrome in women with an odds ratio (OR) of 0.21 (95% CI 0.07-0.58, P = 0.0042). Women with haplogroups G1 and D5 tended to be resistant against metabolic syndrome with an OR of 0.22 (0.06-0.68, P = 0.0129) for G1 and with an OR of 0.32 (0.10-0.96, P = 0.0469) for D5, respectively. These results indicate that mitochondrial haplogroup N9a may be a protective factor against metabolic syndrome in Japanese women.