Usefulness of computed tomography during cholangiography for the diagnosis of multiple hepatic peribiliary cysts: a report of three cases with chronic liver disease

Hepatic peribiliary cysts are composed of multiple tiny cysts along the larger portal tracts and have been reported to be harmless. On clinical images, peribiliary cysts resemble other diseases such as biliary dilatations, cholangitis, or periportal edema. Therefore, it is important to distinguish peribiliary cysts from these diseases using a combination of several imaging modalities. Herein, we report three cases of peribiliary cysts. The first case underwent laparotomy for the presumptive diagnosis of intrahepatic cholangiocarcinoma. In the remaining two cases, hepatic peribiliary cysts were diagnosed and laparotomy was avoided. Magnetic resonance cholangiography contributed to the diagnosis, owing to their characteristic distribution. In addition, computed tomography during cholangiography (cholangio-CT) demonstrated that the cysts had no communication with the intrahepatic biliary system. Therefore, cholangio-CT is considered to be the most useful modality for the diagnosis of peribiliary cysts.     

The accuracy of transcutaneous carbon dioxide monitoring during laparoscopic surgery

BACKGROUND: Laparoscopic procedures are considered relatively low-invasive. However, there exists a small but important risk of developing complications related to carbon dioxide (CO2) insufflation. End-tidal CO2 (PetCO2) monitoring may not be a sufficient guide to adjust pulmonary ventilation during laparoscopic surgery, and arterial CO2 (PaCO2) monitoring is not always indicated. We evaluated the accuracy and feasibility of transcutaneous CO2 (PtcCO2) monitoring during laparoscopic surgery. METHODS: Thirty adult patients undergoing abdominal or gynecological laparoscopic surgery were studied. PtcCO2, PaCO2 and PetCO2 were measured before laparoscopy, and 30 and 60 minutes after beginning of CO2 insufflation. PtcCO2 and PaCO2 were also measured in the recovery room under spontaneous respiration. RESULTS: During operation, the PtcCO2 values demonstrated a high degree of correlation with PaCO2 (r = 0.92), and PetCO2 values also demonstrated generally a good correlation with PaCO2 (r = 0.85). The PtcCO2 PaCO2 gradient was -0.6 +/- 2.2 mmHg, while the PetCO2-PaCO2 gradient was -3.9 +/- 2.7 mmHg. In the recovery room, PtcCO2 values still demonstrated a high correlation with PaCO2 (r = 0.91). CONCLUSIONS: The transcutaneous devices provide an effective method for non-invasive monitoring of PCO2 in situations where continuous monitoring of CO2 levels is desired such as peri-operative period of laparoscopic surgery.     

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.     

Novel retractor for lymph node dissection by video-assisted thoracic surgery

In nonrandomized studies, the video-assisted thoracic surgical (VATS) lobectomy seems to be a safe and effective procedure for treatment of lung cancer. However, there are some difficulties in VATS complete mediastinal lymph node dissection. The presence of the lymph node deep in the mediastinal space necessitates retraction of the surrounding organs. Therefore, we developed a retractor to create enough working space during the VATS procedure. To dissect lymph nodes, we use endoscopic bipolar forceps. These instruments are connected to a special electrosurgical generator to apply bipolar soft coagulation, which enables simultaneous dissection and sealing. Thus, "en bloc" lymph node dissection can be performed during the VATS procedure.     

Effective treatment of acute pain and related symptoms in elderly with herpes zoster

BACKGROUND: The incidence of herpes zoster increases with age. Immediate pain relief is required for prevention of postherpetic neuralgia (PHN) and also its related symptoms that worsen the general condition because acute herpetic pain often interferes with sleep, mood, and general activities in elderly patients. Nerve block is useful to relief acute pain and recommended for prevention of PHN. Tricyclic antidepressant drugs have antinoticeptive effect in acute pain in experimental models, in addition to its antidepressant effect. METHODS: Forty elderly patients with herpes zoster within 3 months after the onset underwent nerve blocks and received tricyclic antidepressant drugs. We assessed the effect of treatments and adverse effects. RESULTS: No significant adverse effects were found in elderly patients who had received nerve blocks and/or tricyclic antidepressant drugs. Alleviation of acute pain was obtained in more than 80% of patients, and in all patients depressive state and/or disturbance of the general condition were significantly improved. CONCLUSIONS: With careful technique and assessment of patients, both nerve block and tricyclic antidepressant drugs were beneficial and safe treatments in elderly patients with herpes zoster.     

Short-term effects of di-（2-ethylhexyl） phthalate on testes,liver, kidneys and pancreas in mice

Aim： To determine the biochemical effect of di-（2-ethylhexyl） phthalate （DEHP） on testes, liver, kidneys and pancreas on day 10 in the process of degeneration of the seminiferous epithelium. Methods： Diets containing 2% DEHP were given to male Crlj：CDI（ICR） mice for 10 days. The dose of DEHP was 0.90±0.52 mg/mouse/day. Their testes, livers, kidneys and pancreata were examined for detection of mono-（2-ethylhexyl） phthalate （MEHP）, nitrogen oxides （NOx） produced by peroxidation of nitric oxide （NO） with free radicals, and lipid peroxidation induced by the chain reaction of free radicals. Results： Histological observation and serum analysis showed the presence of severe sperrnatogenic disturbance, Leydig cell dysfunction, liver dysfunction and dehydration. Unexpectedly, the concentration of MEHP in the testes was extremely low compared with that in the liver. However, the concentration of the NOx in the testes was as high as the hepatic concentration. Furthermore, free radical-induced lipid peroxidation was histochemically detected in the testes but not in the liver. Conclusion： The results indicate that DEHP-induced aspermatogenesis is caused by the high sensitivity of the testicular tissues to MEHP rather than the specific accumulation or uptake of circulating MEHP into the testes.     

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.     

Ultrasound velocity in the tibia in Japanese patients with hip fracture

 The speed of sound in the tibia (tibial SOS) was measured in elderly women to determine whether the tibial SOS declined with age, similarly to bone mineral density (BMD), as determined by dual-energy X-ray absorptiometry (DXA), and whether the tibial SOS in elderly hip fracture patients was lower than that in a control group. The subjects in this study included 38 female patients with hip fracture aged 65 years or more and 38 age-matched women living in a nursing home as the control group. There was a significant decline in the tibial SOS with age in women in the control group, but not in those with hip fracture. In all subjects aged under 80 years, the tibial SOS in women with hip fracture was significantly lower than that in women in the control group. In all subjects who were 80 years or older, the tibial SOS was not significantly different between women with hip fracture and the control group; thus, the tibial SOS in both groups was low, and they were considered to have progressive osteoporosis. The tibial ultrasound velocity can be expected to be useful as an indicator of the risk of limb fracture in the elderly. Received: February 25, 2002 / Accepted: June 4, 2002 Acknowledgments. We thank Omron Institute of Life Science Co., Ltd. for their support. Offprint requests to: S. Muraki     

Accompanying artery of sciatic nerve as recipient vessel for free‐flap transfer: A computed tomographic angiography study and case reports

Suitable recipient vessels for free‐flap transfer are hard to find in the posterior thigh. To investigate the versatility of accompanying artery of sciatic nerve as a recipient vessel in this region, we performed computed tomographic angiographic study of 20 consecutive healthy thighs in 10 patients. The presence and internal diameter of the accompanying artery were studied. The accompanying artery of the sciatic nerve was present in 11 thighs (55%) and the internal diameter of the artery at the mid‐thigh level ranged from 2.1 to 3.2 mm. We used this artery as a recipient vessel for free flaps transferred to reconstruct extensive thigh defects in three patients with sarcomas. In all patients the flaps survived without vascular compromise. No sensory or motor dysfunction in the sciatic nerve distribution occurred in any patients. We believe that the accompanying artery of the sciatic nerve may be a recipient vessel for free‐flap transfer in selected patients. © 2014 Wiley Periodicals, Inc. Microsurgery 35:284–289, 2015.     

Free flow‐through anterolateral thigh flap for complex knee defect including the popliteal artery

Reconstruction of complex knee defects including the popliteal artery presents a challenging problem in reconstructive microsurgery. Reconstruction of the popliteal artery and soft‐tissue coverage should be performed simultaneously for limb salvage. We present the one‐stage reconstruction of a complex knee defect including the popliteal artery using a free flow‐through anterolateral thigh (ALT) flap as a bypass flap in two patients with sarcomas. In both patients, the popliteal artery and vein were reconstructed using branches of the lateral circumflex femoral arterial system. The flaps survived without vascular compromise and the limbs were preserved successfully. Free flow‐through ALT flap enables simultaneous leg revascularization and soft‐tissue coverage with a single free flap. The lateral circumflex femoral arterial system has many branches with large diameters, making it suitable for reconstruction of multiple infrapopliteal arteries. © 2015 Wiley Periodicals, Inc. Microsurgery 35:485–488, 2015.