Risk factors for a prolonged operative time in a single-incision laparoscopic cholecystectomy

Background: A prolonged operative time is associated with adverse post-operative outcomes in laparoscopic surgery. Although a single-incision laparoscopic cholecystectomy (SILC) requires a longer operative time as compared with a conventional laparoscopic cholecystectomy, risk factors for a prolonged operative time in SILC remain unknown.Methods: A total of 20 clinical variables were retrospectively reviewed to identify factors for a prolonged operative time (longer than 3 h) in a total of 220 consecutive patients undergoing SILC.Results: The median operative time was 145 min (range, 55–435) and a prolonged operative time was required in 62 patients (28%). Independent factors that predict a prolonged operative time as identified through multivariate analysis were body mass index (BMI) (P = 0.009), acute cholecystitis (P < 0.001) and operator (resident or staff surgeon) (P < 0.001). Furthermore, a prolonged operative time was significantly associated with an increased amount of intra-operative blood loss (P < 0.001) and a prolonged stay after surgery (P < 0.001).Conclusions: These findings suggest that a higher BMI, acute cholecystitis and a resident as an operator significantly increase the duration of SILC procedures.     

Laparoendoscopic single-site common bile duct exploration using the manual manipulator

Background

Laparoendoscopic single-site (LESS) surgery has developed as a new surgical modality that has increased cosmetic benefits over conventional endoscopic surgery. However, there are no reports about LESS surgery in common bile duct exploration. This report presents a LESS surgery to manage CBD stones by laparoscopic choledochotomy and C-tube placement with favorable outcomes.

Methods

This retrospective review analyzes 13 patients who underwent LESS CBD exploration with C-tube drainage for choledocholithiasis. The technique is herein described and the outcomes measured. The Radius Surgical System (Tübingen Scientific Medical, Tübingen, Germany) is a flexible manual manipulator that was applied for suturing and ligation to overcome the difficulties associated with LESS surgery.

Results

The diameters of the CBDs ranged from 12 to 20 mm, the median number of stones was 5.8, and the median diameter of stones was 9 mm. All of the routine procedures including choledochotomy, intraoperative ultrasound, choledochoscopy, and intraoperative cholangiography guidance were performed. Stone clearance from the CBD was achieved for all but one of the patients. It was possible to close the common bile duct opening with regular forceps, but this required extra effort compared to conventional laparoscopic surgery. On the other hand, the manual manipulator enabled the optimal penetration angle and was useful for both intracorporeal suturing and ligation for the closure of the common bile duct opening. The manual manipulator also helped to overcome in-line viewing and hand/instruments collisions, which are common problems in LESS surgery. No mortality was associated with this procedure, and two wound infections were drained without anesthesia. No recurrent stones were observed during the follow-up period.

Conclusions

LESS surgery was successfully applied to CBD exploration as an available alternative to conventional laparoscopic surgery. This method is technically feasible and produces superior cosmetic results. The manual manipulator may therefore have several advantages for performing LESS surgery.     

A case of secondary hyperparathyroidism with an ectopic intrathyroid gland successfully diagnosed and controlled by percutaneous ethanol injection therapy (PEIT)

Secondary hyperparathyroidism (II HPT) is a major complication in chronic dialysis patients, and percutaneous ethanol injection therapy (PEIT) has become a useful alternative treatment for II HPT. However, the existence of ectopic parathyroid glands is a major problem when conducting PEIT. Ectopic parathyroid gland accepts 10-35% of II HPT, and the missing glands cannot be detected consistently by any imaging techniques, including scintigraphy. Intrathyroid parathyroid gland is as rare as about 1% and recurrence of missing glands after parathyroidectomy (PTx) has been reported in some cases. We report here a 52-year-old female in whom an ectopic parathyroid gland was defected successfully and intact-PTH controlled by tentative PEIT. At the first examination, a left parathyroid adenoma and a right thyroid goiter were pointed out by ultrasonography, CT and scintigraphy. PEIT was applied twice to the left parathyroid adenoma, but intact-PTH was not decreased. Ultrasonography, CT, 201Tl-99mTc subtraction scintigraphy and fine needle aspiration biopsy (FNAB) were performed again to search for the existence of ectopic glands. The results suggested that the right intrathyroid tumor was an ectopic parathyroid gland. Consequently, tentative PEIT was applied to the right intrathyroid tumor, and successful control of intact-PTH and serum Ca was eventually achieved. To our knowledge, this is the first reported case of secondary hyperparathyroidism with an ectopic intrathyroid gland that was successfully controlled by PEIT. In this case, it was suggested that tentative PEIT of intrathyroid tumor was a useful method for detecting an ectopic parathyroid gland.     

A case of curatively resected schirrous gastric cancer effectively treated by combined chemotherapy of weekly paclitaxel (PTX) and CDDP

The patient was a 40-year-old woman who had unresectable advanced gastric cancer with invasion of liver and dissemination to the peritoneal wall. Neoadjuvant chemotherapy consisting of paclitaxel (PTX) and CDDP was performed. PTX (80 mg/m2), and CDDP (25 mg/m2) was administered weekly on day 1, 8 and 15 as one cycle. After four cycles of PTX/CDDP administration,invasion of liver and gastric tumor had decreased to almost normal size, and total gastrectomy was performed. After operation, the patient was treated with six courses of PTX/CDDP and survived without recurrence as of this writing. PTX/CDDP was associated with few adverse events in hospital visits, and thought to be an effective chemotherapy against advanced gastric cancer.     

A case of advanced gastric cancer effectively treated by combined chemotherapy of paclitaxel (TXL) and CDDP

The patient was a 73-year-old man with unresectable advanced gastric cancer and celiac and supraclavicular lymph node metastases. Neoadjuvant chemotherapy consisting of paclitaxel (TXL) and CDDP was administered. TXL (80 mg/m2) and CDDP (25 mg/m2) was administered weekly on day 1, 8 and 15 as 1 cycle. After 4 cycles of TXL/CDDP administration, the lymph node metastases and gastric tumor had decreased almost completely in size and distal partial gastrectomy was performed. After surgery, the patient was treated with 4 courses of TXL/CDDP and has survived without recurrence to the present. TXL/CDDP is associated with few adverse events in hospital visits, and is thought to be an effective chemotherapy against advanced gastric cancer.     

Association of hereditary spherocytosis with familial adenomatous polyposis in a pedigree: a new syndrome or coincidence?

No association of familial adenomatous polyposis (FAP) and hereditary spherocytosis (HS) has been reported, both of which are inherited in an autosomal dominant manner. We present the first reported case of FAP with spherocytosis and construct the family pedigree. In the patient's pedigree, both FAP and spherocytosis were inherited in an autosomal dominant trait. In the 34-year-old Japanese proband's leukocytes, we found no abnormal chromosomal band, and a germline mutation of the APC gene was not detected. All possible genes reported to be linked to HS were located far from chromosome 5q on which the APC gene is located. Although it is unknown if erythrocyte membrane disorder is an additional phenotype of FAP, to the best of our knowledge, this is the first documentation of FAP associated with spherocytosis. Received: July 11, 2001 / Accepted: November 2, 2001 Reprint requests to: K. Hirata