Low-pressure Pneumoperitoneum for Laparoscopic Surgery Using a Disposable,Flexible Abdominal Wall Retractor

Abstract: Since April 1991, we have studied 160 patients who had had a successful laparoscopic cholecystectomy. Nine patients who presented with chronic cholecystitis with severe local adhesion and who were also considered to require a longer operative time were selected as suitable candidates for this procedure. They were successfully treated under a zero- to four-mmHg low-pressured pneumoperitoneum procedure combined with total abdominal wall lifting using a disposable, flexible vinyl tube retractor. This method enabled exactly the same clear laparoscopic vision as is possible in the routinely-used high-pressure pneumoperitoneum even in the marginal portions of the abdominal cavity. Moreover, it facilitated early reinsufflation after the cauterization-produced smoke was exhausted, which minimized the operative time and reduced the surgeon's anxiety concerning the maintenance of a sufficiently airtight condition. We believe that this low-pressure pneumopeqitoneum procedure also benefits the poor-risk patient who has restricted cardiopulmonary function, especially during advanced laparoscopic surgery which requires a longer operative and anesthetic time.     

New Electrophysiologic Features and Catheter Ablation of Atrioventricular and Atriofascicular Accessory Pathways:

Catheter Ablation for Mahaim Pathways. Introduction : Several modalities of catheter ablation have been proposed to eliminate Mahaim pathway conduction. However, limited research has been reported on the electrophysiologic nature of this pathway in its entity.
Methods and Results : In seven patients, electrophysiologic study was performed, and radiofrequency energy was applied to investigate the electrophysiologic clues for successful ablation. In all seven patients, the Mahaim pathway was diagnosed as a right-sided atriofascicular or atrioventricular pathway with decremental properties. In two patients, two different kinds of electrograms were recorded through the ablation catheter positioned at the Mahaim pathway location: one was suggestive of conduction over the decremental portion, demonstrating a dulled potential; and the other of nondecremental conduction, demonstrating a spiked potential. All but one of the Mahaim pathways were eliminated successfully at the atrial origin where the spiked Mahaim potential was recorded. Radiofrequency energy application was performed at the slow potential site resulting in failure to eliminate the conduction over the Mahaim pathway. Conduction block at the site between the slow and fast potential recording sites was provoked by intravenous administration of adenosine, concomitant with a decrease in the amplitude of the Mahaim potential. In one patient, the clinical arrhythmia was a sustained monomorphic ventricular tachycardia originating from the ventricular end of the Mahaim fiber.
Conclusion : The identification of Mahaim spiked potentials may be the optimal method to permit their successful ablation. Detailed electrophysiologic assessment is indispensable for successful ablation of tachycardias associated with Mahaim fibers because tachycardias unassociated with Mahaim fibers can occur despite complete elimination of the Mahaim fiber.     

Acute lower respiratory infections in hospitalized children over a 6 year period in Tokyo

BACKGROUND: Acute lower respiratory infections are major causes of hospitalization in children and are mainly caused by respiratory viruses. In the present study, we investigated the etiologic agents responsible for acute lower respiratory infections from the period November 1986 to October 1992 in order to determine the seasonal pattern and different characteristics of age distribution of respiratory infectious agents, mainly virus infections. METHODS: A total of 1521 patients with lower respiratory infections was hospitalized in Saiseikai Central Hospital, Tokyo, Japan. Nasopharyngeal secretions were obtained for virus isolation and paired sera in the acute and convalescent phases were obtained for serological examination. RESULTS: Etiological agents were identified in 668 of 1521 patients (43.9%) by serological antibody responses, virus isolation and/or detection of virus antigen: 240 (15.8%) with respiratory syncytial (RS) virus; 62 (4.1%) with influenza virus type A; 26 (1.7%) with influenza virus type B; 86 (5.7%) with adenovirus; 81 (5.3%) with parainfluenza virus; 32 (2.1%) with measles virus; 20 (1.3%) with enteroviruses or Herpes virus other than respiratory viruses; 75 (4.9%) with Mycoplasma pneumoniae; 10 (0.7%) with pertussis; and 36 (2.4%) with mixed infections. In the remaining 853 patients (56.1%), etiologic agents were not identified. Respiratory syncytial (RS) virus was a main causative agent of respiratory infections in patients younger than 3 years of age. Influenza virus and M. pneumoniae were two main causative agents in patients with acute respiratory illness over 5 years of age. Parainfluenza virus type 3 was frequently observed in infants from 9 to 12 months of age. A distinct seasonal pattern of viral infections was consistently observed in each year during the study period; RS and influenza viruses were prevalent in winter, parainfluenza virus was prevalent in spring and M. pneumoniae was prevalent in summer and autumn. However, adenovirus infections were observed in all seasons. Serological responses were poor in patients younger than 1 year of age and they were mainly diagnosed by virus isolation or detection of virus antigen. CONCLUSIONS: Virological epidemiology provides useful information in daily clinical practice for the prediction of etiological agents based on patient age and the seasonal distribution of agents. We should examine virus isolation and the detection of virus antigen, along with serological examinations in patients with respiratory infections, especially in infants younger than 1 year of age because of poor serological responses.     

Early experience of laparoscopic radical nephrectomy for T3b renal cell carcinoma

We report our experience with laparoscopic radical nephrectomy for a 79-year-old man who had renal cell carcinoma (RCC) with a renal vein thrombus. For the transaction of the renal vein with the thrombus, we used an endoscopic gastrointestinal anastomosis stapler. The operating time was 4 h and blood loss was 400 mL. The patient could walk and drink on the first postoperative day. He recovered normal activity 30 days postoperatively. There were no intraoperative and postoperative complications. The present report demonstrates the feasibility of laparoscopic radical nephrectomy in patients with T3b RCC who suffer from tumor thrombus in the renal vein.     

Fas-associated phosphatase-1 promotes Fas-mediated apoptosis in human colon cancer cells: Novel function of FAP-1

Background and Aim: Fas‐associated phosphatase‐1 (FAP‐1) has been thought as an inhibitor in Fas‐mediated apoptosis. Here, we investigated the role of FAP‐1 in Fas‐mediated apoptosis of human colon cancer cells. Method: The viability of four colon cancer cell lines treated with agonistic anti‐Fas antibody was determined using WST‐1 assay and cell death detection ELISA. pRc/CMV‐FAP‐1 was transfected to a FAP‐1‐negative, Fas‐resistant colon cancer cell line SW480 by lipofection and the clones expressing FAP‐1 protein were selected by limiting dilution. In the clones, expression of 550 genes was analyzed by cDNA microarrays. Protein expression of FAP‐1 and molecules related to apoptosis was examined by western blot. Results: We obtained two FAP‐1 overexpressed clones which were much more susceptible to Fas‐mediated apoptosis than control cells. In the clones, caspase 8 and caspase 3 were fully activated by agonistic anti‐Fas antibody treatment. Bcl‐2 family proteins were not related to the high susceptibility of these clones, because caspase 9 was not activated. Transfection of FAP‐1 did not suppress the survival actions of insulin‐like growth factor (IGF‐1) which enhanced survival signal through Akt phosphorylation. Upregulation in 21 genes and downregulation in 29 genes was revealed by cDNA arrays. We confirmed protein expression of p21 and phosphorylated p21 were much more enhanced in the clones than in control cells. Conclusions: Overexpression of FAP‐1 enhanced susceptibility to Fas‐mediated apoptosis in SW480 and upregulation of p21 may contribute to this phenomenon. Our results indicate a novel function of FAP‐1 in Fas‐mediated apoptosis of human colon cancer cells.     

An Endoscopically Resected Case of Early Carcinoma of the Duodenal Bulb

We report here on a case of early carcinoma originating in the duodenal bulb. The patient was a 70-year-old woman who complained of nausea. A gastrointestinal endoscopy disclosed a lesion protruding from the duodenal bulb and a biopsy revealed adenocarcinoma. According to the results of the endoscopy, the tumor was subpedunculated and probably confined in the mucosal layer. Based on these findings, we performed an endoscopic tumor resection. A histological examination of the resected specimen revealed a papillotubular adenocarcinoma (1.7 × 1.2 × 0.8 cm) localized in the mucosal layer. No carcinomatous lesion was left in the resected margin. No symptoms of recurrence have been noted during the last 6 months. When considering clinical pathology of the present case, we assessed 39 cases of primary early carcinoma in the duodenal bulb previously reported in the Japanese literature. We considered that our patient was the 14th in Japan with an early carcinoma of the duodenum which was completely excised via endoscopic resection. We expect that endoscopic resection of early duodenal carcinoma will be widely used in the future.     

ACID THYROGLOBULIN PROTEASE ACTIVITIES IN HUMAN DISEASED THYROID GLANDS

The lysosomal acid protease is thought to be a main enzyme in hydrolysis of thyroglobulin. The protease activity of lysosome-rich fractions of various diseased thyroid glands were assayed by the sensitive and reproducible method developed in our laboratory. They included 78 diseased thyroid glands; 37 thyrotoxic goitres, five irradiated thyroids, five Hashimoto's thyroiditis, one granulomatous thyroiditis, six multinodular goitres, 14 'cold' adenomas, four 'hot' adenomas with three paranodular tissues, and six carcinomas. Fifteen paranodular tissues of cold and solitary thyroid nodules were served as controls. The protease activities were significantly increased in thyroid tissues of thyrotoxic goitres, Hashimoto's thyroiditis, adenomas and adenocarcinomas. In thyrotoxic goitres, the protease activity correlated well with the mean area size of colloid follicles. The 'hot' adenomas had higher protease activity than 'cold' ones. The protease activity of multinodular goitres was nearly normal. Only the irradiated thyroid glands had low protease activities. Therefore the high protease activities in hyperfunctioning goitres seem to reflect hormone secretory activities. On the other hand, cold neoplastic goitres seem to have lysosomal protease activities which are not associated with thyroidal secretory process. The assay of acid protease activity will be useful to understand the pathophysiology of lysosomal system in diseased thyroid glands.     

LEARNING CURVE AND CONVERSION TO OPEN SURGERY IN CASES OF LAPAROSCOPIC ADRENALECTOMY AND NEPHRECTOMY

Purpose

We examine how the level of experience acquired by the laparoscopist affects the outcome of laparoscopic adrenalectomy and nephrectomy, and what is necessary to avoid complications in these surgeries.

Materials and Methods

We retrospectively evaluated the experience levels of 8 urological laparoscopists between 1991 and 1995. In addition, other cases that were converted to open surgery were collected from the institutes with which the 8 laparoscopists were affiliated.

Results

The rates of conversion to open surgery were 6.4% in 204 cases of adrenalectomy and 14.3% in 63 of nephrectomy. Conversion rates were related to blood loss volume but not operative time. The major causes of conversion were bleeding in 45% of cases and adhesion in 34%. There were no mortalities. Mean operative time decreased significantly, reaching that of open surgery as the number of procedures increased up to 20 adrenalectomies and 10 nephrectomies. The volume of blood lost remained low from the early experience. Blood transfusion rates were 4.4% for adrenalectomy and 11.1% for nephrectomy.

Conclusions

Operative time of these procedures decreased significantly with surgeon experience and reached that of open surgery. Cases in which adhesion is anticipated should be restricted to avoid conversion. These laparoscopic procedures are acceptable as a standard operative techniques for adrenal and renal diseases.