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.     

Spatial arrangement of the pancreatic ducts in the head of the pancreas with special reference to the branches of the uncinate process

BACKGROUND: It remains very difficult to clarify the spatial arrangement of the branches of the pancreatic ducts in the head of the pancreas despite recent progress in diagnostic imaging techniques. METHODS: We minutely dissected the head region from 15 cadavers after injection of silicone rubber into the ducts through the papilla of Vater to investigate the distribution of these ducts. RESULTS: We found that the branches that drained the uncinate process not only joined the main pancreatic duct but also constantly joined the accessory pancreatic duct. In addition, the branches of the uncinate process that joined the accessory duct ran anterior to those to the main duct. We classified the arrangement of the pancreatic ducts into type 1 (10 cases) and type 2 (5 cases) on the basis of the pattern of the branches of the uncinate process. The distance from the papilla of Vater to the junction of the main and accessory pancreatic ducts in type 1 (> 23.0 mm) was significantly longer than that in type 2 (< 22.0 mm). CONCLUSIONS: Careful attention should be paid to the branches of the uncinate process to the accessory pancreatic duct to enable more accurate diagnoses of the pancreas head region.     

Varicose bleeding after liver transplantation in a patient with severe portosystemic shunts

Recipients for liver transplantation often have portosystemic shunts due to portal hypertension. It is an important problem whether such shunts should be ligated during operations. Ligating the shunts seems of benefit for increasing portal blood flow to the liver, but it is sometimes difficult technically, and it is invasive to the patient. We experienced a recipient with huge portosystemic shunts and no esophageal varices before living-related liver transplantation. Some shunts were ligated during operation to increase portal blood flow to the graft. Unfortunately, the patient suffered severe bleeding from esophagogastric varices after he underwent retransplantation owing to accidental liver failure. Based on our experience, extreme care should be exercised to avoid varicose bleeding after ligating the portosystemic shunts of liver transplantation patients.     

Endoscopic resection of carcinoma in situ of the esophagus accompanied by esophageal varices

Summary A case of carcinoma in situ of the esophagus accompanied by esophageal varices was treated by endoscopic mucosal resection using a transparent tube (EMRT) following eradication of the varices via injection sclerotherapy (EIS). Intravariceal injection sclerotherapy was performed for esophageal varices, and after eradication of the varices had been achieved, half of the circumferential esophageal mucosal resection of the cancer lesion was carried out. No serious complication such as perforation or mass bleeding was observed. Cancer-involved mucosa was completely resected and all specimens contributed well to accurate histopathological study, being diagnosed as intraepithelial squamous-cell carcinoma. The artificial ulcer recovered completely, showing no stenotic changes. Our conclusion from this experience is that EIS + EMRT is a valuable and minimally invasive treatment for patients exhibiting this disease, providing an accurate histopathological diagnosis.     

Curative resection of gallbladder cancer with simultaneous liver metastasis

A 67-year-old man visited our hospital for further check-up of biliary tract disease since his two brothers suffered from biliary tract cancer. Abdominal CT scan revealed a wall thickning at the fundus of gallbladder and its vascularity was rich. Chronic cholecystitis was diagnosed, however, cancer was highly suspected. Cholecystectomy was performed and the frozen section of the gallbladder was compatible for cancer. Therefore, segment-4a and -5 liver resections with regeonal lymph node dissection were added. Although preoperative radiological findings were free of liver metastasis, the resected liver specimen included a nodule of 1 cm in segment-5. Extrahepatic bile duct was not resected because the stump of the cystic duct was free from cancer. The final pathological diagnosis according to the TNM classification was pT3N1M1, Stage IV. We considered the patient to be in the high-risk group of recurrence, adjuvant chemotherapy using both gemcitabine and S-1 was performed. S-1 (80 mg/body/day) was scheduled on day 1-14, and gemcitabine (1,000 mg/body) was scheduled on day 8, day 15. The treatment was continued for two years (a total of 28 courses) without experiencing advese events. The patient is cancer free by means of radiological and hematological studies. Gallbladder cancer with liver metastasis in segment-4a and/or -5 can be considered as "local" metastasis, which a liver resection and adjuvant therapy may lead to a good prognosis.     

Agreement in the detection of chiasmal and postchiasmal visual field defects between imo binocular random single-eye test and Humphrey monocular test

Purpose

To compare the ability of imo binocular random single-eye test (BRSET) to detect visual field (VF) defects due to chiasmal and postchiasmal lesions (C/PCLs) with a Humphrey Field Analyzer (HFA) monocular test.

Study design

Prospective multicenter study

Methods

This study enrolled 40 patients with C/PCLs and measured their VFs using both imo BRSET and HFA monocular test. The VFs were classified into three groups using the cluster criterion: 1) bitemporal group, 2) homonymous group, and 3) others. The agreement and correlation of VF results between imo and HFA were analyzed using the Bland–Altman plot and Spearman correlation coefficient.

Results

The VFs of 34 patients were analyzed and classified. There were 13 patients in the bitemporal, 6 in the homonymous, and 15 in the others group. BRSET showed a significantly shorter test duration than HFA. The imo systematically yielded a lower sensitivity than HFA. The average sensitivity at each test location correlated well between the perimeters in all groups, with the correlation coefficients ranging from 0.89 to 0.98. Bland–Altman plots showed wider limits of agreement in the affected quadrants compared to the unaffected quadrants in the bitemporal and homonymous groups. The fixation loss rate did not differ between the perimeters, but there were significant differences in the false positive and false negative rates between perimeters.

Conclusion

BRSET detected VF defects due to C/PCLs as accurately as the HFA monocular test with a shorter test duration.

     

Differences in the mode of the extension of gastric cancer classified by histological type: new histological classification of gastric carcinoma.

By combining two of the morphological characteristics of gastric cancer, the degree of differentiation of the glandular tubules and the amount of mucus in the cytoplasm, the histological type of the gastric carcinoma was categorised into four groups. Group I: tubular differentiation--well; mucus in cytoplasm--poor; group II: tubular differentiation--well; mucus in cytoplasm--rich; group III: tubular differentiation--poor; mucus in cytoplasm--poor; group IV: tubular differentiation--poor; mucus in cytoplasm--rich. A study of the relation between the types of primary lesion and the mode of extension and recurrence of gastric carcinoma in 200 autopsy cases was then undertaken. In group I, the frequency and extent of haematogenous metastasis such as in the liver was high, while in group IV, that of lymph node metastasis, direct invasion into surrounding organ, and peritoneal dissemination were higher. In group III, which showed the intermediate mode of extension in nature to those of group I and IV, although the frequency and severity of the bone marrow metastasis was the highest. There were significant differences in the modes of development and the extent of infiltration in all groups.     

Postoperative nutritional assessment in gastric and colorectal cancer

From the 200 malnutritional cancer patients, we had obtained, so called, prognostic nutritional index (PNI): PNI = 10 X Alb. + 0.005 Lymph. C., where Alb. is serum albumin level (g/dl) and Lymph. C. is total lymphocytes count of peripheral blood level. This index, as we had reported, shows linear predictive model correlating the risk of operative complication, mortality or both with nutritional status. In this study, we report on the utility of the PNI as a nutritional index (NI) for postoperative patients. The subjects of this study were 22 gastric cancer patients (G group), performed total gastrectomy or proximal gastrectomy, and 18 colorectal cancer patients (C group), underwent colectomy or rectal resection and anastomosis but amputation. All these cases underwent nutritional support by TPN postoperatively. The values of NI of both groups were the lowest at the first postoperative day, and increased gradually to the seventh postoperative day. And the value of C group was higher than that of G group throughout the TPN period: From the first postoperative day to the 14th day. These results reflected the result obtained from the estimation of nitrogen balance, urinary 3-methylhistidine excretion and serum rapid turnover protein (transferrin, prealbumin and retinol binding protein). These results suggest that the NI is useful to estimate the improvement of the postoperative nutritional status.     

Multiple aneurysms of the visceral arteries with migrating vascular bruit on postural change: A case report

Multiple aneurysms of the gastroepiploic artery and the ileocecal branch of the superior mesenteric artery were found in a 68-year-old male patient by angiography. The patient presented with one-hour postprandial epigastric pain of 10 years duration. Abdominal bruit was auscultated at the two different sites, one of which shifted downwards upon upright position. From the freely movable nature of the great omentum, this bruit, migrating upon postural change, was most likely from the gastroepiploic artery aneurysms. The aneurysms were excised and the abdominal bruit disappeared. The etiology of the aneurysms was suggested to be arterial fibrodysplasia histologically. From this experience, it was stressed that postural change should be added to a routine physical examination to rule out an aneurysm from the freely movable great omentum.