Hiroyuki Inui

Preoperative assessment for laparoscopic cholecystectomy: feasibility of using spiral computed tomography.

OBJECTIVE The authors investigated the preoperative feasibility of using spiral computed tomography (SCT) after intravenous infusion cholangiography (IVC-SCT) for laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA In laparoscopic cholecystectomy, the aberrant or unusual anatomy of the bile duct and severe inflammation or adhesions around the gallbladder sometimes require a conversion to open surgery. METHODS Laparoscopic cholecystectomies (LCs) were attempted on 440 patients, and preoperative IVC-SCT also was attempted in all of these patients. Using this spiral scanning technique, the bile ducts, cystic duct, and gallbladder were assessed for contour abnormalities, relative position, and filling defects. Forty-seven patients were diagnosed with having stones in their common bile duct or common hepatic duct. RESULTS Three-hundred eighty-seven patients out of the 440 patients (88.0%) who were subjected to IVC-SCT had the length and course of their cystic duct successfully determined. Anomalous unions of the cystic duct were seen in 59 (15.2%) of 387 patients with respect to the operative findings, and 48 of 440 patients (10.9%) had severe adhesions to Calots triangle and the surrounding tissues. In these 48 patients, 45 patients (94%) had a nonvisualized cystic duct on IVC-SCT. The preoperative assessment of the feasibility (dense adhesions obscuring Calots triangle) of using IVC-SCT demonstrated that the sensitivity, specificity, and accuracy were 93%, 98%, and 94%, respectively. Five patients had to be converted to open surgery, and the overall morbidity rates for patients undergoing laparoscopic cholecystectomy was 0.9% (4 of 440). CONCLUSIONS The most important factor in assessing the feasibility of using laparoscopic cholecystectomy is not the nonvisualized gallbladder, but the nonvisualized cystic duct on IVC-SCT. IVC-SCT may be of benefit to those patients scheduled to undergo laparoscopic cholecystectomy.

Laparoscopic cholecystectomy and choledocholithotomy in patients with a previous gastrectomy

BACKGROUND An increased incidence of cholelithiasis has been widely reported after truncal vagotomy and after gastric resection. In the early phase of patient selection, previous gastrectomy has been considered a relative contraindication to laparoscopic cholecystectomy (LC). In this study, we examined the management of LC in patients with previous gastrectomy. STUDY DESIGN LC was attempted on 1,260 consecutive patients. Of these patients, 29 had a previous gastrectomy. Surgical procedures that had been performed included Billroth I gastrectomies (15), Billroth II gastrectomies (10), and total gastrectomies (4). There were 23 cases of cholelithiasis, 4 chronic cholecystitis, 2 gallbladder polyps, I porcelain gallbladder, and I gallbladder cancer. Nine patients were diagnosed with stones in their common bile duct or common hepatic duct. RESULTS Preoperatively, seven of nine patients with common bile duct stones were subjected to endoscopic sphincterotomy, and the stones were removed successfully from five of these patients. In the remaining two patients, common bile duct stones were removed by laparoscopic choledocholithotomy by choledochotomy. The LC was completed in 26 patients (90%) who had undergone previous gastrectomy. In 449 patients who had previous abdominal surgery without a gastrectomy, only 4 patients (0.9%) required open surgery. In contrast, three patients (10%) with previous gastrectomy required open surgery. No major complications were recorded in this study series, and no residual or retained stones were seen during a followup period of 3 months. CONCLUSIONS Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe LC in these patients. We conclude that in our study patients, a previous gastrectomy is considered an indication for LC and laparoscopic choledochotomy.

Laparoscopic Splenectomy for a Lymphangioma of the Spleen: Report of a Case

Abstract We present the first case report of a suc-cessful laparoscopic complete excision of a splenic lymphangioma. The splenic tumor was preoperatively diagnosed to be a lymphangioma by the combined modalities of ultrasonography, computed tomography, magnetic resonance imaging, and angiography. A laparoscopic splenectomy was subsequently performed and the pathological examination of the mass confirmed the diagnosis of a lymphangioma. Based on the above findings, a laparoscopic splenectomy is recommended when a splenic tumor is suspected to be either benign or borderline.

Acceptance of Skin Allografts in Pigs by Portal Venous Injection of Donor Bone Marrow Cells

OBJECTIVE To confirm in pigs whether a new method for organ allografts, originally established in mice by the authors, might be applicable to humans. SUMMARY BACKGROUND DATA The authors recently established a new method for organ allografts in mice that includes the injection of donor bone marrow cells (BMCs) using the portal vein (PV), followed by the administration of cyclosporin A (CsA) on days 2 and 5, and the intravenous injection of BMCs on day 5. In the present study, they modify this method (a single-day protocol) and apply it to pigs. METHODS Allogeneic BMCs of donor pigs were injected using the PV (a superior mesenteric vein). The skin grafting was carried out on the day of the PV injection. The recipient pigs received donor grafts, autologous grafts, and third-party grafts at the same time. In addition, an open wound was made as the epithelized control. Full-thickness skin grafts were harvested from the dorsal wall of the donors. CsA (10 mg/kg) was injected intramuscularly into recipient pigs on days 2 and 5 after the PV injection. RESULTS One hundred percent of skin grafts survived for >300 days when donor BMCs were injected using the PV (n = 6). However, the skin grafts of the three pigs that had received BMCs using the intravenous route were rejected within 3 to 4 weeks after transplantation. The third-party skin grafts showed necrotic changes on day 21 after transplantation. CONCLUSIONS One hundred percent of skin allografts can be obtained, even in pigs, by injecting donor BMCs using the PV, carrying out skin allografts, and administering CsA on days 2 and 5. This single-day protocol would be of great advantage for human organ transplantation.

Laparoscopic treatment using an argon beam coagulator for nonparasitic liver cysts

BACKGROUND Laparoscopic deroofing has been shown to produce good patient satisfaction and to have results similar to those of open surgical techniques. We evaluated the feasibility and efficacy of laparoscopic deroofing using an argon beam coagulator (ABC) in the patients with nonparasitic liver cysts. METHODS Laparoscopic deroofing for the treatment of liver cysts was attempted on 14 patients. After the deroofing, the secreting epithelium within the residual cystic cavity wall was destroyed using the ABC. RESULTS Laparoscopic deroofing was successful in all patients. No deaths or surgical morbidity occurred, and no postoperative complications were recorded. The median postoperative hospital stay was 7 days. The median follow-up was 56 months for all patients, and all patients have remained completely asymptomatic for 6 months after the surgery, with no recurrence of the cysts. CONCLUSIONS Our results indicate that laparoscopic deroofing using the ABC method in patients with nonparasitic liver cysts was effective in preventing cyst recurrence.

Laparoscopic management of bile duct and bowel injury during laparoscopic cholecystectomy

Accidentai injuries to the bile duct and bowel are significant risks of laparoscopic surgery and sometimes require conversion to open surgery. Although some of the injuries related to laparoscopic cholecystectomy can be managed by endoscopic techniques, laparoscopic surgery is not yet sufficiently perfected. We investigated the efficacy of laparoscopic management combined with endoscopic tube or stent insertion in cases of bile duct and bowel injuries during laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted on 1,190 consecutive patients between April 1992 and June 1999. The first 70 patients underwent only preoperative intravenous infusion cholangiography (IVC), and the remaining 1,120 patients were subjected to both preoperative IVC and intraoperative cholangiography. We experienced 16 cases of bile duct injury (1.4%). Five patients with circumferential injuries of the bile duct were converted to open surgery for biliary reconstruction. The other 11 patients with partial laceration injuries of the bile duct and biliary leakage from the cystic duct underwent a laparoscopic simple closure technique. In 10 of these patients, an endoscopic tube or stent was inserted on the day after surgery to facilitate biliary decompression and drainage. Bowel injuries occurred in seven patients (0.6%). Three intestinal injuries were due to careless technique, and two duodenal injuries and two intestinal injuries were related to dense adhesions. All of these injuries were successfully repaired using laparoscopic techniques, auto-suturing devices, or extracorporeal suturing via the umbilical incision. No postoperative complications were identified. We concluded that the biliary injury site could be closed with a laparoscopic technique so long as the biliary injury was not circumferential. Bowel injuries also could be repaired laparoscopically.RésuméLe risque de lésions accidentelles des voies biliaires et des intestins n’est pas rare au cours de la chirurgie laparoscopique: de temps à autre, une conversion à la chirurgie ouverte est nécessaire. Si certaines lésions en rapport avec la cholécystectomie laparoscopique peuvent être traitée s par des méthodes endoscopiques, le traitement par laparoscopie de ces lésions n’est pas encore suffisamment perfectionné. Nous avons évalué l’efficacité du traitement laparoscopique combiné à l’endoscopie ou par insertion d’un stent en cas de lésion biliaire ou lésion des intestins secondaires à la laparoscopie. Une cholécystectomie a été réalisée par laparoscopie chez 1190 patients consécutifs entre avril 1992 et juin 1999. Les 70 premiers patients ont eu une cholangiographie intraveineuse préopératoire alors que les 1120 patients restants ont eu et une cholangiographie intraveineuse et une cholangiographie peropératoire. Nous avons observé 16 cas de lésions des voies biliaires (1,4%). Cinq patients atteints d’une lésion circonférentielle des voies biliaires ont été convertis en chirurgie ouverte pour reconstruction des voies biliaires. On a pu réaliser un traitement laparoscopique pour les 11 autres patients ayant une plaie partielle des voies biliaires ou une fuite à partir du canal cystique. Chez 10 de ces patients, on a inséré un tube ou un stent endoscopique le jour suivant la chirurgie laparoscopique pour décomprimer et faciliter le drainage biliaire. On a dénombré sept lésions intestinales (0,6%). Trois lésions intestinales étaient en rapport avec une erreur technique, deux lésions duodenales et deux lésions intestinales étaient en rapport avec des adhérences serrées. Toutes les lésions ont été réparées avec succès sous laparoscopie, en utilisant soit un appareil de suture mécanique soit des techniques de sutures extracorporéales à travers le trocart ombilical. On n’a observé aucune complication postopératoire. Nous concluons qu’une lésion biliaire iatrogène lors d’une cholécystectomie laparoscopique a toujours pu être réparée par une technique laparoscopique à condition que la lésion biliaire ne soit pas circonférentielle. Les lésions intestinales peuvent également être réparées sous laparoscopie.ResumenLa cirugia laparoscópica conlleva un riesgo significativo de lesiones accidentales del colédoco e intestino delgado. Aunque algunas de éstas, sobre todo las referidas a la colecistectomia laparoscópica, pueden tratarse mediante técnicas endoscópicas, es evidente que la cirugí laparoscópica no está todavía suficientemente perfeccionada por lo que al tratamiento de estas lesiones se refiere. Investigamos la eficacia del tratamiento laparoscópico en combinación con la inserción de tubos o “stent”, en las lesiones de vías biliares e intestino delgado producidas por colecistectomia laparoscópica. Entre abril 1992 y junio 1999, se realizaron 1,190 colecistectomias laparoscópicas. Sólo en los 70 primeros pacientes se efectuó una colangiografia intravenosa preoperatoria (IVC). En los restantes enfermos 1,120 se realizaron una IVC preoperatoria y una colangiografia intraoperatoria. Se detectaron 16 casos de lesiones de vias biliares (1.4%). 5 casos, con sección completa circunferencial del colédoco, se reconvirtieron realizándose la reconstrucción de la via biliar por cirugia abierta. Los otros 11 casos, con lesiones parciales o con fistulas del conducto cístico, fueron tratados mediante una simple sutura por vía laparoscópica. En 10 de estos pacientes y para descomprimir y facilitar el drenaje biliar se insertaron, al día siguiente de la reparación quirúrgica, por vía endoscópica, una sonda o un “stent”. En 7 pacientes (0.6%) se produjeron lesiones del intestino delgado. Tres de ellas se debieron a faltas técnicas; dos lesiones duodenales y otras dos intestinales fueron propiciadas por la existencia de densas adherencias. Todas estas lesiones se trataron con éxito por técnicas laparoscópicas bien con: autosutura o con suturas extracorpóreas, a través de la puerta umbilical. No se observó complicación postoperatoria alguna. Conclusión: excepción hecha de las secciones circunferenciales totales del colédoco, todas las otras lesiones tanto de las vías biliares como del intestino delgado pueden tratarse por vía laparoscópica.

Cold preservation of rat pancreatic islets just above the freezing point using University of Wisconsin solution

Aims To confirm whether rat islets stored at a temperature just above the freezing point using University of Wisconsin (UW) solution would remain viable for the short term. Methodology Rat islets were stored for 24 hours in UW solution, either at 4°C or at −0.6°C (just above the specific freezing point of the UW solution). After cold storage, the islets were assessed for in vitro viability by static incubation and for in vivo viability by a transplantation study. One thousand islets preserved under different conditions were injected intraportally into a streptozotocin-induced diabetic rat as an isograft. Four weeks after the transplantation, an intravenous glucose tolerance test was performed. Results Islets stored at −0.6°C showed higher insulin secretion rates than those stored at 4°C on a static challenge. The interval from transplantation to the achievement of normoglycemia was also shorter in the −0.6°C group than in the 4°C group. After islet transplantation, the daily nonfasting plasma glucose concentration was higher in the 4°C group than in the −0.6°C group. When compared with the 4°C group, the −0.6°C group showed lower blood glucose values during all investigational periods on an intravenous glucose tolerance test. Conclusion Islet preservation at −0.6°C using UW solution is more advantageous for short term.