Kazuyuki Shimomura

Changes in splanchnic blood flow and cardiovascular effects following peritoneal insufflation of carbon dioxide

SummaryLaparoscopic surgery has rapidly become a popular and widely used technique. Although this procedure has been shown to be generally safe, cardiovascular derangement related to carbon dioxide pneumoperitoneum has been reported. There are few data available on the relationship between systemic and regional hemodynamics in cases of pneumoperitoneum. Changes in splanchnic blood flow and cardiovascular effects following a moderate increase of intraabdominal pressure (IAP) to 16 mmHg during a 3-h period were analyzed in six anesthetized dogs. After insufflation, cardiac output and blood flow in the superior mesenteric artery and portal vein decreased progressively and returned to the preinsufflation values following deflation. Hepatic arterial blood flow did not change significantly, perhaps due to compensatory mechanisms for maintenance of hepatic blood flow. Mechanical compression of the splanchnic capillary beds due to the elevated IAP may possibly reflect the increase in systemic vascular resistance causing the decrease in cardiac output. To prevent this impairment, intermittent decompression of gas during surgical laparoscopy is recommended.

Management of gallstones in cirrhotic patients

Abstract34 cirrhotic patients who underwent either cholecystectomy alone or in conjunction with common duct exploration were retrospectively reviewed. In Child A and B patients morbidity was low and there were no postoperative deaths. However, all patients who underwent additional cholecystectomy during the non-shunting operation for esophageal varices required blood transfusion. Cholecystectomy in Child C patients is frequently associated with considerable intraoperative bleeding and subsequent postoperative complications. In the 23 patients who were not operated upon for gallstones, no patients developed symptomatic biliary disease. Ultrasonographically, most of these gallstones were strongly suspected to be black stones. Elective surgical intervention for symptomatic Child A and B patients would normally be warranted, but hemorrhage and resulting complications due to additional cholecystectomy for asymptomatic gallstones during the non-shunting operation should be minimized. An additional cholecystectomy should be considered, provided such a cholecystectomy is thought to be easily performed judging from the degree of development of collateral circulation around the hepatoduodenal ligament and unless black stones are suspected ultrasonographically. For symptomatic gallstones in Child C patients every type of medical treatment should be attempted. After considering the bleeding tendency or ascites, percutaneous transhepatic gallbladder drainage is considered to be one of the safest treatments.

Muscle Strength and Walking Ability After Laparoscopic Hernioplasty Versus Conventional Repair

Abstract.Purpose: We examined muscle strength and walking ability after hernia repair to compare the effects of laparoscopic hernioplasty and conventional repair. Methods: Twenty-seven patients with primary inguinal hernias were randomly divided into two groups according to the surgical procedure: 15 patients were treated with laparoscopic hernioplasty and 12 with conventional repair. Two types of muscle testing around the inguinal region, one by manual examination and one using a musculator, were done preoperatively and 1 week postoperatively. Walking exercise tests were performed at the same time as muscle testing. Results: Manual examination showed that the postoperative muscle strength of the iliopsoas muscle was decreased in six patients from the conventional repair group, but not in any of those from the laparoscopic hernioplasty group. The musculator showed decreased strength of the iliopsoas muscle after conventional repair, but not after laparoscopic hernioplasty. The walking exercise test showed that conventional hernia repair influenced walking. Conclusion: A decline in muscle strength of the iliopsoas muscle and walking ability was evident after conventional repair, but not after laparoscopic hernioplasty. Thus, laparoscopic hernioplasty is superior to conventional repair from the perspective of muscle testing and walking ability.

Usefulness of Postoperative Spiral Computed Tomography Combined with Drip Infusion Cholangiography in Patients with Congenital Biliary Dilatation.

近年, 経静脈性胆道造影 (drip infusion cholangiography) 併用下のspiral computed tomography (以下, DIC-SCT) が, 胆道系疾患の新しい非侵襲検査として普及した. そこで今回, 先天性胆道拡張症術後症例におけるDIC-SCTの有用性について検討を行った.先天性胆道拡張症の診断で, 以前に胆嚢・拡張胆管切除, 肝管腸吻合術を施行した7例を対象にDIC-SCTを行った. 手術時の年齢は, 4か月～40歳2か月で, 術後の経過観察期間は, 1年6か月～10年7か月であった.全例において, 肝内胆管1次分枝, 吻合部, および吻合部以下の腸管が描出され, 吻合部の横径は4mm～25mm, 前後径は3mm～20mmと測定できた. IV-A型の1例では, 右枝に拡張を認め, 左枝は描出されなかった.DIC-SCTは, 先天性胆道拡張症術後症例における吻合部の形態や胆汁うっ滞の有無を簡便に知る方法として優れていた.