Keitaro Hirai

Three-dimensional computed tomography for analyzing the vascular anatomy in laparoscopic surgery for right-sided colon cancer.

Background: The mesenteric vessels have many branching patterns. This study clarified the anatomic relationship between the superior mesenteric vein (SMV), the right colic artery (RCA), and the ileocolic artery (ICA) using 3-dimensional computed tomography (3D-CT). The relationship between the RCA and the right colic vein (RCV) was also examined. Methods: Between April 2006 and July 2011, all patients with colorectal cancer underwent multidetector computed tomography (MDCT) before laparoscopic surgery. The 100 most recent consecutive cases were analyzed. 3D-CT images were made by combining arterial angiography, venous angiography, colonography, tumor, lymph node, and duodenal images. Results: The RCA branched from the SMA in 37 cases (37%); of these, 21 had an ICA that crossed anterior to the SMV and 16 had an ICA that crossed posterior. When the ICA crossed anterior to the SMV, all had an RCA that crossed anterior to the SMV, and no posterior RCA was seen. Furthermore, the RCV joined the SMV in 10 cases (27%) and the gastrocolic trunk in 27 cases (73%). Conclusions: Our study clarified the anatomic variety of the vessels in right-sided colon cancer. Preoperative 3D-CT is useful for understanding the anatomy to ensure a safe, precise operation.

Superior vena cava rupture caused during balloon dilation for treatment of SVC syndrome due to repetitive catheter ablation : A case report

A 29-year-old woman with an implanted AAI mode permanent pacemaker, who had undergone catheter ablation for inappropriate sinus tachycardia 4 times, experienced complications of superior vena cava (SVC) syndrome. Severe stenosis of the SVC wall was observed in computed tomograms. During balloon dilation for the treatment of SVC syndrome, the SVC was ruptured, resulting in cardiac tamponade. An emergency operation was performed using percutaneous cardiopulmonary support (PCPS). A longitudinal tear 1 cm in length was identified at the junction of the right atrium and the SVC, requiring a patch plasty using an autologous pericardium 2.5 cm x 3 cm in size. SVC rupture is a complication to be completely avoided when we perform balloon dilation for the treatment of SVC syndrome. Therefore, the indication of balloon dilation for the treatment of SVC syndrome requires critical examination and attention.

The Effect of Nicorandil on Ischemia-Reperfusion Injury in a Porcine Total Hepatic Vascular Exclusion Model

BACKGROUND We evaluated the effectiveness of nicorandil, which has both K(ATP) channel opener-like and nitrate-like properties, in liver ischemia-reperfusion (IR) injury using a porcine total hepatic vascular exclusion (THVE) model. METHODS Mexican hairless pigs weighing 25-55 kg were used in this study. The animals were divided into three groups. In the nicorandil group (n = 6), a 100 μg/kg bolus of nicorandil was injected intravenously 30 min before the ischemia, and then a continuous infusion (10 μg/kg/min) was administered intravenously for 30 min until just before the ischemia. In the control group (n = 6), a saline solution was injected in the same manner. In the glibenclamide group (n = 6), glibenclamide (0.1 mg/kg), which closes the K(ATP) channel gate, was orally administered 180 min before the hepatic ischemia, and then nicorandil was injected in the same manner as in the nicorandil group. THVE was performed for 120 min, and animals were observed until 360 min after reperfusion. Serum AST and LDH levels, hepatic tissue blood flow (HTBF), and histologic analyses were compared among the three groups. RESULTS Serum AST and LDH levels in the nicorandil group were significantly lower than in the other two groups after reperfusion, while no significant difference was observed between the control and the glibenclamide groups. HTBF in the nicorandil group was also significantly higher than in the other two groups after reperfusion, while no significant difference was observed between the control and glibenclamide groups. Additionally, histopathologic analyses revealed that the hepatic tissue was better maintained in the nicorandil group than in the other two groups. CONCLUSION Our results using a porcine THVE model suggest that nicorandil inhibits hepatic IR injury. The K(ATP) channel-opener aspect of nicorandil might be primarily responsible for the hepatoprotective effect.

Laparoscopic resection of a paraganglioma located on the border of the thoracic and abdominal cavities using a transabdominal-transdiaphragmatic approach

We treated a 64‐year‐old woman with high blood pressure. Catecholamine metabolite levels were elevated in the blood and urine. CT revealed a densely stained tumor on the right side of the descending aorta dorsal to the inferior vena cava. PET‐CT revealed abnormal accumulation of 18F‐fluorodeoxyglucose, and 123I‐meta‐iodo‐benzylguanidine uptake was apparent on scintigraphy. The tumor was determined to be a paraganglioma located on the border between the thoracic and abdominal cavities, and laparoscopic tumorectomy was performed. The patient was placed in the left lateral position. The right lobe of the liver was turned over, and we cut the diaphragm to expose the front of the tumor. We resected the straight artery flowing in from the aorta and removed the tumor safely. Herein, we describe the removal of a paravertebral paraganglioma located in the border of the thoracic and abdominal cavities with a laparoscopic transabdominal‐transdiaphragmatic approach.

Perioperative management of hepatectomy in patients with interstitial pneumonia: a report of three cases and a literature review

PurposeInterstitial pneumonia (IP) is a progressive and irreversible fibrosis and can be fatal if acute exacerbation (AE) occurs. While a useful risk-scoring system has been established for lung surgery, no risk evaluation exists for AE of IP related to non-pulmonary surgery. The objective of this review is to describe the management for patients with IP.MethodsWe experienced three hepatectomy cases with IP. The first was a 72-year-old male patient diagnosed with hepatocellular carcinoma. Preoperative computed tomography (CT) revealed IP with reticular shadow at the base of both lungs. After hepatectomy, his IP became acutely exacerbated and did not improve with steroid or sivelestat treatment. The second was a 74-year-old male patient diagnosed with hepatocellular carcinoma, and the third was a 75-year-old male patient with liver metastasis. In both these cases, CT revealed a reticular shadow in the lung fields, with increased serum KL-6 levels. We administered pirfenidone for perioperative management, during which time no respiratory complications occurred.ResultsPerioperative management with pirfenidone for hepatectomy accompanied by IP was successful in our cases.ConclusionWe reviewed reports on the perioperative prevention, intraoperative risk factors, and treatment of postoperative AE of IP and summarized the perioperative management techniques for IP patients undergoing non-pulmonary surgery.

Enhanced karyopherin-α2 expression is associated with carcinogenesis in patients with intraductal papillary mucinous neoplasms

BACKGROUND/OBJECTIVES Intraductal papillary mucinous neoplasms (IPMN) can become malignant. Karyopherin-α2 (KPNA2) plays a central role in nucleocytoplasmic transport and is associated with various types of cancer. The current study examined pancreatic KPNA2 expression in cancer patients and evaluated its association with clinicopathological factors, cancer cell proliferation. METHODS KPNA2 expression was investigated by immunohistochemistry in 40 surgically resected IPMN samples and its association with clinicopathological factors and Ki-67 expression were examined. RESULTS Eighteen IPMN samples (45% of patients) showed positive KPNA2 expression. KPNA2 expression levels in IPMN tissue with invasive carcinoma were significantly higher than those in adjacent normal tissues and in IPMN tissue with low-to high-grade dysplasia. KPNA2 expression correlated with pathological malignancy and Ki-67 labeling index and KPNA2 and Ki-67 expression was co-localized in nuclei. E2F were co-localized with KPNA2 in the IPMN tissues with high expression of KPNA2. KPNA2 expression was enhanced in the invasion front and in proliferating Ki-67-positive cells. In addition, KPNA2 expression in IPMN tissues was associated with older age, dilation of main pancreatic duct diameter, the presence of nodules, and histological type. CONCLUSION KPNA2 expression is associated with carcinogenesis of IPMN through the adenoma-carcinoma sequence.

Presence of Cytokeratin 19-Expressing Cholangiocarcinoma-Like Tumour in a Liver Metastatic Lesion of Rectal Neuroendocrine Tumour

Introduction: Tumours with adenocarcinoma and neuroendocrine components have often been reported, although the reason underlying the dual components remains unclear. Case Presentation: A 43-year-old woman with multiple liver metastatic lesions of rectal neuroendocrine tumour underwent primary tumour resection and subsequent liver transplantation. Pathological examination indicated a cholangiocarcinoma-like tumour with gland formation, adjacent to a liver metastatic lesion of the neuroendocrine tumour. This tumour comprised atypical columnar epithelium, and stained positively for neuroendocrine markers and the ductal marker cytokeratin 19, indicating amphicrine properties and a partial cholangiocarcinoma phenotype – features not observed in the primary and metastatic neuroendocrine tumours. Conclusion: The presence of adenocarcinoma only at the metastatic site indicated that neuroendocrine tumour cells acquired stemness and differentiated into adenocarcinoma through metastasis, or that the adenocarcinoma newly arose from the adjacent epithelium influenced by the neuroendocrine tumour. We propose a novel mechanism for the pathogenesis of mixed tumours in neuroendocrine tumours.

Securing the surgical field in laparoscopic pancreatectomy using a Penrose drain and Endo Close.

Introduction: We adopted the use of Penrose drains and Endo Close to secure a good surgical field during laparoscopic pancreatectomy. Methods: We used a Penrose drain with threads ligated on both ends to suspend the stomach. We then pulled the threads out of the body from the side of the trocar or from besides the xiphisternum by using Endo Close. In most cases, 2 Penrose drains were used to retract the stomach. When the greater omentum on the left side of the cardia still blocks the surgical field, we sewed the posterior wall of the stomach onto the dome of the diaphragm. Results: The use of 2 Penrose drains and Endo Close were effective to retract the stomach in most cases. However, in 3 cases, we needed to additionally sew the stomach onto the diaphragm to fully open up the field. Conclusion: This is a simple and effective method to ensure a good surgical field.

Modified Pringle Maneuver Applicable for Laparoscopic Hepatectomy.

INTRODUCTION We present a widely applicable technique of the modified Pringle maneuver to reduce blood loss for laparoscopic hepatectomy. METHODS We use a drip-infusion tube and wrap it around the hepatoduodenal ligament. In the modified Pringle maneuver ① (m-Pringle ①), we use a 60 cm long tube. Both ends of the tube are led out from the side of the umbilical port, then pulled and clipped with Pean forceps to interrupt blood flow. In the modified Pringle maneuver ② (m-Pringle ②), we use a 20 cm long tube with silk threads tied at both ends. The threads were led extraperitoneally in the same manner. RESULTS Although blood flow was sufficiently interrupted, CO2 leak occurred in 14 of 60 cases in m-Pringle ①. Blood flow was interrupted and intra-abdominal pressure was kept in all 10 patients in m-Pringle ②. CONCLUSIONS These maneuvers require no extra port, and tube pulling and releasing is readily performed from outside the body.