Kojun Okamoto

The Use of Autologous Fibrin Glue for the Treatment of Postoperative Fecal Fistula Following an Appendectomy: Report of a Case

We herein report a case of postoperative fecal fistula following an appendectomy which was successfully treated by the use of autologous fibrin glue. An 82-year-old man had acute appendicitis and underwent an appendectomy. Later, a fecal fistula developed and he underwent drainage treatment twice. After 4 weeks of drainage and during the third recurrence, the remaining fistula was successfully treated using autologous fibrin glue, instead of surgery, due to potential complications and the risks of associated with advanced age. No recurrence has been observed for 5 months. In conclusion, autologous fibrin gluing for fecal fistula was found to be a safe, economical, and effective treatment. A search of Medline from 1980 until 2002 revealed no other report of this treatment for postoperative fecal fistula following an appendectomy.

Regeneration of extrahepatic bile ducts by tissue engineering with a bioabsorbable polymer

With the widespread adoption of laparoscopic cholecystectomy and living-donor liver transplantation in recent years, complications involving the biliary system, stenosis in particular, are increasing. Various invasive and non-invasive techniques are now available for the treatment of biliary stenosis, but all are compromised by a high risk of recurrence and other problems. As a potential solution, our group has developed a bioabsorbable polymer (BAP) tube for implantation as a bypass graft. In the study reported here, we implanted this BAP tube and confirmed bile duct regeneration at the graft site after the tube had been degraded and absorbed into the body. We briefly describe our findings on extrahepatic biliary tissue regeneration, focusing on the possibility of its clinical application. This artificial bile duct may promote the development of novel treatments for biliary disease.

Extensive regeneration of the stomach using bioabsorbable polymer sheets

BACKGROUND The growing prevalence of endoscopic surgery in recent years has led to the minimization of postoperative scarring. However, this procedure does not allow for the regeneration of the resected digestive tract, which compromises the postoperative maintenance of digestive function. In this preliminary study, we developed an artificial gastric wall (AGW) using bioabsorbable polymer (BAP), and evaluated the ability of this BAP patch to repair and regenerate a widely defective gastric wall in an animal model. METHODS Pigs were laparotomized under general anesthesia. An 8 × 8-cm, round portion of the anterior gastric wall was excised and replaced by an AGW. The AGW was composed of a copolymer comprising 50% lactic acid and 50% caprolactone. The animals were relaparotomized 4, 8, or 12 weeks after implantation, after which they underwent resection of the entire stomach for gross and histologic evaluation of the graft sites. RESULTS All recipient pigs survived until killing. By 4-8 weeks, the graft site revealed progressively fewer mucosal defect after each day. Moreover, the grafted area was indistinguishable from the native stomach 12 weeks after AGW implantation. The structures of the regenerated mucous membrane and muscle layers were identical to those of the native stomach. Furthermore, proton pumps were found in the regenerated tissue. CONCLUSION The BAP sheets helped to restore extensive gastric defects without causing any deformation. The use of BAP sheets may become a new therapeutic method that prevents alterations of gastric volume after extensive gastrectomy for stomach cancer and other diseases.

A case of aggressive solid pseudopapillary neoplasm: Comparison of clinical and pathologic features with non-aggressive cases

Solid pseudopapillary neoplasms (SPNs) may have an aggressive clinical course, but clinical predictors of this condition have not been thoroughly evaluated. We performed a retrospective study of 11 cases of SPN managed in our hospital between January 2007 and April 2015. Of these 11 cases, we encountered a single case with an aggressive clinical course. Histological, immunohistochemical, and clinical features were compared to identify predictors of poor prognosis. The 11 patients comprised four women and seven men with a median age of 41 years (range, 26–58 years). Clinical symptoms were nonspecific and the median tumor size was 4.6 cm (range, 1.4–18 cm). The patient with an aggressive clinical course developed multiple liver metastases within three months and died seven months after surgery. Pathological features of the tumor in this case included lymph node metastases, a diffuse growth pattern, extensive tumor necrosis, high mitotic rate, and immunohistochemistry. These features were not observed in patients who survived without recurrence at a median follow‐up of 25 months (range, 6–82 months). Characteristic pathological features and a high proliferative index, as assessed by Ki‐67 staining, may predict poor outcome in cases of SPN.

Fibrin Glue Closure for Intractable Pancreatic Fistulae after Pancreaticoduodenectomy

CONTEXT Treatment of pancreatic fistulae after pancreaticoduodenectomy is extremely important because it determines the patients postoperative course. In particular, treatment of grade B cases should be conducted in a timely manner to avoid deterioration to grade C. OBJECTIVE We report the successful treatment of six cases of postoperative intractable, grade B pancreatic fistulae, in which fistula closure was achieved through the use of tissue adhesive. METHODS Six subjects presented at our hospital with grade B pancreatic fistulae after pancreaticoduodenectomy. In all cases, the drain amylase values were high immediately after the operation, and the replacement of the drain was enforced. Closure of the fistula was performed by pouring tissue adhesive into the fistula from the drain, after the fistula had been straightened. RESULTS Closure of the fistula was achieved in all six cases at the first attempt. The average fistula length was 13.2 cm, the average volume of pancreatic fluid discharge just before treatment was 63.3 mL, the average amylase value in the drainage was 40,338.5 IU/L, and the subjects were discharged from hospital an average of 8.8 days after treatment. There were no recurrences after treatment. CONCLUSION Intractable pancreatic fistulae can be effectively treated using the tissue adhesive method.

Liver resection using a soft-coagulation system without the Pringle maneuver.

BACKGROUND/AIMS The Pringle maneuver is generally performed to reduce the amount of blood loss during hepatic resection. We have developed a method to sufficiently control blood loss during hepatectomy without applying the Pringle maneuver. This study was performed to determine the safety and operative blood loss in hepatectomy performed by this new method. METHODOLOGY We performed 102 hepatic resections without the Pringle maneuver. We retrospectively compared the short-term operative outcome between these 102 cases and another 75 hepatic resections performed with the Pringle maneuver. The resections without the Pringle maneuver were performed using a soft-coagulation system. RESULTS The median length of the surgery using the soft-coagulation system without the Pringle maneuver was 135 minutes, significantly shorter than the surgical time required for resection with the Pringle maneuver 297 minutes (p<0.001). The median volume of operative blood loss was significantly lower in the non-Pringle-maneuver group (200cc vs. 704cc; p<0.001). Regarding postoperative liver function, AST, ALT, T-Bil and PT, levels were all significantly improved in the non-Pringle-maneuver group (p<0.01). CONCLUSIONS Our data suggest that hepatic resection using a soft-coagulation system without the Pringle maneuver is extremely safe and effective in controlling bleeding.

Surgical Resection of Metachronous Lymph Node Metastasis From Hepatocellular Carcinoma: Three Case Reports and Review of the Literature

The prognosis for hepatocellular carcinoma (HCC) patients with lymph node (LN) metastasis is generally poor, and no consensus has yet been reached on the optimum treatment strategy. We observed 3 c...

An Artificial Bile Duct Made of Bioabsorbable Polymer: A Viable Substitute for Narrowed Portion of the Extrahepatic Bile Duct

The aim of this study was to investigate whether an artificial bile duct made of bioabsorbable polymer could serve as a substitute for narrowed portions of the bile duct. The experiments were performed using hybrid pigs (n = 11). After laparotomy under general anesthesia, the extrahepatic bile duct was identified and ligated around the confluence with the cystic duct. A week later, repeat laparotomy was performed on the animals, and the bile duct on the hepatic side of the ligature was resected. The cut end was connected to the duodenum using a bioabsorbable artificial bile duct fabricated from a copolymer of polycaprolactone and polylactic acid fibers. The grafts were recovered for gross, histologic, and blood chemical studies at 4 months after the surgery. All recipient pigs survived until they were humanely killed for collection of the implants. A week of ligation of the extrahepatic bile duct dilated the duct to approximately 1 cm in diameter and increased total bilirubin. Total bilirubin had returned...

Novel pancreatoenteric reconstruction using a bioabsorbable polymer sheet and biocompatible bond

BACKGROUND Pancreatoenteric reconstruction often induces severe complications. Although many techniques have been developed to prevent these complications, no standard technique has yet emerged. We developed a novel technique, sutureless pancreatoenteric anastomosis, that uses a bioabsorbable polymer sheet (BAPS) and biocompatible bond (BCB) to prevent the complications associated with pancreatoenteric anastomosis. We used large animals to investigate whether this technique is suitable for clinical use. MATERIALS AND METHODS Six pigs were laparotomized under general anesthesia. The body of the pancreas was divided, and the proximal stump was closed by suture. A BAPS coated with BCB was rolled and fixed around the distal pancreatic stump to form a cylinder that was anastomosed to the duodenum without suturing the pancreas. Twenty weeks after the initial operation the operated sites were extirpated and evaluated grossly and histologically. RESULTS All operated pigs survived without pancreatic juice leakage until they were killed. At 20 wk, the BAPS could not be identified. The pancreatic stump was tightly affixed to the duodenum. Histologic study revealed that the pancreatic stump and duodenal wall were continuous and the main pancreatic duct opened into the lumen of the duodenum. CONCLUSIONS Sutureless pancreatoenterostomy with BAPS and BCB may be clinically feasible.

Tu1038 Laparoscopic Hepatectomy of Segment 7 or 8 of the Liver With a Transthoracic Port

[Background and Aims] Sporadic cases of unexpected recurrence, such as intrahepatic dissemination, extrahepatic seeding, and rapidly growing recurrence have been described following radiofrequency ablation (RFA). Some reports speculated that RFA during energy application may increase intratumoral pressure and favor intravascular spread of the tumor. Therefore, we examined the existence of hepatocytes in the hepatic vein during RFA. [Subjects and Methods] A total of 3 pigs with a mean body weight of 58.8 ± 5.7 kg were intubated and general anesthesia were maintained. Using the 8-Fr sheath inserted into the left jugular vein, a guidewire was used to guide a 4-Fr catheter to the hepatic vein. After median laparotomy, needle electrodes were inserted inside the liver, and RFA was performed near the catheter. A cooled-tip RF needle electrode was used for RFA. Ablation was performed by increasing output by 10 W/min, starting at 40 W. The duration of ablation was 6 min. The blood was collected by placing the catheter 10mm from the needle electrode tip. Fifteen RFA sessions of 3 animals were examined to detect exfoliated tissues. In every RFA session, 30 ml of the down-streaming blood in the vessel attached to the irradiated part was collected to a heparinized syringe and separated by using Ficoll-gradient method. Cell fractions were incubated with the culture medium for 15 hours. The number of cell clusters attached on culture dishes were counted and examined immunohistochemically for albumin as a hepatocyte marker. [Results] The results of immunohistochemistry showed that albumin-positive cells were found in cell clusters those were attaching and spreading on the culture dish. The margin of the cluster showed membrane ruffling. That means the live hepatocytes being trapped in the outbound vessel of RFA treated site. Various sizes of clusters were found. The clusters were classified in four as S-1 (5 to 10 cells), S-2 (11 to 20 cells), S-3 (21 to 50 cells), and S-4 (more than 50 cells) according to the constituted cell amount. The mean number of cell clusters found in every RFA was S-1; 9 ± 7.1, S-2; 5.1 ± 5.7, S-3; 0.6 ± 0.8, S-4; 0.5 ± 0.8, respectively. Smaller sizes of clusters (S-1 and S-2) were more frequently found (P, 0.01 vs. S-3 and S-4). These clusters were never found in the blood before RFA. Therefore, it should be concluded that the cell cluster was derived from the liver and was artificially exfoliated tissue masses by RFA. [Conclusions] The present results demonstrate that hepatocytes are pushed out alive into the hepatic vein from the hepatic lobules by RFA. These results suggested that a risk of dissemination due to RFA exists.