Masahiro Urayama

Altered biliary bilirubin profile in patients with persistent hyperbilirubinaemia after hepatic resection: Analysis of bile bilirubin subfractions by high-performance liquid chromatography

Subfractions of bilirubin in bile, obtained via biliary drainage tubes from 23 patients who had undergone radical surgery for bile duct cancer, were analysed by high‐performance liquid chromatography for 14 days after surgery. Five principal conjugated bilirubins were resolved: bilirubin diglucuronide (BDG); bilirubin monoglucuronide monoglucoside (BGG); bilirubin monoglucuronide monoxyloside (BGX); and two isomers of bilirubin monoglucuronide. After surgery, depression in concentration of BDG and elevation of BGG and BGX were found. These alterations were of higher magnitude in patients who had undergone hepatectomy, and especially prolonged in patients with hyperbilirubinaemia. These results suggest that the alteration in proportions of bilirubin conjugates might be a cause of hyperbilirubinaemia after hepatectomy.

Microsurgical technique used in right anterior segmentectomy and pancreatoduodenectomy with reconstruction of the right posterior hepatic artery for widespread bile duct cancer involving the hepatic hilus

A microsurgical technique was used in performing anterior hepatic segmentectomy and pancreatoduodenectomy with reconstruction of the posterior hepatic artery in a 64-year-old man with widespread bile duct cancer from the intrapancreatic bile duct over the hepatic hilus. The anterior hepatic artery was obviously involved and the posterior hepatic artery just behind common hepatic duct was very close to the cancer. Microsurgical anastomosis between the remnant gastroduodenal artery and the posterior hepatic artery at the hepatic hilus made it possible to preserve the posterior segment of the liver and to perform a curative resection of the cancer. The patient had pyrexia because of suprahepatic abscess after the operation, but the abscess drained spontaneously. Postoperative arteriogram showed neither obstruction nor kinking of the reconstructed artery. He was discharged 2 months after surgery and has been enjoying a normal quality of life for 10 months since, with no signs of recurrence. It is suggested that a microsurgical technique is useful for performing an accurate anastomosis with good patency that allows not only a safe but also a highly curative operation for advanced bile duct cancer.

Early Laparoscopic Cholecystectomy for Acute Cholecystitis in Accordance with the Tokyo Guidelines for the Management of AcuteCholangitis and Cholecystitis

Aims: To determine if early laparoscopic cholecystectomy (LC) for acute cholecystitis, performed in accordance with the Tokyo Guidelines for the Management of Acute Cholangitis and Cholecystitis, was more effective than delayed LC. Methodology: We compared surgical difficulties, clinical courses and complications between 32 patients undergoing delayed LC and 30 undergoing early LC. Results: Delayed LC was associated with more surgical difficulties than early LC, including severe adhesion of the greater omentum (15/32 vs. 1/30), severe cicatrization of Calot’s triangle (15/32 vs. 3/30), inability to identify or skeletonize the cystic duct (18/32 vs. 3/30), and severe cicatrization of the gallbladder bed (27/32 vs. 1/30). Delayed LC was also associated with longer operating times (163 vs. 93 minutes), more conversions to open surgery (7/32 vs. 0/30), more complications (3/32 vs. 1/30), and longer hospitalization (30.5 vs. 10.2 days). Most early LCs was performed during overtime. Conclusions: Despite the retrospective nature of this study, the results demonstrated that changing treatment for acute cholecystitis from delayed to early LC, in accordance with the Tokyo Guidelines, could effectively reduce operation time, duration of symptoms and hospital stay, and thus be of significant benefit to patients. Further, prospective studies are needed to confirm these findings.

Sa1099 Clinical Studies of Gastrectomy for Gastric Cancer in Patients Over 80 Years Old

G A A b st ra ct s indirect effect (2%) mediated by increasing a patients CSBM rate (Figure 1). Spontaneous bowel movements (SBMs) that were not associated with a sense of completeness and BMs associated with rescue medication use did not qualitatively increase the amount of mediated LIN pain effect. The results of the 2-way CSBM stratification analysis (Table 1) indicated that improvement in abdominal pain was influenced by the time since last CSBM and the number of recent CSBMs. However, consistent with the predominant direct effect of LIN on abdominal pain shown in the mediation analysis, in each cell of Table 1, the LIN-treated patients had greater abdominal pain relief than PBO-treated patients when controlling for these CSBM factors. Conclusions: The results of these analyses are consistent with the hypothesis that the LIN effect on abdominal pain (over PBO) was predominantly a direct effect and, to a lesser extent, a mediated effect of increasing CSBM frequency. Table 1. Percent Improvement in Abdominal Pain Stratified by Number of Recent CSBMs and Time Since Last CSBM by Treatment Group (LIN/PBO [LIN-PBO difference])

Two Cases of Acute Emphysematous Cholecystitis.

急性気腫性胆嚢炎はガス産生菌によって生ずるまれな疾患で, 腹部画像検査で胆嚢内や胆嚢壁周囲に異常ガス像を示す特徴を有する.われわれは過去2年間に, 急性気腫性胆嚢炎を2例経験した.症例1は上腹部痛を主訴として入院となった68歳の男性で, 腹部X線写真と腹部CTにて胆嚢内ガス像を認めた.保存的治療の後, 第18病日に待機的に胆嚢摘出術を行った.病理診断は壊疽性胆嚢炎であった.胆汁の細菌培養でClostridium属が検出された.症例2は上腹部痛を主訴として来院した85歳の男性である.腹部X線写真で胆管内ガス像, 腹部CTにて胆嚢内ガス像および胆管内ガス像を認めた.即日, 経皮経肝的胆嚢ドレナージを行ったが, 不成功となったため緊急開腹手術を施行した.病理診断は蜂窩織炎性胆嚢炎で, 胆汁の細菌培養でClostridium perfringensが検出された.両者とも術後経過は順調で, それぞれ術後14日目と16日目に退院した.