Mitsuo Kusano

Delorme’s Procedure for Rectal Prolapse

AbstractPURPOSE: Clinical and physiological results of Delorme’s procedure were assessed retrospectively in patients undergoing this procedure for rectal prolapse. nMETHODS: A consecutive series of 31 patients (7 males, 24 females; age, 14–93, mean 70 years) with full-thickness, rectal prolapse were treated by Delorme’s procedure between 1994 and 2002. Median follow-up was 39 (range, 6–96) months. nRESULTS: Good results were achieved in 27 patients (87 percent), prolapse recurrence was observed in 4 (13 percent), and mean recurrence time was 14 (range, 3–25) months. There were no postoperative deaths. Minor complications occurred in four patients. The median changes in preoperative and postoperative physiologic patterns in 16 patients were as follows: resting pressure from 21.0 (range, 5–48) to 23.5 (range, 12–76) cm H2O (P = 0.030), squeeze pressure from 64.0 (range, 27–248) to 108.0 (range, 32–264) cm H2O (P = 0.041), volume at first sensation from 100 (range, 70–180) to 70 (range, 40–130) ml (P = 0.002), maximum tolerated volume from 260 (range, 120–400) to 160 (range, 70–400) ml (P = 0.001). Incontinence improved in 63 percent. No patient became constipated, and 38 percent of those constipated preoperatively improved. The preoperative incontinence score improved from 11.5 (range, 1–20) to 6.0 (range, 0–20) after operation (P < 0.0001). nCONCLUSION: Delorme’s procedure had a low morbidity, did not lead to constipation, improved anal continence, and had a reasonably low recurrence rate. Improved anal sphincter and rectal sensation were associated with a reduced incidence of defecatory problems after Delorme’s procedure.

The usefulness of ICG video angiography in the surgical treatment of superior cluneal nerve entrapment neuropathy

Superior cluneal nerve (SCN) entrapment neuropathy is a known cause of low back pain. Although surgical release at the entrapment point of the osteofibrous orifice is effective, intraoperative identification of the thin SCN in thick fat tissue and confirmation of sufficient decompression are difficult. Intraoperative indocyanine green video angiography (ICG-VA) is simple, clearly demonstrates the vascular flow dynamics, and provides real-time information on vascular patency and flow. The peripheral nerve is supplied from epineurial vessels around the nerve (vasa nervorum), and the authors now present the first ICG-VA documentation of the technique and usefulness of peripheral nerve neurolysis surgery to treat SCN entrapment neuropathy in 16 locally anesthetized patients. Clinical outcomes were assessed with the Roland-Morris Disability Questionnaire before surgery and at the latest follow-up after surgery. Indocyanine green video angiography was useful for identifying the SCN in fat tissue. It showed that the SCN penetrated and was entrapped by the thoracolumbar fascia through the orifice just before crossing over the iliac crest in all patients. The SCN was decompressed by dissection of the fascia from the orifice. Indocyanine green video angiography visualized the SCN and its termination at the entrapment point. After sufficient decompression, the SCN was clearly visualized on ICG-VA images. Low back pain improved significantly, from a preoperative Roland-Morris Questionnaire score of 13.8 to a postoperative score of 1.3 at the last follow-up visit (p < 0.05). The authors suggest that ICG-VA is useful for the inspection of peripheral nerves such as the SCN and helps to identify the SCN and to confirm sufficient decompression at surgery for SCN entrapment.

Association between intermittent low-back pain and superior cluneal nerve entrapment neuropathy.

OBJECT Superior cluneal nerve (SCN) entrapment neuropathy (SCNEN) is a cause of low-back pain (LBP) that can be misdiagnosed as a lumbar spine disorder. The clinical features and etiology of LBP remain poorly understood. In this study, 5 patients with intermittent LBP due to SCNEN who had previously received conservative treatment underwent surgery. The findings are reported and the etiology of LBP is discussed to determine whether it is attributable to SCNEN. METHODS Intermittent LBP is defined as a clinical condition in which pain is induced by standing or walking but is absent at rest. Between April 2012 and March 2013, 5 patients in this study who had intermittent LBP due to SCNEN underwent surgery. The patients included 3 men and 2 women, with a mean age of 66 years. The affected side was unilateral in 2 patients and bilateral in 3 (total sites, 8). The interval from symptom onset to treatment averaged 51.4 months; the mean postoperative follow-up period was 17.6 months. The clinical outcomes were assessed using the numerical rating scale (NRS) for LBP, the Japanese Orthopaedic Association (JOA) scale, and the Roland-Morris Disability Questionnaire (RDQ) preoperatively and at the last follow-up; these data were analyzed statistically. RESULTS None of the 5 patients reported LBP at rest. Intermittent LBP involving the iliac crest and buttocks was induced by standing or walking an average of 136 m. In 2 patients with unilateral involvement, LBP was improved only by SCN block. Surgeries were performed on 6 sites in 5 patients because the SCN block was only transiently effective. Patients SCNs penetrated the orifice of the thoracolumbar fascia. SCN kinking at the orifice was exacerbated at the lumbar-extension provocation posture, and radiating pain increased upon manual intraoperative compression of the SCN in this posture. After releasing the SCN surgically, disappearance of the pain was intraoperatively confirmed by manual compression of the SCN with the patients in the lumbar-extension posture. Surgery was effective in all 5 patients, and all clinical outcome scores indicated significant improvement (p < 0.05). CONCLUSIONS To the authors knowledge, this is the first report of patients with intermittent LBP due to SCNEN. Clinical and surgical evidence presented suggests that their LBP was exacerbated by lumbar extension and that symptom relief was obtained by SCN block or surgical release of the SCN entrapment. These results suggest that SCNEN should be considered as a causal factor in patients for whom walking elicits LBP.

Macro- and microscopic findings of ICG fluorescence in liver tumors

BackgroundReports detailing microscopic observations of indocyanine green (ICG) fluorescence imaging (IFI) in hepatocellular carcinoma (HCC) and metastatic liver cancer are rare. We were able to perform macro- and microscopic IFI results in postoperative paraffin-embedded tissue samples and formalin-fixed specimens from liver tumors.MethodsBetween April 2010 and March 2014, 19 patients with HCC or liver metastases of colorectal tumors underwent liver resection. ICG solution was injected into the peripheral vein from 14 to 2 days prior to operation. We observed liver tumor IFI during the laparotomy and IFI in resected liver sections using a photo dynamic emission (PDE) camera. The IFI of paraffin-embedded tissue samples was observed using a charge-coupled device (CCD) camera. Moreover, we microscopically performed tissue section IFI using a fluorescence microscope with an ICG-B-NQF.ResultsWe performed that IFI characteristics depended on tumor type macroscopically and microscopically. In normal liver tissue, fluorescence consistent with the bile canaliculus was observed. HCC had heterogeneous IFI, forming a total or partial tumor and rim pattern. In metastatic carcinoma, we performed that non-tumor cells in the marginal region showed fluorescence and tumor cells in the central region did not fluoresce.ConclusionsWe confirmed that the variations of ICG fluorescence imaging patterns reflect different tumor characteristics in not only macroscopic imaging as previous reports but also microscopic imaging. Moreover, the ICG fluorescence method is useful for postoperative pathological detection of microscopic lesions in histopathological specimens. ICG fluorescence in paraffin-embedded tissue samples and formalin-fixed specimens is preserved in the long term.

Evaluation of fluorescence imaging with indocyanine green in hepatocellular carcinoma

BackgroundWe hypothesized that indocyanine green (ICG) fluorescence patterns using Clairvivo OPT in resected liver specimens could confirm hepatocellular carcinoma (HCC) better than earlier commercial imaging systems. This preclinical trial evaluated the effectiveness of fluorescence imaging as an intraoperative cancer navigation tool.MethodsICG fluorescence images of resected specimens from 190 patients with HCC were classified into two groups according to whether high fluorescence was seen in the HCC (high cancerous [HC] group) or in the surrounding liver tissue (high surrounding [HS] group). The HC and HS groups were sub-classified into whole and partial types and whole and ring types, respectively.ResultsThe HC group had significantly higher prevalence of esophageal or gastric varices, and worse liver function than patients in the HS group. The HC group also had a higher percentage of limited resection cases than did the HS group. Cirrhotic liver histology was significantly more common in the HC group than in the HS group. Multivariate analysis revealed that the HC group was a predictive factor for cirrhosis in HCC patients. Among the HC patients, a higher percentage of well-differentiated HCC cases were seen in the partial-type subgroup than in the whole-type subgroup (23/48 (48xa0%) vs. 7/68 (10xa0%)). In the HS group, the ring-type subgroup had a higher percentage of poorly differentiated HCC cases than did the whole-type subgroup (6/37 (16xa0%) vs. 0/37 (0xa0%)).ConclusionTumor differentiation and fibrosis in the non-cancerous liver parenchyma could affect ICG fluorescence imaging in HCC. ICG fluorescence imaging may be a good indication for fibrosis stage. In future, we will try to evaluate fluorescence imaging with ICG for intraoperative cancer navigation in HCC, using a portable near-infrared fluorescence imaging system.

Navigation using indocyanine green fluorescence imaging for hepatoblastoma pulmonary metastases surgery

To achieve precise and sensitive detection of chemotherapy-resistant hepatoblastoma pulmonary metastases, we performed surgery using indocyanine green (ICG) fluorescence imaging navigation. Lung metastasectomies were performed in 10 patients aged from 1 to 11xa0years. ICG (0.5xa0mg/kg) was injected intravenously 24xa0h before the operation. After a thoracotomy had been performed, a 760-nm infrared ray was applied to the lung using a generator and the 830-nm evoked fluorescence was collected and visualized on a real-time display. In total, 250 fluorescence-positive lesions were extirpated in 37 operations. All of the pathologically positive lesions were clearly fluorescence positive. The diameter of the smallest detectable lesion was 0.062xa0mm. In two patients, there were 29 extirpated lesions that were pathologically proven not to be hepatoblastoma metastases. Although a problem of false positive remains, this method is very useful for the detection of small pulmonary metastases.

Intraoperative localization of arteriovenous malformation of a jejunum with combined use of angiographic methods and indocyanine green injection: Report of a new technique

Highlights • The localization of small intestine sources of obscure gastrointestinal bleeding is a challenge.• The use of indocyanine green (ICG) is effective in aiding intraoperative localization.• The ICG fluorescence imaging can visualize the lesion as an arteriovenous malformation.

Staining of Liver Segments

Anatomic hepatic segmentectomy is considered the gold standard approach for liver resection in patients with hepatocellular carcinoma, with the goal of reducing cancer recurrence after liver resection

Indocyanine Green Fluorescence Properties

The properties of indocyanine green (ICG) enable the observation of fluorescence images with a photodynamic eye (PDE) system after ICG is injected into a subject locally or intravenously. Over the last decade, many clinical applications using an ICG approach have been introduced, e.g., the detection of sentinel nodes in breast cancer and melanoma and the use of ICG as the contrast medium in cerebral angiography. However, an insufficient amount of basic research on the fluorescence properties of ICG has been done. In the present study, we first sought to identify the optimal ICG concentration that provides the maximum brightness fluorescence, in an in vitro experiment. The ICG solution used was 2.5 mg/10 mL of distilled water (original ICG solution). For additional diluted ICG solutions, we used physiological saline (saline) and distilled water. The results did not reveal the optimal concentration ratio of ICG and diluted solutions for obtaining the maximum fluorescence and intensity in each respective solution. In the next experiment, we added bovine albumin (2 g/dL) to each diluted solution. We then evaluated the appropriate dilution ratio of bovine albumin solution and ICG solution, and the maximum brightness of the ICG fluorescence was observed using the dilution of ICG solution to approx. 90-fold from 100-fold. In another experiment, the maximum intensity of ICG fluorescence was present in approx. 90-fold-diluted ICG solution in plasma. We further assessed the characteristics of ICG fluorescence in various conditions of temperature, pH, and light/dark. We observed no remarkable changes of ICG fluorescence intensity from 10 to 50 °C. Additionally, the ICG fluorescence was affected by the acid or alkali status and was preserved under the cold/dark condition.

Fluorescent Navigation Surgery for Gastrointestinal Tract Cancers: Detection of Sentinel Nodes, Tumor Tattooing, and Harvesting of Lymph Nodes

The applications of indocyanine green (ICG) fluorescence imaging (IFI) for fluorescent-guided surgery have been expanding. Here we assessed the use of IFI in gastrointestinal tract surgeries. We first evaluated the feasibility of sentinel lymph node (SLN) mapping guided by IFI in gastrointestinal cancers. Twenty-two gastric cancer patients and 26 colorectal cancer patients who had undergone standard surgical resection were enrolled. The SLN detection rate in our preliminary study was 90.9 % and the mean number of SLNs was 3.6 in the gastric cancer patients, and the corresponding values in the colorectal cancer patients were 88.5 % and 2.6. Among the gastric cancer patients, the accuracy was 88.9 % and the false-negative rate was 33.3 %. Secondly, we assessed the efficacy of a new method for tattooing the tumor location using IFI instead of India ink. We succeeded in the ICG marking of early-stage stomach cancer and colon cancer, and our results may lead to the establishment of a new marking procedure instead of the conventional India ink and clipping methods. Lastly, we evaluated whether an IFI method of harvesting lymph nodes (LNs) from resected specimens could improve the accuracy of LN staging. ICG fluorescence-labeled LNs were found even though the ICG solution was injected ex vivo. The IFI method thus improved the LN harvest from resected specimens. This method will provide precise evaluations of the pathological status of LNs.