Naruhiko Murase

Sulphonylurea receptors differently modulate ICC pacemaker Ca2+ activity and smooth muscle contractility

Appropriate gastrointestinal motility is essential to properly control the body energy level. Intracellular Ca2+ ([Ca2+]i) oscillations in interstitial cells of Cajal (ICCs; identified with c-Kit immunoreactivity) are considered to be the primary mechanism for the pacemaker activity in gastrointestinal motility. In the present study, RT-PCR examinations revealed predominant expression of the type 1 isoform of sulphonylurea receptors (SUR1) in ICCs of the mouse ileum, but expression of SUR2 was predominant in smooth muscle. In cell clusters prepared from the same tissue, smooth muscle contractility and pacemaker [Ca2+]i activity in ICCs were found to be differentially modulated by KATP channel openers and sulphonylurea compounds, in accordance with the expression of SUR isoforms. 1 μM cromakalim nearly fully suppressed the mechanical activity in smooth muscle, whereas ICC pacemaker [Ca2+]i oscillations persisted. Greater concentrations (∼10 μM) of cromakalim attenuated pacemaker [Ca2+]i oscillations. This effect was not reversed by changing the reversal potential of K+, but was prevented by glibenclamide. Diazoxide at 30 μM terminated ICC pacemaker [Ca2+]i oscillations, but again treatment with high extracellular K+ did not restore them. These results suggest that SUR can modulate pacemaker [Ca2+]i oscillations via voltage-independent mechanism(s), and also that intestinal pacemaking and glucose control are closely associated with SUR.

A New Era of Laparoscopic Revision of Kasai Portoenterostomy for the Treatment of Biliary Atresia

Purpose. Kasai portoenterostomy is the standard therapy for biliary atresia (BA). If Kasai is unsuccessful, there is controversy over whether revision of Kasai restores adequate biliary drainage. Although there are several reports of laparoscopic Kasai (Lap-Kasai), none has described laparoscopic revision (Lap-revision). The purposes of this study were to evaluate the feasibility and efficacy of Lap-revision. Methods. 65 patients underwent open Kasai between November 2001 and November 2013, and 12 patients underwent Lap-Kasai between December 2013 to January 2015. The indications for revision included bile flow cessation and recurrent cholangitis. Clinical data were compared between open and laparoscopic revisions of Kasai. Results. Open revision of Kasai was performed in 20 patients after open Kasai, and Lap-revision was performed in 4 patients after Lap-Kasai. Lap-revision was completed without conversion or major complication in any patient. The bilirubin level was normalized by Lap-revision in all four patients, and three of them were alive with their native liver. Open and laparoscopic revisions of Kasai were comparable in terms of the operation time, blood loss, and surgical outcomes. Conclusion. Lap-revision is a feasible and effective method for the treatment of BA and might herald a new era for the treatment of this disease.

Prophylactic effect of H2 blocker for anastomotic stricture after esophageal atresia repair.

Anastomotic stricture is the main complication after esophageal atresia (EA) repair. In this study, we assessed the efficacy of long‐term prophylactic H2 blocker treatment in preventing stricture.

The umbilical Benz incision for reduced port surgery in pediatric patients.

Background and Objectives: For reduced port surgery in pediatric patients, the initial umbilical incision plays an important role in both functional ability and cosmetic impact. Larger umbilical incisions enable better manipulation of forceps, extraction of larger surgical specimens, and easier exteriorization of the intestine for anastomosis. We have pursued an incision of the small pediatric umbilicus that allows for enlargement of the orifice of the abdominal opening with preservation of the natural umbilical profile. This article aims to present a new umbilical incision technique and describe the outcomes. Methods: We devised a new umbilical incision technique for reduced port surgery in pediatric patients. Our incision is made in an inverted Y shape (Benz incision), allowing for access port device insertion. The Benz incision technique was applied between November 2010 and May 2014 and was retrospectively studied. Results: Seventy-five patients underwent Benz incisions. The median age of all patients was 6 years 6 months (range, 26 days to 18 years), and the median body weight was 21.7 kg (range, 3.1–54.3 kg). Benz incisions were applied for various procedures, including reduced port surgery with hepaticojejunostomy for congenital biliary dilatation, portojejunostomy for biliary atresia, Meckel diverticulectomy, tumor resection, varicocelectomy, cholecystectomy, splenectomy, ileus surgery, ileocecal resection, and total colectomy. All patients were successfully treated, without a significant increase in operating time or severe complications. The cosmetic profile of the umbilicus was maintained after surgery. Conclusion: The Benz incision is a feasible, effective, and scarless approach for reduced port surgery in pediatric patients whose umbilical rings are too small for the conventional approach.

Two-Stage Thoracoscopic Repair of Long-Gap Esophageal Atresia Using Internal Traction Is Safe and Feasible

BACKGROUND The treatment of long-gap esophageal atresia remains an issue for pediatric surgeons. Many techniques for treating long-gap esophageal atresia have been proposed, but the optimal method has not been established. The thoracoscopic esophageal elongation technique has recently been developed. We previously reported a case in which two-stage thoracoscopic repair was performed using internal esophageal traction without esophageal tearing, and we retrospectively reviewed the outcomes of this procedure in this study. METHODS Five patients underwent thoracoscopic treatment involving internal esophageal traction for esophageal atresia involving a long gap or vascular ring over a 5-year period. RESULTS Between November 2010 and November 2015, 5 patients were treated with thoracoscopic traction. All of these patients successfully underwent thoracoscopic-delayed primary anastomosis. Conversion to open thoracotomy was not required in any case. The postoperative complications experienced by the patients included minor anastomotic leakage in 2 cases, anastomotic stenosis in 1 case, gastroesophageal reflux (GER) in 4 cases, and a hiatal hernia in 1 case. None of the patients died. CONCLUSIONS Two-stage thoracoscopic repair for esophageal atresia involving a long gap or vascular ring is a safe and feasible procedure; however, we must develop methods for treating minor anastomotic complications and GER due to esophageal traction in future.

The efficacy of resection of intrahepatic bile duct stenosis-causing membrane or septum for preventing hepatolithiasis after choledochal cyst excision

BACKGROUND/PURPOSE We previously found that many patients who developed hepatolithiasis after choledochal cyst excisions had intrahepatic bile duct stenosis (IHBDS). In 1992, we started resection of the membrane or septum which was found at the site of IHBDS during choledochal cyst excisions. Since intrahepatic stones usually take years to form, the efficacy of this procedure has not been proved. METHODS The records of patients who had IHBDS-causing membrane or septum and underwent choledochal cyst excision with Roux-Y hepaticojejunostomy between January 1979 and December 2006 were retrospectively analyzed. The patients who underwent surgical treatment for IHBDS-causing membrane or septum were compared with those who did not undergo the procedure. RESULTS Sixty-nine patients met the criteria, and seven patients who were followed up for less than 5years were excluded from the study. Thirty-three patients underwent surgical treatment for IHBDS, and three of them developed intrahepatic stones. Meanwhile, 10 of 29 patients who did not undergo the procedure developed intrahepatic stones. A statistically significant difference in intrahepatic stone formation was observed between the two groups in a log-rank test (P=0.016). CONCLUSIONS Meticulous probing and excision of the IHBDS-causing membrane or septum are effective for preventing hepatolithiasis after choledochal cyst excisions. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.

Long-term outcomes after revision of Kasai portoenterostomy for biliary atresia

The indications for and efficacy of revision of portoenterostomy (PE) for biliary atresia (BA) needs to be reassessed in an era of liver transplantation. We therefore reviewed the long‐term outcomes following revision of PE.

New Navigation Surgery for Resection of Lymphatic Malformations Using Indocyanine Green Fluorescence Imaging

Patient: Male, 15 Final Diagnosis: Lymphatic malformations Symptoms: Abdominal pain Medication: — Clinical Procedure: Navigation surgery Specialty: Surgery Objective: Unusual or unexpected effect of treatment Background: We used indocyanine green (ICG) fluorescence imaging to completely resect lymphatic malformations (LMs). This is the first report of navigation surgery utilizing ICG fluorescence imaging for resection of LMs. Case Report: A 15-year-old boy was diagnosed with LMs in the abdominal wall. The extent of the tumor was determined by an ultrasound, and ICG (Diagnogreen®, Daiichi-Sankyo Pharma, Tokyo, Japan) was injected subcutaneously and intradermally into the core and 2 marginal regions of the tumor (3 injections in total), respectively. During surgery, the extent of the tumor was confirmed with a photodynamic eye, and the tumor was completely resected. A fluorescent portion macroscopically estimated as normal was additionally resected and no residual fluorescence or tumor were confirmed in the remaining tissue. Abnormal lymphatic vessels were histopathologically observed in the additionally resected tissue, indicating the invasion of LMs. The surgery had a good outcome with no evidence of recurrence. Conclusions: We performed near-infrared fluorescence-guided imaging surgery for the resection of LMs in the abdominal wall. This is a single case study; therefore, assessment of more cases is warranted for further validation. This procedure could provide significant benefit to patients requiring resection of LMs.

Laparoscopic-assisted pancreaticoduodenectomy in a child with gastrinoma

Gastrinoma is rare in children. We report the case of a 9‐year‐old boy with weight loss and vomiting. Upper gastrointestinal imaging showed severe stenosis of the duodenum. Although gastrin was very high, imaging did not show a gastrinoma. Selective arterial secretagogue injection (SASI) test indicated a tumor within the gastroduodenal arterial zone. In accordance with the SASI test result, we performed laparoscopic‐assisted pancreaticoduodenectomy (LAPD). Postoperative biochemistry confirmed complete resection of the gastrinoma, and the patient was asymptomatic at follow up, 30 months after surgery. Even in patients with negative imaging for gastrinoma, aggressive resection following accurate localization on SASI test is biochemically curative. In such cases, the tumor is probably very small and LAPD may offer a minimally invasive procedure. As far as we know, LAPD in a child has not been previously reported.

Novel thoracoscopic navigation surgery for neonatal chylothorax using indocyanine-green fluorescent lymphography

BACKGROUND Postoperative chylothorax after surgery for esophageal atresia/tracheoesophageal fistula (TEF) is a rare but serious complication, especially in neonates. This study aimed to identify the thoracic duct and ligate chylous leakage sites, using thoracoscopic navigation of an indocyanine-green (ICG)-based near-infrared (NIR) fluorescence imaging system. METHODS From November 2014 to April 2017, thoracoscopic intraoperative ICG-NIR imaging was performed in 10 newborns (11 surgeries) with first TEF operation or with persistent postoperative chylothorax after TEF operation. NIR imaging was performed 1h after an inter-toe injection of ICG. Thoracoscopic ligations against the NIR-detected leakage sites were performed with sutures. RESULTS The thoracic duct or lymphatic leakage was directly visualized in each patient. In 8 surgeries with first thoracoscopic TEF operation, one case had suspected minor chylous leakage without postoperative chylothorax. Another case with no chylous leakage at the first operation resulted in chylothorax at postoperative day 11. In three neonates with postoperative chylothorax, leakage points were detected near the ablation site of the azygos vein during the first operation. These points were properly ligated, and postoperative chylous leakage ceased with no adverse events. CONCLUSIONS Thoracoscopic ICG-NIR imaging encourages the repair of refractory chylothorax and seems reliable. LEVEL OF EVIDENCE IV.