Satoshi Hirano

Simultaneous Near-Infrared Fluorescence Imaging of the Bile Duct and Hepatic Arterial Anatomy for Image-Guided Surgery

Two independent wavelengths of a near-infrared (NIR) fluorescent light probe are currently available in the clinical setting. These enable us to simultaneously see two different anatomies and/or functions. Many reports are available showing that NIR fluorescence imaging and merged imaging of normal light and NIR light are useful for intraoperative image guidance. Dual-channel NIR fluorescence imaging has already been reported. It has potential to provide easy-to-understand, real-time, intraoperative imaging in more detail than single-channel NIR fluorescence imaging. Indocyanine green (ICG), of which the fluorescence wavelength is about 800 nm, and methylene blue (MB), of which the fluorescence wavelength is about 700 nm, can be used for the probe of NIR fluorescence imaging with the use of an appropriate NIR camera. The FLARE (Fluorescence-Assisted Resection and Exploration) system provides simultaneous dual-channel fluorescence imaging. The results of the initial preclinical trial of dual-channel NIR imaging for a cardiac application have been published as well as the simultaneous visualization of bile ducts and hepatic arteries in the preclinical setting. Both ICG and MB eliminate into bile after intravenous injection. The nonmetabolized elimination of both ICG and MB can detect fluorescence out of the bile. Intravenous injection of ICG, MB, and their combination can visualize the hepatic arteries and bile ducts in a different phase. MB has a lower extinction coefficient than ICG, i.e. ICG is a brighter fluorescence material than MB. However, ICG has poor liver-bile duct signal contrast because ICG accumulates in the liver rapidly and persistently. Furthermore, MB can visualize the bile duct more rapidly after intravenous injection than ICG because MB shows faster elimination into bile after intravenous injection. This technology has potential to provide appropriate intraoperative image guidance that can enable us to perform surgery more safely and precisely in a clinical situation.

A Case of Perforation of Diverticulum of the Third Duodenal Part due to Ileus Tube

3回の開腹歴がある79歳の女性が, イレウスの診断で当院内科に入院となった. 同日イレウス管の挿入が行われたが, 十二指腸水平脚近位にとどまり, より遠位に進めることが困難であった. 翌々日, 症状の改善なく, イレウス管造影検査で腸管外への造影剤の漏出と, 腹部CTで十二指腸周囲のfree airを認めたため, イレウス管による十二指腸穿孔の診断で緊急開腹術を施行した. 手術所見では十二指腸水平脚に憩室が存在し, 同部よりイレウス管の脱出を認めた.憩室切除, ドレナージ術, 結腸右半切除術を施行した. 十二指腸憩室が穿孔を来すことはまれであり, 穿孔例の多くは下行脚の憩室である. 医原性穿孔は3例のみ報告されているが, イレウス管による穿孔例は, 本邦では他に報告は見当たらない. イレウス管挿入時に十二指腸にて先進しない場合は, 憩室の存在も念頭におき, 慎重な操作を心がける必要があると考えられた.