Shigeyuki Ueshima

Endothelin A-Receptor Blockade Worsens Endotoxin-Induced Hepatic Microcirculatory Changes and Necrosis

BACKGROUND & AIMS Endothelin 1 is considered to be an important regulator of sinusoidal blood flow and increases during endotoxemia. The purpose of this study was to investigate the role of endothelin 1 in hepatic microcirculation, oxygen transport, and liver injury during endotoxemia. METHODS Male Sprague-Dawley rats were continuously infused with 2.5 mL/h of saline, 0.8 mg . kg-1 . h-1 of lipopolysaccharide (LPS), 3 mg . kg-1 . h-1 of BQ-485, an endothelin A-receptor antagonist, or LPS plus BQ-485 for 7 hours. RESULTS BQ-485 infusion had no significant effect on hepatic microcirculation and liver injury. LPS increased the plasma levels of aspartate aminotransferase (AST) and total bilirubin and decreased the hepatic adenosine triphosphate (ATP) level and bile flow rate. LPS + BQ-485 infusion further increased the plasma levels of AST and total bilirubin and decreased the bile flow rate and the hepatic ATP level. Dual-spot microspectroscopy revealed mild decreases in sinusoidal erythrocyte velocity and oxygen transport in the LPS group and profound decreases in these parameters in the LPS + BQ-485 group. Histological examinations revealed massive necrotic changes in the pericentral regions of the LPS + BQ-485 group. CONCLUSIONS These results suggest that blockade of endothelin A receptors disturbs hepatic microcirculation and oxygen transport and aggravates the necrotic injury induced by endotoxin.

Totally laparoscopic low anterior resection for lower rectal cancer: combination of a new technique for intracorporeal anastomosis with prolapsing technique.

Background: Laparoscopically assisted low anterior resection is difficult even for experienced surgeons because of difficulties in selecting the appropriate transection line and completing anastomosis in the narrow pelvic space. The prolapsing technique resolves these problems. We combined our new technique for intracorporeal anastomosis with this prolapsing technique and achieved a totally laparoscopic low anterior resection. Methods: After the total mesorectal excision, a semi-circumferential colotomy is made at the anterior colonic wall just proximal to the proximal transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the anvil penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. The distal rectum is everted and pulled transanally outside the body using a grasping forceps inserted from the anus. Staple-closure and transection of the distal rectum is performed under direct vision. Anastomosis is established using the double-stapling technique. Results: Totally laparoscopic low anterior resections using this technique were performed for 7 patients with rectal cancer. There was no anastomotic leakage/stenosis. Conclusions: Our procedure can be performed easily, which enables surgeons to achieve minimal invasiveness compared with hybrid NOTES.

A Simple and Safe Method for Gastrojejunostomy in Laparoscopic Distal Gastrectomy Using the Hemidouble-Stapling Technique: Efficient Purse-String Stapling Technique

Aim: To describe a simple technique for intracorporeal circular-stapled gastrojejunostomy in laparoscopic distal gastrectomy with Roux-en-Y reconstruction. Methods: After the stomach and duodenum were mobilized, gastrotomy was established in the anterior gastric wall. An anvil, which was secured with a suture needle, was inserted completely through the gastrotomy. The needle was advanced to the greater curvature of the gastric wall to enable penetration of the central rod into the gastric wall. Subsequently, the stomach was cut using a linear stapler to secure the anvil on the stomach and was sequentially transected using another linear stapler to achieve distal gastrectomy. Circular-stapled gastrojejunostomy was then performed intracorporeally using the hemidouble-stapling technique, while handling the shaft of the instrument via the umbilical incision. The jejunal stump was closed using a linear stapler. Results: Gastrojejunostomies were successfully performed in 20 gastric cancer patients using this technique. None of the patients showed anastomotic leakage and/or stenosis. There were no mortalities in this series. Conclusions: Gastrojejunostomy performed using the above-mentioned technique was safe and simple. The most important feature of the technique was the elimination of the need for purse-string suture placement, as well as the achievement of better cosmesis using the transumbilical approach.

Multiple benign metastasizing leiomyomas in the pelvic lymph nodes and biceps muscle: Report of a case

A 47-year-old woman with an earlier history of uterine leiomyoma suffered from multiple recurrent tumors in the retroperitoneal lymph nodes and biceps muscle of the right upper arm. The woman with a right lower abdominal tumor was referred to our hospital. An abdominal computed tomography scan revealed two round nodules with well-defined margins in the retroperitoneum in the pelvis, and echography revealed a similar nodule in the biceps of the right upper arm. A biopsy of the abdominal retroperitoneal tumor demonstrated benign metastasizing leiomyoma (BML). An extirpation of the abdominal tumors was therefore performed. After the operation, false climacteric medical treatment was performed for 3 years and no recurrence has since been observed. This is the first reported case of multiple BML in the lymph nodes and muscle occurring simultaneously.

Recovery of blood flow and oxygen transport after temporary ischemia of rat liver

Hepatic tissue perfusion and O2 supply after ischemia are indispensable for recovery of cellular functions, but few studies have been performed regarding the recovery of tissue blood flow and O2 transport. After 5, 15, and 30 min of ischemia of rat livers, hepatic tissue perfusion, hepatic arterial and portal blood flow, plasma PO2, and O2 transport parameters were measured. Hepatic tissue blood flow and erythrocyte velocity in the sinusoids showed biphasic recoveries after temporal ischemia for 5, 15, and 30 min. The first peak in the flow appeared at 3-4 min after the initiation of tissue perfusion, and the second peak appeared at approximately 20 min, irrespective of the ischemic period. Hepatic blood flow during the initial increase contained relatively low O2-saturated blood compared with that in the second increase. Livers that had been subjected to a prior hepatic artery ligation only showed the first peak at approximately 4 min. The first increase in hepatic blood flow corresponded to the peak in the portal venous flow, and the second increase corresponded to that of the hepatic artery. These results suggested that hepatic microcirculation after temporary hepatic ischemia showed biphasic recoveries because of different restoration patterns of the portal vein and hepatic artery.Hepatic tissue perfusion and O2 supply after ischemia are indispensable for recovery of cellular functions, but few studies have been performed regarding the recovery of tissue blood flow and O2 transport. After 5, 15, and 30 min of ischemia of rat livers, hepatic tissue perfusion, hepatic arterial and portal blood flow, plasma[Formula: see text], and O2 transport parameters were measured. Hepatic tissue blood flow and erythrocyte velocity in the sinusoids showed biphasic recoveries after temporal ischemia for 5, 15, and 30 min. The first peak in the flow appeared at 3-4 min after the initiation of tissue perfusion, and the second peak appeared at ∼20 min, irrespective of the ischemic period. Hepatic blood flow during the initial increase contained relatively low O2-saturated blood compared with that in the second increase. Livers that had been subjected to a prior hepatic artery ligation only showed the first peak at ∼4 min. The first increase in hepatic blood flow corresponded to the peak in the portal venous flow, and the second increase corresponded to that of the hepatic artery. These results suggested that hepatic microcirculation after temporary hepatic ischemia showed biphasic recoveries because of different restoration patterns of the portal vein and hepatic artery.

Short-term outcome of single-incision laparoscopic totally extra-peritoneal inguinal hernia repair.

We performed single‐incision laparoscopic surgery for totally extra‐peritoneal (SILS‐TEP) repair using a lightweight mesh fixed by absorbable tacks and without balloon dilation. Thirty‐four patients (mean age, 66.5 years) underwent SILS‐TEP repair in our hospital between September 2011 and April 2012; 30 patients had unilateral hernia and 4 had bilateral hernias. Mean operative time was 85.6 min for unilateral hernia and 137.7 min for bilateral hernias. All patients underwent successful SILS‐TEP repair. Mean hospital stay was 3.4 days. Mean duration of follow‐up was 7.1 months. Four seromas were observed, but no recurrences or major complications occurred. SILS‐TEP is an economical and useful method for decreasing postoperative complications, such as neuralgia and recurrence, and it could be an attractive approach for inguinal hernia.

Single-port laparoscopic colectomy is safe and feasible in patients with previous abdominal surgery.

BACKGROUND The aim of this study was to assess the impact of previous abdominal surgery (PAS) on single-port laparoscopic colectomy (SPLC). METHODS We studied 429 consecutive patients who underwent SPLC in our department from May 2009 to December 2013. Patients were divided into 2 groups: those with PAS (PAS group) and those with NPAS (NPAS group). Operative parameters and outcomes were analyzed between the 2 groups retrospectively. RESULTS SPLC was performed in 152 PAS patients and 277 NPAS patients. Eight patients in the PAS group and 6 patients in the NPAS group were converted to multiport laparoscopic colectomy (5.3% vs. 2.2%, respectively; P = .077). Three patients in the PAS group and 2 patients in the NPAS group had inadvertent enterotomy (2.0% vs. .7%, respectively; P = .352). No patients were converted to open surgery. There were no significant differences between the 2 groups in terms of blood loss, operative time, and postoperative outcomes. CONCLUSION Our experience has demonstrated the safety and feasibility of SPLC in patients with PAS.

Multiple hepatic sclerosing hemangioma mimicking metastatic liver tumor successfully treated by laparoscopic surgery: Report of a case.

Highlights • Sclerosing hemangioma should be included among the differential diagnoses of multiple liver tumors in patients with colorectal cancer.• Laparoscopic hepatectomy is useful for diagnostic therapy for undiagnosed multiple liver tumors.• This report is the first to describe multiple hepatic sclerosing hemangiomas treated by laparoscopic surgery.

Laparoscopic Distal Pancreatectomy for Multiple Epithelial Cysts in an Intrapancreatic Accessory Spleen. A Case Report and Review of Literature

CONTEXT Accessory spleen is a congenital abnormality consisting of normal splenic tissue in ectopic sites that is found in approximately 10-15% of the general population. However, an intrapancreatic accessory spleen has seldom been reported and multiple epithelial cysts in the intrapancreatic accessory spleen are extremely rare. CASE REPORT A 37-year-old woman with no clinical manifestations presented with two cystic lesions in the tail of the pancreas. The tumor markers CA 19-9 (251 U/mL) and SPAN-1 (38 U/mL) were increased. Computed tomography showed a multilocular cyst, 40 mm in size, and a unilocular cyst, 20 mm in size, in the tail of the pancreas and gallstones. The cystic component was hypointense on T1-weighted magnetic resonance images and hyperintense on T2-weighted magnetic resonance images. A laparoscopic distal pancreatectomy was performed with the presumptive diagnosis of a mucinous cystic neoplasm or an intraductal papillary mucinous neoplasm with gallstones. The pathological examination showed that the walls of the two cysts were covered with non-keratinized stratified squamous epithelium, surrounded by normal splenic tissue. The final pathological diagnosis was two epithelial cysts originating from an intrapancreatic accessory spleen. CONCLUSIONS Even though multiple masses were detected in the pancreatic tail, the possibility of epithelial cysts originating from an accessory spleen should be considered. Laparoscopic distal pancreatectomy might be a safe and effective procedure and provide good cosmetic result for a benign or low-grade malignant tumor in the pancreas.

Single-incision laparoscopic totally extraperitoneal obturator hernia repair in a patient on antiplatelet therapy: A case report

An 83‐year‐old woman who complained of right lower limb discomfort was diagnosed with a right obturator hernia by CT scan. On examination, she had a soft and flat abdomen without signs of peritoneal irritation. The Howship–Romberg sign was present. She had a history of vasospastic angina and paroxysmal supraventricular tachycardia, and took aspirin and dipyridamole until she was admitted to the hospital. Exploratory laparoscopy identified a spontaneously reduced small bowel from the right obturator canal, but there were no signs of ischemic and necrotic bowel. The patient underwent SILS for totally extraperitoneal obturator hernia repair without a dissection balloon. The patient recovered without perioperative complications such as hemorrhage and thrombotic episodes. She remains well, and CT scans showed no signs of obturator hernia recurrence at the 7‐month follow‐up.