Shunji Sakuramachi

Intraabdominal contamination after gallbladder perforation during laparoscopic cholecystectomy and its complications

AbstractBackground: Gallbladder perforation often occurs during laporoscopic cholecystectomy. Methods: The frequency and causes of gallbladder perforation as well as the relevant clinical background factors were investigated in 110 patients undergoing laparoscopic cholecystectomy. We also evaluated intraperitoneal contamination by bacteria and gallstones at the time of gallbladder perforation and investigated whether perforation caused early or late postoperative complications. Results: Intraoperative gallbladder perforation occurred in 29 of the 110 patients (26.3%). It was caused by injury with an electric knife during dissection of the gallbladder bed, injury during gallbladder retraction with grasping forceps, injury during gallbladder extraction from the abdomen, and slippage of cystic duct clips (potentially causing bile and stone spillage). Perforation was more frequent in patients with positive bile cultures and in those with pigment stones (p<0.02), but not in patients with cholecystitis or cystic duct obstruction. The peritoneal cavity was contaminated by bacteria in 11/29 patients (37.9%) and by spilled stones in 3/29 patients (10.3%). There was no difference in the incidence of postoperative complications between the patients with and without perforation either in the early postoperative period or during follow-up for 24–42 months. Only one patient developed abdominal pain and fever in the early postoperative period, and they were probably related to perforation. Conclusions: Although gallbladder perforation is sometimes unavoidable during laparoscopic cholecystectomy, the risk of severe complications appears to be minimized by early closure of perforation, retrieval of as many of the spilled stones as possible, and intraperitoneal lavage.

Laparoscopic cholecystectomy using fine-caliber instruments

The advantages of laparoscopic cholecystectomy (LC) are based on its low invasiveness due to the small surgical wounds. If LC could be performed using fine-caliber instruments, these advantages would be amplified. We developed 3-mm-caliber instruments and performed LC in 20 patients using one 5-mm and two 3-mm instrument ports. The results were retrospectively compared with those of standard LC. The operating time (107.2 ± 50.0 min), complication rate (0%), number of doses of analgesia (0.80 ± 0.83), and postoperative hospital stay (4.9 ± 1.2 days) were not significantly different between our method and standard LC. At 6 months postoperatively, the scars were smaller with our method. Surgery using fine-caliber instruments was no more difficult than standard LC and achieved a superior cosmetic outcome.

Benign schwannoma of the esophagus: Report of two cases with immunohistochemical and ultrastructural studies

Two cases of benign schwannoma of the esophagus are presented. The tumors were found in the thoracic esophagus of women of 56 and 64 years of age, respectively, who had complained of dysphagia and back pain. Tumorectomies were performed and the tumors were found to be located within the esophageal wall arising from the muscularis propria. The tumors were examined immunohistochemically and ultrastructurally. These tumors were identical in gross, histological and electron microscopic features. Grossly, the tumors showed yellowish‐white cut surfaces without hemorrhage or necrosis. Microscopically, they were composed of spindle‐shaped cells showing moderate variation in size and shape, and nuclear palisading. Lymphoid aggregates with germinal centers surrounded the tumors. Immunohistochemically, strong reactions for S‐100 protein and neuron‐specific enolase were observed in the cytoplasm of spindle cells, whereas reactions for muscle actin and desmin were negative. These findings, together with electron microscopic observations, supported the Schwann cell origin of these tumors.

Carcinoma of the reconstructed stomach tube following esophageal resection for a benign stricture: report of a case and review of the literature.

We report herein the case of a 60-year-old woman who presented with dysphagia and anorexia and was subsequently diagnosed as having gastric cancer of the reconstructed stomach tube 36 years after undergoing surgery for a benign esophageal stricture. Reports on carcinoma of the reconstructed stomach tube are rarely found and interestingly, all of the previous cases, which were documented only in the Japanese literature, corresponded to metachronous double cancers after esophageal malignancies. To our knowledge, this is the first case of carcinoma of the reconstructed stomach tube following esophageal resection for a benign stricture, and it is thought that the carcinoma probably developed at the site of the anastomosis a long time after the first operation. We reviewed 30 cases of carcinoma of the reconstructed stomach tube for which the clinicopathological data was complete, and we believe that this new type of cancer needs more than 10 years to develop and should be defined as “carcinoma of the gastric remnant”.

Laparoscopic ultrasonography and operative cholangiography prevent residual common bile duct stones in laparoscopic cholecystectomy.

We retrospectively evaluated the role of intraoperative cholangiography (IOC) combined with laparoscopic intraoperative ultrasonography (LIOU) for detection of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy. We reviewed 184 patients with biliary stones. Preoperatively, all patients underwent ultrasonography (US); 183 of the patients were investigated by cholangiography (oral and intravenous cholangiography in 145 and endoscopic retrograde cholangiography in 44). LIOU was carried out in all patients and IOC was done in 183. LIOU visualized the bile duct in 94.6% of the patients and IOC was successful in 95.6%. CBD stones were detected in a total of 17 patients, 9 (52.9%) of whom were positive on preoperative investigations. The sensitivity for detecting CBD stones was 29.4% with US, 22.2% with oral and intravenous cholangiography, 50.0% with endoscopic retrograde cholangiography, 82.4% with LIOU, and 93.3% with IOC. The diameter of the stones visualized intraoperatively (4.4 +/- 1.2 mm) was smaller than that of the stones detected preoperatively (6.9 +/- 2.6 mm). The stones were removed during laparoscopy in 15 patients and after conversion to laparotomy in 2. None of the patients had residual CBD stones after follow-up for 6 to 50 months. Intraoperative examination using both LIOU and IOC was useful for prevention of residual CBD stones.

Experimental study of laparoscopic selective proximal vagotomy using a carbon dioxide laser

This study investigated the effectiveness of laparoscopic selective proximal vagotomy using a CO2 laser. Irradiation of the stomach was performed from the serosal aspect using a defocused CO2 laser beam. In the first experiment, the inhibitory effect on cysteamine ulcers in rats was compared between surgical vagotomy and CO2 laser vagotomy using three different irradiation fields. The results suggested that irradiation near the lesser curvature provided sufficient denervation. In the second experiment, CO2 laser vagotomy was performed laparoscopically in dogs. The procedure lasted less than 1 h and a postoperative endoscopic Congo red test confirmed its effectiveness. Subserosal tissues including the vagus nerve branches showed degeneration and were replaced by fibrosis 3 months postoperatively, but the deeper tissues were spared. In conclusion, laparoscopic CO2 laser vagotomy may be as effective for reducing acid secretion as standard surgical vagotomy. Its simplicity and safety suggest that a clinical trial in humans may be warranted.

Villous Adenoma with Advanced Cancer of the Rectum, Clinically Accompanied with Hypopotassemia.

大腸のvillous adenomaにおいて, 腫瘍からの大量の粘液排泄が原因で血清電解質などに異常をきたすことは極めてまれである. 今回われわれは, 臨床的に低カリウム血症を呈した進行癌を伴う直腸villous adenomaの2例を経験したので報告する.症例1は89歳の女性. 多量の粘液便排泄を主訴に入院した. 直腸に大きさ15×7cmの進行癌を伴う巨大villous adenomaを認め, 腫瘍からの粘液排泄が原因と考えられる低カリウム血症 (K3.1mEq/l) と低蛋白血症 (TP5.5g/dl) を呈していた. なお, 排泄液の電解質組成はNa140mEq/l, K56mEq/l, Cl 141mEq/lと, カリウムの著しい高値を示した.症例2は68歳の女性. 多量の粘液性下痢と全身倦怠感を主訴に入院した. 直腸に大きさ16×6cmの進行癌を伴う巨大villous adenomaを認め, 血清カリウム値は2.5mEq/lであった. 2症例とも直腸切断術が行われ, 術後低カリウム血症は改善した.