Yasuro Ishikawa

Experience with Laparoscopic Cholecystectomy

Abstract: Laparoscopic cholecystectomy is rapidly replacing conventional cholecystectomy as the treatment of choice for gallbladder stone disease because of its lower morbidity. Our study began on 29th May, 1990 and continued until February 28th, 1991. 40 laparoscopic cholecystectomies were successfuly performed. 4 patients had an open cholecystectomy instead because of bleeding in 1, dense adhesions in 2 and Mirizzis Syndrome in 1. The two technical measures taken to avoid common bile duct injury, were 1) exposure of both the cystic duct and cystic artery in the same field before clipping and division 2) demonstration of the continuity between the cystic duct and the Hartmans pouch. Technical difficulties often encountered were extensive adhesions, multiple or giant stones, inflamed gallbladder and a short or dilated cystic duct. There were 4 complications; one diaphragmatic injury resulting in a pneumothorax, one periumbilical subcutaneous emphysema and 2 mild bile leaks. On average, each patient required 1.3 intramuscular analgesic injections and spent 10 days recuperating in hospital. In Japan, many patients insist on staying longer in hospital. We believe that laparoscopic cholecystectomy will rapidly become the preferred treatment for gallbladder stone disease.

Effects of an ACE Inhibitor and a Calcium Channel Blocker on Cardiovascular Autonomic Nervous System and Carotid Distensibility in Patients with Mild to Moderate Hypertension

We investigated the relationship between cardiovascular autonomic nervous system function and carotid arterial distensibility during treatment with an angiotensin converting enzyme inhibitor (derapril) or a calcium channel blocker (manidipine) for hypertension. In 37 patients with hypertension, autonomic function was assessed by heart rate variability and baroreceptor sensitivity using phenylephrine injection. Left ventricular mass index and carotid arterial distensibility were assessed by ultrasound examinations. Before the medication, both baroreceptor sensitivity and heart rate variability correlated with carotid arterial distensibility, but not with left ventricular mass index by multiple regression analysis. Subsequently, patients were randomly allocated into two groups, derapril (n = 18) and manidipine (n = 19) for 20 weeks. At the end of the study, the change in baroreceptor sensitivity correlated with change in carotid arterial distensibility (r = 0.41, P < .05), but not with change in left ventricular mass index. Although derapril and manidipine decreased blood pressure and left ventricular mass index to the same extent, the former improved heart rate variability, baroreceptor sensitivity (5.0 +/- 1.9 --> 5.6 +/- 2.0 msec/mm Hg), and carotid arterial distensibility (2.1 +/- 0.8 --> 2.5 +/- 1.0 %kPa), but the latter did not improve them at all. Thus, impairment of the autonomic balance was related to the impairment of carotid arterial distensibility in hypertension; derapril, but not manidipine, significantly improved these abnormalities.

Prevention of laparoscopic surgeon's thumb

Laparoscopic surgery is being used in an increasing number of operations today. We have been performing various types of laparoscopic techniques in our department. A problem we sometimes have encountered involves a ring of pressure that develops around the surgeons thumb at the end of the procedure, which is accompanied by an area of paresthesia in the distribution of the lateral digital nerve. We report our own experience and a small review of the literature.

Laparoscopic cholecystectomy: A report of 409 consecutive cases and its future outlook

A retrospective study was conducted on 409 patients who underwent laparoscopic cholecystectomy at Teikyo University Hospital between May, 1990 and October, 1992. The operation had to be converted to an open cholecystectomy in ten of these patients because of uncontrollable bleeding from the cystic artery in one, venous bleeding due to portal hypertension in one, extensive adhesions of the omentum and the duodenum to the gallbladder in two, extensive adhesions around the gallbladder in four, and extensive adhesions between the gallbladder and the common bile duct (CBD) in two. The time taken to complete the procedure ranged from 30 to 235 min, the average time being 81 min, and the postoperative hopital stay ranged from 3 to 56 days, the average stay being 6.5 days. Eleven patients developed complications intra- or postoperatively: bile duct injury which became manifest after the operation and required laparotomy in three patients; injury to the right hemidiaphragm resulting in a right pneumothorax in one; periumbilical subcutaneous emphysema in one; mild bile leaks which resolved in a few days in two; and a severe bile leak which resolved after 6 days in one. The indications for laparoscopic cholecystectomy have widened with experience and now, CBD stones and a history of previous gastrectomy are no longer contraindications for laparoscopic cholecystectomy. Thus, it seems that laparoscopic cholecystectomy can be performed as safely as a standard cholecystectomy, provided the patients are selected properly and appropriate caution is exercised.

Negative Regulation of Opioid Receptor-G Protein-Ca2+ Channel Pathway by the Nootropic Nefiracetam

Abstract: It has recently been reported that nefiracetam, a nootropic agent, is capable of attenuating the development of morphine dependence and tolerance in mice. The mechanism of this antimorphine action is not clear. The present study was designed to address this issue using Xenopus oocytes expressing δ‐opioid receptors, G proteins (Gi3α or Go1α), and N‐type (α1B) Ca2+ channels. Membrane currents through Ca2+ channels were recorded from the oocytes under voltage‐clamp conditions. The Ca2+ channel currents were reduced reversibly by 40‐60% in the presence of 1 μM leucine‐enkephalin (Leu‐Enk). The Leu‐Enk‐induced current inhibition was recovered promptly by nefiracetam (1 μM), while control currents in the absence of Leu‐Enk were not influenced by nefiracetam. A binding assay revealed that 3H‐nefiracetam preferentially bound to the membrane fraction of oocytes expressing Gi3α. When δ‐opioid receptors were coexpressed, the binding was significantly increased. However, an additional expression of α1B Ca2+ channels decreased the binding. The results suggest that nefiracetam preferentially binds to Gi3α associated with δ‐opioid receptors, thereby inhibiting the association of G proteins with Ca2+ channels. In conclusion, nefiracetam negatively regulates the inhibitory pathway of opioid receptor‐G protein‐Ca2+ channel.

Laparoscopic cholecystectomy — key technical points to prevent bile duct injury

During the period May, 1990 to the end of December, 1992, 434 patients (203 males and 231 females; aged 16–87 years; mean 49.4 years) underwent laparoscopic cholecystectomy at our Department, Teikyo University Hospital, Mizonokuchi. Eleven out of these 434 patients were converted to open cholecystectomy, due to uncontrollable bleeding from the cystic artery (n=1), venous bleeding due to portal hypertension (n=1), extensive adhesions of the omentum and the duodenum to the gallbladder (n=2), extensive adhesions around the gallbladder (n=4), and extensive adhesion between the gallbladder and the common duct (n=3). The time taken to complete the procedure ranged from 25 to 235 min, the mean being 74 min. Seventeen complications manifested intra- or postoperatively. Three cases of bile duct injury which manifested after operation required laparotomy. In 1 patient, injury to the right hemidiaphragm resulted in a right pneumothorax. One patient had periumbilical subcutaneous emphysema, 2 patients had mild bile leaks that cleared up within a few days, and 1 patient had considerable bile leaks which stopped 6 days later. Indications for laparoscopic cholecystectomy widened as our experience grew. Common bile duct stones and previous gastrectomy are no longer contraindications for this procedure. Based on our experience with laparoscopic cholecystectomy, we describe here our technique and the rules we consider important for the successful accomplishment of this procedure.

Experience with Laparoscopic Appendectomy —The Technique and Our Views of its Indications—

Abstract: Since June, 1991 a laparoscopic appendectomy (LA) was performed on eleven patients with suspected appendicitis which could not be confirmed by the conventional diagnostic methods. The patients included 7 males and 4 females, with a mean age of 27, 9, ranging from 16 to 46 years. No postoperative complications were encountered. The laparoscopic diagnoses included gangrenous appendicitis in 2, suppurative appendicitis in 2, catarrhal appendicitis in 4, salpingitis in 2 and an appendiceal mass in one patient (Case 7). Histopathological diagnoses were phlegmonous appendicitis in 3, mucinous cystadenoma in one and catarrhal appendicitis in 7 patients. Two cases of salpingitis and a case with ovarian bleeding were treated conservatively after incidental laparoscopic removal of the appendix. Case 7 was histopathologically diagnosed as having mucinous cystadenoma. The patients’postoperative hospital stay was from 5 to 8 days, with an average of 6.9 days. All patients had been given the permission to be discharged by the third POD but they stayed longer because of benefits given by the health insurance system very specific to Japan.

Laparoscopic Cholecystectomy: Treatment o Choice in Elderly Patients

Abstract: The application of laparoscopic] cholecystectomy, first reported in 1987, has grown rapidly worldwide, replacing the open cholecystectomy. This trend is attributable to the benefits of minimal surgical access, i. e. a smaller incision, less postoperative pain and faster recovery. However, doubts persist concerning the role of laparoscopic cholecystectomy in elderly patients. The purpose of this study was to assess morbidity and mortality in elderly patients who underwent laparoscopic cholecystectomy at Teikyo University Hospital at Mizonokuchi. Forty‐eight patients, 65 years or older, underwent attempted or successful laparoscopic cholecystectomy. To assess operative risk in these patients, the American Society of Anesthesiologists Surgical Risk (A. S. A.) category was used. The risk ranged from 1 to 3 with a median of 2. Twenty‐five percent of the patients were defined as A. S. A. I, 61% as A. S. A. II and 14% as A. S. A. III. Four patients required intraoperative conversion of the procedure to open cholecystectomy (conversion rate of 8.3%). The indications for conversion in three patients were severe adhesion and thickened gallbladder wall and in the other were secondary to gallbladder bed oozing. This conversion rate is similar to that reported in other series. The conversion was not related to the surgical risk. The morbidity rate was 4.5%. the mortality rate zero. These results compared favorably with those reported for open cholecystectomy in elderly patients and with the overall published morbidity‐mortality rate of laparoscopic cholecystectomy in large series. We conclude that laparoscopic cholecystectomy is a suitable procedure for elderly patients.

Left-sided Gallbladder Resected by Laparoscopic Cholecystectomy. Report of a Case and Review of the Literature in Japan.

胆嚢の先天性位置異常のうち, 内臓逆位を伴わない左側胆嚢は非常にまれな奇形といわれている.最近我々は腹腔鏡下に摘出した胆嚢結石を伴う左側胆嚢の1例を経験した.術前, ultrasonography (以下, US), endoscopic retrogradecholangio-pancreatography (以下, ERCP) およびcomputedtomography (以下, CT) を施行したところ, USでは位置異常を指摘できなかったが, ERCPおよびCT検査の所見から, 胆嚢は肝左葉下面で肝鎌状間膜の左側に位置していると考えられた.腹腔鏡下胆嚢摘出術が施行され, 術中所見で胆嚢は肝鎌状間膜の左側にあり, 胆嚢床が肝左葉下面に認められ本症と診断した.教室では, 1990年5月29日に本邦第1例目の腹腔鏡下胆嚢摘出術を施行して以来, 約450例に同術式を施行してきたが, 左側胆嚢と診断されたのは本症例のみである.左側胆嚢は, 本邦では我々が検索した範囲では, 自験例を含め33例の報告があり, かつ腹腔鏡下に摘出したのは本例のみである.本症は手術中に発見されることがほとんどであるが, 術前診断には, CTあるいはUSが有用であると考えられた.

A Huge Solitary Aneurysm of the Right Coronary Artery Successfully Treated by Surgery—A Case Report

The case of a symptomatic fifty-four-year-old woman with a huge, solitary aneurysm of the right coronary artery is presented. A coronary angiogram did not visualize the aneurysm because of tightly packed thrombi in it, but it was definitely diagnosed intraoperatively after the mass was opened. Excision of the aneusymal wall, removal of thrombi, closure of coronary ostium, and plication of the aneurysmal wall were performed without revascularization. Histologic ex aminations demonstrated cystic medial necrosis with deposition of acid- mucopolysaccharides, suggesting that pathogenesis might be a dissecting aneurysm.