Yoichi Ishizaki

Changes in splanchnic blood flow and cardiovascular effects following peritoneal insufflation of carbon dioxide

SummaryLaparoscopic surgery has rapidly become a popular and widely used technique. Although this procedure has been shown to be generally safe, cardiovascular derangement related to carbon dioxide pneumoperitoneum has been reported. There are few data available on the relationship between systemic and regional hemodynamics in cases of pneumoperitoneum. Changes in splanchnic blood flow and cardiovascular effects following a moderate increase of intraabdominal pressure (IAP) to 16 mmHg during a 3-h period were analyzed in six anesthetized dogs. After insufflation, cardiac output and blood flow in the superior mesenteric artery and portal vein decreased progressively and returned to the preinsufflation values following deflation. Hepatic arterial blood flow did not change significantly, perhaps due to compensatory mechanisms for maintenance of hepatic blood flow. Mechanical compression of the splanchnic capillary beds due to the elevated IAP may possibly reflect the increase in systemic vascular resistance causing the decrease in cardiac output. To prevent this impairment, intermittent decompression of gas during surgical laparoscopy is recommended.

Aortobronchial fistula after an aortic operations

A 71-year-old man with a postoperative aortobronchial fistula was successfully treated. The fistula occurred between the left lower lobe and the descending thoracic aorta, to which a distal anastomosis of a temporary bypass graft had been placed during thoracic aortic aneurysmectomy 3 years before. For saving patients with this complication, early surgical treatment during episodes of intermittent hemoptysis is important. The use of an omentum pedicle flap for the isolation of the suture line is a important adjunct.

Appraisal of intraoperative ultrasonography during laparoscopic cholecystectomy

BACKGROUND The usefulness of intraoperative ultrasonography during laparoscopic cholecystectomy (LC) has yet to be evaluated fully. METHODS In 50 patients who underwent LC, the intraoperative ultrasonography findings were compared with those of preoperative ultrasonography, intraoperative cholangiography, and histology, and then its usefulness for examining anatomic relationships in the hepatoduodenal ligament, detecting bile duct stones, diagnosing gallbladder polyps and abnormally thickened walls, and determining the propriety of LC was appraised. RESULTS The preoperative ultrasonography diagnoses were gallstones in 38 patients, polyps in 10, and cancer and adenomyomatosis in one each. In four patients endoscopic retrograde cholangiography showed bile duct stones. In all 50 patients intraoperative ultrasonography was useful for examining the anatomic relationships between the bile duct and vessels, such as the portal vein and hepatic artery, and showing the presence or absence of bile duct stones. On the basis of the intraoperative ultrasonography findings, gallstones were diagnosed in 38 patients, in five of whom bile duct stones were shown clearly, cholesterol polyps in eight, early-stage cancer or adenoma in two, and adenomyomatosis in two, and subsequently LC was performed. Histologic diagnoses of cholesterol polyps were made in eight of ten patients with polyps, and intramucosal cancer and an inflammatory polyp in one each. In one patient with a preoperative diagnosis of cancer the apparently elevated flat lesion was found to be partial thickening of the gallbladder wall, which was diagnosed as adenomyomatosis, and LC was chosen as the operative procedure. CONCLUSIONS Intraoperative ultrasonography during LC is useful for detecting bile duct stones, diagnosing gallbladder polyps and abnormally thickened walls, and deciding whether LC is adequate for resection of the gallbladder.

Management of gallstones in cirrhotic patients

Abstract34 cirrhotic patients who underwent either cholecystectomy alone or in conjunction with common duct exploration were retrospectively reviewed. In Child A and B patients morbidity was low and there were no postoperative deaths. However, all patients who underwent additional cholecystectomy during the non-shunting operation for esophageal varices required blood transfusion. Cholecystectomy in Child C patients is frequently associated with considerable intraoperative bleeding and subsequent postoperative complications. In the 23 patients who were not operated upon for gallstones, no patients developed symptomatic biliary disease. Ultrasonographically, most of these gallstones were strongly suspected to be black stones. Elective surgical intervention for symptomatic Child A and B patients would normally be warranted, but hemorrhage and resulting complications due to additional cholecystectomy for asymptomatic gallstones during the non-shunting operation should be minimized. An additional cholecystectomy should be considered, provided such a cholecystectomy is thought to be easily performed judging from the degree of development of collateral circulation around the hepatoduodenal ligament and unless black stones are suspected ultrasonographically. For symptomatic gallstones in Child C patients every type of medical treatment should be attempted. After considering the bleeding tendency or ascites, percutaneous transhepatic gallbladder drainage is considered to be one of the safest treatments.

Cystic duct dilation during laparoscopic transcystic common bile duct exploration

Successful laparoscopic common bile duct exploration (CBDE) is being reported with increasing frequency. Three techniques for accessing common duct stones laparoscopically have been described: (1) laparoscopic choledochotomy, stone extraction and T-tube placement; (2) endoscopic retrograde sphincterotomy to remove common bile duct stones in conjunction with laparoscopic cholecystectomy; and (3) laparoscopic transcystic CBDE. From the viewpoint of preservation of papillary function, shorter hospitalization, reduction of pain, and faster patient recovery, the last method is superior to the former two. In this procedure, the cystic duct should be initially dilated widely, for passage of a flexible small choledochoscope. Here we report a safe and effective technique for dilation of the cystic duct.