Yukihiko Muraoka

A new simplified technique of endoscopic esophageal mucosal resection using a cap-fitted panendoscope (EMRC)

We have previously reported on our novel esophageal mucosal resection technique using a specially devised tube (EMRT) for early-stage esophageal cancer [1, 2]. Acquired specimens lent themselves well to accurate histopathological diagnosis, such as the depth of cancer invasion, type of cancer, grade of differentiation, and vascular involvement. EMRT has been confirmed to be a safe and reliable procedure. There has been no experience of perforation or massive bleeding in six early esophageal cancer cases demonstrated, though EMRT demands a certain degree of skill from the endoscopist. A considerably simplified technique is thus expected to be established only as a therapeutic measure

A Case of Popliteal Cystic Degeneration with Pathological Considerations

Adventitial cystic degeneration of the popliteal artery is seldom encountered; only 39 cases have been reported up to now in Japan. The pathogenesis of this disease remains controversial, and the authors describe a case in which the pathological findings differed from cases reported in the previous literature. The subject was a 74-year-old man admitted to our hospital complaining of intermittent claudication. The characteristic findings of cystic degeneration of the popliteal artery were uncovered by contrast-enhanced computed tomography (CT) and duplex sonography. The contrast-enhanced CT showed a low-density area and duplex sonography revealed a multi-lobulated low-echoic lesion. The Doppler signal of the low-echoic lesion could not be detected. While some cysts were found in the adventitia, they were mainly located in the media. The media also showed a remarkable decrease of smooth muscle cells and a prominent mucinous degeneration that had occurred circumferentially. These findings suggest that the medial degeneration noted had occurred prior to cystic formation. Because of this and other findings, we recommend the use of the termcystic degeneration of the popliteal artery in addition to the termcystic adventitial disease of the popliteal artery.

Intra-operative Monitoring of the Pelvic Circulation Using a Transanal Doppler Probe*

The authors have developed a new device to examine the pre-, intra-, and postoperative pelvic blood flow, consisting of a plastic rectoscope with a commercially available 10 MHz flat Doppler probe mounted at the tip surrounded in use by a thin, acoustic gel filled condom and inserted transanally. Blood flow in the superior rectal artery can easily be detected in this way through the posterior wall of the rectum. The authors have used this technique in 70 patients, 49 undergoing abdominal aortic aneurysmectomy and 21 aorto-femoral bypass surgery. In all cases following clamping of the infrarenal aorta a synthetic bifurcated graft was anastomosed usually to the aorta using an end-to-end or end-to-side anastomosis. Immediately after application of the aortic clamp the Doppler recorder was started in order to determine the time when rectal blood flow reappeared. In the superior mesenteric artery dominant group, a good pulse wave was seen within 15 min of clamping and 88% of the aneurysm and 62% of the aorto-iliac patients fell into this group. Fourteen patients in this group underwent triple vessel ligation (bilateral internal iliac and inferior mesenteric arteries) without any postoperative colonic ischaemia. In an additional study consisting of eight patients with vasculogenic impotence and/or hip claudication, the effectiveness of surgery was assessed by the increase in amplitude of the Doppler signals following reconstruction of the internal iliac artery. Following successful internal iliac reconstruction, an improvement in the amplitude of the waveform could be observed and followed postoperatively. In conclusion, the transanal Doppler probe can be used to follow the adequacy of the pelvic circulation allowing safer aorto-iliac and aorto-femoral surgery.

The assessment of pelvic circulation after internal iliac arterial reconstruction:—A retrospective study of the treatment for vasculogenic impotence and hip claudication

The standard surgical treatment of vasculogenic impotence or hip claudication involves repairing vascular lesions, especially in the internal iliac arteries. It is difficult, however, to make a definite diagnosis or an accurate judgement of the therapeutic effects of this treatment due to the trouble in ruling out any other disorders. During the last five years, 19 patients with impotence and associated apparent internal iliac artery stenosis or occlusion and 2 patients with hip claudication, underwent internal iliac arterial reconstruction. The patients’ ages ranged from 37 to 70 with a mean age of 63.7 and the main procedure performed in all patients was aorto-iliac to femoral bypass grafting, or abdominal aortic aneurysmectomy. A retrospective study revealed that 74 per cent of those treated regained penile erectile activity postoperatively, and that hip claudication disappeared completely in all cases. One of the patients received percutaneous transluminal angioplasty (PTA) for the treatment of vasculogenic impotence, after which his postoperative penile brachial pressure index (PBPI) improved, demonstrating a statistically significant difference compared to the preoperative value. Trans-anal Doppler measurement also proved useful in providing complication-free perioperative understanding of pelvic circulation.

The Cosmetic Benefit of Three-Port Laparoscopic Cholecystectomy and Umbilical Trocar Insertion

Abstract: From April 1991, we performed successful laparoscopic cholecystectomy (LC) on 221 patients. Among them, 198 patients were treated using the standard procedure based on four‐trocar insertion. We developed a new three‐port LC, which might have several cosmetic advantages, and used it with 23 selective patients with non‐inflammatory cholecystolithiasis. LC was conducted in all of the patients without any technical difficulties using the three ports method. The mean operating time was 52 minutes and was 10 minutes longer than for four‐port LC. As regards the cosmetic benefits, a 10‐mm port for the laparoscope was inserted through the inside of the umbilicus. This wound scar cannot be distinguished from the normal umbilical configuration after complete wound healing and there are only two small recognizable surgery scars. We believe this three‐port method has more cosmetic advantages, and its application could be gradually extended. (Dig Endosc 1994; 6 : 49–51)

Combination therapy of laparoscopic cholecystectomy and endoscopic transpapillary lithotripsy for both cholecystolithiasis and choledocholithiasis

SummaryThis report describes five patients with cholecystolithiasis and choledocholithiasis who were treated by combination endoscopic extraction of common bile-duct stones with sphincterotomy (EST) and laparoscopic cholecystectomy (LC). Following this combination procedure the patients were relieved completely of obstructive jaundice and right upper quadrant pain, leaving only small trocar insertion scars made during the short course of hospitalization. The combination therapy of EST and LC will be recommended for this kind of patient as a minimally invasive procedure.

One-point measurement of the peak-to-peak pulsatility index as an indicator for evaluation of infrainguinal bypass procedures.

While duplex scanning has been advocated as the most accurate modality for postoperative graft surveillance, it is time-consuming for evaluating the entire graft. The aim of the present study was to determine which parameter predicts graft failure most simply and precisely, by examining 62 men and 1 woman who collectively underwent 71 infrainguinal arterial bypasses. A total of 212 scannings were obtained using a duplex scanner, and the peak systolic velocity (PSV), PSV ratio, and peak-to-peak pulsatility index (PPI) were analyzed. This analysis revealed 7 occlusions, 9 stenoses, and 1 arteriovenous fistula. When a PSV < 45 cm/s and/or a PSV ratio >2.0 was defined as graft failure, the sensitivity was 84.0% and the specificity was 81.8%; however, a PPI < 7.0 at the midgraft, indicating graft failure, showed a sensitivity of 100% and a specificity of 83.3%. The PPI exhibited better sensitivity and specificity than the PSV, even though the PPI needs only to be measured at the midgraft whereas the PSV should be measured at at least two points. Thus, we believe that the PPI could be the most useful and simple parameter to assess infrainguinal bypass grafts.

Hip Claudication—Its Pathophysiology and Treatment

Hip claudication (HC) is a comparatively rare symptom in patients with chronic arterial occlusive disease. Although the role of the internal iliac artery (IIA) is important in the occurrence of HC, the relationship between HC and the IIA collateral system with the external iliac artery and the superior rectal artery is not clear and is possibly very complex. During the past three years 15 patients who presented with HC, and 3 patients who presented with bilateral IIA occlusion without HC, were studied. In all patients angiography revealed variable IIA occlusive changes. The pressure in the bilateral profunda penis arteries was measured and was found to correspond well with the angiographic findings. The superior rectal arterial flow was examined transrectally with a Doppler probe developed by the authors. In addition to the main arterial recon struction (bifurcated synthetic grafting 8 cases, femorofemoral crossover or fe moropopliteal bypass 6 cases, etc.), direct IIA reconstruction was performed in 13 IIAs (8 patients) with good results. HC was removed in 2 of the 3 femorofe moral crossover bypass cases. Their study suggests that many variations of hip claudication exist. The pe nile brachial pressure index in HC patients was 0.3±0.13 or less. Bilateral IIA occlusion cases with no HC were found to be getting blood via the superior rectal artery. It was also observed that there were to a certain extent independ ent supplies to the hip and genitalia, for elevation of the penile pressure was seen on the IIA repair side. In some cases, without IIA repair, the rich blood plexus to the pelvic organs via the iliac circumflex and others provided complete relief from hip claudication.

Radiographic and histological studies of calcification in the media of muscular-type arteries

To learn about the process of calcification in the media of muscular-type arteries, the authors used light and electron microscopy to examine a total of 77 femoral and external iliac artery samples. In addition, 33 femoral arteries were examined by plain radiography. These observations yielded the following results: 1. The calcification of the femoral arteries were radiographically detected in patients who were over 60 years old, and were then divided into two types: a long-axis type calcification and a patchy type calcification. The former was extended along the arterial wall and was suggestive of medial calcification, and the latter was suggestive of intimal calcification as seen under light microscopy. 2. Calcium was distributed in two patterns: a media-type in which calcium accumulated in the extracellular matrix of the media, and an internal elastic lamina (IEL)-type, in which calcium deposition spread around a calcified IEL. 3. Scanning electron microscopy revealed various-sized granules on the extracellular matrix of the media as well as on the IEL. Using with X-ray EDS micro-analysis, calcium and phosphorus were detected in these depositions. 4. Calcium deposition of the media, first noted in the 40-year-old, became more exaggerated in size and extent with individual sample age, and typical Mönckebergs arteriosclerosis was present total in a total of 9.1% of examined cases over 60 years old. These findings suggested that the calcium deposition in the arterial media was a normal physiological process with aging, and Mönckebergs arteriosclerosis was initiated on the basis of medial calcium deposition, occuring at around 60 years old.

A balloon-tipped liver lobe retractor

Liver lobe retraction is an important procedure instituted to obtain a good visual field for the surgeon intent on reconfirming the hemostasis of the liver bed during laparoscopic cholecystectomy [3] or intent on approaching esophageal hiatus during laparoscopic Nissens procedure [1,2]. Any kind of retractor featuring a hard metal tip sometimes risks injury to the liver parenchyma, causing continuous bleeding. To prevent this problem from arising, we devised a novel balloon-tipped liver lobe retractor (Prototype, Sumitomo Bakelite Corporation, Japan) (Fig. ! a). This device is composed of a 5-ram-diameter metal rod featuring a silicone balloon at its tip. The balloon is inflated by 3 ml of air after the retractor has been inserted. The inflated balloon functions to prevent liver injury during retraction of the liver parenchyma (Fig. Ib,c). We used this retractor on seven laparoscopic cholecystectomy patients and in more than that number in an ongoing animal experimental study. The results obtained thus far confirm the devices effectiveness in ameliorating liver injury. Accordingly, we believe that this device provides the patient with a high degree of safety and the assistant who controls the retractor with exceptional easy use even when outside the laparoscopic visual field. References