Abstract: PURPOSE: To retrospectively assess 64-detector row computed tomography (CT) in the preoperative depiction of the cystic duct and cystic arteries in and around the Calot triangle. MATERIALS AND METHODS: Institutional review board approval was obtained, with waiver of informed consent. A total of 245 consecutive patients (133 men, 112 women), including 48 patients who subsequently underwent cholecystectomy, were examined. Two independent observers evaluated the CT data set on the basis of axial sections, coronal and sagittal multiplanar reformations, and three-dimensional volume rendering. The relationship between the cystic arteries and the Calot triangle--which is bordered by the undersurface of the liver, common hepatic duct, and cystic duct--was also evaluated, and each patient was classified on the basis of the origin of the cystic arteries and the course to the Calot triangle. Statistical analysis was performed, and percentages and confidence intervals were calculated. RESULTS: The cystic arteries were delineated in 234 of the 245 patients. Both the Calot triangle and the cystic arteries were delineated in 223 patients. One cystic artery was seen in the Calot triangle in 173 patients, and two cystic arteries were seen in the Calot triangle in 12. One artery in the Calot triangle with accessory arteries from different origins outside the Calot triangle was seen in 18 patients, and no cystic artery was identified in 20. Cystic arteries were seen in 42 (92%; 95% confidence interval: 87%, 98%) of the 48 patients who subsequently underwent cholecystectomy. The relationship between the cystic arteries and the Calot triangle was in agreement with the surgical records for all patients. CONCLUSION: The configuration of the cystic duct and cystic arteries can be depicted preoperatively with 64-detector row CT in patients scheduled to undergo cholecystectomy.
Abstract: BACKGROUND: Laparoscopic colorectal cancer surgery has become widely accepted recently. However, the oncological validity of this surgery has not yet been well analyzed, especially for advanced cancer. The aim of this study is to assess the clinical outcome of laparoscopic surgery for stage II/III colorectal cancer in our hospital. PATIENTS AND METHODS: Between June 1999 and August 2006, 321 patients underwent laparoscopic colorectal cancer surgery in our hospital; of those 121 cases whose pathological findings revealed stage II/III were included in this study. Among these cases, we assessed a short-term outcome and a medium-term outcome in terms of survival evaluation. RESULTS: The male:female ratio was 73:48, and mean age of patients was 62.4 years. Thirteen tumors were located in the cecum, 29 in the ascending colon, five in the transverse colon, one in the descending colon, 43 in the sigmoid colon, and 30 in the rectum. Average duration of operation was 184 minutes, and mean estimated blood loss was 53.5 ml. Five patients (4.1%) were converted to open procedures. No intraoperative complication was observed but eight complications (6.6%) occurred postoperatively. Forty-two cases were classified as stage II, 62 as stage IIIA /B, and 17 as stage IIIC. Five patients died of cancer relapse (4.1%), and 18 cases had recurrence of disease (14.9%), to date. No port-site recurrence was detected. Overall five-year survival was 95.7% in stage II, 84.1% in stage IIIA/B, 70.0% in stage IIIC. Meanwhile disease-free five-year survival was 75.6% in stage II, 80.1% in stage IIIA/B, and 66.8% in stage IIIC. No significant difference was observed between stages, in terms of either overall or disease-free survival. CONCLUSION: Although further evaluation is required, laparoscopic surgery for stage II/III colorectal cancer is safe and would be an oncologically adequate procedure.
Abstract: BACKGROUND: Laparoscopic knot tying can be stressful. We reported two simple techniques, known as the Thumbs up! knot and the Tornado knot. We have further refined these procedures with the development of a new needle holder, called the Excalibur suturing needle holder. MATERIALS: This forceps differ from most conventional forceps in that the hinge is designed to stick out. The large hinge is stored out of the way when the forceps are closed, to prevent the thread accidentally catching. RESULTS: The thread is hooked on the projected hinge, which resembles the heel of a high-heel shoe. By using this forceps, the laparoscopic knot tying becomes easier for not only well experienced but also less experienced surgeons. CONCLUSIONS: The Excalibur, with its high heel, can complete knots with simple straight-line motion, making knot tying easier. This forceps will help reduce the stresses associated with intra-corporeal knot tying.
Abstract: BACKGROUND: Several authors have presented the feasibility of laparoscopic pancreatic surgery. However, the pathophysiological effect of laparoscopic pancreatic surgery is not well known. METHODS: Ten mongrel dogs were randomly operated for laparoscopic and conventional distal pancreatectomy. Fed state gastrointestinal transit times were assessed using radiopaque markers. To assess surgical stress, we determined serum IL-1 and cortisol. RESULTS: Postoperative mouth-to-anus transit time in the laparoscopic group was not prolonged while it was significantly prolonged in the conventional group compared with the baseline study, but no significant differences between groups were detected. First defecation was observed significantly earlier in the laparoscopic group. Serum cortisol levels were elevated significantly at 4 h after skin incision in both groups and decreased thereafter. In the laparoscopic group, they returned close to the normal level at 8 h after incision, but were still significantly higher in the conventional group. The level of IL-1 was elevated significantly higher in conventional group at 24 h after the skin incision. CONCLUSION: Thus, we conclude that laparoscopic distal pancreatectomy demonstrated faster recovery of the bowel transit and less stress than conventional distal pancreatectomy in dogs.
Abstract: To assess the advantages of a laparoscope-assisted proctocolectomy with ileal J-pouch anal anastomosis compared with conventional procedures, we retrospectively analyzed the results of the two procedures as follows: Eleven patients including five patients with familial adenomatous polyposis (FAP) and six with ulcerative colitis (UC) underwent a laparoscope-assisted proctocolectomy and hand-sewn ileal J-pouch anal anastomosis at our department from June 1997 to November 1999. This laparoscope-assisted colectomy (LAC) group was then compared with a group of 13 patients who had undergone conventional ileal pouch anal anastomosis using a standard laparotomy from 1986 to 1997. The median operative time of the LAC group was 8h 23min, which was 81 min longer than that of the standard colectomy (SC) group. The number of days during which eating was prohibited were similar in the two groups but the median postoperative hospital stay was significantly shorter in the LAC group (24.1 days). In the LAC group, the small incisions showed better cosmetic results and there was also a remarkable reduction in the degree of postoperative pain. In conclusion, a laparoscope-assisted proctocolectomy with ileal J-pouch anal anastomosis can be employed widely in patients with FAP and also in selected patients with UC.
Abstract: BACKGROUND: The extrahepatic biliary tree with the exact anatomic features of the arterial supply observed by laparoscopic means has not been described heretofore. Iatrogenic injuries of the extrahepatic biliary tree and neighboring blood vessels are not rare. Accidents involving vessels or the common bile duct during laparoscopic cholecystectomy, with or without choledocotomy, can be avoided by careful dissection of Calot's triangle and the hepatoduodenal ligament. METHODS: We performed 244 laparoscopic cholecystectomies over a 2-year period between January 1, 1995 and January 1, 1997. RESULTS: In 187 of 244 consecutive cases (76.6%), we found a typical arterial supply anteromedial to the cystic duct, near the sentinel cystic lymph node. In the other cases, there was an atypical arterial supply, and 27 of these cases (11.1%) had no cystic artery in Calot's triangle. A typical blood supply and accessory arteries were observed in 18 cases (7.4%). CONCLUSION: Young surgeons who are not yet familiar with the handling of an anatomically abnormal cystic blood supply need to be more aware of the precise anatomy of the extrahepatic biliary tree.
Abstract: Background: Some of the persistent problems associated with laparoscopic surgery stem from the inability of the surgeon to palpate the abdominal contents during the operation. This lack of tactile sensation can lead to poor abdominal exploration, difficulty in extracting the organs, and a relatively long operation time compared to conventional procedures. The Dexterity Pneumo Sleeve is a new device that allows the surgeon to insert his or her hand into the abdominal cavity through a small incision while preserving the pneumoperitoneum. Methods: Recently, 13 of our patients underwent hand-assisted advanced laparoscopic surgery using this device. In this series, we had two cases of gastrectomy, two cases of gastric bypass for morbid obesity, two Whipple cases for periampullary tumor, and seven cases of bowel resection. On the basis of this series, we were able to assess the utility of this device. Results: Satisfactory pneumoperitoneum was maintained in 12 of 13 cases. The length of the skin incision was 7.8 cm on average, which was almost the same size as surgeon's glove. The device proved to be very useful for tissue retraction and abdominal exploration in all cases and for intracorporeal knot tying in some cases. Conclusions: We found that the device permitted an easier dissection, resection, and anastomosis. It also helped to decrease the operation time.
Abstract: The rabbit polyclonal antibody against rat organic anion transporting polypeptide 2 (oatp2) was raised and immunoaffinity-purified. Western blot analysis for oatp2 detected two bands ( 74 and 76 kDa) in rat brain and a single band (76 kDa) in the liver. By immunohistochemical analysis, the oatp2 immunoreactivity was specifically high at the basolateral membrane of rat hepatocytes. Functionally, the oatp2-expressing oocytes were found to transport dehydroepiandrosterone sulfate, delta1 opioid receptor agonist [D-Pen2,D-Pen5]enkephalin, Leuenkephalin, and biotin significantly, as well as the substrates previously reported. These data reveal the exact distribution of the rat oatp2 at the protein level in the liver, and that oatp2 appears to be involved in the multispecificity of the uptaking substrates in the liver and brain.
Abstract: BACKGROUND & AIMS: Recently, we isolated a new complementary DNA (cDNA) encoding human liver-specific organic anion transporter (LST-1), representing the multispecificity of human liver. The aim of this study was to isolate a rat counterpart of human LST-1 and examine the expression regulation of its messenger RNA (mRNA) to clarify the molecular basis of cholestasis. METHODS: A rat liver cDNA library was screened with human LST-1 cDNA as a probe. Xenopus oocyte expression system was used for functional analysis. Northern blot analyses were performed using the isolated cDNA (termed rlst-1). The bile duct ligation model and the cecum ligation and puncture model were used for expression analyses. RESULTS: rlst-1 encodes 652 amino acids, predicting at least 11 transmembrane regions. The overall homology with human LST-1 was 60.2%, which is the highest among all known organic anion transporters. rlst-1 also belongs to the same new gene family as human LST-1, located between the organic anion transporter family and the prostaglandin transporter. rlst-1 preferably transports taurocholate (K(m), 9.45 micromol/L) in an Na(+)-independent manner. The rlst-1 mRNA is exclusively expressed in the liver. In both the bile duct ligation model and the cecum ligation and puncture model, mRNA expression levels of rlst-1 were down-regulated. CONCLUSIONS: rlst-1 is a counterpart of human LST-1 and is one of the important transporters in rat liver for the clearance of bile acid. The expression of rlst-1 may be under feedback regulation of cholestasis by biliary obstruction and/or sepsis.
Abstract: We have isolated a novel liver-specific organic anion transporter, LST-1, that is expressed exclusively in the human, rat, and mouse liver. LST-1 is a new gene family located between the organic anion transporter family and prostaglandin transporter. LST-1 transports taurocholate (Km = 13.6 microM) in a sodium-independent manner. LST-1 also shows broad substrate specificity. It transports conjugated steroids (dehydroepiandrosterone sulfate, estradiol-17beta-glucuronide, and estrone-3-sulfate), eicosanoids (prostaglandin E2, thromboxane B2, leukotriene C4, leukotriene E4), and thyroid hormones (thyroxine, Km = 3.0 microM and triiodothyronine, Km = 2.7 microM), reflecting hepatic multispecificity. LST-1 is probably the most important transporter in human liver for clearance of bile acids and organic anions because hepatic levels of another organic anion transporter, OATP, is very low. This is also the first report of the human molecule that transports thyroid hormones.
Abstract: Ventral hernia repair is one of the most common abdominal operations. Recurrence rate remains high despite all preventive measures. "Tension-free" repair has been postulated as the surgical method of choice. A laparoscopic approach to ventral hernia repair has been described recently. Theoretical advantages of a laparoscopic repair include faster recovery, less postoperative pain, less morbidity, and a better cosmetic result. However, the approach requires advanced laparoscopic skills and familiarity with its technique. An animal model of ventral hernia, suitable for laparoscopic repair, was developed to be used for educational and experimental purposes. The model is simple, reliable, and reproducible in any minimally invasive surgery facility. We conclude that the pig can be used as an excellent model to learn the technique and evaluate a variety of endpoints for laparoscopic ventral hernia repair.
Abstract: BACKGROUND: The fervor surrounding minimally invasive surgery, which began with laparoscopic cholecystectomy in the late 1980s, has spread to nearly all surgical specialties. METHODS: After experimental success in an animal model, we recently performed our first case of endoscopic subtotal parathyroidectomy in a 37-year-old man. The patient, who had a history of severe pancreatitis and pancreatic calculi, was diagnosed as having hyperparathyroidism. The option of endoscopic parathyroidectomy was proposed and accepted. After placing the first trocar directly under the platysma, a space was created by bluntly dissecting with the tip of a 5-mm endoscopic camera. Four parathyroid glands were identified, and after a frozen-section diagnosis of parathyroid hyperplasia, three-and-one-half of the glands were resected. RESULTS: The patient developed slight hypercarbia and subcutaneous emphysema during the procedure, but no other problems were noted. His postoperative course was otherwise unremarkable. CONCLUSIONS: This is the first case reported of an endoscopic parathyroidectomy. This experience makes us optimistic about the future of endoscopic neck surgery.
Abstract: We used infrared absorption spectroscopy to clarify the characteristics of black pigment in gallstones, which is insoluble and amorphous, and is considered to be a polymer of bilirubin or calcium bilirubinate with tetrapyrrol units. Black stones contain several metallic elemental components that exist as complex compounds with bilirubin. Chemical analysis of gallbladder bile indicates that the mechanism by which unconjugated bilirubin is precipitated depends on the pH level or on bile acid components. Black pigment is formed by the bridging action of mucin, forming complexes with metal ions in the bile. Hemolytic jaundice, liver cirrhosis, and cardiac valve replacement have been implicated in the etiology of black stone formation. In hemolytic jaundice and cardiac valve replacement, overproduction of bilirubin, due to hemolysis, is responsible for black stone formation, while in liver cirrhosis, a high concentration of ionized calcium and increased pH levels are the main factors in such stone formation.
Abstract: BACKGROUND: Laparoscopic surgery has been successfully applied to several gastrointestinal procedures. Although the totally laparoscopic gastrectomy is feasible, tactile sensation and manipulation of the organ as well as the lesion are decreased when compared to open surgery. The Dexterity Pneumo Sleeve is a new device which allows the surgeon to insert a hand into the abdominal cavity while preserving the pneumoperitoneum. This device was used for patients who underwent laparoscopic gastric surgery. METHODS: The first patient presented with a non-Hodgkin's lymphoma of the stomach. A laparoscopically assisted distal gastrectomy was performed with Roux-en-Y reconstruction. The second patient had a 5-cm leiomyoma involving the greater curve of the stomach, and this device was used for manipulation of the tumor. The last patient suffered from morbid obesity with its associated medical complications and a ventral hernia. The Sleeve was applied at the hernia site and a laparoscopically assisted gastric bypass was performed. RESULTS: The Pneumo Sleeve was useful in these cases for tactile localization of the tumor and for retraction and manipulation of the stomach and surrounding upper abdominal organs. CONCLUSIONS: The utilization of this device resulted in a more easily performed dissection, resection, and anastomosis and was felt to decrease operation time.
