[Chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae treated by open window thoracostomy followed by thoracoplasty and latissimus dorsi muscle transposition]

We describe a case of chronic tuberculous methicillin-resistant Staphylococcus aureus (MRSA) empyema with bronchopleural fistulae successfully treated by open window thoracostomy followed by thoracoplasty and transposition of the latissimus dorsi muscle. A 69-year old man with a history of artificial pneumothorax for pulmonary tuberculosis was referred to our hospital with fever and purulent bloody sputum. He was diagnosed as having right chronic tuberculous empyema with bronchopleural fistulae. Immediate tube thoracostomy markedly relieved symptoms except for low-grade fever. Sputum and empyema cavity cultures were repeatedly positive for MRSA. Open window thoracostomy (5th to 7th ribs resection) was performed to control the infection. The empyema cavity was cleaned with no residual calcified pleura. His condition gradually improved and he underwent thoracoplasty and transposition of the latissimus dorsi muscle 22 months after the initial surgery. He was discharged 25 days postoperatively in good condition. Seventeen months after the curative surgery, he remains well with no evidence of recurrence. A two-stage operation, open window thoracostomy to control infection followed by thoracoplasty and transposition of the latissimus dorsi muscle, is useful in cases of chronic tuberculous MRSA empyema with bronchopleural fistulae.

Endoscopic diverticulotomy for symptomatic pediatric esophageal diverticula

There have so far been few reports on esophageal diverticulum in children. We experienced two symptomatic pediatric cases with esophageal diverticulum. Our cases manifested high fever and dysphagia with chest pain during swallowing. The patients underwent endoscopic diverticulotomy. The septum between the diverticulum and the esophagus was cut using the argon plasma coagulation (APC 3000) system. We recommend an endoscopic diverticulotomy as an effective treatment modality for such symptomatic cases.

[Surgically resected lung cancer in patients complicated with diffuse interstitial pulmonary shadow]

In 25 patients operated on for idiopathic interstitial pneumonia (IIP) associated with primary lung cancer, we clinically examined the predictive factors related to the acute exacerbation of IIP preoperatively and during operation. Most were male heavy smokers. Ages ranged 57 to 78 years. Standard surgery was performed in 11 patients, extended resection in 4 patients and limited resection in 10 patients. The incidence of postoperative acute exacerbation of IIP was 40% (10 patients). These patients were treated with steroid pulse therapy, 3 patients died due to acute exacerbation but 7 patients recovered. It seemed difficult to anticipate postoperative exacerbation of IIP based on preoperative patients evaluation and the degree of surgical invasiveness. Seven patients were alleviated with erythromycin before and after the operation and 4 patients were alleviated with high-dose steroid during or after surgery, with these patients not developing exacerbation of IIP. From these results, it was suggested that high-dose steroid administration during or after surgery and erythromycin before and after the operation were effective to avoid postoperative exacerbation of IIP.

Preoperative planning system for surgical robotics setup with kinematics and haptics

Recently, some useful robotic surgical systems have been developed and applied in many surgical situations. Systems such as the da Vinci surgical system of Intuitive Surgical Inc., which facilitates minimally invasive surgery with increased dexterity, are commercially available. Preoperative simulation and planning of surgical robot setups should accompany advanced robotic surgery if their advantages are to be further pursued. Feedback from the planning system will play an essential role in computer-aided robotic surgery in addition to preoperative detailed geometric information from patient CT/MRI images. Surgical robot setup simulation systems for appropriate trocar site placement have been developed especially for abdominal surgery. The motion of the surgical robot can be simulated and rehearsed with kinematic constraints at the trocar site, and the inverse-kinematics of the robot. Results from simulation using clinical patient data verify the effectiveness of the proposed system.

A robotic wide-angle view endoscope using wedge prisms

BACKGROUND

The aim was to develop a new type of robotic wide-angle view endoscope that does not require rotation or bending of the endoscope to move the field of view. This endoscope allows the surgeon to make extensive observations in a small space. It is safe because it avoids the possibility of hitting organs accidentally.

METHODS

The system consists of an endoscope with a zoom facility and two wedge prisms at the tip. Each prism is set on its own sleeve at the end of the endoscope, and both prisms rotate independently about the axis of the endoscope.

RESULTS

In the in vivo experiment, the high quality of the image was confirmed, and almost whole liver could be observed without the observer moving the endoscope itself.

CONCLUSIONS

This system provides safe robotic endoscopic surgery because of the high quality of the image. It has great significance for future clinical use.

[Solitary hemangioma of the rib; report of a case]

A case of solitary hemangioma which occurred in the rib. Tumor located in the right seventh rib, incidentally taken X-ray film demonstrated bone tumor, but she had no symptoms. Four years after, chest pain occurred and taken X-ray film, tumor size was inceeced. Computed tomography (CT) showed an expansile, well demarcated lesion, with thin corices and fine trabeclae. Chest wall, from the sixth rib to the eighth rib resection was performed and surgical margin was 4 cm. This case were diagnosed hemangioma of the rib. Hemangiomas of the bone are rare benign vascular tumors that account for less than 1% of all bony neoplasms. These lesions are most often occurring in the vertebral column or in the skull. The localization to the ribs is even more rare, with only sporadic case reports in the literature.

An ultrasound-driven needle-insertion robot for percutaneous cholecystostomy

A real-time ultrasound-guided needle-insertion medical robot for percutaneous cholecystostomy has been developed. Image-guided interventions have become widely accepted because they are consistent with minimal invasiveness. However, organ or abnormality displacement due to involuntary patient motion may undesirably affect the intervention. The proposed instrument uses intraoperative images and modifies the needle path in real time by using a novel ultrasonic image segmentation technique. In phantom and volunteer experiments, the needle path updating time was 130 and 301 ms per cycle, respectively. In animal experiments, the needle could be placed accurately in the target.

Renal tubular dysfunction in children living in the Aral Sea Region

BACKGROUND

The Aral Sea region is a natural area seriously polluted by human activities. Recent surveillance revealed the increased prevalence of diverse chronic diseases in children.

AIMS

To investigate the function of renal tubules, which are most at risk of damage as a result of heavy metal intoxication, in children of the Aral Sea region.

METHODS

A group of 205 children living in Kazalinsk, close to the Aral Sea, and a group of 187 children living in Zhanakorgan, far from the Aral Sea, were examined by means of random urine samples. Both urinary N-acetyl-beta-D-glucosaminidase (NAG; U/mmol Cr) and beta2 microglobulin (BMG; microg/mmol Cr) were calculated for each subject.

RESULTS

Mean urinary NAG and BMG were both significantly higher in Kazalinsk than in Zhanakorgan (NAG: 0.77 (0.58) and 0.62 (0.37) U/mmol Cr; BMG: 41.8 (54.8) and 22.5 (20.4) microg/mmol Cr, respectively; mean (SD), p < 0.01). The number of children with abnormal values of NAG (>1.5 U/mmol Cr) was significantly more prevalent in Kazalinsk than in Zhanakorgan (7.9% and 2.6%, respectively, p < 0.05).

CONCLUSION

Renal tubular function of children around the Aral Sea region is profoundly impaired. This should be taken into account when considering the health problems of this area.

Anemia and iron deficiency among schoolchildren in the Aral Sea region, Kazakhstan

The objectives of this study were to estimate the prevalence of anemia and iron deficiency among schoolchildren in the Aral Sea region of Kazakhstan and to determine the various factors associated with anemia in this population. We conducted a cross-sectional study of randomly selected schoolchildren. Blood samples were collected for measuring hemoglobin (Hb), serum ferritin (SF), total iron binding capacity (TIBC), and other hematological indices, and subjects were screened for anemia and iron deficiency. Associations between Hb concentration and SF, TIBC, anthropometric, and socioeconomic data were evaluated using regression analysis. The prevalence of anemia was 49.8 per cent although levels were mostly mild. Twenty-two per cent of the children were iron depleted (SF < 12 microg/l). Of the anemic children, 32.4 per cent were found to have iron deficiency anemia (anemia with SF < 12 microg/l). There were significant positive correlations between the levels of Hb and SF, but a negative correlation with serum TIBC. Age, mean corpuscular volume (MCV) and SF were found to be significantly related to Hb by stepwise multiple regression analysis. Multiple logistic regression analysis revealed that anemia was independently related to living district, education of father, and child's age. The results suggest that iron deficiency is an important determinant of anemia in this population; however, whole anemia cannot be solely explained by iron deficiency. Further studies are needed for consideration of micronutrients status, parasite infestation, hereditary disorders, and exposure to environmental pollutants.

Extremely high prevalence of hypercalciuria in children living in the Aral Sea region

The Aral Sea region is a natural area seriously polluted by human activities. In addition to the increased prevalence of diverse chronic diseases in children, the risk of developing urolithiasis is reported to be high in this region. This study was undertaken to clarify the prevalence of hypercalciuria in children of the Aral Sea region. A group of 205 children living in Kazalinsk, close to the Aral Sea, and a group of 187 children living in Zhanakorgan, far from the Aral Sea, were screened for hypercalciuria. Urinary sodium excretion (sodium per creatinine, uNa/Cr) in addition to calcium excretion (calcium per creatinine, uCa/Cr) was also calculated for each subject. Mean uCa/Cr (mmol/mmol) and uNa/Cr (mmol/mmol) excretions were significantly higher in Kazalinsk than in Zhanakorgan (uCa/Cr: 0.75 +/- 0.74 and 0.33 +/- 0.30; uNa/Cr: 3.54 +/- 2.27 and 2.89 +/- 1.69, respectively, mean +/- SD, p < 0.01). Hypercalciuria regarded as an uCa/Cr of more than 0.703 was observed in 79 out of 205 Kazalinsk children (38.6%) while this was seen in only 24 out of 187 Zhanakorgan children (12.8%). Linear regression analysis revealed a direct positive correlation between urinary calcium and sodium excretion (p < 0.01) in Kazalinsk children.

CONCLUSION

The prevalence of hypercalciuria in children around the Aral Sea region is extremely high. This may be associated with excessive intake of calcium and sodium, or due to impaired renal tubular function caused by toxic chemicals. Therefore, hypercalciuria that may lead to urolithiasis should be taken into account when considering the health problems of this area.

Laparoscope-assisted distal gastrectomy for early gastric cancer in a 76-year-old man with situs inversus totalis

We report a case of a 76-year-old man with situs inversus totalis (SIT) who developed early gastric cancer. He was successfully treated by laparoscope-assisted distal gastrectomy for the gastric cancer. This case suggests that patients with SIT with malignancy could also undergo laparoscopic surgery. To the best of our knowledge, no case of laparoscopic surgery for malignant neoplasms associated with SIT has been reported in the English literature. We therefore believe this is the first case report.

Early experiences of endoscopic procedures in general surgery assisted by a computer-enhanced surgical system

We performed a variety of complete total endoscopic general surgical procedures, including colon resection, distal gastrectomy, and splenectomy, successfully with the assistance of the da Vinci computer-enhanced surgical system. The robotic system allowed us to manipulate the endoscopic instruments as effectively as during open surgery. It enhanced visualization of both the operative field and precision of the necessary techniques, as well as being less stressful for the endoscopic operating team. This technological innovation can therefore help surgeons overcome many of the difficulties associated with the endoscopic approach and thus has the potential to enable more precise, safer, and more minimally invasive surgery in the future.

Beneficial effects of 3-dimensional visualization on hepatic vein reconstruction in living donor liver transplantation using right lobe graft

BACKGROUND

Recently, virtual operation planning and navigation systems have been introduced in the field of neurosurgery and orthopedic surgery. We report here the beneficial effects of 3-dimensional (3D) visualization on hepatic venous reconstruction in living donor liver transplantation (LDLT) using right lobe graft.

METHODS

3D-image reconstruction of the liver was rendered with 3-mm slices of helical computed tomography (CT) data using zioM900 (Zio Software Inc., Tokyo, Japan). To understand the anatomy of the donor's vessels and design an operation plan, a picture of the vessels in and around the liver was reconstructed.

RESULTS

The 3D image demonstrated two short hepatic veins next to the inferior right hepatic vein (IRHV) as well as a large IRHV. The 3D image showed a more precise diameter of the right hepatic vein (RHV) and the IRHV and a more accurate distance between the two hepatic veins than did images measured by 2-dimensional CT. This preoperative information allowed the donor surgeon to dissect the inferior vena cava (IVC) and hepatic veins with reduced blood loss because of reduced risk of injury to the blood vessels. The 3D image revealed that both the RHV and the IRHV branched off at the same angle from the cylindrical IVC. Preoperative planning based on this information secured smooth anastomosis.

CONCLUSIONS

3D visualization is useful for hepatic venous reconstruction of the recipient as well as for donor surgery in LDLT using right lobe graft.

[A survey on attitudes and practice concerning International Health]

OBJECTIVE

A survey was conducted to help understanding of the attitudes and practice of Japanese medical students concerning "International Health".

MATERIALS AND METHODS

One thousand seven hundred and ninety six students from eleven medical schools responded in the questionnaire study. One thousand and ninety seven were males and 699 were females with average ages of 22 and 21 years, respectively.

RESULTS

32.3% of the students answered that they have/had an interest in "International Health". About half of the students answered that they wanted to have a lecture on "International Health" and they also had a willingness to engage in activities for "International Health" someday. Further, 4% of the students had experience of participation in activities related to "International Health". Female students showed that they have a stronger willingness to take part in the "International Health activities" than males.

CONCLUSION

Human resources that can work in the field of international cooperation are required because ODA from Japan has ranked first in the world for nine years in succession. However, the willingness to participate in "International Health activities" among students decreased conversely with their years of learning in medical school. This result might be a basic material when we look at the education toward "International Health" in the medical school.

Hyperbilirubinemia induced by endoscopic variceal ligation for esophageal varices in a patient with primary biliary cirrhosis: a case report

We describe the case of a 51-year-old woman with primary biliary cirrhosis who developed hyperbilirubinemia with transient liver dysfunction after undergoing endoscopic variceral ligation to control hemorrhaging from esophageal varices. After undergoing a variceal ligation, the serum total bilirubin increased from 4.0 mg/dL to 9.5 mg/dL, and the degree of liver failure worsened. She finally had to undergo a liver transplant. We discuss the mechanism of hyperbilirubinemia after endoscopic variceal ligation.

Measles epidemiology and outbreak investigation using IgM test in Laos

Following the Pan American Health Organization (PAHO) recommendation on measles elimination, the Western Pacific Region of WHO (WPR) is emphasizing accelerated measles control programme especially since the achievement of polio eradication in WPR in 2000. This includes upgraded surveillance and mass measles vaccination campaign for children aged 9 months to 4 years. However, there are limited scientific evidences supporting the feasibility of this programme in Laos. To examine measles elimination feasibility in the country, we conducted measles outbreak investigation using immunoglobulin M (IgM). From March 1999 to March 2000, we conducted 7 outbreak investigations. At the outbreak sites, we examined clinical manifestations of cases and collected individual data. About five blood samples were drawn from each outbreak, and IgM antibodies to measles were tested. Of 7 investigated outbreaks, 5 were confirmed as measles, one was chickenpox, and one occurred in the inaccessible area due to flooding. In a village of high land Lao, blood drawn was refused. Of 185 cases, 64 (34.6%) cases were immunized, and 110 (59.5%) were unimunized. The estimated vaccine efficacy is 67.9%. The number of measles cases among school-aged children was 74 (40.0%), which represented 2.5% of the total population in investigated villages. Our findings showed various difficulties of the surveillance and the limited outcomes of mass measles vaccination campaign under the accelerated measles control programme by WPR. Efforts to improve cold chain as well as increasing routine immunization coverage must be the priority of measles control.

Further observation of content uniformity of d-alpha-tocopheryl acetate as an oily drug in granules obtained by wet granulation with a high-shear mixer

Using d-alpha-tocopheryl acetate (VE) as a model drug, we investigated the effects of the amount of binder solution on content uniformity of oily drugs in granules obtained by, wet granulation with a high-shear mixer. When the amount of binder solution was below the water volume for the plastic limit, the content of VE was less than 50% in the fractionated fine granules, but was more than 200% in the fractionated large granules. Large variations were seen in the contents of VE even if the granulation time was extended up to 30 min. This large variation was not decreased by the milling process. On the other hand, when the amount of binder solution was at or above the water volume for the plastic limit, less variation was observed in the content of VE throughout the granules, and the content of VE was fairly uniform. Nuclei rich in VE were formed when VE was adsorbed with the powder before granulation. When the amount of binder solution was below the water volume for the plastic limit, the shearing force of mixer blades to the granules was low, so that the nuclei rich in VE were not fragmented. This led to the nonuniformity of VE content throughout the granules. On the other hand, when amount of binder solution was at or above the water volume for the plastic limit, the shearing force of mixer blades against the granules increased and became sufficient to fragment the nuclei. This led to the uniformity of VE content throughout the granules. This study showed that content uniformity of VE in the granules can be achieved by controlling the physical shearing force of mixer blades by regulating the amount of binder solution.

[Current status and future of surgical robotic systems]

In this review, we are commenting the current status and the future of surgical robotic systems. AESOP is a voice-controlled laparoscope manipulator that enables the "Solo-surgery". ZEUS is a master-slave manipulator that is characterized by its simplicity and lightness. da Vinci is another master-slave manipulator that has more range of freedom, therefore a surgeon can perform the operation with fewer difficulties. The technological development of high-quality and real-time 3D simulation, minimization of scopes and power saving techniques made these surgical robots realized. Although many pending matters such as lack of safety guideline or lack of accuracy of sensor/monitor have been raised in current surgical robotics, the development of the technologies may promise to resolve such matters in the future.

A comparison of an open and laparoscopic appendectomy for patients with liver cirrhosis

Liver cirrhosis is a critical factor contributing to morbidity and mortality in abdominal surgery, because patients with cirrhosis have a particularly high risk of developing bleeding, infection, and ascites. Laparoscopic appendectomy (LA) recently has gained a lot of attention around the world; however, comparisons between the benefits of LA and those of conventional open appendectomy (OA) for patients with liver cirrhosis have yet to be sufficiently compiled. In the present retrospective study, 40 patients with liver cirrhosis who were diagnosed with acute appendicitis before surgery underwent an appendectomy (OA in 25 patients and LA in 15 patients). This study focused on the operative time, amount of postoperative pain, use of analgesics, the restart of a normal diet, number of complications, length of hospital stay, and cost-effectiveness of the procedure in such patients. The amount of postoperative pain and the length of hospital stay were significantly smaller in the LA group. The mean values of the serum C-reactive protein on postoperative days 1, 3, and 7 were significantly less in the LA group. The number of wound infections and wound bleeding was also less in the LA group. The difference in the total cost of hospitalization was not significant. The cost of the operation was greater in the LA group than in the OA group, whereas the hospitalization cost in the LA group was less than that in the OA group. The results of this study suggest that LA may be superior to OA for the treatment of postoperative pain and postoperative complications for patients with liver cirrhosis. Long-term follow-up studies are still necessary, however, to determine any possible decrease in the number of late complications.

Laparoscopic hepatectomy for hepatocellular carcinoma

BACKGROUND

No reports exist on the role of laparoscopic hepatectomy in the short- and long-term outcomes of patients with hepatocellular carcinoma (HCC). We present our results from using laparoscopic hepatectomy for HCC and discuss the importance of this procedure.

METHODS

To investigate the role of laparoscopic hepatectomy in the short- and long-term outcomes, 17 patients with HCC who underwent laparoscopic hepatectomy (laparoscopic hepatectomy group) were compared with 38 patients who underwent conventional open hepatectomy (open hepatectomy group) during the same period.

RESULTS

No differences in operation time, blood loss, rate of blood transfusion, or incidence of postoperative complications were found between the two groups. The postoperative hospital stay for the laparoscopic hepatectomy group was significantly shorter than for the open hepatectomy group. With long-term prognosis, no difference was found in survival rate and disease-free survival rate between the two groups. No recurrence was found in the stump of the remaining liver after laparoscopic hepatectomy.

CONCLUSIONS

Laparoscopic hepatectomy has resulted in a better short-term outcome after surgery than conventional open hepatectomy. The long-term prognosis in the laparoscopic hepatectomy group was similar to that in the open hepatectomy group. Therefore, laparoscopic hepatectomy can be a new alternative for treatment of cirrhotic patients with HCC when patients are strictly selected.

Immunohistochemical localization of vascular endothelial growth factor in the rat portal hypertensive gastropathy

BACKGROUND AND AIMS

Portal hypertensive gastropathy (PHG) is now recognized to be a distinct entity. Recently, angiogenesis has been noticed as a key factor in clarifying the pathophysiology of various diseases. Angiogenesis in the PHT of explored gastric mucosa has yet to be explored. Vascular endothelial growth factor (VEGF) is a potent angiogenic factor. The aim of the present study was thus to investigate whether the hypoxic state exists in PHG, and whether VEGF appears more strongly in PHG than in normal gastric mucosa and, if so, what exactly is the role of the hypoxic state and VEGF in PHG.

METHODS

At 1, 3, 7 and 14 days after either a portal ligation or sham operation, the portal venous pressure, the gastric mucosal blood flow volume and the blood gas were measured and, the expression of VEGF and antiproliferating cell nuclear antigen (PCNA) in gastric mucosal specimens was immunohistochemically assessed.

RESULTS

The portal pressure (PP) and the gastric mucosal blood flow (GMBF) in the PHT rats were significantly greater than in the control (CTR). Both the SaO2 and PaO2 of the arterial blood gas were lower in the PHT rats than in the control rats. The percentage of VEGF expression in the PHG was found to be higher than that in the control gastric mucosa. The percentage of PCNA expression in the PHG was higher than that in the control gastric mucosa.

CONCLUSION

The levels of SaO2 and PaO2 were lower in the PHT rats. There is a possibility that a kind of portal hypertensive gastric change may trigger an enhanced histochemical expression of VEGF. The increased activity of VEGF may have a possibility of the hypoxic gastric mucosal state caused by the presence of active congestion. This damaged mucosal state 'PHG' may thus facilitate the fragility in PHG and such lesions may be slow and insidious, which may therefore lead to sudden and severe anemia, thus causing massive and sometimes fatal hemorrhaging.

Differentiation stages of eosinophils characterized by hyaluronic acid binding via CD44 and responsiveness to stimuli

To characterize interleukin (IL)-5-induced eosinophils, we examined the expression of CD44, very late antigen (VLA)-4, and the IL-5 receptor alpha chain, as well as the levels of eosinophil peroxidase and the generation of superoxide. Eosinophils were prepared from IL-5-transgenic mice, then characterized using electron microscopy to determine their responses to stimuli. Whereas CD44 densities remained almost constant, the level of VLA-4 increased in parallel with eosinophil maturation. Although a subset of IL-5-induced eosinophils with high side scatter recovered from bone marrow and rare ones found in blood recognized hyaluronic acid (HA), most did not have this property. Bone marrow eosinophils with high side scatter and lower density contained eosinophil peroxidase, not only in granules, but also in membranous structures for 30% of this population. This population developed HA-binding ability in response to IL-3, IL-4, IL-5, granulocyte-macrophage colony-stimulating factor, macrophage inflammatory protein (MIP)-2, monocyte chemotactic protein (MCP)-1, eotaxin, nerve growth factor (NGF), and opsonized zymosan (OZ). Peripheral blood eosinophils acquired HA-binding ability in response to the same stimuli, but their responses were less than those of bone marrow eosinophils with high levels of side scatter. However, splenic eosinophils did not respond to these stimuli. Although peripheral blood eosinophils did not proliferate when stimulated by IL-5, these were the only cells that released eosinophil peroxidase in response to IL-4, MIP-2, MCP-1, eotaxin, NGF, and OZ. With the exception of a subset of bone marrow eosinophils, the ability to acquire HA binding, but not the ability to generate superoxide, correlated with eosinophil peroxidase activity and major basic protein accumulation in the granules of maturing cells.

Endoscopic extirpation of benign breast tumors using an extramammary approach

BACKGROUND

Skin incision has been made directly in the breast for treatment of benign breast tumor in spite of the young age of the patient population.

METHODS

Small incisions (12 mm, 5 mm, and 2 mm) were made in the extramammary line, and the benign tumors (diagnosed by imaging and aspiration needle cytology) were endoscopically extirpated.

RESULTS

The mean age of 36 patients was 27.6 years, and the mean mass size was 3.6 cm (7 masses at maximum). The average operation time per mass was 2.6 hours in the first 18 operations and 1.4 hours in the latter 19 operations. Overall blood loss was 19 mL. Postoperative complications were seen in 2 patients: an extended subcutaneous emphysema due to excessive CO2 gas inflation and a mild burn, both of which were reversible. All patients were extremely satisfied with the cosmetic results of the procedure.

CONCLUSIONS

Endoscopic removal by the extramammary approach is the best option for benign breast tumors considering the patient's age and the excellent cosmetic results.

The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age

BACKGROUND/AIMS

Gastroduodenal ulcer is a very common illness in Japan. As the number of elderly persons in Japan increases the same as in Europe and America, the number of such patients requiring a gastroduodenal emergency operation has also increased. Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of this study is to investigate the operative risk factors and the long-term recurrence rates and to define the optimal surgical procedures in emergency situations in elderly patients.

METHODOLOGY

From April 1988 through March 1997, 130 patients over 70 years of age with a perforated gastroduodenal ulcer (a duodenal ulcer perforation in 50 patients and a gastric ulcer perforation in 80 patients) were operated on in an emergency situation in our clinic. We investigated the following items; medical illness, preoperative risk factor, optimal surgical procedure, postoperative organ failure and the cumulative recurrence-free rates after surgical treatment.

RESULTS

A significant correlation with mortality was observed in patients with established comorbidity in the following organs: lung (P = 0.03), heart (P = 0.02), kidney (P = 0.04), and diabetes (P = 0.03). The highest postoperative mortality rate was recorded in patients who underwent a simple closure of a duodenal ulcer perforation (4 patients; 26.7%), while the lowest postoperative mortality rate was recorded in patients who underwent a simple closure and vagotomy of a duodenal ulcer perforation (3 patients; 12.5%). In gastric ulcers, the mortality rate in patients with a gastrectomy was significantly higher than in patients with a simple closure. The practical application of the three risk factors (preoperative shock, delay to surgery over 24 hours, and medical illness) was shown by the progressive rise in the mortality rate with the increasing number of risk factors. Based on the 5 postoperative years after treating a perforated duodenal ulcer, the cumulative recurrence rate after a simple closure (63.6%) was significantly higher than that after a simple closure and vagotomy (38.1%) (n = 0.02) or after gastrectomy (0%) (P < 0.001). At 5 years postoperatively, the cumulative recurrence rate after a simple closure (41.2%) was significantly higher than that after a gastrectomy (15.9%) (P < 0.01).

CONCLUSIONS

In conclusion, in an emergency situation, elderly patients are in a highly unfavorable prognostic condition due to their advanced age, and comorbidity, which thus leads to poorer results, not only worldwide, but also in Japan. Based on our findings, in duodenal ulcer cases, a simple closure and vagotomy is recommended because of its low mortality and minimal stress, except for cases with a giant perforation measuring over 20 mm in diameter at the perforation hole or with severe duodenal stenosis. In stomach ulcer cases, a gastrectomy may be recommended because of its low recurrence rate.

Effectiveness of gastric devascularization and splenectomy for patients with gastric varices

BACKGROUND

Bleeding from gastric varices is difficult to control and has a high mortality rate. Recently, newly developed treatments for this serious lesion have been used, but surgical intervention is still advocated by several studies. We report our experience with gastric devascularization and splenectomy and its effectiveness for patients with gastric varices.

STUDY DESIGN

Gastric devascularization and splenectomy was successfully performed to treat patients with isolated gastric varices (n = 42). The patients included 27 men and 15 women who ranged from 29 to 73 years of age (average 53.7 years). We analyzed the findings of gastric varices using endoscopy, the results of gastric devascularization and splenectomy, and survival after the operation.

RESULTS

No patient had tortuous varices (F1). Twenty-seven patients (64.3%) had nodular varices (F2) and 15 (35.7%) had tumorous varices (F3). Twenty-five patients (59.5%) had large varices that occupied two or more areas. Twenty-nine patients (69.0%) had varices with a positive red color sign. No major complications during or after the operation were observed, and peri-operative death did not occur. Gastric varices were eradicated in all 42 patients. Survival rates were 97.6% after 1 year, 88.1% after 3 years, 76.2% after 5 years (mean followup period, 46 months).

CONCLUSIONS

This study showed that gastric devascularization and splenectomy provides satisfactory results for patients with gastric varices that are likely to bleed and that it can be performed even on patients who have had other treatments.

Risk of poliomyelitis importation and re-emergence in Laos

The declaration of poliomyelitis eradication in the western pacific region is scheduled for Oct 29, 2000, in Kyoto, Japan. Our survey in the border areas of the southeast Asia region, however, revealed that there remains a risk of re-emergence and importation of poliomyelitis into Laos. We report the evidence based on our border area investigations during the past 4 years under the bilateral supervision of the governments of Laos and Japan.

Laparoscopic hepatectomy: new approach for hepatocellular carcinoma

This article presents the rationale for the laparoscopic approach to liver surgery, showing the technique of fully endoscopic and endoscopic-assisted formal and wedge hepatic resections. The early results are comparable to those of conventional surgery, with the benefits derived from minimal access surgery. Laparoscopic liver resections are technically feasible, with an acceptable morbidity and mortality rate, but extensive experience in conventional liver surgery, advanced laparoscopic surgery, and the availability of all requested technologies are indispensable prerequisites.

Laparoscopic hepatectomy: new approach for hepatocellular carcinoma

This article presents the rationale for the laparoscopic approach to liver surgery, showing the technique of fully endoscopic and endoscopic-assisted formal and wedge hepatic resections. The early results are comparable to those of conventional surgery, with the benefits derived from minimal access surgery. Laparoscopic liver resections are technically feasible, with an acceptable morbidity and mortality rate, but extensive experience in conventional liver surgery, advanced laparoscopic surgery, and the availability of all requested technologies are indispensable prerequisites.

Endoscopic ligation of oesophageal varices compared with injection sclerotherapy in primary biliary cirrhosis

BACKGROUND AND AIMS

Oesophageal varices are an important complication in primary biliary cirrhosis (PBC). However, there have yet to be any studies made on treatment of oesophageal varices in PBC. We therefore studied the efficacy and related complications of endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) as an initial treatment in primary biliary cirrhotic patients.

METHODS

From December 1985 to March 1999, 29 biliary cirrhotic Japanese patients with portal hypertension and oesophageal varices were treated in our clinics. Eleven patients were treated with EVL and EIS, and 18 patients underwent EIS only. The liver function, renal function and respiratory function were studied before and after endoscopic treatment and any complications were also examined.

RESULTS

In stages III and IV, significant differences were observed in the serum levels for total bilirubin and gamma-glutamic pyruvic transaminase only in the EIS group. Significant differences were observed in the rate of appearance of pyrexia, retrosternal pain and pleural effusion between the EIS and EVL groups.

CONCLUSION

EVL significantly reduced the adverse effects associated with EIS at the initial session in primary biliary cirrhotic patients.

Role of nitric oxide and endothelin-1 in a portal hypertensive rat model

BACKGROUND

Portal hypertension is often accompanied by a hyperdynamic circulation state. Some reports have suggested that nitric oxide (NO) plays an important role in this hyperdynamic state. On the other hand, although endothelin (ET)-1, a powerful vasoconstrictor, was recently identified, little is known about its role in portal hypertension or about the interaction between NO and ET-1. The aim of this study was therefore to investigate whether or not the inhibitor of NO synthase (NOS) might improve portal hypertension, and also to clarify the relationship between NO and ET-1.

METHODS

Portal hypertensive (PHT) rats, in which hypertension was induced by a two-step ligation of the portal vein (PVL), were used. The mean arterial pressure (MAP), portal pressure (PP), visceral blood flow volume (BFV), and serum levels of NO and ET-1 were determined in PVL rats treated with two NOS inhibitors with different functions: N(G)-nitro-L-arginine methyl ester (L-NAME) and aminoguanidine (AG). Control (CTR) rats. treated by a sham operation (SO), were also studied.

RESULTS

Two-step PVL treatment induced a significant increase in the serum level of NO3-and ET-1 in the portal vein. L-NAME and AG administration significantly decreased PP at doses of 50 mg/kg in PHT rats after 60 min administration, while no inhibitor effected any modification in the CTBR rats. Both NOS inhibitors increased MAP and decreased PP and BFV in the portal vein, gastric mucosa, and spleen, in addition to decreasing the serum levels of NO3- and ET-1 in the PHT rats, while neither blockade modified any parameters in the CTR rats. In PHT rats, L-arginine, a NO substance, reversed the effect of L-NAME, while it did not induce any recovery from the AG effect.

CONCLUSIONS

In PHT rats, NO seems to contribute to portal hypertension. PVL increases not only the serum level of NO3-, but also that of ET-1 in the portal vein. Both L-NAME and AG reduce PP and BFV of the portal vein, spleen, gastric mucosa. and liver. In addition, the inhibition of NOS diminishes the serum level not only of NO, but also of ET-1. Use of an appropriate NOS inhibitor may therefore positively affect the hyperdynamic state in portal hypertension.

Serum testosterone:estradiol ratio and the development of hepatocellular carcinoma among male cirrhotic patients

The reason for the large male predominance in the occurrence of hepatocellular carcinoma (HCC) remains unknown, and sex hormones may contribute to this phenomenon. We examined possible associations of serum levels of testosterone, free testosterone, estradiol, sex hormone binding globulin, and testosterone:estradiol ratio (T:E2 ratio) with HCC development in a follow-up study of 46 Japanese male patients with liver cirrhosis predominantly of hepatitis C virus origin (76%). Serum samples were collected between December 1985 and December 1987, and the patients were completely followed until the end of 1995 for an average of 5.1 years. During the follow-up period, 20 patients (43%) developed HCC. Univariate analysis demonstrated that serum T:E2 ratio and testosterone were significant predictors of HCC; the hazard ratios (and 95% confidence intervals) in the middle and upper tertiles relative to the lower tertile were 2.0 (0.5-7.6) and 4.0 (1.1-14.6; P trend = 0.03) for T:E2 ratio and 0.8 (0.2-3.1) and 2.9 (1.0-8.5; P trend = 0.05) for testosterone. Adjustment for age, serum albumin, hepatitis virus markers, and other clinicobiological variables substantially increased the corresponding hazard ratios. In multivariate analysis, serum free testosterone appeared to be associated with increased risk, yet independent associations with estradiol and sex hormone binding globulin were not evident. These results indicate that elevated serum testosterone, together with decreased serum estrogens, may promote the development of HCC in cirrhosis.

Role of vascular endothelial growth factor in portal hypertensive gastropathy

BACKGROUND AND AIMS

Portal hypertensive gastropathy (PHG) is now recognized as a distinct entity; however, the angiogenesis in the portal hypertensive gastric mucosa has yet to be elucidated. Vascular endothelial growth factor (VEGF) is a potent angiogenic factor involved in both physiological and pathological angiogenesis. The aim of this study was thus to examine the function of VEGF in the portal hypertensive and non-portal hypertensive gastric mucosa.

METHOD

Forty-five cirrhotic patients were divided into 3 groups as follows. Group I included 15 patients without PHG who were treated with 1.5 g teprenone/day for 8 weeks: PHG(-)-t. Group II included 15 patients with PHG who were not treated with teprenone: PHG(+)-n. Group III included 15 patients with PHG who were treated with teprenone for 8 weeks: PGH(+)-t. The gastric mucosal blood flow (GMBF), the concentration of gastric mucosal VEGF and hexosamine and the endoscopic findings were studied both before and after medication.

RESULTS

Before teprenone treatment, the GMBF in the antrum, fundus, fornix were significantly higher in PHG(+)-n than PHG(-)-t. After treatment, the GMBF in the fundus and fornix significantly decreased more than before treatment in the PHG(+)-t. After treatment, the GMBF in the antrum increased significantly more than before treatment in PHG(-)-t. The gastric VEGF and hexoxamine concentration in the antrum were significantly higher in PHG(+)-n than in PHG(-)-t. After treatment, the gastric VEGF and hexosamine concentration in the antrum significantly decreased in PHG(+)-t while no change in concentration was recognized in PHG(+)-n. In the endoscopic findings, a decrease in the PHG score was recognized in 2 patients in PHG(+)-t.

CONCLUSION

Portal hypertensive gastric mucosal change was thus found to trigger a high concentration of VEGF and hexosamine. Such increased activity of VEGF and hexosamine may thus account for the presence of active congestion in PHG.

A new surgical strategy for cirrhotic patients with hepatocellular carcinoma and hypersplenism. Performing a hepatectomy after a laparoscopic splenectomy

BACKGROUND

Hepatectomy for cirrhotic patients with hypersplenism is a high-risk operative procedure. We report herein a new strategy for high-risk patients with hepatocellular carcinoma (HCC).

METHODS

Six cirrhotic patients with HCC and hypersplenism received a partial hepatectomy after first undergoing a laparoscopic splenectomy. We then compared the variables for these patients before splenectomy and before hepatectomy.

RESULTS

The platelet count and the white blood cell count were found to be significantly elevated before hepatectomy. The ammonia value decreased significantly before hepatectomy. The albumin value tended to be elevated before hepatectomy. Furthermore, the Child's classification of all patients improved significantly before hepatectomy. However, other variables-such as the indocyanine green dye excretion test at 15 min and the bilirubin value-did not change after splenectomy. For hepatectomy patients who first underwent a laparoscopic splenectomy, operation time ranged from 265 to 440 min (average time, 361 min), and blood loss ranged from 500 to 2,200 ml (median volume, 1,300 ml). Four of six patients did not require any blood transfusion; furthermore, no patient needed a platelet-rich plasma transfusion. All but one patient, who suffered postoperatively from an intractable duodenal ulcer, had an uneventful postoperative course.

CONCLUSION

Partial hepatectomy after an initial laparoscopic splenectomy is a new and effective choice of treatment for cirrhotic patients with HCC and hypersplenism.

Role of endothelin-1 in congestive gastropathy in portal hypertensive rats

BACKGROUND

The aim of this study was to determine the role of endothelin (ET)-1 in portal hypertensive gastropathy (PHG) under portal hypertension, in order to investigate whether the ET(A/B) receptor inhibitor improves the permeability of gastric mucosal microvessels in PHG.

METHODS AND RESULTS

Portal hypertensive rats (PVL) and sham-operated rats (CTR) were prepared and then the concentration of plasma ET-1 was measured and the vasopressor response to ET-1 was compared between the two groups. The plasma ET-1 levels in PVL increased significantly compared with CTR; however, the vasopressor response to ET-1 in PVL decreased more than in CTR. Next, the portal venous pressure was measured in both CTR and PVL pretreated with or without a nitric oxide (NO) synthase inhibitor, N(G)-nitro-L-arginine methyl ester (L-NAME), before the injection of ET-1. The portal venous pressure of PVL after receiving ET-1 and being pretreated with L-NAME significantly increased in comparison to the pressure of PVL treated with ET-1 alone (without L-NAME). Moreover, Evans-Blue was injected into each rat and the absorbancy of the gastric contents was measured. The absorbancy of Evans-Blue in PVL increased significantly compared with CTR; however, the absorbancy in PVL+ ET(A/B) receptor inhibitor (Ro47-0203) decreased significantly more than in PVL.

CONCLUSIONS

This study showed that ET-1 is a potent vasoconstrictive substance that also has a transitory vasodilative response through NO induced by ET-1 in portal hypertension. In addition, it was found that the vascular permeability of the gastric mucosa increased in portal hypertension and that Ro47-0203 inhibited the hyper-permeability. Accordingly, ET-1 may, thus, play an important role in the development of PHG through NO induced by ET-1. Ro47-0203 may, therefore, be a useful substance for improving PHG in portal hypertension.

Leiomyosarcoma of the thyroid gland with rapid growth and tracheal obstruction: A partial thyroidectomy and tracheostomy using an ultrasonically activated scalpel can be safely performed with less bleeding

Primary leiomyosarcoma of the thyroid gland is rare, and to the best of our knowledge only nine well-documented cases have been previously reported in the world literature. We herein report a 90-year-old female patient with primary leiomyosarcoma of the thyroid gland who showed a rapid tumor growth and tracheal obstruction. The patient was successfully treated by a partial resection of the thyroid gland using an ultrasonically activated scalpel and emergency tracheostomy. Immunohistochemically, the tumor cells showed positive reactivity to smooth muscle actin and negative reactivity to thyroglobin. Palliative surgery successfully allowed the patient to recover from the symptoms of dyspnea related to this rare disease. The use of an ultrasonically activated scalpel and tracheostomy thus allowed us to safely perform a thyroidectomy with substantially less bleeding than normal.

The effect of carbon dioxide pneumoperitoneum on the portal hemodynamics in a portal-hypertensive rat model

As use of laparoscopic surgery grows, various complications with pneumoperitoneum have been reported. However, there are no reports on the relation between the carbon dioxide (Co2) pneumoperitoneum and portal hemodynamics. The purpose of this study was to determine how the pneumoperitoneum affects the portal hypertensive state. Portal-hypertensive rats, control rats, and sham operation rats were studied. The mean arterial pressure, portal venous pressure, central venous pressure, red blood flow volume of the viscera, and liver and renal function were investigated. The findings of this study suggest that Co2 pneumoperitoneum at less than 10 mm Hg does not present any undue risk to the portal hemodynamics in portal-hypertensive rats; however, more attention should be paid to the IAP in PHT patients undergoing surgery.

Coil embolization of arterioportal fistula that developed after partial gastrectomy

A 51-year-old man suffered from bleeding esophageal varices. He had undergone partial gastrectomy for gastric cancer 1 year before. An extrahepatic arterioportal fistula and resultant portal hypertension were found. We successfully performed transarterial embolization of the fistula using stainless steel coils. Portal hypertension improved dramatically.

A selective cyclo-oxygenase-2 inhibitor, NS-398, may improve portal hypertension without inducing gastric mucosal injury

BACKGROUND AND AIMS

Prostacyclin has been shown to play a role in hyperdynamic circulation in portal hypertension. Recently, a new subtype of cyclo-oxygenase (COX), COX-2, which acts as an inducible synthase in response to various stimuli. The aim of this study was to investigate whether COX-2 contributes to portal hypertension and whether a COX-2 blockade induces the same sort of gastric mucosal injury as a COX-1 blockade.

METHODS

Portal hypertension (PHT) in rats was induced by a two-step ligation of the portal vein. The mean arterial pressure (MAP), portal pressure (PP), visceral blood flow volume (BFV), serum levels of 6-keto-prostaglandin F1alpha (PGF1alpha), thromboxane B2 (TXB2) and gastric mucosal injury induced by pure ethanol were all measured in PHT rats receiving different inhibitors (indomethacin, a highly selective COX-1 inhibitor; NS-398, a highly selective COX-2 inhibitor). Control rats treated by a sham operation were also studied.

RESULTS

The NS-398 administration significantly decreased PP to the same extent as indomethacin at doses of 5 and 10 mg/kg in PHT rats after a 60 min administration, while neither inhibitor affected the control rats. Both inhibitors significantly increased PP after a 30 min administration in the PHT and control rats at a dose of 5 mg/kg while both inhibitors significantly decreased PP after 60 min administration only in the PHT rats. Portal vein ligation treatment induced a significant increase in PP and BFV of the portal vein, gastric mucosa, oesophageal mucosa and the serum levels of 6-keto-PGF1alpha and TXB2, while portal vein ligation treatment induced a significant decrease in BFV of the liver. Both blockades increased MAP and decreased PP and BFV in the splanchnic area and decreased the serum level of 6-keto-PGF1alpha and TXB2 in the PHT rats, while neither blockade modified any parameters in the control rats, except that indomethacin administration significantly decreased the BFV of the gastric mucosa. Indomethacin administration significantly increased the ulcer index (UI). The NS-398 had no effect on UI in either the PHT or control rats. Only indomethacin significantly increased the number of rats demonstrating gastric mucosal long lesions (> 2 cm) in the PHT rats.

CONCLUSION

In the PHT rats, prostaglandin seemed to contribute to portal hypertension. Both COX blockades reduced PP and BFV of the portal vein and gastric mucosa. NS-398, a selective COX-2 inhibitor, may, therefore, improve portal hypertension without inducing gastric mucosal injury.

Laparoscopic splenectomy for splenic artery aneurysm

Two cases undergoing a laparoscopic splenectomy for the treatment of a splenic artery aneurysm are herein reported. This lesion is relatively rare. Surgical treatment is indicated for such cases since approximately 10% of these aneurysms tend to rupture which thus results in fatal hemorrhaging. Both cases demonstrated aneurysms measuring more than 2 cm in diameter based on the ultrasonography, computed tomography and celiac angiography findings and, as a result, a laparoscopic splenectomy was thus prophylactically performed. This procedure is the preferred technique for high risk patients, such as those with chronic renal failure, as observed in case 1, since patients can be spared the disadvantages of undergoing a laparotomy.

Results of laparoscopic splenectomy for immune thrombocytopenic purpura

BACKGROUND

Laparoscopic splenectomy has been demonstrated to be technically feasible and safe for the treatment of immune thrombocytopenic purpura (ITP), hereditary spherocytosis, and Hodgkin's disease.

PATIENTS AND METHODS

The study comprised 76 consecutive patients with chronic ITP who were admitted to our hospital from 1968 to 1997 and underwent splenectomy; 35 patients underwent a laparoscopic splenectomy, and 41 had open surgery.

RESULTS

Laparoscopic splenectomy involved minimal incision, and a significantly lower frequency of analgesia was required for postoperative abdominal pain (1.4 versus 3.3); postoperative hospital stay was shorter (9.6 versus 20.1 days, P <0.05). Operative time was significantly longer for the laparoscopic surgery (204.5 versus 99.8 minutes, P <0.01), but blood loss was less (154.4 versus 511.7 g, P <0.01). During the present study (range 3.8 to 80 months), accumulative nonrecurrence rate was 67.9% in 5 years after surgery, which is similar to that of the previous open splenectomy.

CONCLUSIONS

Laparoscopic splenectomy can become an alternative therapeutic modality in the treatment of ITP.

Laparoscopic splenectomy: the latest modern technique

BACKGROUND/AIMS

Recent advances in technical instruments have resulted in increased safety and simplicity in laparoscopic surgery. The purpose of this article is to introduce our latest operative techniques for laparoscopic splenectomy.

METHODOLOGY

The patient is placed in the right semidecubitus position and the gastrosplenic ligament including the short gastric vessels was performed by using an ultrasonically activated scalpel. The splenic artery and vein were resected at the splenic hilum with an autosuture device. The electromechanical morcellator was used to remove the spleen.

RESULTS

The laparoscopic splenectomy was successfully performed in all 74 patients from 1992-1997. There was no deaths related to the operation. Conversion to open surgery with a small incision of 5 cm was required in one patient with advanced liver cirrhosis and portal hypertension and 45 patients with portal hypertension.

CONCLUSIONS

A laparoscopic splenectomy is considered to be a safe and feasable modality for the treatment for hematologic disorders of both the spleen and other benign tumors.

Systemic effects of ethanolamine oleate in analbuminemic rats

BACKGROUND/AIMS

The present study was an attempt to clarify whether only serum albumin inactivates ethanolamine oleate (EO) in vivo and whether EO has an adverse effect on the lung, kidney, and liver in the presence of analbuminemia.

METHODOLOGY

Fifty-five female Nagase Analbuminemia Rats (NAR) and 55 female Sprague-Dawley Rats (SDR) were injected with 5% EO in the left femoral vein. Changes in respiratory, renal, and hepatic function and the extent of hemolysis following the injection of the EO were examined.

RESULTS

In both groups, a transient but significant increase was seen in serum hemoglobin at up to 1 hour after injection of EO. No significant changes in PaO2, PaCO2, blood urea nitrogen, or serum creatinine following injection of EO were seen in either group. The total bilirubin significantly increased within 30 min in the SDR group, but this increase was prolonged for 5 days in the NAR group. Glutamic pyruvic transaminase (GPT) increased for 12 hours in the NAR group, while no change was seen in the SDR group.

CONCLUSIONS

These observations suggest that EO may have hepatotoxic effects, that serum albumin may afford protection, and that other humoral substances which inactivate EO, including serum globulin, may be present.