Usefulness of laparoscopic cholecystostomy in children with complicated choledochal cyst

INTRODUCTION

In children with choledochal cysts (CC), obstruction of the discharge of bile or pancreatic juice is frequently observed, and biliary perforation and severe pancreatitis may occur. In such cases, temporary drainage is necessary to stabilize these patients. We employed laparoscopic cholecystostomy followed by laparoscopic cyst excision in cases with complicated CC.

METHODS

Between 2009 and 2013, emergency laparoscopic cholecystostomy for bile drainage was performed in seven girls with complicated CC in whom conservative treatment failed to ameliorate abdominal pain, vomiting, and jaundice; among these seven patients included two with biliary perforation, one with a huge cyst, and four with peribiliary edema suggestive of impending biliary rupture. Protein plugs in the common channel or the terminal portion of the cyst were present in six patients.

RESULTS

Amelioration of symptoms, such as abdominal pain and jaundice, was achieved in all patients after laparoscopic cholecystostomy. Saline irrigation of the bile duct via cholecystostomy was commenced 2 days postoperatively. All patients underwent laparoscopic cyst resection after improvement of their general condition and detailed evaluation of the intrahepatic and extrahepatic bile ducts and pancreaticobiliary maljunction. Impacted protein plugs or gallstones were eliminated in all patients by the time of laparoscopic cyst excision.

CONCLUSION

Laparoscopic cholecystostomy followed by laparoscopic cyst excision is a useful and safe procedure for the treatment of complicated CC. This technique is also favorable from a cosmetic viewpoint because the resultant wound can be reused as the trocar insertion site at the time of laparoscopic cyst excision.

Thoracoscopic repair of a large neonatal congenital diaphragmatic hernia using Gerota's fascia

A large congenital diaphragmatic hernia needing patch repair has a high risk of recurrence. Thus, managing these large congenital diaphragmatic hernias under thoracoscopy has become a problem. Here, a large congenital diaphragmatic hernia that was repaired using Gerota's fascia under thoracoscopy is reported. In the present case, it was impossible to close the hernia directly under thoracoscopy because the hernia was too large. Gerota's fascia was raised up by the left kidney and used for the repair. The left colon adhering to Gerota's fascia was mobilized, and a large space was made under thoracoscopy. Gerota's fascia was fixed to the diaphragmatic defect. The patient's postoperative course was good, and there was no recurrence. This technique could be one option for repairing a large hernia under thoracoscopy.

Diaphragmatic eventration in children: laparoscopy versus thoracoscopic plication

AIM

To determine the best way to perform diaphragmatic plication for diaphragmatic eventration (DE) using minimally invasive surgery.

MATERIALS AND METHODS

We conducted a retrospective review of pediatric cases of DE treated between 2007 and 2012. Thoracoscopic plication (TP) is performed using single-lung ventilation with three 5-mm ports; laparoscopic plication (LP) is performed using three or four 5-mm ports. The choice of technique was determined preferentially by the treating surgeon.

RESULTS

There were 20 subjects (13 treated by LP and 7 treated by TP). Etiology of DE was phrenic nerve injury (LP, n=11; TP, n=1) and muscular deficiency (LP, n=2; TP, n=6). Mean age (LP, 18 months; TP, 25 months) and weight (LP, 8.0 kg; TP, 9.7 kg) at surgery were not significantly different. Mean operating time was 155.6 minutes in LP and 167.0 minutes in TP (P=not significant). Mean intraoperative end-tidal CO2 was 41.9 mm Hg (range, 35-52 mm Hg) in LP and 36.9 mm Hg (range, 33-41 mm Hg) in TP (P=.01). Mean duration of postoperative ventilation was 1.2 days in LP and 1.3 days in TP (P=not significant). Mean time taken to recommence feeding postoperatively was 1.6 days in both groups (P=not significant). Complications were one conversion to thoracotomy in TP, 1 case of atelectasis in each group (P=not significant), and 6 cases of recurrence in LP versus none in TP (P=.04).

CONCLUSIONS

Both TP and LP are beneficial for treating small children with DE. However, there is a higher incidence of recurrence after LP, and the role of TP in cardiac patients requiring subsequent surgery is debatable.

Unilateral pulmonary agenesis associated with oesophageal atresia and tracheoesophageal fistula: A case report with prenatal diagnosis

We describe herein a case of unilateral pulmonary agenesis (PA) with oesophageal atresia (EA)/tracheoesophageal fistula (TEF) that was diagnosed prenatally and repaired by esophagoesophagostomy with stable postoperative course. The patient was born at 34 weeks gestation, after ultrasonography at 22 weeks gestation showed possible right-sided diaphragmatic eventration or PA and EA was subsequently suspected due to hydramnios. The initial X-ray showed mediastinal shift to the right, and coil up sign of the nasogastric tube, without intracardiac anomaly. Immediately after the diagnosis of EA/TEF and unilateral PA on day 0, the patient was intubated in the operating room, and a gastrostomy tube was placed. After pulmonary status stabilized, at 4 days old, EA/TEF was repaired through a thoracotomy in the right 4 th intercostal space. The right main bronchus was noted to continue into the distal oesophagus; this fistula was ligated and divided, and a single-layer esophagoesophagostomy was performed under mild tension with one vertebral gap. The neonate was maintained on mechanical ventilation and gradually weaned to extubation at 7 days old. The postoperative course was uneventful, with the exception of prolonged jaundice that emerged at 3 months old. Laparoscopic cholangiography at that time excluded biliary atresia, and jaundice resolved spontaneously. The patient has not shown any respiratory symptoms or feeding difficulties as of the 12-month follow-up.

Human early liver regeneration after hepatectomy in patients with hepatocellular carcinoma: special reference to age

BACKGROUND AND AIMS

This study was conducted to clarify the effects of age on human liver regeneration.

PATIENTS AND METHODS

Thirty major hepatectomies, equal to or more than two segmentectomies for hepatocellular carcinoma, were performed. Ages ranged from 37 to 85 years and five octogenarians were included. The early regenerative index was defined: (liver volume after 7 days after hepatectomy - estimated remnant liver volume before hepatectomy)/estimated remnant liver volume, using three-dimensional computed tomographic volumetry. Farnesoid X receptor and forkhead box m1 expression in the liver, which has been reported to age-related decrease of liver regeneration in animal model, were examined using real-time polymerase chain reaction. The patients were divided into two groups: low early regenerative index (n = 15), early regenerative index less than 55% and high early regenerative index (n = 15), early regenerative index equal to or more than 55%.

RESULTS

The mean early regenerative index was 57%. Age (R (2) = 0.274, P = 0.003) and estimated blood loss (R (2) = 0.134, P = 0.0466) were inversely correlated with the early regenerative index, and the expression of farnesoid X receptor and forkhead box m1 was not. The incidence of post-hepatectomy liver failure in the low early regenerative index group was higher than that in the high early regenerative index group (P = 0.0421).

CONCLUSIONS

Age and intraoperative blood loss are inversely correlated with early liver regeneration in humans. In elderly patients, massive blood loss should be avoided in view of liver regeneration.

Impact of laparoscopy for diagnosis and treatment in patients with disorders of sex development

OBJECTIVE

To review laparoscopy in patients with disorders of sex development (DSD) in order to clarify its usefulness in diagnosis, devising subsequent therapeutic strategies and managing patients with various conditions.

PATIENTS AND METHODS

Between April 1992 and December 2012, 29 laparoscopic surgeries were performed in 25 DSD patients. Among them, ten were diagnostic laparoscopy including gonadal biopsy, and 19 were therapeutic laparoscopy. Surgical procedures and complications were evaluated.

RESULTS

For diagnostic laparoscopy, laparoscopic gonadal biopsy was performed in three patients. Inspection, with or without open gonadal biopsy, was performed on four out of seven patients with 46XY DSD or mixed gonadal dysgenesis (MGD). Additional surgery was planned and performed based on diagnostic laparoscopic findings in six out of seven patients. In the three patients with ovotesticular DSD, the gonadal pathology was diagnosed as: testis/ovary in one, testis/ovotestis in one and ovary/ovotestis in one--this was from the laparoscopic inspection and/or gonadal biopsy. However, the final diagnoses were bilateral ovotestis in two patients and ovary/ovotestis in one patient. For therapeutic laparoscopy, surgical procedures were: gonadectomy in 17 patients (bilateral in 13, unilateral in three, partial in two); hysterectomy in two patients; orchiopexy in one; and sigmoid vaginoplasty in one patient (included multiple procedures). There were no severe perioperative complications. In the four patients with a history of diagnostic laparoscopy, no severe intra-abdominal adhesions that would disturb therapeutic laparoscopic surgery were observed.

CONCLUSION

While diagnostic laparoscopy was helpful in devising a therapeutic surgical strategy in most of the patients with DSD who were suspected as having complex gonadal status or Müllerian duct derivatives, attention must be paid to precisely diagnosing the gonadal status in ovotesticular DSD. On the other hand, therapeutic laparoscopic surgeries were valuable procedures in treating DSD patients, even with a history of previous diagnostic laparoscopy.

Nuclear chemistry. Synthesis and detection of a seaborgium carbonyl complex

Experimental investigations of transactinoide elements provide benchmark results for chemical theory and probe the predictive power of trends in the periodic table. So far, in gas-phase chemical reactions, simple inorganic compounds with the transactinoide in its highest oxidation state have been synthesized. Single-atom production rates, short half-lives, and harsh experimental conditions limited the number of experimentally accessible compounds. We applied a gas-phase carbonylation technique previously tested on short-lived molybdenum (Mo) and tungsten (W) isotopes to the preparation of a carbonyl complex of seaborgium, the 106th element. The volatile seaborgium complex showed the same volatility and reactivity with a silicon dioxide surface as those of the hexacarbonyl complexes of the lighter homologs Mo and W. Comparison of the product's adsorption enthalpy with theoretical predictions and data for the lighter congeners supported a Sg(CO)6 formulation.

Thoracoscopic versus open repair of esophageal atresia with tracheoesophageal fistula at a single institution

PURPOSE

The potential benefits of thoracoscopic repair (TR) of esophageal atresia and tracheoesophageal fistula (EA/TEF) in newborns are still unclear. Our aim was to define the criteria, perioperative outcome after undergoing TR versus open repair (OR) for EA/TEF.

PATIENTS AND METHODS

A retrospective chart review was conducted of 36 consecutive neonates who underwent EA/TEF repair between 2001 and 2012 in Shizuoka Children's Hospital. Patients in this study were birth weight >2,000 g, and did not have severe cardiac malformations or chromosomal aberrations. Of the 26 newborns who met the selection criteria, 11 patients underwent attempts at TR compared to 15 patients who underwent OR. All cases were followed 1 year after operation at least.

RESULTS

All 11 TR were successfully completed. There were no significant differences between intra- and perioperative complications in the two groups. Intraoperative EtCO2 and arterial blood gases were not significantly different between the two groups. We did not found eating disorder, respiratory disorder, and failure of growth in all cases.

CONCLUSION

In our study, the thoracoscopic approach appeared to be favorable and safe for EA/TEF repair in carefully selected patients.

Right ventricular dynamic cardiomyoplasty for the univentricular heart with pulmonary hypertension

OBJECTIVES

We conducted an acute experimental study to test the feasibility of dynamic cardiomyoplasty in a setting of modified Fontan procedure for univentricular heart with pulmonary hypertension to obtain a possible proxy for high-risk Fontan candidates.

METHODS

After electrical preconditioning of the left latissimuss dorsi for 6 weeks in 8 dogs, the right ventricular cavity was totally obliterated with concomittent closure of the tricuspid valve and right pulmonary artery. Modified Fontan circulation was established with the aortic homograft anastomosed between the right atrium and pulmonary trunk, incorporated with a pericardial pouch as a compression chamber (neoright ventricle) fixed onto the epicardial surface of the ventricle. After cardiopulmonary bypass termination, a latissimus dorsi was applied to wrap the pericardial pouch and ventricle clockwise and stimulated with a trained-pulse (25 Hz) at 1:1 synchronization ratio with cardiac beats.

RESULTS

Profound right heart failure was noted during Fontan circulation in increased pulmonary vascular resistance (11 +/- 3.2 Wood units), whereas graft pacing showed significant augmentation of systolic pulmonary pressure by 54 +/- 12%, the mean pulmonary flow by 68 +/- 23%, and aortic pressure by 23 +/- 5% at a physiological range of central venous pressure (13.2 +/- 0.7 mmHg). Right heart function curve analysis confirmed marked augmentation of right heart performance, restoring almost normal pulmonary circulation. These functional benefits were sustained up to 4 hours in 4 animals until experiments were terminated.

CONCLUSIONS

Dynamic cardiomyoplasty in a modified Fontan procedure is a viable surgical option for univentricular heart, not a Fontan candidate.

Solid pseudopapillary tumor of the pancreas in children: surgical intervention strategies based on pathological findings

PURPOSE

The appropriate surgical intervention strategies for solid pseudopapillary tumor (SPT) of the pancreas in children are still controversial. The aim of this study was to establish surgical intervention strategies based on the pathological findings.

METHODS

We retrospectively reviewed the medical records of patients who underwent surgery for SPT between January 1994 and April 2013.

RESULTS

Five patients with SPT were identified. Tumors were located in the pancreatic head (n = 1), body (n = 2) and tail (n = 2). One patient showed spleen, liver and lung metastases. All five patients underwent pancreatectomy. Enucleation was not performed. One patient with metastases underwent partial hepatectomy. Four tumors had infiltration into the adjacent pancreatic parenchyma. The main pancreatic duct was incorporated into the tumor capsule wall in two patients. Surgical margins were negative in all patients without metastases. The median follow-up period was 37.8 months (range 7-74 months). One patient with metastases died at 60 months after surgery. All other patients were alive and showed no evidence of recurrence.

CONCLUSION

Radical resection with negative margins should be performed for SPT. From the perspective of curability, we suggest that pancreatectomy is the first choice for SPT in children.

Effect of lidocaine on dynamic changes in cortical reduced nicotinamide adenine dinucleotide fluorescence during transient focal cerebral ischemia in rats

Rats were subjected to 90min of focal ischemia by occluding the left middle cerebral and both common carotid arteries. The dynamic changes in the formation of brain ischemic areas were analyzed by measuring the direct current (DC) potential and reduced nicotinamide adenine dinucleotide (NADH) fluorescence with ultraviolet irradiation. In the lidocaine group (n=10), 30min before ischemia, an intravenous bolus (1.5mg/kg) of lidocaine was administered, followed by a continuous infusion (2mg/kg/h) for 150min. In the control group (n=10), an equivalent amount of saline was administered. Following the initiation of ischemia, an area of high-intensity NADH fluorescence rapidly developed in the middle cerebral artery territory in both groups and the DC potential in this area showed ischemic depolarization. An increase in NADH fluorescence closely correlated with the DC depolarization. The blood flow in the marginal zone of both groups showed a similar decrease. Five minutes after the onset of ischemia, the area of high-intensity NADH fluorescence was significantly smaller in the lidocaine group (67% of the control; P=0.01). This was likely due to the suppression of ischemic depolarization by blockage of voltage-dependent sodium channels with lidocaine. Although lidocaine administration did not attenuate the number of peri-infarct depolarizations during ischemia, the high-intensity area and infarct volume were significantly smaller in the lidocaine group both at the end of ischemia (78% of the control; P=0.046) and 24h later (P=0.02). A logistic regression analysis demonstrated a relationship between the duration of ischemic depolarization and histologic damage and revealed that lidocaine administration did not attenuate neuronal damage when the duration of depolarization was identical. These findings indicate that the mechanism by which lidocaine decreases infarct volume is primarily through a reduction of the brain area undergoing NADH fluorescence increases which closely correlates with depolarization.

Long-term outcome of single institutional experience with conservative and surgical management for renal artery aneurysm

BACKGROUND

Spontaneous rupture risk of a renal artery aneurysm (RAA) is extremely low. Indications for surgical repair of RAA remain uncertain.

OBJECTIVE

Long-term outcomes of conservative therapy and surgical repair were evaluated.

PATIENTS

The study included 58 patients (17 males, 41 females) who were diagnosed with RAA during the last 21 years. Median age at the time of diagnosis was 62 (19-85) years, and the median follow-up 69 months (range 3-216).

METHODS

The patients were divided into two groups, conservative group (n = 30) who had been followed with blood pressure control, and treatment group (n = 29), who underwent an intervention.

RESULTS

Multiple efferent aneurysmal branches were observed in seven conservative and 16 treatment cases (P = .002). The median maximum diameter of the aneurysm was lower in the conservative than the treatment group (15 versus 25 mm, P = .005). Two conservative group cases showed increases in aneurysm size during follow-up. The hypertensive state showed essentially no change in either group during the follow-up. Renal function decreased with age similarly both in conservative and treatment groups.

CONCLUSIONS

Our conservative management criteria for RAA are justifiable and even too strict.

Clinical practice at a multi-dimensional treatment centre for individuals with early psychosis in Japan

Early intervention for psychosis in Japan has lagged behind that in western countries, but has rapidly begun to attract attention in recent years. As part of a worldwide trend, a multi-dimensional treatment centre for early psychosis consisting of a Youth Clinic, which specialises in young individuals with an at-risk mental state for psychosis, and Il Bosco, a special day-care service for individuals with early psychosis, was initiated at the Toho University Omori Medical Center in Japan in 2007. The treatment centre aims to provide early intervention to prevent the development of full-blown psychosis in patients with an at-risk mental state and intensive rehabilitation to enable first-episode schizophrenia patients to return to the community. We presently provide the same programmes for both groups at Il Bosco. However, different approaches may need to be considered for patients with an at-risk mental state and for those with first-episode schizophrenia. More phase-specific and need-specific services will be indispensable for early psychiatric interventions in the future.

Successful kidney transplantation ameliorates arterial stiffness in end-stage renal disease patients

PURPOSE

Successful kidney transplantation (KTx) can ameliorate bodily damage caused by end-stage renal disease (ESRD). Arterial stiffness (AS) is one of the critical factors that shorten the survival of patients due to cardiovascular events. KTx may reduce AS as well; however, this has not been investigated well. We therefore conducted a retrospective study using noninvasive pulse wave velocity (PWV), which is a useful index of aortic damage.

PATIENTS AND METHODS

Fifty-eight consecutive kidney recipients (34 men, 24 women) were enrolled in this study. Mean age at transplantation was 40.5 ± 12.3 years and the dialysis period was 73.1 ± 95.8 months. The brachial-ankle PWV was measured preoperatively and 6 months postoperatively. First, we investigated the relationship between the PWV and the other parameters related to AS. Second, we studied the pre- to posttransplant change in PWV to evaluate the amelioration of AS after successful KTx.

RESULTS

PWV showed significant positive correlations with age, systolic blood pressure (BP), diastolic BP, and abdominal aortic calcification index. After successful KTx, PWV significantly decreased (P < .01). In addition, systolic and diastolic BP significantly decreased (P < .01 and P < .05, respectively).

CONCLUSION

Successful KTx ameliorates AS in ESRD patients. This might explain the improved cardiovascular prognosis of ESRD patients who undergo KTx.

Impact of human T cell leukemia virus type 1 in living donor liver transplantation

Human T cell leukemia virus type 1 (HTLV-1) is an endemic retrovirus in southwestern Japan, which causes adult T cell leukemia (ATL) or HTLV-1 associated myelopathy in a minority of carriers. Here, we investigated the impact of HTLV-1 status in living donor liver transplantation (LDLT). Twenty-six of 329 (7.9%) HTLV-1 carriers underwent primary LDLT. One recipient negative for HTLV-1 before LDLT received a graft from an HTLV-1 positive donor. Eight donors were HTLV-1 positive. Twenty-seven recipients (13 male and 14 female; mean age 52.5 years) were reviewed retrospectively. ATL developed in four recipients who ultimately died. The intervals between LDLT and ATL development ranged from 181 to 1315 days. Of the four ATL recipients, two received grafts from HTLV-1 positive donors and two from negative donors. The 1-, 3- and 5-year HTLV-1 carrier survival rates were 91.3%, 78.3% and 66.3%, respectively. Fulminant hepatic failure as a pretransplant diagnosis and a pretransplant MELD score ≥ 15 was identified as risk factors for ATL development in this study (p = 0.001 and p = 0.041, respectively). In conclusion, LDLT can be performed for HTLV-1 positive recipients. However, when fulminant hepatic failure is diagnosed, LDLT should not be performed until further studies have revealed the mechanisms of ATL development.

Comparison of 3D FLAIR, 2D FLAIR, and 2D T2-weighted MR imaging of brain stem anatomy

BACKGROUND AND PURPOSE

Although 3D FLAIR imaging visualizes detailed structures of the brain stem, it has not been used to evaluate its normal anatomy. The purpose of this study was to evaluate whether 3D FLAIR images can provide more detailed anatomic information of the brain stem than 2D FLAIR and 2D T2WI.

MATERIALS AND METHODS

We prospectively evaluated MR images in 10 healthy volunteers. 3D and 2D FLAIR images, 2D T2WI, and DTI were obtained on a 3T MR imaging scanner. A VISTA technique was used for 3D FLAIR imaging. White matter tracts and nuclei of the brain stem were determined on 3D and 2D FLAIR images and 2D T2WI by referring to anatomic atlases and DTI color maps. The subjective assessment of the visibility by using a 4-point grading system and the contrast ratio of the structures on 3D and 2D FLAIR images and 2D T2WI were evaluated.

RESULTS

The visibility of the SCP and MCP, DSCP, CST, and CTT was higher on 3D FLAIR images than on 2D T2WI and 2D FLAIR images. The contrast ratio for the CST, SCP, MCP, DSCP, and CTT was significantly different on 3D FLAIR images and 2D T2WI and on 3D FLAIR and 2D FLAIR images; there was no significant difference in contrast ratio for the SCP at the pons on 3D FLAIR and 2D T2WI.

CONCLUSIONS

3D FLAIR images provide detailed anatomic information of the brain stem that cannot be obtained on 2D T2WI and 2D FLAIR images.