Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation.

BACKGROUND: Controversy remains whether preoperative pneumatic balloon dilation (PBD) influences the surgical outcome of laparoscopic esophagocardiomyotomy in patients with esophageal achalasia. The aim of this study was to evaluate whether preoperative PBD represents a risk factor for surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD). METHODS: A retrospective chart review was conducted on a prospectively compiled surgical database of 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n = 26) and without PBD (non-PBD group; n = 77): (1) patients' demographics: age, gender, body mass index, duration of symptoms, maximum transverse diameter of esophagus; (2) operative findings: operating time, blood loss, intraoperative complications; (3) postoperative course: complications, clinical symptoms, postoperative treatment; and (4) esophageal functional tests: preoperative and postoperative manometric data and postoperative profile of 24-h esophageal pH monitoring. RESULTS: (1) No significant differences were observed in the patients' demographics. (2) Operative findings were similar between the two groups; however, the incidence of mucosal perforation was significantly higher in the PBD group (n = 8; 30.7 %) compared to the non-PBD group (n = 6; 7.7 %) (p = 0.005). (3) Postoperative complications were not encountered in either group. The differences were not significant for postoperative clinical symptoms, the incidence of gastroesophageal reflux disease, or necessity of postoperative treatments. (4) Lower esophageal sphincter pressure was effectively reduced in both groups, and no differences were observed in manometric data or 24-h pH monitoring profiles between the two groups. Multivariate logistic regression analysis showed that preoperative PBD and the maximum transverse diameter of esophagus were significantly associated with intraoperative mucosal perforation. CONCLUSIONS: Although postoperative outcomes were not affected, additional caution is recommended in identifying intraoperative mucosal perforation in patients with preoperative PBD when performing LHD.

[A case of recurrent colon cancer involved in multiple organs maintaining complete response over the long-term after chemotherapy].

We report a case of recurrent colon cancer successfully treated by mFOLFOX6 and FOLFIRI, and maintaining a complete response(CR)over the long-term. A 60-year-old woman complained of abdominal discomfort 18 months after surgery for advanced descending colon cancer(tub2, pT3, pN2, cM0, fStage IIIb). A pelvic mass was demonstrated by abdominal computed tomography(CT)scan, and relapse of the cancer was suspected. Positron emission tomography-CT fusion image revealed metastases at Douglas' pouch, liver, right ovary and right inguinal lymph nodes. Systemic chemotherapy followed by mFOLFOX6 regimen was started. After 8 courses of mFOLFOX6, severe neuralgic side effects forced us to change the regimen to FOLFIRI. After completion of 4 courses of FOLFIRI, CR was proved by CT scan. Chemotherapy was stopped after an additional 4 courses of FOLFIRI. CR has been maintained for 4 years and 4 months after confirmation of CR. There were 18 cases reported in the literature that had CR by FOLFOX and/or FOLFIRI. Among those reports, our case was considered to have kept CR for the longest duration of time.

Dose-response effects of an aqueous formulation of calcitriol and evaluation of renal function in nonpregnant cows.

Dose responses of plasma calcitriol, calcium (Ca), bone metabolic markers and glomerular filtration rate (GFR) were evaluated in four nonpregnant Holstein cows treated subcutaneously with an aqueous formulation of calcitriol at four doses in a 4 × 4 Latin-square design. Calcitriol, Ca, and markers of bone metabolism were analyzed in plasma samples. GFR was measured in predose and day 5 samples. Plasma calcitriol and Ca concentrations increased dose-dependently. The calcitriol dose was positively correlated with the area under the concentration-time curve of plasma calcitriol. Bone formation markers tended to increase from day 3 onward for all doses. No significant changes in GFR were noted. Thus, exogenous calcitriol administered between 0.0625 and 0.5 µg/kg body weight elicited dose-dependent increases in both plasma calcitriol and Ca and elevated bone formation markers without affecting renal function in nonpregnant cows.

Genotyping of Japanese field isolates of Mycoplasma synoviae and rapid molecular differentiation from the MS-H vaccine strain.

Mycoplasma synoviae is an important causative agent of avian mycoplasmosis. In the present study the conserved domain of the variable lipoprotein and hemagglutinin (vlhA) gene of M. synoviae was sequenced and analyzed for 19 field strains of M. synoviae isolated from chickens across Japan. This analysis revealed that there were at least nine genotypes of M. synoviae present in Japan. Furthermore, we found a single nucleotide polymorphism (SNP) within this region in all the Japanese isolates, and based on this finding, we established a PCR method with cycling probe technology to differentiate between these field isolates and the live M. synoviae vaccine strain Mycoplasma synoviae-H (MS-H).

Effects of an oleaginous calcitriol on changes in plasma calcitriol, calcium and bone metabolic markers in dairy cows.

The present study evaluated the effects of calcitriol dissolved in an oleaginous vehicle (calcitriol-OLE) on changes in plasma calcitriol, calcium and bone metabolic markers in nonpregnant, nonlactating Holstein cows. Five cows were treated intramuscularly or subcutaneously with calcitriol-OLE and oleaginous vehicle alone using a 5 × 5 Latin square design. Additionally, cows were also treated intravenously with calcitriol dissolved in an aqueous vehicle (calcitriol-AQU) for comparison. The plasma calcitriol concentrations after intramuscular and subcutaneous calcitriol-OLE administrations peaked at 24 and 12 hr, respectively, remained significantly elevated until day 3, returned to the respective control levels on day 5 and decreased significantly on day 7. In cows given intravenous calcitriol-AQU, the calcitriol levels decreased with linearity on day 1. The plasma calcium levels rose from 12 hr post-dose and peaked on day 2 for both preparations and in all three administration routes. Significantly increased calcium levels continued until day 5 in the intramuscular and intravenous routes and day 7 in the subcutaneous route. The plasma osteocalcin concentrations significantly increased from day 3 for calcitriol-OLE and from day 5 for calcitriol-AQU, whereas the bone resorption markers, tartrate-resistant acid phosphatase isoform 5b and hydroxyproline, decreased during this time. These results suggest that either intramuscular or subcutaneous injection of calcitriol-OLE extends and maintains supraphysiological calcitriol levels in the plasma and prolongs hypercalcemia. Moreover, exogenous calcitriol in normocalcemic cows increases the plasma osteocalcin concentration and decreases the plasma levels of bone resorption markers probably due to hypercalcemia.

Response of plasma bone markers to a single intramuscular administration of calcitriol in dairy cows.

To elucidate the effects of an exogenous calcitriol (1,25-dihydroxyvitamin D(3)) on plasma bone markers, the formation item osteocalcin (OC), undercarboxylated OC (ucOC) and bone-specific alkaline phosphatase (BALP), and the resorption parameter tartrate-resistant acid phosphatase isoform 5b (TRAP5b) and hydroxyproline (HYP) were measured in conjunction with plasma calcitriol and calcium (Ca) concentrations in dairy cows receiving calcitriol or its vehicle according to a 2×2 crossover design. Calcitriol (0.5 µg/kg, i.m.) increased significantly its plasma level during 6 h to day 2 and plasma Ca concentration during 12 h to day 7 compared to the vehicle. Also, plasma OC and ucOC started to rise from day 3 and 1, respectively, and remained elevated until day 7. No change in plasma BALP, TRAP5b or HYP associated with calcitriol treatment was noted. These results demonstrate that exogenous calcitriol stimulates osteoblasts to biosynthesise OC, a determinant of the bone formation in cows.

Laparoscopic intragastric surgery under carbon dioxide pneumostomach.

BACKGROUND: Laparoscopic intragastric surgery (LIGS) requires a "pneumostomach," which is created by air insufflation via gastroscopy. If the procedure is done without duodenal clamping, migrated air from the stomach causes excessive, prolonged bowel distention, which may lead to drawbacks during and after the operation. Carbon dioxide (CO(2)), with its faster absorption than air, can attenuate bowel distention when used to establish the pneumostomach. The aims of this study were to evaluate feasibility, safety, and effectiveness of the CO(2) pneumostomach in LIGS. METHODS: We have performed 15 LIGSs under the CO(2) pneumostomach (January 1997 to August 2004). The stomach was insufflated with CO(2) through an automatic surgical insufflator up to 8 mm Hg of intraluminal pressure. Neither a duodenal clamp nor an occlusion was employed prior to insufflation. Cardiopulmonary parameters were prospectively registered and retrospectively analyzed. The degree and extent of bowel distention was assessed by a concluding laparoscopy, and the amount of intestinal gas was evaluated by a postoperative plain abdominal radiograph. RESULTS: LIGS was completed in all 15 cases, with a mean intragastric insufflation time of 100 minutes. The CO(2) pneumostomach provided good, constant surgical exposure with sufficient working space. No adverse impact of intragastric CO(2) insufflation was observed on the cardiopulmonary function. Even without duodenal clamping, the insufflated small bowel loops already shrank at the time of the concluding laparoscopy. Fair residual gas was documented radiologically in 2 cases, whereas it was only faint in the remaining 13 cases. No patients showed abdominal pain or bloating postoperatively. CONCLUSIONS: The CO(2) pneumostomach is a feasible, safe alternative and is potentially effective for LIGS by eliminating the need for prior duodenal clamping and by minimizing bowel distention.

Laparoscopic left-sided Nissen fundoplication in children.

It is sometimes difficult or inappropriate to adopt the standard surgical steps of adult laparoscopic procedures in pediatric patients because of the inevitably smaller anatomical structures and confined intra-abdominal working space. During laparoscopic Nissen fundoplication difficulties are usually encountered, especially when dissecting the diaphragmatic crura, creating the retroesophageal window, and repairing the crura. Thus, we devised a technique to accomplish these steps in pediatric patients. Both crural dissection and repair are approached from the left side of the esophagus and the port configuration for the laparoscope and other instruments is altered, providing better surgical exposure and easier handing of the instruments, even in very small patients. We describe this technique in detail and our results.

A new parameter for assessing postoperative recovery of physical activity using an accelerometer.

PURPOSE: While many retrospective and prospective observational studies have shown laparoscopic surgery to be less invasive than conventional open surgery, this issue has not been evaluated by objective parameters. Currently available clinical parameters, such as the day of first ambulation, the day food intake is commenced, and the length of postoperative hospital stay, are subjective. The purpose of this study was to investigate whether measuring postoperative physical activity with an accelerometer is a useful parameter for evaluating postoperative recovery after surgical stress. METHODS: The subjects included 20 patients who underwent laparoscopic partial gastrectomy (LPG group), 35 patients who underwent open distal gastrectomy (ODG group), and 20 patients who underwent open total gastrectomy (OTG group). The cumulative acceleration of voluntary movement, measured by an Active tracer AC-301 (ACT) accelerometer for 7 days postoperatively, was compared among these three groups. RESULTS: The cumulative acceleration of physical activity for 24 h was significantly better in the LPG group than in the ODG and OTG groups on each postoperative day. The recovery time, defined as the day that cumulative acceleration had recovered to more than 90% of the preoperative level, was significantly shorter in the LPG group (2.8 +/- 0.9 days) than in the ODG (6.6 +/- 2.1 days) and OTG (7.8 +/- 1.2 days) groups. CONCLUSION: These results showed that convalescence differed with the degree of surgical stress, and that measurement of the cumulative acceleration of voluntary movement by using an accelerometer could be a useful objective and quantitative parameter for evaluating postoperative recovery.

Effect of mucosal suture on the healing of mucosal defect in laparoscopic intragastric surgery.

BACKGROUND: The efficacy of mucosal suturing for the healing of a mucosal defect in laparoscopic intragastric surgery (LIGS) for gastric lesions is not yet known. METHODS: We prospectively studied ten patients who underwent mucosal resection by LIGS for gastric tumors: four patients with early gastric cancer and six with gastric adenoma. Patients were randomly divided into two groups: group I (n = 5); patients who underwent mucosal resection by LIGS with mucosal defect suturing and group II (n = 5); patients who underwent mucosal resection by LIGS without mucosal defect suturing. We performed endoscopy on day 10, and 1 month, 2 months, and 3 months after the operation to observe the healing process of the mucosal defect. The ulcer stage by endoscopy was classified as active, healing, or scarring according to the classification of Sakita and colleagues. Patients were given an H(2)-blocker daily until the mucosal defect improved to the scarring stage. RESULTS: There were no significant differences in sex, age, tumor location, size of mucosal resection, or the incidence of Helicobacter pylori infection between groups I and II. The ulcer stages in group I were significantly lower than those in group II on day 10, and 1 month, 2 months, and 3 months postoperation. The medication cost (H2-blocker) in group I was significantly lower than that in group II. CONCLUSION: Mucosal defect suturing after mucosal resection by LIGS promotes more rapid healing of mucosal defects and reduces drug costs for patients.

Endoscopic thyroid surgery through the axillo-bilateral-breast approach.

We developed a new endoscopic thyroid surgery by the axillo-bilateral-breast approach (ABBA) method, which is different from the previously described breast approach (BA) in that the port sites are modified to obtain a better view and to prevent the interference of surgical instruments. This modification also improves cosmetic results by eliminating the parasternal incision, which results in hypertrophic scar in a significant number of cases treated with BA. Twelve patients with benign thyroid tumors successfully underwent endoscopic thyroid surgery by ABBA, and their clinical outcomes were compared with those of four patients treated with BA. The mean operation time was significantly shorter in the ABBA group than in the BA group (188 minutes vs. 270 minutes; P < 0.01). Furthermore, the mean blood loss in the ABBA group (53 mL) was half of that in the BA group (108 mL). Neither conversion to open surgery nor significant intraoperative complications were experienced. The operative scars by ABBA became inconspicuous in a few weeks. These results seem to indicate that ABBA is a better method than BA and can be a feasible option, particularly for young patients who opt for the better cosmetic outcome.

A modular laparoscopic training program for pediatric surgeons.

OBJECTIVES: A structured endoscopic training program for pediatric surgeons has not yet been established. This study was conducted to develop a modular training program (MTP) for pediatric surgeons and to evaluate its effectiveness for surgeons with and without previous experience in laparoscopic surgery. METHODS: Nine pediatric surgeons participated in the study. They were divided into 2 groups: group A (n=4), surgeons who had experienced more than 10 cases of laparoscopic surgery prior to MTP; group B (n=5), those who had experienced fewer than 10 cases. They participated in a standardized MTP workshop, which consisted of 2 "see-through" and 3 "laparoscopic" tasks. Each participant's psychomotor skills were evaluated objectively before and after MTP with a computer-generated virtual simulator and were evaluated for precision, efficiency, and speed. RESULTS: In participants, speed was significantly enhanced after MTP. In group A, no differences were observed after MTP, whereas significant improvements were noted in efficiency and speed after MTP in group B. Before MTP, efficiency was significantly higher in group A than in group B; however, no difference remained between the 2 groups after MTP. CONCLUSIONS: MTP is effective for nonlaparoscopic pediatric surgeons to become familiar with basic endoscopic skills.

Totally laparoscopic distal gastrectomy using the hand-sewn Billroth-I anastomotic technique: report of a case.

The development of more sophisticated instruments has enabled advanced laparoscopic surgery. We recently devised a totally laparoscopic method of performing Billroth-I hand-sewn anastomosis and established this technique in an animal training model. This report presents the case of a 50-year-old man in whom totally laparoscopic distal gastrectomy was successfully performed for gastric cancer, using the hand-sewn Billroth-I anastomotic technique. The patient was admitted with gastric cancer in the angle of the stomach and underwent laparoscopic distal gastrectomy with radical lymph node dissection. After the resected specimen was extracted through the small incision, a Billroth-I anastomosis was performed laparoscopically by the hand-sewn technique using the Albert-Leinbert method. The patient was discharged on the seventh postoperative day without any intra- or postoperative complications. Laparoscopic hand-sewn anastomosis was performed safely and allowed for quick recovery and good cosmesis in this patient.

Laparoscopically assisted surgery for congenital gastric or duodenal diaphragm in children.

Presented are our recent experiences with successful laparoscopically assisted surgery in two children with congenital gastric or duodenal diaphragm. Laparoscopy was used as an adjunct in performing the following surgical procedures: (1) inspection of the entire bowel, (2) identification and evaluation of the involved site, and (3) mobilization and exteriorization of the involved site. A minimal transverse incision was made for exteriorization. Extracorporeal removal of the diaphragm was followed by pyloroplasty or duodenoplasty. Each patient had a rapid and uncomplicated recovery with complete resolution of the symptoms. Laparoscopically assisted surgery may be a valuable modality in pediatric patients with congenital gastric or duodenal diaphragm. It allows better assessment of the entire bowel, minimizing the disfiguring and morbid abdominal incisions, without impeding the effectiveness of the planned operation. Avoidance of full-scale laparotomy may decrease the risk of future adhesions. These advantages seem attractive especially for children with longer life expectancy.

Completely laparoscopic total colectomy for chronic constipation: report of a case.

Laparoscopic surgery has had a remarkable impact on the practice of colorectal surgery. However, most operations are performed using a technique of laparoscopic assistance, whereby extracorporeal bowel division and anastomosis are made following laparoscopic mobilization of the bowel. To our knowledge, this is the first report to describe a case of chronic constipation managed by total colectomy with ileorectal anastomosis, performed completely laparoscopically. The diagnosis of slow transit constipation was made by a transit time study. After dissection of the entire colon, the colon to be resected was delivered through the open rectal stump and brought out transanally. The anvil of an intraluminal circular stapler was passed through the rectum into the peritoneal cavity and the end of the open distal rectum was closed with a linear cutting stapler. The anvil of the circular stapler was inserted into the end of the open terminal ileum and fixed with an Endo-Loop, following which an intracorporeal double-stapling anastomosis was performed. By 3 months following surgery, the patient was passing 3-4 stools a day. Thus, we highly recommend this technique as it eliminates the need for a small incision to deliver the resected colon, thereby minimizing the operative time and risk of wound infection.