Preoperative ultrasound measurements predict the feasibility of gallbladder extraction during transgastric natural orifice translumenal endoscopic surgery cholecystectomy.

BACKGROUND: Extraction of a gallbladder through an endoscopic overtube during natural orifice translumenal endoscopic surgery (NOTES) transgastric cholecystectomy avoids potential injury to the esophagus. This study examined the rate of successful gallbladder specimen extraction through an overtube and hypothesized that preoperative ultrasound findings could predict successful specimen passage. METHODS: Gallbladder specimens from patients undergoing laparoscopic cholecystectomy were measured, and an attempt was made to pull the specimens through a commercially available overtube with an inner diameter of 16.7-mm. A radiologist blinded to the outcomes reviewed the available preoperative ultrasound measurements from these patients. Ultrasound dimensions including gallbladder length, width, and depth; wall thickness; common bile duct diameter; and size of the largest gallstone (LGS) were recorded. Multiple logistic regression analysis was performed to determine whether ultrasound findings and patient characteristics (age, body mass index [BMI], and sex) could predict the ability of a specimen to pass through the overtube. RESULTS: Of 57 patients, 44 (77%) who had preoperative ultrasounds available for electronic review were included in the final analysis. Gallstones were present in 35 (79%) of these 44 patients. Intraoperative gallbladder perforation occurred in 18 (41%) of the 44 patients, and 16 (36%) of the 44 gallbladders could be extracted through the overtube. Measurement of LGS was possible for 23 patients, and indeterminate gallstone size (IGS) was determined for 12 patients. The rate for passage of perforated versus intact gallbladders was similar (40% vs. 23%; p = 0.054). The LGS (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.02-1.33; p = 0.021) and IGS (OR, 22.97; 95% CI, 1.99-265.63; p = 0.025) predicted failed passage on multivariate logistic regression analysis. The passage rate was 80% for LGS smaller than 10 mm or no stones present, 18% for LGS 10 mm or larger, and 8% for IGS (p < 0.001). CONCLUSION: A majority of cholecystectomy specimens cannot pass through an endoscopic overtube. Preoperative ultrasound findings can predict successful specimen extraction. An IGS or a gallstone 10 mm or larger should be considered a relative contraindication to transgastric NOTES cholecystectomy.

Laparoscopic management of a cystic duct cyst.

BACKGROUND: Choledochal cysts are rare cystic dilatations of the biliary tree. Though their cause is uncertain, these cysts are usually referred for surgical resection because of their association with developing malignancy. Traditionally, choledochal cysts have been classified under 5 main types. Not included in this classification are cysts of the cystic duct, a condition that is even rarer, with only 14 cases reported in the literature to date. We describe one such rare case of a cyst of the cystic duct that we successfully treated via laparoscopic resection. METHODS AND RESULTS: A 41-year-old male was found to have a biliary abnormality on a routine follow-up computed tomography (CT) scan for an unrelated medical condition. Further magnetic resonance cholangiopancreatography (MRCP) imaging identified a cystic dilation consistent with a Type II choledochal cyst. Laparoscopic resection was performed using a total of 5 trocars, at which time a cyst of the cystic duct was found instead of the expected Type II choledochal cyst. Intraoperative cholangiography was used as a surgical adjunct to confirm the anatomy, and resection of the cyst was completed without complications. CONCLUSIONS: Our case adds to the body of reports showing that cysts of the cystic duct, while extremely rare, do occur and need to be recognized. Given the preoperative similarity between cystic duct cysts and other choledochal cysts, proposal for a new "Type VI" category for choledochal cysts may be considered so that clinicians can be prepared for this variation. Once recognized, cysts of the cystic duct can be safely and effectively removed by laparoscopic excision, as we have demonstrated.

Quantification of inflammatory cellular responses using real-time polymerase chain reaction.

The introduction of tissue engineering strategies for the repair and replacement of human body components extends the application and importance of biomaterials. Implanted biomaterials frequently evoke inflammatory responses that are complex and not well understood at present. The goals of this work were to develop improved measurement methods for the quantification of cellular inflammatory responses to biomaterials and obtain data that lead to an enhanced understanding of the ways in which the body responds to the introduction of biomaterials. To evaluate the biocompatibility of materials, we established a system that allows for the analysis and quantitation of cellular inflammatory responses in vitro. In this study, the inflammatory responses of murine macrophages (RAW 264.7) were analyzed. The cells were incubated with polymethylmethacrylate (PMMA) microspheres in the presence and absence of lipopolysaccharide (LPS) at 8 and 18 h. The analysis of the genetic material obtained from the cells was quantitated using real-time reverse transcription polymerase chain reaction (RT-PCR). The cell populations treated with LPS or PMMA microspheres singly resulted in an elevation of cytokine levels compared to the untreated control. LPS resulted in a 258-fold increase, while PMMA resulted in an 87.9-fold increase at 8 h. RAW 264.7 cells incubated with LPS and PMMA particles demonstrated a synergistic effect by producing a marked increase in the level of cytokine expression, 336-fold greater than that of the untreated control at 8 h. Fluorescence microscopy studies that assessed cellular viability were also performed and are consistent with the RT-PCR results.