Cystic duct with no visible signal on magnetic resonance cholangiography is associated with laparoscopic difficulties: an analysis of 695 cases.

BACKGROUND/AIMS: We investigated the association between the magnetic resonance cholangiography (MRC) results and surgical difficulties and bile duct injuries during laparoscopic cholecystectomy (LC). METHODS: MRC was performed on 695 consecutive patients before LC. We divided the patients into two groups (visible cystic duct group and "no signal" cystic duct on MRC group) and compared them with regard to the length of the operation, conversion rate to open cholecystectomy (OC) and rate of bile duct injury. RESULTS: The "no signal" cystic duct on MRC group had a longer operation and higher rate of conversion to OC compared with the visible cystic duct group. However, there was no statistically significant difference in the occurrence rate of bile duct injury between the two groups. CONCLUSIONS: The "no signal" cystic duct on MRC group was associated with laparoscopic difficulties, but not with an increased rate of biliary injury. When a visible cystic duct is not observed on MRC an early conversion to open surgery may avoid a bile duct injury during LC.

Pancreaticoduodenectomy for bile duct carcinoma of a patient undergoing hemodialysis.

A 69-year-old Japanese man underwent pancreaticoduodenectomy for the resection of carcinoma at lower part of the common bile duct. Hemodialysis had already begun to treat chronic renal failure. He had been admitted for obstructive jaundice due to the carcinoma four months earlier. The serum total bilirubin was then 38.5 mg/dL, and the serum creatinine was 7 mg/dL. Hemodialysis was performed the day before the operation, and on the 1st, 3rd, 5th, 7th postoperative day. A rapidly degrading synthetic protease inhibitor was used as an anti-coagulant in the dialyzer to prevent systemic bleeding during the first postoperative week. Heparin was used from the second week. The maximum discharge from the drains was 2,300mL on the 3rd postoperative day. The drip intravenous infusion was changed from 1,900mL to 3,300mL during the first week to maintain the same body weight as the preoperative weight. Fresh frozen plasma and partial plasma fraction were used to maintain the colloidal pressure in the vessels so body weight reflects the fluid volume in the vessels. The postoperative course was uneventful. We present herein a successful case of pancreaticoduodenectomy for a patient undergoing hemodialysis to maintain the same body weight.

A crescent-shaped sparing proximal to a liver tumor may indicate underlying portal tumor thrombus.

A primary or metastatic liver tumor sometimes blocks portal venous flow and causes a focal sparing in the fatty liver. We herein report a case of segmental sparing due to the portal tumor thrombus extending from the metastatic liver tumor. The present case demonstrates characteristic computer-associated tomographic findings, a distal oval hypodense tumor with proximal "crescent-shaped sparing", which may indicate underlying portal tumor thrombus at the apex of the sparing.

Effects of helicopter transport on red blood cell components.

BACKGROUND: There are no reported studies on whether a helicopter flight affects the quality and shelf-life of red blood cells stored in mannitol-adenine-phosphate. MATERIALS AND METHODS: Seven days after donation, five aliquots of red blood cells from five donors were packed into an SS-BOX-110 container which can maintain the temperature inside the container between 2 °C and 6 °C with two frozen coolants. The temperature of an included dummy blood bag was monitored. After the box had been transported in a helicopter for 4 hours, the red blood cells were stored again and their quality evaluated at day 7 (just after the flight), 14, 21 and 42 after donation. Red blood cell quality was evaluated by measuring adenosine triphosphate, 2,3-diphosphoglycerate, and supernatant potassium, as well as haematocrit, intracellular pH, glucose, supernatant haemoglobin, and haemolysis rate at the various time points. RESULTS: During the experiment the recorded temperature remained between 2 and 6 °C. All data from the red blood cells that had undergone helicopter transportation were the same as those from a control group of red blood cell samples 7 (just after the flight), 14, 21, and 42 days after the donation. Only supernatant Hb and haemolysis rate 42 days after the donation were slightly increased in the helicopter-transported group of red blood cell samples. All other parameters at 42 days after donation were the same in the two groups of red blood cells. DISCUSSION: These results suggest that red blood cells stored in mannitol-adenine-phosphate are not significantly affected by helicopter transportation. The differences in haemolysis by the end of storage were small and probably not of clinical significance.

Intracellular activation of trypsinogen in rat pancreatic acini after supramaximal secretagogue stimulation: cysteine protease and serine protease activity.

OBJECTIVE: The aim of the study was to explore the mechanism by which trypsinogen becomes activated during acute pancreatitis. METHODS: Given the ability of cholecystokinin (CCK) to induce pancreatitis in vivo, the effects of high-dose CCK on preparations of isolated pancreatic acini were examined using immunofluorescence techniques for the detection of trypsinogen activation. Acini were pretreated with weak base or serine or cysteine protease inhibitors before CCK hyperstimulation. RESULTS: CCK was found to stimulate the generation of trypsinogen activation peptide (TAP), a marker for trypsinogen processing. The generation of TAP was inhibited by pretreatment with a weak base, chloroquine (40 micromol/L). TAP generation was also inhibited by pretreatment with serine protease inhibitor FUT-175 (1 micromol/L) but not cysteine protease inhibitor E64 (0.1 mmol/L) or E64-d (0.1 mmol/L). Although treatment with a high dose of E64-d (1 mmol/L) reduced activation, it also caused cell injury. CONCLUSIONS: High-dose CCK stimulated the intracellular activation of trypsinogen within isolated pancreatic acini. This event appears to require an acidic subcellular compartment and serine protease activity. The role for thiol proteases in this model remains unclear.

Effects of pancreatic duct ligation on pancreatic response to bombesin.

To examine mechanisms that might be related to biliary pancreatitis, we examined the effects of pancreatic duct ligation (PDL) with pancreatic stimulation in vivo. PDL alone caused no increase in pancreatic levels of trypsinogen activation peptide (TAP), trypsin, or chymotrypsin and did not initiate pancreatitis. Although bombesin caused zymogen activation within the pancreas, the increases were slight and it did not cause pancreatitis. However, the combination of PDL with bombesin resulted in prominent increases in pancreatic TAP, trypsin, chymotrypsin, and the appearance of TAP in acinar cells and caused pancreatitis. Disruption of the apical actin network in the acinar cell was observed when PDL was combined with bombesin but not with PDL or bombesin alone. These studies suggest that when PDL is combined with pancreatic acinar cell stimulation, it can promote zymogen activation, the retention of active enzymes in acinar cells, and the development of acute pancreatitis.

The pH modulator chloroquine blocks trypsinogen activation peptide generation in cerulein-induced pancreatitis.

INTRODUCTION AND AIMS: We examined the effects of a weak base, chloroquine, on the trypsinogen processing in cerulein-induced pancreatitis. METHODOLOGY: Immunofluorescence studies were performed using newly generated affinity-purified antibodies to the trypsinogen activation peptide (TAP). RESULTS: The present study showed that chloroquine pretreatment blocked intracellular TAP generation in cerulein-induced pancreatitis. CONCLUSION: These results indicate that intracellular trypsinogen activation, which plays an important role in acute pancreatitis, requires a low-pH compartment, as well as serine protease activity.