Combination of electrohydraulic lithotripsy and laparoscopy for gallbladder access in type III Mirizzi syndrome.

INTRODUCTION: A 50-year-old Japanese man presented with obstructive jaundice. We performed endoscopic retrograde biliary drainage before biliary decompression. CT showed a thickened gallbladder wall with low-density areas and a 35-mm gallstone; the stone was impacted in the gallbladder neck and cystic duct. The patient was therefore diagnosed with Mirizzi syndrome (type II or III) and scheduled for laparoscopic treatment. We performed subtotal cholecystectomy and intraoperative choledochoscopy because we recognized a fistula between the gallbladder and common bile duct preoperatively. MATERIALS AND SURGICAL TECHNIQUE: We opened the ductus choledochus, and a choledochoscope was introduced under laparoscopic guidance. An electrohydraulic lithotripsy probe with irrigation was passed through the choledochoscope to extract the gallstone. DISCUSSION: This fragmentation technique is effective for impacted large stones observed in Mirizzi syndrome. Therefore, electrohydraulic lithotripsy with laparoscopy is effective in cases of difficult gallbladder access such as that that occurs in type II or III Mirizzi syndrome.

Laparoscopic and endoscopic cooperative surgery for intra-mucosal gastric carcinoma adjacent to the ulcer scars.

BACKGROUND: Laparoscopic and endoscopic cooperative surgery (LECS) was performed for the local resection of gastrointestinal stromal tumors (GIST). LECS enables less resection of the lesion area and preserves function. Furthermore, LECS can be safely performed and independent of tumor location. However, LECS is not usually used for cases involving gastric carcinoma because it may seed tumor cells into the peritoneal cavity when the gastric wall is perforated. Here, we report seven cases of LECS for intra-mucosal gastric carcinoma, which were difficult to carry out by endoscopic submucosal dissection (ESD) because of ulcer scars. METHODS: We performed LECS (classical LECS and inverted LECS) in seven cases of intra-mucosal gastric carcinoma. All cases had ulcer scars beside the tumor. LECS was chosen because ESD was thought to be difficult because of the ulcer scars. We only selected cases in which the patients did not prefer gastrectomy and endoscopic examination was indicative of intra-mucosal gastric carcinoma. RESULTS: In all cases, LECS was performed without severe complications including postoperative stenosis. Histopathology findings proved that the tumors were intra-mucosal carcinoma and had been resected completely. Furthermore, there were ulcer scars (Ul IIIs-IVs) beside the tumor. Currently, dissemination and recurrence have not been apparent. CONCLUSIONS: LECS for intra-mucosal gastric carcinoma is an efficient procedure, but strict observation is necessary because of the possibility of peritoneal dissemination. Results suggest that LECS is likely to be effective for cases involving intra-mucosal gastric carcinoma that are difficult to treat by ESD due to ulcer scars.

Colocalization of NO and VIP in neurons of the submucous plexus in the rat intestine.

Since very few previous studies have carried out the quantitative analysis for the colocalization of nitric oxide (NO) and vasoactive intestinal peptide (VIP) in the submucous neurons in the rat digestive tract, we applied in vivo treatment of colchicine to enhance the immunoreactivity and examined the colocalization of NO synthase (nNOS) and VIP in neurons of the submucous plexus throughout the rat digestive tract. The density of nNOS-containing neurons in the submucous plexus in the stomach corpus (103+/-25 cells/cm(2), n=3) and that in the antrum (157+/-9 cells/cm(2), n=3) were significantly lower than those in small and large intestine. However no difference was detected in the cell density among duodenum (1967+/-188 cells/cm(2), n=3), jejunum (2640+/-140 cells/cm(2), n=3), ileum (2070+/-42 cells/cm(2), n=3), proximal colon (2243+/-138 cells/cm(2), n=3) and distal colon (2633+/-376 cells/cm(2), n=3). The proportion of nNOS-immunoreactive (IR), nNOS/VIP-IR and VIP-IR neurons to the total number of submucous neurons was examined. nNOS/VIP-IR neurons comprised 45-55% of total number of submucous neurons from the duodenum to the proximal colon, however those comprised 66.4+/-5.1% in the distal colon. The results showed that the dense distribution of nNOS-containing neurons was found in the submucous plexus throughout the small and large intestine, and large population of submucous neurons co-stored nNOS and VIP.