Tape ligature of cystic duct and fundus-down approach for safety laparoscopic cholecystectomy: outcome of 500 patients.

It is important to identify the structure of Calot's triangle at the time of cystic duct isolation to decrease intraoperative bile duct injury. Isolation of the cystic duct is the first dangerous technique in laparoscopic cholecystectomy. In conventional open cholecystectomy, the fundus-down approach (retrograde) is a more common procedure than the approach in the reverse direction. Similarly, the fundus-down approach is safe and has benefits of reducing common bile duct injury. We report the easy and safe contrivance for laparoscopic cholecystectomy with taping of the cystic duct followed by resection of the gallbladder with the fundus-down approach, performed for 500 patients. The identified cystic duct was ligatured temporarily with Teflon tape. Then, fundus of the gallbladder was isolated with the fundus-down approach except for Calot's triangle. The tape was used for pulling down the cystic duct and Calot's triangle was easily visible. The cystic duct was cut off only after the confirmation of no bile duct injury. Thanks to this tape procedure, there was no bile duct injury in our 500 cases. We recommend this tape ligature of the cystic duct with the fundus-down approach to decrease the incidence of common bile duct injury.

[A patient with peritoneal metastasis from gastric cancer who responded to weekly chemotherapy with paclitaxel on the third line and could take meal].

We report a patient with peritoneal metastasis from gastric cancer who responded to weekly chemotherapy with paclitaxel (TXL) as the third line treatment and could take meals for half a year. The patient was a 64-year-old man who underwent total gastrectomy for advanced gastric cancer with peritoneal metastasis. He was first treated with TS-1 as an outpatient treatment; however, tumor markers rose. He could not take meals and had to be hospitalized. CPT-11 was infused on the second line, but due to disease progress, the patient was administered weekly TXL. TXL (70 mg/m2) was infused over 1 hour after short premedication. Administration was continued for 3 weeks followed by 1 week rest. The tumor markers decreased, and he could take meals and was discharged from hospital. The toxic events were leukopenia (grade 2), alopecia (grade 2) and pneumonia (grade 3).

Does radical resection improve the survival in patients with carcinoma of the gallbladder who are 75 years old and older?

Radical resections have been reported to improve the surgical outcome for patients with carcinoma of the gallbladder. In recent years surgeons have had more opportunities to operate on elderly patients. We investigated whether the survival rate of aged patients who had radical resections were better than rates for those who had simple cholecystectomy. Of the 300 patients treated for carcinoma of the gallbladder between 1971 and 1999, 206 resected cases (except pancreaticoduodenectomy and hepatectomy) were divided into two groups: age 75 years or older, 54 patients (the older group), and age less than 75 years, 152 patients (the younger group). Clinical features and progression of the carcinomas did not differ between the two groups. In the older group, 22 patients (40.7%) had simple cholecystectomy, 32 (59.3%) had radical resections; in the younger group, 65 patients (42.8%) had simple cholecystectomy, and 87 (57.3%) had radical resection. None of the older patients who had radical resection died postoperatively. Postoperative survival was not different between the two groups. In the older group the 5-year survival rate for patients who had radical resections was better (60.9%) than the rate for those who had simple cholecystectomy (14.1%) (p = 0.0098). Radical resection is effective for the aged patients with the carcinoma of gallbladder.