Safer video-assisted thoracoscopic thymectomy after location of thymic veins with multidetector computed tomography.

BACKGROUND: Video-assisted thoracoscopic (VATS) thymectomy has been applied as a surgical option for autoimmune myasthenia gravis. Prior identification and fine division of the thymic veins are critical to the prevention of unexpected severe bleeding that may require conversion to open surgery. Until recently, such bleeding could be avoided only by meticulous dissection of thymic fat tissue away from the left brachiocephalic vein (LBV). With recent advances in computed tomography (CT), multidetector-row computed tomography (MDCT) can readily be obtained and provides three-dimensional (3D) images. This study explored its value for preoperative identification of the thymic veins draining into the LBV, and thus for prevention of injury to these veins during endoscopic thymectomy. METHODS: Five patients with myasthenia gravis, thymoma, or both underwent enhanced MDCT preoperatively. The thymic veins draining into the LBV were visualized using both horizontal and sagittal/coronal CT images. Then 3D images were reconstructed to enable operators to simulate endoscopic views. During each VATS extended thymectomy, the numbers and branching patterns of the thymic veins were compared with the preoperative MDCT images. RESULTS: The thymic veins draining into the LBV were clearly identified with MDCT in all five patients examined. Reconstructed 3D images clearly located their courses in the thymic/fat tissue and their entry routes into the LBV, thus simulating the actual intraoperative endoscopic views. All tributaries divided during surgery were identified preoperatively with MDCT. CONCLUSIONS: Location of thymic veins with MDCT can provide precise preoperative information about thymic venous anatomy. This easy and less invasive examination has the potential to make VATS thymectomy easier and safer.

A new technique for two-trocar laparoscopic cholecystectomy.

BACKGROUND: New techniques for laparoscopic cholecystectomy (LC) that reduce the number of trocars or use very thin instruments have been devised with the goal of further minimizing surgical invasiveness. METHODS: We performed two-trocar LC using an original new technique in 70 consecutive patients. A 10-mm trocar and a 5-mm trocar were inserted in the subumbilical and epigastrium positions, respectively. A 2-mm grasper forceps was inserted directly without a trocar below the costal margin. The fundus of the gallbladder was ligated and lifted up with a folded 0 silk string and a 16-gauge vessel cannula. RESULTS: The mean operative time was 73.2 +/- 23.5 min. A third trocar was added in two cases. None of the patients required conversion of the procedure to an open cholecystectomy, and there were no intraoperative complications. CONCLUSION: Based on our experience, we think that this technique is as safe and effective as the classic four-trocar technique; moreover, it has a cost benefit.

Adrenergic regulation of prostaglandin biosynthesis in cultured rabbit gastric epithelial cells.

Adrenergic regulation of prostaglandin (PG) biosynthesis was investigated in 1-14C-arachidonic acid-prelabeled cultured rabbit gastric epithelial cells (RGECs). RGECs expressed adrenergic alpha 1- and beta-receptors and muscarinic receptors. Norepinephrine facilitated the synthesis of PGs I2 (determined as the stable metabolite 6-keto PGF1 alpha) and E2 and hydroxyfatty acids, while epinephrine facilitated the synthesis of PGI2 and hydroxyfatty acids, but not PGE2. However, isoproterenol did not affect PG biosynthesis. The effects of norepinephrine and epinephrine on PG biosynthesis were markedly suppressed by the non-selective alpha-blocker phentolamine and/or the selective alpha 1-blocker prazosin. In combination with epinephrine, the selective alpha 2-blocker yohimbine or the beta-blocker propranolol facilitated PGE2 synthesis. Acetylcholine did not affect PG biosynthesis. These results indicate that norepinephrine and epinephrine act on PG biosynthesis as adrenergic agonists in these cultured RGECs and that an alpha 1-receptor couples PGI2 and PGE2 synthesis.

Studies on the metabolism of d-Limonene (p-Mentha-1,8-diene). III. Effects of d-Limonene on the lipids and drug-metabolizing enzymes in rat livers.

1. After a single oral dose of d-limonene (200-1200 mg/kg) no effects were observed on liver triglyceride, microsomal protein, cytochrome b5, and the drug-metabolizing enzymes. Glycogen content was slightly decreased at doses higher than 800 mg/kg, and cytochrome P-450 and delta-aminolaevulinic acid synthetase activity was slightly increased at 1200 mg/kg. 2. After repeated treatment (400 mg/kg/day) for 30 days, the relative liver weight and hepatic phospholipid content were only slightly increased, and liver and serum cholesterol were decreased 49 and 8%, respectively. Of the phospholipid fatty acids, palmitic, linoleic and arachidonic acids were increased, and stearic acid was decreased. Aminopyrine demethylase and aniline hydroxylase were increased 26 and 22%, respectively, and cytochrome P-450 and b5 were likewise increased 31 and 30%.

Nonfunctioning islet cell carcinoma of the pancreas associated with massive intra-abdominal hemorrhage.

Pancreatic islet cell tumors are rarely associated with intra-abdominal hemorrhage. We report herein a rare case of nonfunctioning islet cell carcinoma associated with massive hemorrhage into the abdominal cavity caused by spontaneous rupture of the tumor. A 44-year-old man presenting with sudden upper abdominal pain was admitted to his local hospital on April 18, 1994. On April 19, a laparotomy was performed with the diagnosis of peritonitis. Massive hemorrhage of unknown origin occurred, and he was transferred to our hospital in a state of hypovolemic shock. Imaging findings revealed massive hematoma in the abdominal cavity and a hypervascular tumor arising from the body of the pancreas. Because the hemorrhage was life-threatening, an emergent re-laparotomy was performed on April 20. Apart from the massive hemorrhage, a pancreatic tumor (60 x 35 x 30 mm in size) with spontaneous rupture was noted. Distal pancreatectomy, combined with splenectomy and removal of the hematoma, was performed. Histological findings revealed an islet cell carcinoma of the pancreas with venous invasion. Peritoneal dissemination, liver metastasis, and lymph node metastasis were not observed. The patient is alive without recurrence 6 years and 5 months after the operation.