Laparoscopic treatment of gastrointestinal stromal tumors located at the duodenojejunal junction.

Gastrointestinal stromal tumors are the most common subepithelial tumors of the gastrointestinal tract. Gastrointestinal stromal tumors are commonly detected in the stomach followed by the small intestine. Surgery for gastrointestinal stromal tumors affecting the duodenojejunal junction is technically challenging because of the anatomical complexity of this area. A 56-year-old woman visited the outpatient clinic with the chief complaint of melena associated with dizziness from 5 days ago. Abdominal computed tomography revealed an enhancing small bowel mass measuring 4 cm × 5 cm in the left upper abdomen abutting the duodenojejunal junction. She underwent successful laparoscopic small bowel segmental resection of the duodenojejunal junction area. Laparoscopic segmental resection with side-to-side duodenojejunostomy for a gastrointestinal stromal tumor at the duodenojejunal junction is an advanced and challenging procedure requiring experience and a good surgical technique.

Rectal perforations caused by cleansing enemas in chronically constipated patients: Two case reports.

Constipation is a common disease that is frequently treated with cleansing enemas. Enemas are considered as effective and in some cases may cause serious adverse events. Iatrogenic perforations due to enemas lead to adverse outcomes in elderly patients with a poor general condition. Perforation remains an infrequent and rarely reported complication. In this work, we describe the cases of two patients with rectal perforation caused by a cleansing enema. The first patient had rectal perforation that led to a para-rectal abscess and the second patient had generalized peritonitis caused by rectal perforation.

Vessel-specific coronary perfusion territories using a CT angiogram with a minimum cost path technique and its direct comparison to the American Heart Association 17-segment model.

OBJECTIVES: This study compared the accuracy of an automated, vessel-specific minimum cost path (MCP) myocardial perfusion territory assignment technique as compared with the standard American Heart Association 17-segment (AHA) model. METHODS: Six swine (42 ± 9 kg) were used to evaluate the accuracy of the MCP technique and the AHA method. In each swine, a dynamic acquisition, comprised of twenty consecutive whole heart volume scans, was acquired with a computed tomography scanner, following peripheral injection of contrast material. From this acquisition, MCP and AHA perfusion territories were determined, for the left (LCA) and right (RCA) coronary arteries. Each animal underwent additional dynamic acquisitions, consisting of twenty consecutive volume scans, following direct intracoronary contrast injection into the LCA or RCA. These images were used as the reference standard (REF) LCA and RCA perfusion territories. The MCP and AHA techniques' perfusion territories were then quantitatively compared with the REF perfusion territories. RESULTS: The myocardial mass of MCP perfusion territories (MMCP) was related to the mass of reference standard perfusion territories (MREF) by MMCP = 0.99MREF + 0.39 g (r = 1.00; R2 = 1.00). The mass of AHA perfusion territories (MAHA) was related to MREF by MAHA = 0.81MREF + 5.03 g (r = 0.99; R2 = 0.98). CONCLUSION: The vessel-specific MCP myocardial perfusion territory assignment technique more accurately quantifies LCA and RCA perfusion territories as compared with the current standard AHA 17-segment model. Therefore, it can potentially provide a more comprehensive and patient-specific evaluation of coronary artery disease. KEY POINTS: • The minimum cost path (MCP) technique accurately determines left and right coronary artery perfusion territories, as compared with the American Heart Association 17-segment (AHA) model. • The minimum cost path (MCP) technique could be applied to cardiac computed-tomography angiography images to accurately determine patient-specific left and right coronary artery perfusion territories. • The American Heart Association 17-segment (AHA) model often fails to accurately determine left and right coronary artery perfusion territories, especially in the inferior and inferoseptal walls of the left ventricular myocardium.

Moxibustion as an adjunct for lower urinary tract symptoms associated with benign prostate enlargement: A randomized controlled pilot trial.

BACKGROUND: Benign prostatic enlargement (BPE) causes discomfort in daily life, including lower urinary tract symptoms (LUTSs) caused by the enlarged prostate, and requires long-term management as a chronic, irreversible disease. To improve LUTS, certain complementary therapies have been used with or without doctors' directions. Conventional treatments and complementary therapies tend to be combined unsystematically, depending on patient preference; thus, research for safe and efficient combination therapy is warranted. METHODS: Twenty-nine participants were randomly assigned to an integrative group (IG, n = 15) or a conventional group (CG, n = 14). The IG received moxibustion (twice weekly for 4 weeks, at the acupuncture points SP6, LR3, and CV4) and conventional medication for 4 weeks, followed by conventional medication alone for 8 weeks. The CG received conventional medication alone for 12 weeks. The outcome measures were International Prostate Symptom Score (IPSS), patient's global impression of changes (PGIC), maximum urinary flow rate (Qmax), postvoid residual urine volume (PVR), and frequency-volume chart. RESULTS: Total IPSS (IG, -2.4 ±â€Š4.2; CG, 0.9 ±â€Š4.0; P = .039), PGIC-A (IG, 3.5 ±â€Š1.0; CG, 2.2 ±â€Š1.0; P = .001), and PGIC-B (IG, 3.5 ±â€Š0.1; CG, 4.7 ±â€Š0.6; P = .004) were significantly improved in the IG compared with the CG, 4 weeks after baseline. Among the IPSS items, incomplete emptying (IG, -0.6 ±â€Š0.7; CG, 0.4 ±â€Š1.2; P = .019), straining (IG, -0.6 ±â€Š0.8; CG, 0.2 ±â€Š1.2; P = .046), and nocturia (IG, -0.8 ±â€Š1.4; CG, 0.1 ±â€Š1.0; P = .045) showed significant differences. The Qmax and PVR volume did not differ significantly at 12 weeks after the baseline. CONCLUSION: Moxibustion can be considered an adjunct therapy to improve LUTS in BPE patients. A full-sized randomized controlled trial would be feasible with comparator modifications and an extended study period. The study design should include a placebo group and narrow the eligibility to subjects who do not respond well to conventional treatments.

Low-Radiation-Dose Stress Myocardial Perfusion Measurement Using First-Pass Analysis Dynamic Computed Tomography: A Preliminary Investigation in a Swine Model.

OBJECTIVES: The aim of this study was to assess the feasibility of a prospective first-pass analysis (FPA) dynamic computed tomography (CT) perfusion technique for accurate low-radiation-dose global stress perfusion measurement. MATERIALS AND METHODS: The prospective FPA technique was evaluated in 10 swine (42 ± 12 kg) by direct comparison to a previously validated retrospective FPA technique. Of the 10 swine, 3 had intermediate stenoses with fractional flow reserve severities of 0.70 to 0.90. In each swine, contrast and saline were injected peripherally followed by dynamic volume scanning with a 320-slice CT scanner. Specifically, for the reference standard retrospective FPA technique, volume scans were acquired continuously at 100 kVp and 200 mA over 15 to 20 seconds, followed by systematic selection of only 2 volume scans for global perfusion measurement. For the prospective FPA technique, only 2 volume scans were acquired at 100 kVp and 50 mA for global perfusion measurement. All prospective global stress perfusion measurements were then compared with the corresponding reference standard retrospective global stress perfusion measurements through regression analysis. The CTDIvol and size-specific dose estimate of the prospective FPA technique were also determined. RESULTS: All prospective global stress perfusion measurements (PPRO) at 50 mA were in good agreement with the reference standard retrospective global stress perfusion measurements (PREF) at 200 mA (PPRO = 1.07 PREF -0.09, r = 0.94; root-mean-square error = 0.30 mL/min per gram). The CTDIvol and size-specific dose estimate of the prospective FPA technique were 2.3 and 3.7 mGy, respectively. CONCLUSIONS: Accurate low-radiation-dose global stress perfusion measurement is feasible using a prospective FPA dynamic CT perfusion technique.

Effectiveness and safety of moxibustion for alleviating symptoms of overactive bladder: A prospective, randomized controlled, crossover-design, pilot study.

BACKGROUND: This study aimed to evaluate trial feasibility and explore the potential efficacy and safety of moxibustion in the treatment of overactive bladder (OAB). METHOD: A randomized, controlled, cross-over, assessor blinded design was used. This study was conducted in an outpatient department of a university hospital in Republic of Korea. The overall study period was 8 weeks. Participants were randomly allotted to either Group A or Group B. Group A participants underwent 8 to 12 sessions of moxibustion with behavioral training during the first 4 weeks, while the Group B participants received behavioral training only. Over the next 4 weeks, the treatment offered to the 2 groups was reversed (Group A participants received behavioral training only, while Group B participants underwent the moxibustion session with behavioral training). The OAB-validated 8-question awareness tool (OAB-V8), OAB symptom scores (OABSS), visual analog scale (VAS) for lower urinary tract symptoms, and frequency voiding chart were used to assess outcomes. For analysis, we used effect size, measured as Hedge's g, to present descriptive results indicating the actual difference between the groups. RESULTS: Compared to that in Group B, the Hedge's g of OAB-V8 for the former 4 weeks in Group A was -0.248, that of OABSS was -1.531, and that of VAS was -0.713. During the latter 4 weeks, Group B showed similar effect with g = 0.465, 1.207, and 0.427 for OAB-V8, OABSS, and VAS, respectively, compared to Group A. The portion of nocturnal voiding volume decreased (g = -0965), the mean voiding volume increased (g = 0.690), and the voiding frequency decreased (g = -0.498) with moxibustion. CONCLUSIONS: Moxibustion might be considered as an alternative for OAB. A full-sized randomized controlled trial may be feasible with minimal modification in outcome measures and comparator population. OTHER INFORMATION: This clinical trial has been registered on clinicaltrials.gov (NCT02271607).

Quantification of vessel-specific coronary perfusion territories using minimum-cost path assignment and computed tomography angiography: Validation in a swine model.

BACKGROUND: As combined morphological and physiological assessment of coronary artery disease (CAD) is necessary to reliably resolve CAD severity, the objective of this study was to validate an automated minimum-cost path assignment (MCP) technique which enables accurate, vessel-specific assignment of the left (LCA) and right (RCA) coronary perfusion territories using computed tomography (CT) angiography data for both left and right ventricles. METHODS: Six swine were used to validate the MCP technique. In each swine, a dynamic acquisition comprised of twenty consecutive volume scans was acquired with a 320-slice CT scanner following peripheral injection of contrast material. From this acquisition the MCP technique was used to automatically assign LCA and RCA perfusion territories for the left and right ventricles, independently. Each animal underwent another dynamic CT acquisition following direct injection of contrast material into the LCA or RCA. Using this acquisition, reference standard LCA and RCA perfusion territories were isolated from the myocardial blush. The accuracy of the MCP technique was evaluated by quantitatively comparing the MCP-derived LCA and RCA perfusion territories to these reference standard territories. RESULTS: All MCP perfusion territory masses (MassMCP) and all reference standard perfusion territory masses (MassRS) in the left ventricle were related by MassMCP = 0.99MassRS+0.35 g (r = 1.00). MassMCP and MassRS in the right ventricle were related by MassMCP = 0.94MassRS+0.39 g (r = 0.96). CONCLUSION: The MCP technique was validated in a swine animal model and has the potential to be used for accurate, vessel-specific assignment of LCA and RCA perfusion territories in both the left and right ventricular myocardium using CT angiography data.

Laparoscopic management of massive intraperitoneal haemorrhage caused by an acute gallbladder perforation.

Laparoscopic cholecystectomy is the gold standard for managing the treatment of patients with symptomatic gallstone disease. Certain patients with acute cholecystitis will develop gallbladder perforation (GP). Furthermore, massive intraperitoneal haemorrhage following perforation is a rare complication. The high morbidity and mortality rates associated with this condition are due to delays in the diagnosis and treatment since signs and symptoms of perforation do not differ significantly from those of uncomplicated cholecystitis. Severe inflammation and haemodynamic instability necessitate exploratory laparotomy in many patients. To the best of our knowledge, no study had described laparoscopic completion cholecystectomy for massive intraperitoneal haemorrhage caused by an acute GP. Laparoscopy can be an option for the management of these patients, in selected cases and with available expertise.

Peritoneal Simple Mesothelial Cyst Misdiagnosed as a Gastric Subepithelial Tumor.

Peritoneal simple mesothelial cysts are very rare mesenteric cysts of mesothelial origin. A peritoneal simple mesothelial cyst may be misdiagnosed, even by advanced diagnostic tools, as a gastric subepithelial tumor. A few cases that were misdiagnosed as a regarding peritoneal simple mesothelial cysts. To the best of our knowledge, there are no reports regarding peritoneal simple mesothelial cysts.

Moxibustion as an adjuvant for benign prostatic hyperplasia with lower urinary tract symptoms: a protocol for a parallel-group, randomised, controlled pilot trial.

INTRODUCTION: This study aims to explore the feasibility of using moxibustion as a supplementary intervention and to assess the sample size for verifying the effectiveness and safety of integrative treatment involving moxibustion compared with conventional treatment for patients with benign prostatic hyperplasia accompanying moderate to severe lower urinary tract symptoms. METHODS AND ANALYSIS: A total of 60 patients diagnosed with benign prostatic hyperplasia by a urologist based on prostate size, prostate-specific antigen and clinical symptoms will participate of their own free will; urologists will monitor the patients and evaluate their symptoms. The patients will be randomised to either a conventional group or an integrative group with a 1:1 allocation according to computer-generated random numbers concealed in opaque, sealed, sequentially numbered envelopes. Watchful waiting or oral medication including α blocker, 5α-reductase inhibitors or antimuscarinic drugs will be offered as conventional treatment. Integrative treatment will include moxibustion therapy in addition to the conventional treatment. The moxibustion therapy will be conducted twice a week for 4 weeks on the bilateral acupoints SP6, LR3 and CV4 by a qualified Korean medical doctor. The primary outcome will be the International Prostate Symptom Score (IPSS) after eight sessions. The secondary outcomes will be the post-void residual urine volume, the maximum urinary flow rate, IPSS, the results of a Short-Form 36-Question Health Survey after 12 weeks, and the patients' global impression of changes at each visit. ETHICS AND DISSEMINATION: Written informed consent will be obtained from all participants. This study was approved by the institutional review boards of both Pusan National University Yangsan Hospital and Pusan National University Korean Medicine Hospital. The trial results will be disseminated through open-access journals and conferences. TRIAL REGISTRATION NUMBER: NCT02051036.

Spontaneous intrahepatic portosystemic shunt managed by laparoscopic hepatic vein closure.

Intrahepatic portosystemic shunt (IPSS) is uncommon and usually follows trauma or iatrogenic injury, but spontaneous shunts may also occur, in patients without the evidence of chronic liver disease. Although interventional endovascular management of the shunts is the treatment of choice, a surgical approach can be used when the percutaneous approach fails. We report here a case of symptomatic spontaneous IPSS between the posteroinferior branch of right portal vein and the right inferior hepatic vein, which was successfully managed with laparoscopic closure of the hepatic vein. To the best of our knowledge, this is the first case report of laparoscopic management of spontaneous IPSS.

Delayed laparoscopic cholecystectomy after more than 6 weeks on easily controlled cholecystitis patients.

BACKGROUNDS/AIMS: There is debate on the timing of cholecystectomy in acute cholecystitis. Although there is a recent trend toward early laparoscopic cholecystectomy (eLC), that is, within 72 hours of symptom onset, some surgeons still prefer delayed operations, or operations after several weeks, expecting subsidence of the inflammation and therefore a higher chance of avoiding open conversion and minimizing complications. Our experience of LC for 10 years was reviewed retrospectively for the timing of the operation and perioperative outcomes, focusing on evaluating the feasibility of delayed LC (dLC). METHODS: The severity of the acute cholecystitis was classified into three grades: easily responding to antibiotics and mostly symptom-free (mild, grade I), symptoms persisting during the treatment (moderate, grade II), and worsening into a septic state (severe, grade III). RESULTS: Among 353 cholecystectomy patients, grade I (N=224) patients had eLC in 152 cases and dLC in 72 cases. Grade II (N=117) patients had eLC in 103 cases and 12 had dLC. All grade III patients (N=12) underwent open cholecystectomy. In Grade I patients, when the operation was delayed, there were fewer open conversion cases compared to eLC patients (20.45% vs 7.69%) (p<0.05), and complications also were decreased (p>0.05). Grade II patients' rate of open conversions (58.3% vs 44.2%) and complications (25.0% vs 19.5%) increased when the operations were delayed compared with eLC patients (p<0.05). In grade I and II patients, the most common reason for open conversion was bleeding, and the most common complication was also bleeding. CONCLUSIONS: For patients with cholecystits that easily responds to antibiotics (grade I), dLC showed a higher laparoscopic success rate than eLC at the expense of prolonged treatment time and examinations, With moderate to severe cholecystitis (grade II, III), however, there was no room for delayed operations.

Fate of lost gallstones during laparoscopic cholecystectomy.

BACKGROUNDS/AIMS: The fate of gallstones that remain in the peritoneal cavity due to perforation of the gallbladder during laparoscopic cholecystectomy (LC) has been studied vigilantly since the early 1990s when this surgical procedure started to be used. But the complication statistics vary with each report. So we reviewed our 47 cases of lost stones that were traceable from 1998 to 2007. METHODS: Stones entered the peritoneal cavity through the perforation site during dissection of the body or Hartmann's pouch of gallbladder from the liver bed, despite trials of stone removal like irrigation and using a glove finger pouch especially in the case of numerous small stones. There were nine cases of lost stones that were caused by fragments of stone breaking from a large stone during its retrieval. RESULTS: No patient was forced into revision surgery or intervention for the missing stones but only negative suction drains were inserted, and information to the patients was given. Most of the stones (N=42, 89.4%) remained silent during the follow-up period of 10.4±3.6 years, and 5 patients (10.6%) developed inflammatory complications in the peritoneal cavity and abdominal wall. Two intraperitoneal abscesses were found in the right subhepatic area and a cul-de-sac and these were managed by laparotomy. Subhepatic abscess was later associated with intestinal obstruction. Two patients suffered an umbilical portal site fistula and a right flank portal fistula respectively, requiring prolonged wound care. One patient suffered immediate postoperative peritonitis that was cured by antibiotics. CONCLUSIONS: Lost stones should be retrieved or fragmented as much as possible for removal through a drain, and caution should be exercised during dissection of the gallbladder to avoid perforating the gallbladder. Considering the approximately 10% incidence of serious inflammatory complications of lost stones, the complications should be explained to patients to allow for earlier diagnosis of complications later.

Ten-year experience on common bile duct exploration without T-tube insertion.

BACKGROUNDS/AIMS: Common bile duct (CBD) exploration has been a procedure necessary to remove stones which are not removable by endoscopic sphincterotomy (EST). T-tube was installed mainly in the concern of bile leakage after procedure. But T-tube itself can only cause bile peritonitis and thus, prolonged discomfort and care after operation. In addition, in the era of laparoscopy, T-tube insertion adds much operation time and is technically difficult for installation during the procedure. METHODS: Our case of open cholecystectomy and primary closure of CBD not leaving T-tube (n=28, group I) with reports dating from July 1998 to June 2007 is presented here to see whether primary closure without T-tube is safe as compared with T-tube inserted cases performed at the same center (n=15, group II). Operative cholangiography, CT scan, ultrasound and biochemical data were followed up for both groups and surveyed on operative complications as well to determine the outcomes. RESULTS: Bile leakage in 1, recurrent stone in 2 and obstructive jaundice in 1 were all considered during the follow up period among 28 group I patients (n=6), when compared to T-tube inserted group II patients with 2 bile peritonitis, 1 residual stones and 1 pancreatitis (n=4), showing no meaningful differences (p=0.07). CONCLUSIONS: CBD exploration and direct primary closure not leaving T-tube is an acceptable operational option as recently tried in many choledochotomies.

Utility of digital pulse oximetry in the screening of lower extremity arterial disease.

PURPOSE: The aim of this study was to evaluate screening methods in the lower extremities by measurement of the digital pulse oximetry (oxygen percent saturation [SpO(2)]) of toes for peripheral arterial disease (PAD). METHODS: A prospective study was performed among 49 patients (98 limbs) with lower extremity arterial occlusive disease. We attempted to measure the ankle-brachial index (ABI), digital pulse oximetry (SpO(2)), and computerized tomographic angiography (CTA). Patients were divided into three groups by the traditional Fontaine classification system by symptom and CTA criteria: 1) Critical limb ischemia (Fontaine III and IV), 2) Claudication; (Fontaine II), and 3) asymptomatic limbs (Fontaine I). RESULTS: The sensitivity, specificity, positive and negative predictive values between active treatment groups (group I and II; endovascular and open surgery) and conservative group (group III) are all statistically significant. ABI; 55.09%, 94%, 96.7%, 39.02% (R = 12.54, P < 0.000) SpO(2); 87.06%, 87.8%, 84.3%, 90% (R = 40.11, P < 0.000). Pre-SpO(2) and pre-ABI all show statistically significant correlation in group I vs. group II, symptomatic PAD (group I and II) vs. asymptomatic PAD (group III), and the total PAD comparison. The Pearson's correlation coefficient between SpO(2) and ABI all show significant correlation in group II. Pre-SpO(2) vs. Pre-ABI show strong positive correlation except asymptomatic group (group III). CONCLUSION: Digital pulse oximetry can be a useful, simple, noninvasive screening device as well as ABI in PAD.

Hemorrhagic cholecystitis: report of a case.

Hemorrhagic cholecystitis is an uncommon cause of abdominal pain that can be fatal. We report a case of hemorrhagic cholecystitis in a 75-year-old male taking an anticoagulant. The patient was brought to the hospital with uncontrolled right upper quadrant abdominal pain. On computed tomography, mild gallbladder wall thickening and high density with gallstones in the gallbladder suggested acute calculous cholecystitis or hemorrhagic cholecystitis. An urgent laparoscopic cholecystectomy was performed that revealed a gallbladder filled with large blood clots and two black stones. Patients who develop hemorrhagic complications were often receiving anticoagulation therapy or had pathologic coagulopathy. An early diagnosis of this potentially fatal condition is important to facilitate urgent surgical treatment.