Elevation in white blood cell count and development of hyper LDL cholesterolemia.

To investigate the relationship between white blood cell (WBC) count and incidence of hyper-low-density lipoprotein (LDL) cholesterolemia in a population-based longitudinal study. This is a retrospective study using data of annual health check-ups for residents of Iki City, Japan. A total of 3312 residents (≥ 30 years) without hyper-LDL cholesterolemia at baseline were included in this analysis. Primary outcome was incidence of hyper-LDL cholesterolemia (LDL cholesterol levels ≥ 3.62 mmol/L and/or use of lipid lowering drugs). During follow-up (average 4.6 years), 698 participants development of hyper-LDL cholesterolemia (incidence 46.8 per 1000 person-years). Higher incidence of hyper-LDL cholesterolemia was observed among participants with higher leukocyte count (1st quartile group: 38.5, 2nd quartile group: 47.7, 3rd quartile group: 47.3, and 4th quartile group: 52.4 per 1,000 person-years, P = 0.012 for trend). Statistically significant relation was observed even after adjustment for age, gender, smoking, alcohol intake, leisure-time exercise, obesity, hypertension and diabetes: hazard ratio 1.24 (95% confidence interval 0.99 to 1.54) for 2nd quartile group, 1.29 (1.03-1.62) for 3rd quartile group and 1.39 (1.10-1.75) for 4th quartile group, compared with 1st quartile group (P for trend = 0.006). Increased WBC count was related to incidence of hyper-LDL cholesterolemia in general Japanese population.

Acute Myocarditis with Severe Fever and Thrombocytopenia Syndrome.

A 67-year-old man, hospitalized with fever and pancytopenia, experienced cardiogenic shock on the 3rd day of hospitalization. He complained of chest pain and exhibited cardiac dysfunction, upregulated serum troponin levels, and an ST elevation on electrocardiogram. Severe fever with thrombocytopenia syndrome (SFTS) was suspected based on the symptom course after a tick bite and was definitively diagnosed using the serum polymerase chain reaction (PCR) test. An endomyocardial biopsy performed in the convalescent phase revealed a sign of myocardial inflammation with increases in CD3- and CD68-positive cells. We herein report the first case of acute myocarditis complicated with SFTS.

Impact of Helicobacter pylori infection on fluid duodenal microbial community structure and microbial metabolic pathways.

BACKGROUND: The bioactivities of commensal duodenal microbiota greatly influence the biofunction of hosts. We investigated the role of Helicobacter pylori infection in extra-gastroduodenal diseases by determining the impact of H. pylori infection on the duodenal microbiota. We sequenced 16 S rRNA genes in samples aspirated from the descending duodenum of 47 (male, 20; female, 27) individuals who were screened for gastric cancer. Samples were analysed using 16 S rRNA gene amplicon sequencing, and the LEFSe and Kyoto Encyclopaedia of Genes and Genomes methods were used to determine whether the duodenal microflora and microbial biofunctions were affected using H. pylori infection. RESULTS: Thirteen and 34 participants tested positive and negative for H. pylori, respectively. We identified 1,404 bacterial operational taxonomic units from 23 phyla and 253 genera. H. pylori infection changed the relative mean abundance of three phyla (Proteobacteria, Actinobacteria, and TM7) and ten genera (Neisseria, Rothia, TM7-3, Leptotrichia, Lachnospiraceae, Megasphaera, F16, Moryella, Filifactor, and Paludibacter). Microbiota features were significantly influenced in H. pylori-positive participants by 12 taxa mostly classified as Gammaproteobacteria. Microbial functional annotation revealed that H. pylori significantly affected 12 microbial metabolic pathways. CONCLUSIONS: H. pylori disrupted normal bacterial communities in the duodenum and changed the biofunctions of commensal microbiota primarily by upregulating specific metabolic pathways. Such upregulation may be involved in the onset of diseases associated with H. pylori infection.

Effects of Weight Gain after 20 Years of Age and Incidence of Hyper-Low-Density Lipoprotein Cholesterolemia: The Iki Epidemiological Study of Atherosclerosis and Chronic Kidney Disease (ISSA-CKD).

The aim of this study was to investigate the effects of long-term weight gain from the age of 20 on incidence of hyper-low-density-lipoprotein (LDL) cholesterolemia in the general population of Japanese people. METHODS: We conducted a population-based retrospective cohort study using annual health checkup data for residents of Iki City, Nagasaki Prefecture, Japan. A total of 3179 adult (≥30 years old) men and women without hyper-LDL cholesterolemia at baseline, who underwent two or more health checkups were included in the analysis. Information on weight gain (≥10 kg) after 20 years of age was obtained using questionnaire. The outcome of this study was development of hyper-LDL cholesterolemia defined as LDL-cholesterol level ≥3.62 mmol/L and/or initiation of lipid-lowering medications. RESULTS: During a mean follow-up period of 4.53 years, 665 of the 3179 participants developed hyper-LDL cholesterolemia (46.5/1000 person-years). The incidence of hyper-LDL cholesterolemia was higher in participants with a weight gain of ≥10 kg (55.3/1000 person-years) than among those with a weight gain of <10 kg (41.8/1000 person-years). This association remained statistically significant even after adjustment for age, sex, smoking, daily drinking, exercise, obesity, hypertension, and diabetes (multivariable hazard ratio 1.31, 95% confidence interval 1.08-1.58, p = 0.006). CONCLUSION: A weight gain of ≥10 after 20 years of age affected the development of hyper-LDL cholesterol regardless of age, sex, and obesity in a general population of Japanese.

Familial episodic limb pain in kindreds with novel Nav1.9 mutations.

We previously performed genetic analysis in six unrelated families with infantile limb pain episodes, characterized by cold-induced deterioration and mitigation in adolescence, and reported two new mutations p.R222H/S in SCN11A responsible for these episodes. As no term described this syndrome (familial episodic pain: FEP) in Japanese, we named it as"". In the current study, we recruited an additional 42 new unrelated Japanese FEP families, between March 2016 and March 2018, and identified a total of 11 mutations in SCN11A: p.R222H in seven families, and p.R225C, p.F814C, p.F1146S, or p.V1184A, in independent families. A founder mutation, SCN11A p.R222H was confirmed to be frequently observed in patients with FEP in the Tohoku region of Japan. We also identified two novel missense variants of SCN11A, p.F814C and p.F1146S. To evaluate the effects of these latter two mutations, we generated knock-in mouse models harboring p.F802C (F802C) and p.F1125S (F1125S), orthologues of the human p.F814C and p.F1146S, respectively. We then performed electrophysiological investigations using dorsal root ganglion neurons dissected from the 6-8 week-old mice. Dissected neurons of F802C and F1125S mice showed increased resting membrane potentials and firing frequency of the action potentials (APs) by high input-current stimulus compared with WT mice. Furthermore, the firing probability of evoked APs increased in low stimulus input in F1125S mice, whereas several AP parameters and current threshold did not differ significantly between either of the mutations and WT mice. These results suggest a higher level of excitability in the F802C or F1125S mice than in WT, and indicate that these novel mutations are gain of function mutations. It can be expected that a considerable number of potential patients with FEP may be the result of gain of function SCN11A mutations.

Association of the Serum Endostatin Level, Renal Function, and Carotid Atherosclerosis of Healthy Residents of Japan: Results from the Kyushu and Okinawa Population Study (KOPS).

AIM: To analyze associations among the serum endostatin level, renal function, and carotid atherosclerosis of healthy residents of Japan. METHODS: Among 1,057 Japanese residents who attended free public physical examinations between 2010 and 2011, we evaluated the data of 648 healthy residents (200 men and 448 women, age 24 to 84 years) for whom the serum endostatin level and common carotid intima-media thickness (IMT) were measured. Renal function was assessed by estimated glomerular filtration rate (eGFR). Multiple linear regression analysis was done to determine the association of eGFR and serum endostatin level after adjustment for known covariates. Mediation analysis was done using Baron and Kenny's regression approach. RESULTS: The median endostatin level was 63.7 ng/mL (interquartile range: 49.7-93.2). The mean eGFR was 78.4±14.8 mL/min/1.73m2. Univariate analysis showed that age (r=－0.37, P＜0.01), non current smoking (85.8±13.0 vs. 77.5±14.8 mL/min/1.73 m2, P＜0.01), hemoglobin A1c (r=－0.08, P=0.05), low-density lipoprotein-cholesterol (r=－0.13, P＜0.01), uric acid (r=－0.15, P＜0.01), carotid IMT (r=－0.11, P＜0.01), and log-transformed endostatin (r=－0.36, P＜0.01) were significantly associated with eGFR. In multiple linear regression analysis, log-transformed endostatin was significantly associated with eGFR (beta=－0.24, P＜0.01). While, carotid IMT was no longer significant. Mediation analysis showed serum endostatin level to be a mediator in the association between carotid IMT and eGFR. CONCLUSIONS: The association between carotid IMT and eGFR is mediated by the serum endostatin level of healthy individuals.

Correlation between Thyroid Stimulating Hormone and Renal Function in Euthyroid Residents of Japan: Results from the Kyushu and Okinawa Population Study (KOPS).

AIM: The present large-scale Japanese population study was performed to evaluate the relation between the serum thyroid stimulating hormone (TSH) level and renal function. METHODS: Out of 1,374 residents who participated in a free public physical examination between 2010 and 2011, we evaluated the data of 888 participants for whom the serum TSH level and estimated glomerular filtration rate (eGFR) were successfully measured. The participants were categorized into three groups based on TSH levels (normal TSH, ≤2.4; high-normal TSH, 2.5-4.4; and subclinical hypothyroid, ≥4.5 µIU/mL). Multiple linear regression analysis adjusted for cardiovascular risk factors was performed to determine the relationship between serum TSH level and renal function. RESULTS: The mean±SD TSH level was 2.0±1.4 µIU/mL, and 75.9% (n=674) of the participants had normal, 17.9% (n=159) had high-normal, and 6.2% (n=55) had subclinical hypothyroid TSH levels. The mean eGFR significantly decreased with increased TSH levels (normal TSH, 79.3±14.1; high-normal TSH, 77.4±13.0; and subclinical hypothyroid, 72.3±12.2 mL/min/1.73 m2: P for trend ＜0.01). Multiple linear regression analysis extracted log-transformed TSH level as an independent factor correlated with eGFR in the high-normal TSH group (beta=-0.18, P=0.02). CONCLUSIONS: Our findings demonstrated a significant correlation between serum TSH levels and eGFR in high-normal TSH participants. In healthy individuals, high-normal TSH levels indicate increased the risk of chronic kidney disease.

The Relation between Serum Endostatin Level and Carotid Atherosclerosis in Healthy Residents of Japan: Results from the Kyushu and Okinawa Population Study (KOPS).

AIM: To examine the association between the serum endostatin levels and subclinical atherosclerosis independent of traditional risk factors in a healthy Japanese population. METHODS: Among 1,057 residents who attended free public physical examinations between 2010 and 2011, we evaluated the data of 648 healthy residents for whom the serum endostatin level and common carotid intima-media thickness (IMT) were successfully measured. RESULTS: The median endostatin level was 63.7 ng/mL (interquartile ranges: 49.7-93.2 ng/mL), and the mean carotid IMT was 0.68±0.12 mm. Residents with above median endostatin had significantly higher carotid IMT than did those with below median endostatin (0.71±0.14 vs. 0.65±0.09 mm, P＜0.001). Multiple linear regression analysis demonstrated that increased serum endostatin is significantly associated with carotid IMT (above vs. below median endostatin level; beta=0.11, P=0.03), independent of the known covariates of age, sex, body mass index, drinking and smoking status, systolic blood pressure, diastolic blood pressure, hemoglobin A1c, low density lipoprotein cholesterol, estimated glomerular filtration rate, and log-transformed high sensitive C-reactive protein. CONCLUSIONS: A higher serum endostatin level reflected subclinical atherosclerosis in this Japanese population.

The relation of postprandial plasma glucose and serum endostatin to the urinary albumin excretion of residents with prediabetes: results from the Kyushu and Okinawa Population Study (KOPS).

BACKGROUND: Previous clinical studies have shown that the circulating level of endostatin is related to kidney injury. We hypothesized that the impact of HbA1c, fasting, and postprandial plasma glucose on urinary albumin excretion would be related to the serum endostatin level. METHODS: A cross-sectional, community-based population study of 1057 Japanese residents was conducted. Of these subjects, 162 with a fasting plasma glucose value between 5.5 and 6.9 mmol/L and an HbA1c level of <6.5 % received an oral glucose tolerance test, had serum endostatin measured, and had the urinary albumin/creatinine ratio (UACR) calculated. RESULTS: In multivariate analysis, 2-h postprandial plasma glucose (ß = 0.26, P < 0.01) was significantly associated with log-transformed UACR, independently of fasting plasma glucose (ß = 0.14, P = 0.28) and HbA1c (ß = -0.08, P = 0.57). When divided by the median value of endostatin (82.2 ng/mL), 2-h postprandial plasma glucose (ß = 0.38, P = 0.01) remained significantly associated with the log-transformed UACR of the participants below the median, while the fasting plasma glucose (ß = 0.34, P = 0.046) was independently associated with the log-transformed UACR of participants above the median. CONCLUSION: Postprandial plasma glucose was independently associated with the urinary albumin excretion of the residents with prediabetes. Moreover, this relationship was limited to residents with a serum endostatin level below the median.

Hepatitis B virus-related immune reconstitution inflammatory syndrome in two patients coinfected with human immunodeficiency virus diagnosed with a liver biopsy.

Hepatic flares occurred in two patients with HBV/HIV coinfection following the commencement of antiretroviral therapy (ART). At that time, the HIV RNA and HBV DNA levels had decreased. The results of liver biopsies showed lymphocytic infiltration that was diffusely positive for CD8(+) T cells in the portal areas and lobules. These findings suggested HBV-related immune reconstitution inflammatory syndrome (IRIS). The alanine aminotransferase levels of both patients gradually decreased with the continuation of ART. Because there are few reports of the liver histology of HBV-related IRIS, these cases provide a better understanding of the pathogenesis of HBV-related IRIS.

Retroperitoneoscopic nephrectomy/heminephrectomy in children planned, performed, and managed by supervised senior pediatric surgical trainees.

INTRODUCTION: Retroperitoneoscopic nephrectomy (R-neph) is still not generally favored by pediatric surgeons for various reasons, including lack of experience of retroperitoneal anatomy compared with pediatric urologists, concern about long operative times, and related complications. MATERIALS AND METHODS: We compared nephrectomies/heminephrectomies planned, performed, and managed by five senior pediatric surgical trainees (SPST) under the supervision of a board-certified pediatric surgeon (BCPS) (A.Y.) using four-trocar retroperitoneoscopy (R-neph) (n=11) with conventional open nephrectomy and heminephrectomy (O-neph) (n=20) performed by 4 BCPS. RESULTS: O-neph comprised 14 nephrectomies and 6 upper pole nephrectomies; R-neph comprised 9 total nephrectomies and 2 upper pole nephrectomies. Mean age and mean weight at nephrectomy were not statistically different. Mean operating time (MOT) was 137 (range, 85-290) minutes in O-neph versus 197 (116-341) minutes in R-neph. MOT for the first 5 R-neph cases was 249 minutes versus 153 minutes for the last 6 cases. Mean blood loss was 17 (range, 1-55) mL in O-neph versus 10.3 (2-40) mL in R-neph. One R-neph case required conversion to O-neph. There were no transfusions and no intraoperative complications. Two partial heminephrectomy patients (one O-neph and one R-neph) developed transient urinoma postoperatively that resolved conservatively. Mean duration of postoperative bed rest was 1.0 day in O-neph versus 0.6 days in R-neph. Differences in mean postoperative fentanyl requirement (O-neph, 21.5 [10-40] µg/kg; R-neph, 4.1 [0-20] µg/kg) and duration of nonsteroidal anti-inflammatory suppository usage (O-neph, 2.3 [0-5] days; R-neph, 0.9 [0-2] days) were significant (both P<.05). Full oral feeding was resumed after a mean of 1.6 (1-2) days in O neph and 1.2 (1-2) days in R-neph. CONCLUSIONS: R-neph was safely performed by SPST, and results were comparable to those with O-neph performed by BCPS.

Patchy innervation confirmed in pull-through bowel with normal conventional biopsy results in Hirschsprung's disease - the benefit of circumferential biopsying.

The effectiveness of pull-through for Hirschsprung's disease is dependent on accurate identification of normoganglionic bowel in intraoperative biopsy specimens. We report 2 cases of patchy innervation of pull-through bowel in children with Hirschsprung's disease only identified by circumferential biopsying. Case 1 was an 8-month-old boy. During laparoscopy-assisted transanal endorectal pull-through, extra biopsies of bowel were taken circumferentially, 2 cm proximal to the level of normoganglionosis confirmed by laparoscopic colon biopsies. Aganglionosis was found at 3 o'clock, suggesting that bowel innervation at this level was patchy. Circumferential biopsies were performed a further 2cm proximally, and all sites were normoganglionic. This level was used for pull-through with excellent outcome. Case 2 was a 27-day-old boy. Similarly, extra biopsies were taken circumferentially, 2cm proximal to the level of "normoganglionosis" as indicated by conventional biopsying. Normoganglionosis was found only at 3 o'clock, while all other sites were hypoganglionic. A further series of circumferential biopsies was performed 2 cm proximally and hypoganglionosis was still identified, but only at 6 o'clock. Circumferential biopsies were repeated another 2cm proximally, and all sites were normoganglionic. We recommend circumferential biopsies be performed routinely to prevent bowel with patchy innervation from being used for pull-through and possibly causing postoperative bowel dysmotility in a subgroup of Hirschsprung's disease patients.

Anorectal neural crest derived cell behavior after the migration of vagal neural crest derived cells is surgically disrupted: implications for the etiology of Hirschsprung's disease.

BACKGROUND/PURPOSE: In Hirschsprung's disease (HD), thick extrinsic nerve fibers can be associated with the aganglionic segment in the anorectum. We surgically disrupted the migration of vagal neural crest cell-derived cells (vagal NCC) in embryos from transgenic mice we created previously (SOX10-VENUS Tg) which have the SOX10 gene labeled with Venus (V), a green fluorescent protein, to observe sacral NCC activity in the anorectum. METHOD: Proximal colon harvested from SOX10-VENUS Tg embryos on day 10.5 (n = 10) was transected at the ascending colon. V-positive sacral NCC in the anorectum were observed during organ culture under fluorescence stereoscopic microscopy, and compared with non-transected control specimens (n = 10). RESULTS: In transected specimens, no V-positive sacral NCC were identified initially in the anorectum. By day 2, there were thick beaded sacral NCC in the anorectum in 6/10 (60 %) that migrated steadily to the transected end over 3-4 days. In controls, thinner and shorter V-positive sacral NCC began migrating cranially on day 2, and were met by distally migrating vagal NCC. CONCLUSION: Disruption of vagal NCC migration appears to induce sacral NCC activity in the anorectum, suggesting that thick extrinsic nerve fibers seen in HD may be a secondary phenomenon.

Fecal and urinary continence after scope-assisted anorectovaginoplasty for female anorectal malformation.

AIM: We assessed continence after scope-assisted anorectovaginoplasty (SARVP) for female anorectal malformation (FARM). METHODS: Five FARM cases were assessed; cases 1 and 2: cloacal malformation; case 3: urogenital sinus, and rectovestibular fistula (RF); case 4: RF, absent vagina, and sacral anomaly; case 5: covered cloacal exstrophy. Treatment was SARVP in all cases, with perineal vaginoplasty (case 1), vagina pull-through (PT) similar to Georgeson's colon PT (case 2), and the use of the native RF/cloaca channel as a vagina (cases 3-5). Continence was assessed pre and postoperatively. RESULTS: SARVP was performed in the lithotomy position without repositioning. Mean age at surgery was 3.2 (1.7-5.5) years. Current mean age: 8.8 years (range 7.5-12.2). Mean follow-up: 5.7 years. Preoperative continence: fecal: all had stomas; urinary: cases 1 and 2: continent; cases 3-5: incontinent. Postoperative continence: fecal: cases 1-3: continent; case 4: incontinent; case 5: awaiting stoma closure; urinary: cases 1 and 2: continent; cases 3 and 4: incontinent; case 5: continent (intermittent catheterization). Fetal continence evaluation questionnaire (CEQ) scores for cases 1-4 were 7.5, 9, 10, and 2 (maximum score 10, mean 7.1). CONCLUSION: Scope assistance improves visualization, thus pelvic sphincter dissection/division is minimized with less detrimental impact on postoperative continence.

An unusual foreign body in an inguinal hernia sac: case report and literature review.

A 13-month-old boy accidentally ingested a 5 cm dressmaker's pin. On presentation, the pin was in the duodenum and there was a right inguinal hernia. After 17 days, the pin failed to progress. At surgery, the sac contained appendix perforated by the pin. This is the first case in the literature.

Reappraising the portoenterostomy procedure according to sound physiologic/anatomic principles enhances postoperative jaundice clearance in biliary atresia.

BACKGROUND: The portoenterostomy (PE) procedure for treating biliary atresia (BA) has been so repeatedly modified that it currently hardly resembles Kasai's original PE (KOPE). Now PE involves an extended lateral dissection and a wide anastomosis (extended PE: EPE). We reappraised KOPE and created our-KOPE (OKOPE) by adhering strictly to its principles and techniques. We compared outcome of EPE and OKOPE. METHODS: We reviewed 24 consecutive cases of PE for BA performed at our institution from 2005 to 2011. Thirteen had EPE, and 11 had OKOPE. Body weight, serum total bilirubin, age at PE, total steroid dosage required for jaundice clearance (JC: total bilirubin ≤1.2 mg/dL), JC ratio, time taken for JC, survival rate with the native liver (SNL), and SNL after JC (SNL + JC) were compared at 16 months (shortest mean follow-up). Postoperative management protocols were identical for both groups. RESULTS: The JC ratio was significantly higher for OKOPE (90.9%) than EPE (46.2%) (p = 0.02). Both SNL and SNL + JC were significantly higher for OKOPE (90.9 and 72.7%) than EPE (30.8 and 30.8%) (p = 0.003 and p = 0.04, respectively). All other variables were similar for both groups. CONCLUSIONS: Jaundice clearance following OKOPE would appear to be better than after EPE.

Visualization of enteric neural crest cell migration in SOX10 transgenic mouse gut using time-lapse fluorescence imaging.

BACKGROUND: Enteric neural crest cells (ENCCs) were labeled with VENUS, an enhanced green fluoroscein protein, to record their migration in genetically engineered transgenic (SOX10-VENUS) mice. MATERIALS AND METHODS: Pregnant SOX10-VENUS mice were killed on day 12.5 of gestation. The colorectum was excised from each embryo (n = 20) and placed in tissue culture medium. Time-lapse images captured using fluorescence microscopy at 10-minute intervals for 3000 minutes were compiled into a video to display ENCC migration. RESULTS: At 0 minutes, VENUS(+) ENCC were observed to be clustered in the cecum and proximal colon (vagal ENCC), and similar cells were also seen in the rectum/sacrum (sacral ENCC). After 500 minutes, vagal VENUS(+) ENCC had migrated caudally from the proximal colon to the midcolon, reaching the distal colon after 800 minutes. Sacral VENUS(+) ENCC had migrated rostrally and transversely by 1250 minutes and had integrated with vagal ENCC by 2500 minutes. CONCLUSION: We recorded the actual rostral-to-caudal migration of vagal ENCC, caudal-to-rostral migration of sacral ENCC, and their integration in the developing mouse hindgut. Such direct evidence of ENCC migration may further elucidate understanding of ENCC development, thus providing insight into the histopathology of bowel dysmotility disorders.

Laparoscopic portoenterostomy for uncorrectable biliary atresia using Kasai's original technique.

AIM: Laparoscopic Kasai portoenterostomy (LKPE) is generally regarded to have a poorer outcome than open Kasai portoenterostomy for the surgical treatment of uncorrectable biliary atresia. We will describe our LKPE as the only center using laparoscopy to perform Kasai portoenterostomy in Japan. TECHNIQUES: For our LKPE, a 5-mm trocar is placed in the epigastrium in addition to conventional trocar placement. A Ligasure device is inserted through this additional trocar to seal portal vein branches at the porta hepatis draining into the caudate lobe, instead of hook diathermy that is used universally elsewhere because there is an unacceptably high risk for lateral thermal injury to microbile ducts. We minimize porta hepatic microbile duct injury during anastomosis between the Roux-en-Y jejunum and the liver parenchyma around the transected biliary remnant by not suturing where the original right and left bile ducts were present and making sutures deliberately shallow but deep enough to prevent leakage. Our anastomosis is more central to the porta hepatis, like the original Kasai, compared with "extensive lateral dissection" commonly performed elsewhere in Japan. The length of the Roux-en-Y jejunal limb should be individualized, not predetermined to be 30, 40, or 50 cm as is common practice; the jejuno-jejunostomy should fit naturally into the splenic flexure, otherwise the redundant limb may become tortuous as the patient grows, causing bile stasis and possible cholangitis. CONCLUSIONS: Our LKPE can be performed safely and successfully with encouraging outcome.

Intralaparoscopic endoscopy: its value during laparoscopic repair of choledochal cyst.

AIM: We report our experience of laparoscopic repair of choledochal cyst (CC). METHODS: We reviewed 10 CC patients (mean age 3.3 years) who had lap CC repair. Eight patients had minimally dilated/fusiform type CC (fusiform CC) and presented with pancreatitis, and two had cystic type CC (cystic CC). Using conventional trocar placement (right upper quadrant, left paraumbilical, left upper quadrant; laparoscope in the umbilicus), the CC was isolated and transected at mid level. An additional 3.9 mm trocar in the left epigastrium was used to introduce a fine ureteroscope. Its tip was inserted into the common channel through the distal CC to remove protein plugs (PP) under laparoscopic guidance. To perform intralaparoscopic endoscopy of the intrahepatic ducts, a trocar placed in the left lower quadrant was used. Two extra trocars (3 and 5 mm) were added for hepatico-jejunostomy anastomosis (HJA); one lateral right subcostal, and one between the right subcostal and right upper quadrant trocars, respectively. HJA was performed using interrupted 5/0 absorbable sutures with the right upper quadrant trocar as a needle holder in the right hand, 5 mm for the laparoscope, and 3 mm subcostal trocar as a needle receiver in the left hand. Both the right and left edge sutures were exteriorized and used as traction sutures during anastomosis of the anterior wall. RESULTS: Seven of eight fusiform CC patients had PP (massive in 3, moderate in 3, little in 1) in the common channel successfully removed with normal saline washouts through the side channel of the ureteroscope. Eight of ten CC patients had debris (moderate in 4, little in 4) in the intrahepatic ducts. Two complications were encountered; pancreatitis that resolved with conservative management and duodenal obstruction due to inadequate Roux-en-Y limb fixation that was treated by laparoscopic intervention. All are well after a mean follow-up of 12 months with cosmetically attractive wounds. CONCLUSION: Although three additional trocars are required, we recommend our HJA technique and intraoperative common channel endoscopy during laparoscopic repair of CC.

A prospective analysis of endoloops and endostaples for closing the stump of the appendix in children.

AIM: The aim of this study was to compare endoloops and endostaples for closing the stump of the appendix during laparoscopic appendectomy (LA) for uncomplicated appendicitis in children. METHODS: All LA performed for appendicitis from 2005 to 2009 were analyzed prospectively. Cases of complicated appendicitis such as perforated appendicitis or intra-abdominal abscess were excluded, leaving 75 cases closed with loops and 81 cases closed with staples. Choice of technique was determined by the attending surgeon's preference. All patients were managed according to the same pre-, intra-, and postoperative protocols. RESULTS: There were no significant differences between mean age at surgery, gender ratio, preoperative mean white blood cell count and mean C-reactive protein, histopathologic findings, mean duration of surgery, and mean hospitalization. There were no intra-operative complications in either group, but one loop case required conversion to open surgery (P = NS). There were no significant differences in the incidences of intra-abdominal abscess, transient ileus, small bowel obstruction, and wound infection. The postoperative readmission rate for management of complications was 4.0% for loop cases and 2.5% for staple cases (P = NS). Overall, using staples for a standard LA (anesthesia and stump closure) was U.S. $405 more expensive than when loops were used. CONCLUSION: This is the first prospective study comparing endoloops with endostaples for closing the stump of the appendix during LA for uncomplicated appendicitis in children. Although stapling proved to be more expensive, the choice of technique should reflect the surgeon's experience and confidence to ensure that the patient has the safest possible LA.