Usefulness of laparoscopic subtotal cholecystectomy with operative cholangiography for severe cholecystitis.

PURPOSE: Cholecystectomy can become hazardous when inflammation develops, leading to anatomical changes in Calot's triangle. We attempted to study the safety and efficacy of laparoscopic subtotal cholecystectomy (LSC) to decrease the incidence of complications and the rate of conversion to open surgery. METHODS: Patients who underwent LSC between January 2005 and December 2008 were evaluated retrospectively. The operations were performed laparoscopically irrespective of the grade of inflammation estimated preoperatively. However, patients with severe inflammation of the gallbladder underwent LSC involving resection of the anterior wall of the gallbladder, removal of all stones and placement of an infrahepatic drainage tube. To prevent intraoperative complications, including bile duct injury, intraoperative cholangiography was performed. RESULTS: LSC was performed in 26 elective procedures among 26 patients (eight females, 18 males). The median patient age was 69 years (range 43-82 years). The median operative time was 125 min (range 60-215 min) and the median postoperative inpatient stay was 6 days (range 3-21 days). Cholangiography was performed during surgery in 24 patients. One patient underwent postoperative endoscopic sphincterotomy for a retained common bile duct stone that was found on cholangiography during surgery. Neither complications nor conversion to open surgery were encountered in this study. CONCLUSIONS: LSC with the aid of intraoperative cholangiography is a safe and effective treatment for severe cholecystitis.

Neonatal iliopsoas abscess.

Iliopsoas abscess (IPA) is rare in children, particularly in neonates. A male neonate was born at 38 weeks of gestation with a weight of 2915 g. On day 22 after birth, his family noticed that his right thigh was swollen. Abdominal computed tomography showed a mass extending to the right iliopsoas from the right thigh with thick septa. Puncture to the right groin yielded purulent fluid, and so a diagnosis of abscess was made. The puncture was followed by surgical drainage through a small inguinal incision, and the abscess cavity was irrigated thoroughly using normal saline. Culture of abscess fluid was positive for Streptococcus pneumoniae, so intravenous ABPC infusion was continued. The postoperative magnetic resonance imaging indicate that the IPA was derived from arthritis of the hip, and the patients received Riemenbügel for the incomplete hip dislocation. He is doing well at 2 years of age.

Acute respiratory distress syndrome after gastrointestinal surgery.

BACKGROUND/AIMS: Acute respiratory distress syndrome (ARDS) occasionally occurs after gastrointestinal surgery involving severe inflammation such as diffuse peritonitis. Management of this condition has been difficult and effective therapies have not yet been established. In the present study the management for ARDS after gastrointestinal surgery was evaluated. METHODOLOGY: A total of 15 patients developed ARDS after gastrointestinal operations performed in our institution. The mean patient age was 75.4±11.1 years. Onset of ARDS occurred ≤24 hours postoperatively in 12 patients and 3- 11 days postoperatively in 3 patients. Treatment for ARDS comprised continuous hemodiafiltration (CHDF), high-dose glucocorticoid therapy or administration of a neutrophil elastase inhibitor (sivelestat). RESULTS: Four patients died 3-45 days after onset of ARDS (mortality rate, 26.6%). CHDF was performed in 12 patients, 8 patients received highdose glucocorticoid therapy and 11 patients received sivelestat. No differences in severity scores and clinical data were noted between survivors and non-survivors. PaO2/FiO2 ratio was significantly lower in non-survivors than in survivors from 5 days after starting treatment, whereas no difference was apparent at the onset of ARDS. CONCLUSIONS: Multimodal therapies for ARDS were effective. Longitudinal fluctuation in PaO2/ FiO2 ratio after starting treatment appears to offer a prognostic factor for ARDS.

Metachronous intraductal papillary mucinous neoplasm with carcinoma in situ of the pancreas arising within a short interval: report of a case.

A 61-year-old man with an intraductal papillary mucinous neoplasm (IPMN) and carcinoma in situ (CIS) of the pancreatic body initially underwent a distal pancreatectomy. Postoperative follow-up included computed tomography (CT) and ultrasonography (US) every 6 months. Intraductal papillary mucinous neoplasm of the pancreatic head was diagnosed 17 months later using peroral pancreatoscopy (POPS) including a biopsy, revealing IPMN with highly dysplastic changes. A total pancreatectomy was therefore performed. The pathological examination revealed IPMN with CIS. The patient was discharged from the hospital and is doing well as of 1 year postoperatively. Although cautious surveillance seems mandatory, consensus has not yet been reached regarding postoperative surveillance. This report presents an unreported case of metachronously arising IPMN with CIS within a relatively early interval, thus suggesting that surveillance every 6 months is preferable to > or = 1 year. In addition, endoscopic US, endoscopic retrograde cholangiopancreatography, intraductal US, or POPS should be included in pathological examinations to avoid missing opportunities to treat lesions such as noninvasive IPMN with a good prognosis. Surgically indicated patients with noninvasive recurrence should therefore be strongly considered to undergo a total pancreatectomy.

Continuous irrigation with gabexate mesilate around pancreaticojejunostomy after pancreaticoduodenectomy.

UNLABELLED: BACKGOUND/AIMS: The aim of this study is to present the new method of continuously irrigated around the pancreaticojejunostomy to reduce postoperative complications after pancreaticoduodenectomy. METHODOLOGY: Twenty-seven patients underwent pancreaticoduodenectomy in our institution between 2002 and 2007. Pancreaticojejunostomy was performed with the external pancreatic duct stent tube, and continuous irrigation around the pancreaticojejunostomy was started on the operative day with physiological saline solution containing gabexate mesilate. RESULTS: Mean duration of irrigation was 7.1 +/- 4.4 days, mean duration of drainage tube placement was 14.2 +/- 9 days, and mean duration of pancreatic duct drainage tube placement was 24.9 +/- 4.7 days. Pancreatic fistula was diagnosed in 8 patients. Three cases were classified as grade A and 5 cases were grade B. These pancreatic fistulae were closed by non-invasive treatment and the in-hospital death rate was 0%. CONCLUSIONS: External total drainage of the main pancreatic duct and continuous irrigation around pancreaticojejunostomy appears to avoid severe postoperative complications.

Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions.

BACKGROUND/PURPOSE: In 1995, we developed laparoscopic percutaneous extraperitoneal closure (LPEC) to treat inguinal hernias in children. This study evaluated LPEC's safety, efficacy, and reliability in 3 hospitals. METHODS: In 2 hospitals, LPEC was the standard procedure used to repair inguinal hernias in children, and in 1 hospital, it was done optionally in girls. During LPEC, a 4.5-mm laparoscope was placed through an umbilical incision, a 2-mm grasping forceps was inserted on the left side of the umbilicus, and a 19-gauge LPEC needle with suture material was inserted at the midpoint of the right or left inguinal line. The hernial sac orifice was closed extraperitoneally by circuit suturing around the internal inguinal ring using the LPEC needle. RESULTS: Nine hundred seventy-two LPECs were performed on 711 children (age range, 18 days to 19 years): 384 boys had 500 internal inguinal rings closed and 327 girls had 472 internal inguinal rings closed. Operating time for uni- or bilateral inguinal hernias ranged from 10 to 30 minutes. No complications occurred during surgery. The recurrence rate was 0.73% during follow-up (range, 5 months to 10 years). No hydroceles or testicular atrophy occurred after surgery. CONCLUSION: Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children appears to be safe, effective, and reliable.