Intraoperative near-infrared indocyanine green fluorescence angiography (NIR-ICG AG) can predict delayed small bowel stricture after ischemic intestinal injury: report of a case.

We herein report the case of a 15-year-old male who developed delayed intestinal stricture after undergoing massive intestinal resection due to severe small intestinal volvulus. At the time of the initial surgery, the laparotomy findings showed a massive intestinal volvulus without malrotation. Most of the small intestine appeared to be necrotic; therefore, massive necrotic intestinal resection was performed. The residual intestine comprised only the proximal jejunum and short ileum, including the ileocecal valve and entire colon. After the resection, the serosal surface color of the distal part of the residual jejunum (DPRJ) initially showed a slightly darker hue than normal. However, the color improved with time, and the other clinical findings also improved, which were considered to indicate that the perfusion of the DPRJ was preserved. The perfusion of that area was therefore clinically expected to improve with time. On the other hand, repeated intraoperative near-infrared indocyanine green fluorescence angiography (NIR-ICG AG) consistently showed abnormal vascular flow patterns in the same region, which were suspected to indicate the presence of perfusion damage of the DPRJ, in spite of improvements in the clinical findings. Although the necessity of additional resection was discussed at the time of reconstruction, we finally estimated that the perfusion of the DPRJ was preserved, mainly based on the improvement of the clinical findings of the intestine. The primary anastomosis was performed without additional resection, to maximize the lengths of the residual intestine. However, after the initial surgery, the patient developed a delayed partial stricture of the residual intestine, and an additional resection was necessary on the 22nd postoperative day. The stricture segment corresponded to the area that presented abnormal findings by NIR-ICG AG. This case suggests that abnormal NIR-ICG AG findings may predict delayed intestinal ischemic complications. We believe that NIR-ICG AG can intraoperatively provide more useful real time information for the assessment of intestinal perfusion, than conventional clinical assessment methods.

Invasive cholangiocarcinoma identified in congenital biliary dilatation in a 3-year-old boy.

We herein report a 3-year-old male demonstrating invasive cholangiocarcinoma (CC) associated with congenital biliary dilatation (CBD). A 3-year-old Japanese boy was admitted to our hospital with abdominal pain and vomiting. Computed tomography and magnetic resonance imaging demonstrated a dilated extrahepatic bile duct. A diagnosis of Todani's type 1a CBD was made. Intraoperative cholangiography demonstrated the presence of pancreaticobiliary maljunction but could not reveal any tumor lesion in the bile duct. The excision of extrahepatic bile duct and gallbladder and Roux-en-Y hepaticojejunostomy were performed. On gross inspection, we could not find any tumor lesion in the resected specimen. However, the postoperative histopathologic examinations confirmed the presence of well-differentiated tubular adenocarcinoma with lymphovascular invasion. Most of the carcinoma remained within the mucosal layer, and the carcinoma was identified at both the distal and proximal surgical margins of the bile duct. We scheduled additional surgery to eradicate the residual carcinoma, but informed consent for the extra surgery could not be obtained. A close follow-up with abdominal computed tomography has been going on without either additional surgery or adjuvant chemotherapy about for 1 year. The patient has so far been clinically doing well without any obvious symptoms of recurrent disease. To our knowledge, this report is the youngest case of CC associated with CBD.

Whole-blood manganese levels and brain manganese accumulation in children receiving long-term home parenteral nutrition.

Recent reports attribute neurological and cerebral disorders to the accumulation of manganese (Mn) in the brain in patients receiving home parenteral nutrition (HPN). It is desirable to control the amount of Mn delivered to these patients, but a suitable method for monitoring an individual's Mn status and assessing Mn accumulation remains debatable. The aim of this study was to evaluate whether whole-blood manganese levels (WB-Mn) correlate with the accumulation of Mn in the brains of children who receive long-term HPN, using magnetic resonance imaging (MRI) of the brain. Six patients who had received HPN (duration of HPN, 18-137 months) were included in this study. The daily parenteral doses of Mn were calculated while on HPN. WB-Mn was measured and T1-weighted MRI of the brain was obtained for each patient with a 1.5-T MR imager. Twelve months after the withdrawal of Mn from HPN, measurements of WB-Mn and brain MRI were repeated in all patients except for one who was lost after initial examination. The same examinations were performed on an additional patient who had been successfully weaned off a 179 month course of HPN 20 months prior to the initial examination. The parenteral dose of Mn while receiving HPN ranged from 15.7 to 91.5 micro g/kg/day. Initially, MRI showed hyperintensity in the globus pallidus in all patients and in the anterior pituitary in one patient. WB-Mn was elevated in four patients, but was in the normal range in the remaining three. Following subsequent measurements 12 months later, WB-Mn was normal in all patients and MRI hyperintensity remained in the globus pallidus in one patient. One patient was lost after the initial examinations. WB-Mn does not necessarily correlate with the accumulation of Mn in the brain. Periodic MRI should be performed in patients receiving long-term NPN to monitor for excessive Mn accumulation in the brain.