Learning curve for the surgical time of laparoscopic cholecystectomy performed by surgical trainees using the three-port method: how many cases are needed for stabilization?

BACKGROUND: The assessment of laparoscopic cholecystectomy (LC) skills using operating times has not been well reported. We examined the total and partial operating times for LC procedures performed by surgical trainees to determine the required number of surgeries until the surgical time stabilizes. METHODS: We reviewed the video records of 514 consecutive LCs using the three-port method, performed by 16 surgical trainees. The total and partial surgical times were calculated and correlated to the surgeons' experience. RESULTS: The median total surgical time for a trainee's first LC was 112 (range 71-226) minutes. It reduced rapidly after the first 20 LCs and plateaued to its minimum after approximately 60 cases. A statistically significant time decrease was observed between the first 10 (median, range 112, 46-252 min) and the next 50-59 cases (64, 34-198 min), but not between the 50-59 and the subsequent 100-109 cases (71, 33-127 min). The total times taken by trainees who had performed > 50 operations were not significantly different from those taken by instructors during the study period. Surgery for 125 patients with acute cholecystitis took a significantly longer time (median 99 vs. 74 min with non-acute cholecystitis); however, the abovementioned time reduction findings showed similar results regardless of the patient's acute inflammation status. The partial operating times around the cervical/cystic duct and gallbladder bed reduced uniformly between the first 10 and the following 50-59 cases. Although time variations in total and cervical/cystic duct operating times were not correlated to the surgical experience, time fluctuation of gallbladder bed procedures reduced after 60 cases. CONCLUSION: The time required to perform an LC was inversely correlated with the experience of surgical trainees and halved after the first 60 cases. The surgical experience required for LC time stabilization is approximately 60 cases.

Treatment for Appendicitis With Appendicolith by the Stone Size and Serum C-Reactive Protein Level.

INTRODUCTION: Appendicolith causes acute appendicitis. However, surgical indications for appendicolith-related acute appendicitis have not been established. We aimed to clarify the clinical features of appendicolith-associated appendicitis and determine an appropriate treatment strategy based on the initial presentation. MATERIALS AND METHODS: We retrospectively reviewed the records of 479 consecutive patients with acute appendicitis and verified the therapeutic strategy as per the appendicolith and clinical status. RESULTS: Appendicoliths were identified in 214 of 479 patients (44.6%) using computed tomography. Surgery was more frequently required in patients with appendicolith than in patients without appendicolith (82.7 versus 64.9%; P < 0.001). The stones were smaller and serum C-reactive protein (CRP) concentration was lower among patients with appendicoliths treated with medication alone than among those surgically treated (both P < 0.001). An appendicolith measuring ≤5 mm in diameter and CRP concentration ≤5.36 mg/dL were predictive of completion of nonsurgical therapy. CRP concentration >10 mg/dL and stone diameter of 10 mm were significantly associated with appendiceal perforation. CONCLUSIONS: Nonsurgical therapy could be considered for patients with appendicoliths measuring ≤5 mm in diameter and in cases where the serum CRP concentration is ≤5 mg/dL. An appendicolith measuring >10 mm in diameter or CRP concentration >10 mg/dL is an indication for surgery.

Laparoscopic surgery for a hydrocele of the canal of Nuck with an ovarian tumor: An extremely rare clinical finding.

This clinical image presents an unusual report of simultaneous laparoscopic resection of a hydrocele of the canal of Nuck and an ovarian tumor. Laparoscopic treatment with a proper approach is a useful technique in some cases.

Laparoscopic transabdominal preperitoneal hernioplasty for bilateral obturator hernias and left inguinal hernia with emaciation caused by anorexia nervosa: A case report.

A 55-year-old woman receiving treatment for anorexia nervosa presented with abdominal pain and right thigh pain. Her body mass index was 12.9 kg/m2 . Computed tomography showed fluid storage in the distal side of the right obturator foramen and revealed a dilated small bowel without a starting point of obstruction. We diagnosed a naturally reduced incarcerated right obturator hernia and performed elective surgery with a laparoscopic approach for hernia repair the next day. Intraperitoneal observation revealed bilateral obturator hernias and a left direct-type inguinal hernia. Transabdominal preperitoneal hernioplasty was performed using two self-gripping polyester meshes for bilateral obturator hernia repair and a lightweight 3D-shaped mesh for left inguinal hernia repair. Women with emaciation caused by anorexia nervosa may be more likely to have complex hernias, including obturator hernia, and laparoscopic approaches may be useful for preoperatively diagnosed nonstrangulated obturator hernias.

Comparison of surgical smoke between open surgery and laparoscopic surgery for colorectal disease in the COVID-19 era.

BACKGROUND: Surgical smoke during operation is a well-known health hazard for medical staff. This study aimed to investigate the dynamics of surgical smoke during open surgery or laparoscopic surgery for colorectal disease. METHODS: This study quantitated particulate matter (PM) counts as part of surgical smoke in 31 consecutive patients who underwent colectomy at the Niigata City General Hospital using a laser particle counter. Particles were graded by size as ≤ 2.5 µm PM (PM2.5) or > 2.5 µm PM (large PM). Operative procedures were categorized as either open surgery (n = 14) or laparoscopic surgery (n = 17). RESULTS: The median patient age was 72 (range 41-89) years and 58.1% were male. The total PM2.5, PM2.5 per hour, and maximum PM2.5 per minute counts during operation were significantly higher in open surgery than in laparoscopic surgery (P = 0.001, P < 0.001, and P = 0.029, respectively). Large PM counts (total, per hour, and maximum per minute) were also higher in the open surgery group than in the laparoscopic surgery group. The maximum PM2.5 concentration recorded was 38.6 µm/m3, which is considered "unhealthy for sensitive groups" according to the U.S. Environment Protection Agency air quality index standards, if it was a 24-h period mean value. CONCLUSION: Exposure to surgical smoke is lower during laparoscopic surgery than during open surgery for colorectal diseases.

Is radiological psoas muscle area measurement a predictor of postoperative complications after rectal resection for rectal cancer? A retrospective study.

PURPOSE: Previous studies have reported that sarcopenia increases the risk of postoperative complications following colorectal resection. This retrospective study assessed the postoperative complications of rectal resection associated with sarcopenia. METHODS: We retrospectively analyzed 262 patients who underwent curative low anterior resection for primary rectal cancer from January 2008 to May 2020 at our institution. The patients were divided into a sarcopenia group (normalized total psoas muscle area < 6.36 cm2/m2 in males and < 3.92 cm2/m2 in females; N = 49) and a non-sarcopenia group (N = 213). RESULTS: The overall rate of postoperative complications within 30 days of surgery was higher in the sarcopenia group than in the non-sarcopenia group (46.9 vs. 29.6%; P = 0.028). The rate of postoperative remote infections was higher in the sarcopenia group than in the non-sarcopenia group (12.2 vs. 2.8%; P = 0.012). Sarcopenia was found to be a predictor of remote infection by a multivariate analysis (odds ratio, 4.08; 95% confidence interval, 1.12-14.80; P = 0.033). CONCLUSION: Sarcopenia diagnosed using the psoas muscle index was found to be an independent predictive factor for postoperative remote infection after curative low anterior resection for rectal cancer.

Surgical approach for right-sided colonic diverticular bleeding: A single-center review of 43 consecutive cases.

INTRODUCTION: While Asian populations develop colonic diverticular disease predominantly in the right colon, Western populations mainly present with left-sided disease. The present study aimed to clarify the outcomes of surgical treatment for right-sided colonic diverticular bleeding. METHODS: Medical records of 43 patients who underwent surgery for right-sided colonic diverticular bleeding between 2010 and 2019 were reviewed. Those whose general condition became unstable underwent open surgery at our institution. Patients were then divided into two groups, the open surgery group (n = 17) and laparoscopic surgery group (n = 26), after which operative outcomes between both groups were compared. RESULTS: This study included 36 men and seven women with a median age of 76 (range: 37-91) years. Laparoscopic surgery had a significantly longer operative time (183.5 minutes vs 110 minutes; P < .001) and significantly lower intraoperative blood transfusion rate (19.2% vs 82.4%; P < .001) than open surgery. The laparoscopic surgery group had earlier resumption of postoperative meals than open surgery group (postoperative day 3 vs postoperative day 4; P = .010). No significant difference in postoperative complications was observed between both groups. With regard to long-term outcomes, none of the cases exhibited rebleeding from the right-sided colon. CONCLUSION: The present study revealed that laparoscopic surgery promoted lower intraoperative blood transfusion rates and earlier resumption of postoperative meals compared to open surgery for right-sided colonic diverticular bleeding. Hence, laparoscopic surgery can be feasible for right-sided colonic diverticular bleeding provided that the patient's general condition is stable.

Perforation of anastomotic peptic ulcer following pancreaticoduodenectomy: a report of three cases.

BACKGROUND: Perforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention. CASE PRESENTATION: Marginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65-79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients. CONCLUSIONS: Lack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.

Internal hernia beneath the obturator nerve after robot-assisted lateral lymph node dissection for rectal cancer: A case report and literature review.

A 63-year-old man who underwent robot-assisted laparoscopic low anterior resection and right lateral lymph node dissection (LLND) for rectal cancer presented with right thigh pain, nausea, vomiting, and abdominal pain on postoperative day 17. CT revealed dilated small bowel in the pelvis, and a small bowel loop was detected outside the internal iliac artery branch. Emergent laparoscopic surgery revealed the migration of the small bowel into the space beneath the right obturator nerve. The herniated bowel was reduced, and the obturator nerve was sharply dissected from the herniated bowel and preserved. The hernial orifice was left unrepaired. Postoperative recovery was uneventful, and the right thigh pain disappeared. It is important to consider the possibility of internal herniation beneath the obturator nerve after minimally invasive lateral lymph node dissection for rectal cancer.

Integrated analysis of 8-week glecaprevir/pibrentasvir in Japanese and overseas patients without cirrhosis and with hepatitis C virus genotype 1 or 2 infection.

BACKGROUND: Chronic hepatitis C virus (HCV) infection with genotypes (GT) 1 and 2 accounts for over 50% of HCV infections globally, including over 97% of all HCV infections in Japan. Here, we report an integrated analysis of efficacy and safety of 8-week treatment with the all-oral, fixed-dose combination of the direct acting antivirals (DAA), glecaprevir and pibrentasvir (G/P), in DAA-naïve Japanese and overseas patients without cirrhosis and with HCV GT1 or GT2 infection. METHODS: Data from 899 DAA-naïve patients without cirrhosis and with HCV GT1 or GT2 infection treated with G/P (300/120 mg) for 8 weeks in the six Phase 2 or 3 overseas or Japan-only clinical trials were included. All patients who received ≥ 1 dose of G/P were included in an intent-to-treat (ITT) analysis. The objectives were to evaluate rate of sustained virologic response 12 weeks post-treatment (SVR12) and safety of the 8-week regimen in the ITT population. RESULTS: Overall, SVR12 was achieved by 98.9% (889/899) of DAA-naïve patients without cirrhosis, including 99.2% (597/602) of GT1-infected and 98.3% (292/297) of GT2-infected patients. Less than 1% (2/899) of patients overall and no Japanese patients experienced virologic failure. SVR12 rate was > 97% for patients regardless of baseline characteristics, and common comorbidities or co-medications. Overall, < 1% (2/899) discontinued G/P due to an adverse event (AE) and 1.6% (14/899) of patients experienced a serious AE. CONCLUSIONS: 8-week G/P treatment is safe and efficacious in DAA-naive patients without cirrhosis and with HCV GT1 or GT2 infection, demonstrating high SVR12 rates regardless of baseline patient and disease characteristics. CLINICALTRIALS. GOV IDENTIFIERS: The trials discussed in this paper were registered with ClinicalTrials.gov as follows: NCT02707952 (CERTAIN-1), NCT02723084 (CERTAIN-2), NCT02243280 (SURVEYOR-I), NCT02243293 (SURVEYOR-II), NCT02604017 (ENDURANCE-1), NCT02738138 (EXPEDITION-2).

A rare case of peritoneal deposits with carbon pigmentation after preoperative endoscopic tattooing for sigmoid colon cancer.

PURPOSE: We report a case in which pigmented peritoneal deposits were found during laparoscopic surgery following preoperative endoscopic tattooing for sigmoid colon cancer. METHODS: The patient's clinical, endoscopic, and histological data from the Niigata City General Hospital were reviewed, as well as the literature on laparoscopic surgery involving the preoperative endoscopic tattoo, with a focus on the relevance of peritoneal deposits and tattooing ink. RESULTS: A 71-year-old man presented to our hospital complaining of vomiting and abdominal distention. Abdominal computed tomography revealed obstructive sigmoid colon cancer. An emergency endoscopic colon stenting procedure and injection of 0.2 ml India ink to the submucosal layer of the tumor's anal side were performed. Laparoscopic-assisted sigmoid colectomy was done 14 days after stenting. At surgery, seven small peritoneal deposits were seen in the rectovesical pouch and at the site adjacent to the tumor. All peritoneal deposits were stained by the ink. Gross leakage of the ink into extraintestinal sites was seen. The seven peritoneal deposits were resected under laparoscope. Histological findings revealed that the seven peritoneal deposits were composed of adenocarcinoma and carbon pigments. Immunohistochemical staining for cluster of differentiation 163 showed that the carbon pigments in the peritoneal deposits were within macrophages. CONCLUSIONS: The possibility of the tattooing procedure causing peritoneal dissemination cannot be completely denied, but it can be hypothesized that the carbon pigmentation was transferred to peritoneal deposits by macrophages. In the future, we hope that this phenomenon becomes a keystone for diagnoses and treatments for peritoneal dissemination.

Initial Features of Hepatic Metastases From Pancreatic Cancer: Histological and Radiolographical Appraisal of Hepatic Micrometastases Detected by Real-Time Fluorescent Imaging.

OBJECTIVE: The pathophysiology of primary-stage hepatic metastases from gastrointestinal cancers may provide clues to their formation. We investigated initial features of hepatic metastases from pancreatic cancer by examining the histologies of radiographically occult hepatic micrometastases. METHODS: We examined 133 consecutive pancreatic cancer patients with no evident hepatic metastases on preoperative imaging. An indocyanine green near-infrared camera system was used to detect hepatic metastases during surgery; preoperatively acquired images of patients were then retrospectively reviewed. RESULTS: Hepatic micrometastases were histologically confirmed in 20 patients (15%). Immunohistochemically, the metastatic cells were with higher positivity of carcinoembryonic antigen (100%), p53 overexpression (40%), and Ki-67 labeling index (38%, median). All the micrometastases were portal thromboemboli in the intrahepatic portal triad that invaded extravenous structures, causing desmoplasis, local biliary obstruction, and indocyanine green-contained bile stasis A review of preoperative dynamic computed tomography or magnetic resonance images revealed focal circular alterations presenting as arterioportal shunts in 50% of the patient with micrometastases and 11% of those without (P < 0.01). CONCLUSIONS: Hepatic metastasis from pancreatic cancer involves portal vein thrombosis that alters local circulation and bile stasis at the portal triad; this is detectable by presurgical radiological examination or intraoperative fluorescent imaging.

Diagnosis of autoimmune pancreatitis with cholesterol granuloma mimicking intraductal papillary-mucinous carcinoma: A case report.

INTRODUCTION: Pancreatic cysts are often observed incidentally on abdominal computed tomography (CT). For cysts involving intracystic nodules, malignant neoplasms such as intraductal papillary-mucinous carcinoma (IPMC) should be suspected. In contrast, cholesterol granuloma (CG) rarely occurs in the pancreas, and CG-associated autoimmune pancreatitis (AIP) has not yet been reported. To our knowledge, this is the first reported case of AIP with CG mimicking IPMC. PRESENTATION OF CASE: A 56-year-old woman underwent abdominal CT for preoperative breast cancer screening. Asymptomatic polycystic lesions were detected in the pancreatic tail (maximum diameter, 5cm). Magnetic resonance cholangiopancreatography and endoscopic ultrasonography revealed main pancreatic duct obstruction and a lesion with intracystic nodules (maximum diameter, 10mm). Serum levels of pancreatic cancer tumor markers and IgG4 were within normal ranges. Because IPMC was suspected, distal pancreatectomy and splenectomy with regional lymphadenectomy were performed after surgery for breast cancer. Pathological examination of the specimen revealed no epithelial neoplasm; however, cholesterol crystals with foreign body giant cells were observed. Moreover, IgG4-positive plasma cells, diffuse lymphocyte infiltration, storiform fibrosis, and obliterative phlebitis were identified in the non-cystic pancreatic parenchyma. The final diagnosis was AIP with CG. DISCUSSION: CG in the pancreas is rare and its pathogenesis remains unclear. The findings of the present case suggest that chronic inflammation due to AIP may cause local bleeding, and that a reaction to the leaked blood cells causes CG. CONCLUSIONS: Although preoperative diagnosis may be difficult, AIP with CG should be considered as a differential diagnosis in pancreatic cysts involving nodular lesions.

Safety and efficacy of a novel continuous incision technique for laparoscopic transcystic choledocholithotomy.

INTRODUCTION: The purpose of this study was to evaluate the safety and efficacy of a novel continuous incision technique for the cystic duct and the bile duct over the orifice for laparoscopic transcystic choledocholithotomy (LTCL). METHODS: LTCL was attempted in 103 consecutive patients from January 1998 to March 2015 and was successful in 96 patients. The cystic duct confluence was made by cutting upward from the orifice in 19 patients. The cystic duct was incised downward beyond the orifice to the bile duct in the other 77 patients. Both of these procedures involved LTCL. RESULTS: LTCL was successful in 96 patients. It failed in seven patients because of large bile duct stones (BDS), left lateral entry of the cystic duct, or the cystic duct's small diameter. The success rates of LTCL were 98% (47/48), 96% (42/44), and 64% (7/11) for patients with BDS <10 mm, 10-20 mm, and ≥20 mm, respectively. The success rate for removing BDS <20 mm was significantly higher than the removal rate for BDS ≥20 mm (P < 0.0001). There was no significant difference between the incidences of complications associated with BDS ≥10 mm and with BDS <10 mm (P = 0.49). In those who underwent successful LTCL, complications occurred in 3 of 23 patients with failed preoperative duodenoscopic sphincterotomy and in 9 of the other 73 patients; the incidence of complications did not significantly differ between these groups (P = 0.93). CONCLUSION: LTCL is safe and feasible for exploration of the bile duct and removal of BDS <20 mm.

Effectiveness of a barbed suture in the repair of bile duct injury during laparoscopic cholecystectomy: Report of two cases.

INTRODUCTION: Bile duct injury during laparoscopic cholecystectomy occurs in rare cases. We report two cases using barbed suture for repair in bile duct injury during laparoscopic cholecystectomies. PRESENTATION OF CASES: The first patient was a 73-year-old woman who underwent elective laparoscopic cholecystectomy for cholecystolithiasis. When the gallbladder was dissected from the bed, bile spillage was observed and an injured small bile duct was detected. The bile duct could not be managed using a titanium clip. The second patient was an 83-year-old woman who underwent emergent laparoscopic cholecystectomy for gallbladder torsion. After the gallbladder was dissected from the bed, bile spillage was observed. In both cases, a running suture, of absorbable monofilament 3-0 barbed suture, was used to laparoscopically repair the injuries. DISCUSSION: Laparoscopic repair of a bile duct injury is technically challenging, especially in the gallbladder bed where suturing is very difficult because of the tangential approach and the risk of additional liver laceration. Barbed sutures have the benefit of being knotless, thus, performing a running suture is not difficult, even in laparoscopic procedures. Further, absorbable and monofilament threads are generally better suited for biliary surgery, compared with non-absorbable and braided sutures, because of the potential association of the other types of materials with bile duct stone and stricture formation. CONCLUSION: We believe that the V-Loc™ device is an effective and appropriate option for bile duct injuries that occur during laparoscopic cholecystectomies, particularly around the gallbladder bed, and it is especially useful for surgeons unfamiliar with intracorporeal knot tying.

Cigarette smoking and the risk of head and neck cancer in the Japanese population: a systematic review and meta-analysis.

OBJECTIVE: Although cigarette smoking is a well-established risk factor for head and neck cancer, the impact of smoking on head and neck cancer might vary among geographic areas. To date, however, no systematic review of cigarette smoking and head and neck cancer in the Japanese population has yet appeared. METHODS: We conducted a systematic review of previous epidemiological studies for cigarette smoking and head and neck cancer among Japanese. Evaluation of associations was based on the strength of evidence ('convincing', 'probable', 'possible' or 'insufficient') and the magnitude of association ('strong', 'moderate', 'weak' or 'no association'), together with biological plausibility as previously evaluated by the International Agency for Research on Cancer. A meta-analysis was conducted to obtain summary estimates for the overall magnitude of association. RESULTS: We identified five cohort studies and 12 case-control studies. Four of five cohort studies and 11 of 12 case-control studies showed a strong positive association between cigarette smoking and head and neck cancer. Nine of 12 studies indicated a dose-response relationship between cigarette smoking and the risk of head and neck cancer. Meta-analysis of 12 studies indicated that the summary relative risk for ever smokers relative to never smokers was 2.43 (95% confidence interval: 2.09-2.83). Summary relative risks for current and former smokers relative to never smokers were 2.68 (2.08-3.44) and 1.49 (1.05-2.11), respectively. CONCLUSIONS: Cigarette smoking is a convincing risk factor for head and neck cancer in the Japanese population.

Near-infrared fluorescence cholangiography with indocyanine green for biliary atresia. Real-time imaging during the Kasai procedure: a pilot study.

INTRODUCTION: Hepatoportoenterostomy (HPE) with the Kasai procedure is the treatment of choice for biliary atresia (BA) as the initial surgery. However, the appropriate level of dissection level of the fibrous cone (FC) of the porta hepatis (PH) is frequently unclear, and the procedure sometimes results in unsuccessful outcomes. Recently, indocyanine green near-infrared fluorescence imaging (ICG-FCG) has been developed as a form of real-time cholangiography. METHODS: We applied this technique in five patients with BA to visualize the biliary flow at the PH intraoperatively. ICG was injected intravenously the day before surgery as the liver function test, and the liver was observed with a near-infrared camera system during the operation while the patient's feces was also observed. RESULTS: In all patients, the whole liver fluoresced diffusely with ICG-containing stagnant bile, whereas no extrahepatic structures fluoresced. The findings of the ICG fluorescence pattern of the PH after dissection of the FC were classified into three types: spotty fluorescence, one patient; diffuse weak fluorescence, three patients; and diffuse strong fluorescence, one patient. In all five patients, the feces evacuated after HPE showed distinct fluorescent spots, although that obtained before surgery showed no fluorescence. One patient with diffuse strong fluorescence who did not achieve JF underwent living related liver transplantation six months after the initial HPE procedure. Four patients, including three cases involving diffuse weak fluorescence and one case involving spotty fluorescence showed weak fluorescence compared to that of the surrounding liver surface. CONCLUSION: We were able to detect the presence of bile excretion at the time of HPE intraoperatively and successfully evaluated the extent of bile excretion using this new technique. Furthermore, the ICG-FCG findings may provide information leading to a new classification and potentially function as an indicator predicting the clinical outcomes after HPE.

Successful balloon dilatation for postoperative caval stenosis caused by primary venorrhaphy for traumatic retro-hepatic caval injury in a three-year-old child: Report of a case.

Inferior vena cava injuries are highly lethal. We experienced a case of retrohepatic inferior vena cava injury as a result of blunt trauma in a three-year-old female. Because the site of bleeding of the IVC was identified, we repaired it with running sutures. An attempt at primary repair resulted in postoperative narrowing of the vena cava. There was pressure gradient of the right atrium and inferior vena cava, and collateral circulation developed. Since it was also found that the haemodynamics was unstable, the child underwent another intervention before the stenosis of the IVC was fixed. To the best of our knowledge, there have been no previous reports of therapeutic radiological intervention for stenosis that developed after treatment of a traumatic IVC injury. The IVC in the present case recovered enough patency so that the collateral venous flow could be decreased after balloon dilatation angioplasty.

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.

Bile duct stone formation around a nylon suture after gastrectomy: a case report.

BACKGROUND: Many cases of choledocholiths formed around sutures and clips used during cholecystectomy have been reported. We describe a case of gallstone formation around a nylon suture after non-biliary surgery. To the best of our knowledge, this is the first report of such a case. CASE PRESENTATION: A 75-year-old Japanese man, who had undergone distal gastrectomy for gastric cancer and reconstruction with the Billroth II method 8 years earlier, presented with gastric discomfort. Abdominal ultrasonography was conducted and we diagnosed cholecysto-choledocholithiasis with dilatation of the intrahepatic bile duct. He underwent cholecystectomy and cholangioduodenostomy for choledocholith removal. Gallstones, which had formed around a nylon suture used during the previous gastrectomy, were found in the bile duct. Sutures of the same material had also been placed on the duodenum. Chemical analysis revealed that the stones were composed of calcium bilirubinate. The patient was discharged on postoperative day 19, and choledocholithiasis has not recurred thus far. CONCLUSION: The findings from this case suggest that standard, non-resorbable sutures used in gastrectomy may be associated with the formation of bile duct stones; therefore, absorbable suture material may be required to avert gallstone formation even in the case of gastrectomy.