Study of Learning Curve in a Surgeon for Near-Infrared Fluorescence Cholangiography During Laparoscopic Cholecystectomy-A Retrospective Evaluation.

BACKGROUND: Near-infrared indocyanine green fluorescence cholangiography (NIRF) has shown promising results on delineating extra-hepatic biliary anatomy during laparoscopic cholecystectomy to avoid bile duct injury. However its routine usage remains in question. In this study, the technique was evaluated further with learning curve estimation and learning factors were observed. METHODS: One hundred ninety-nine cases which underwent laparoscopic cholecystectomy for acute or chronic cholecystitis within a 2-year period including 51 cases with initial use of NIRF by 2 surgeons were studied retrospectively. The learning curve was evaluated for a surgeon as primary objective. A case-matched comparison of the operative time between NIRF and conventional group, in terms of acute and chronic cholecystitis was also conducted as a secondary calculation. RESULTS: Learning curve was evaluated with 61% learning rate for NIRF experience. Cysto-biliary junction non-illuminated cases under fluorescent view, had mean operative time of 80.83 ± 22.82 min, which was shorter than the cysto-biliary junction illuminated cases. The NIRF group exhibited longer operative time compared with the conventional group with mean difference of 34.39 min (significant at P < .05). CONCLUSIONS: While the initial learning phase might be affected by surgeons' behavior and attitude, our results may provide a reference to learn at one's own pace and to employ NIRF teaching strategies during surgical training programs to overcome the initial phase during training period itself and facilitate universal achievement.

Single-incision laparoscopic common bile duct exploration in 101 consecutive patients: choledochotomy, transcystic, and transfistulous approaches.

BACKGROUND: Laparoscopic surgery for choledocholithiasis is still evolving. Only a few reports of single-incision laparoscopic common bile duct exploration (LCBDE) have been published. METHODS: One hundred and one consecutive patients underwent single-incision LCBDE (SILCBDE) by one surgeon with straight instruments during a 42-month period. RESULTS: Choledochotomies were performed on 61 patients (60.4%). The success rate of intrahepatic duct exploration was 68.0% (17/25) for patients undergoing transcystic choledochoscopic bile duct explorations following longitudinal cystic ductotomies. The ductal clearance rate was 100%. Eighteen procedures (17.8%) were converted, including one open surgery. Nineteen patients (18.8%) experienced 26 episodes of complications; the majority (19 episodes) were classified as Clavien-Dindo grade I. Excluding those patients with Mirizzi syndrome (McSherry type II), multivariate logistic regressions showed that patients who were older or had complicated cholecystitis had higher procedure conversion rates and that higher modified APACHE II scores, higher white blood cell counts, and longer operative times were independent risk factors for complications. Based on operative times, 20 successful SILCBDEs were needed to get through the learning phase. A higher transcystic approach rate (46.5 vs. 8.3%; P < 0.01) and a shorter operative time (207 ± 62 vs. 259 ± 66 min; P < 0.01) were observed in the experienced phase. Compared with our early series of multi-incision LCBDE, the SILCBDE group had a higher bile duct stone clearance rate (100 vs. 94.4%; P < 0.05) and a higher proportion of patients with concomitant acute cholecystitis (59.6 vs. 22.2%; P < 0.01). CONCLUSIONS: LCBDE with a 100% ductal clearance rate is possible following an algorithm for various approaches. SILCBDE is feasible under a low threshold for procedure conversion. A transcystic approach should be tried first if indicated, and a longitudinal cystic ductotomy to the cystocholedochal junction is beneficial. Prospective, randomized trials comparing single-incision and multi-incision LCBDE are anticipated.

Intraperitoneal metastasis of hepatocellular carcinoma after spontaneous rupture: a case report.

Rupture of hepatocellular carcinoma (HCC) is a life-threatening complication. Peritoneal metastasis of HCC after spontaneous rupture was seldom noted. We report a case of intraperitoneal metastasis of HCC after spontaneous rupture. A previously asymptomatic 72-year-old man was admitted due to dull abdominal pain with abdominal fullness. He had a history of HCC rupture 10 mo ago and transarterial embolization was performed at that time. Abdominal computer tomography (CT) scan showed a huge peritoneal mass over the right upper quadrant area. Surgical resection was arranged and subsequent microscopic examination confirmed a diagnosis of moderately-differentiated HCC.

Ruptured appendiceal cystadenoma presenting as right inguinal hernia in a patient with left colon cancer: a case report and review of literature.

BACKGROUND: Mucoceles resulting from cystadenomas of the appendix are uncommon. Although rare, rupture of the mucoceles can occur with or without causing any abdominal complaint. There are several reports associating colonic malignancy with cystadenomas of the appendix. Herein, we report an unusual and interesting case of right inguinal hernia associated with left colon cancer. CASE PRESENTATION: A case of ruptured mucocele resulting from cystadenoma of the appendix was presented as right inguinal hernia in a 70-year-old male. The patient underwent colonoscopy, x-ray, ultrasound and computed tomography. Localized pseudomyxoma peritonei associated with adenocarcinoma of the descending colon was diagnosed. The patient underwent segmental resection of the colon, appendectomy, debridement of pseudomyxoma and closure of the internal ring of right inguinal canal. He is free of symptoms in one year follow-up. CONCLUSION: Synchronous colon cancer may occur in patients with appendiceal mucoceles. In such patients, the colon should be investigated and colonoscopy can be performed meticulously in cases of ruptured mucoceles and localized pseudomyxoma peritonei. Surgical intervention is the current choice of management.

F18-fluorodeoxyglucose positron emission tomography in detecting metastatic papillary thyroid carcinoma with elevated human serum thyroglobulin levels but negative I-131 whole body scan.

UNLABELLED: Papillary carcinomas are the most common thyroid malignancies. They invade the regional lymphatics and metastasize frequently to local lymph nodes in the neck. Distant metastasis, generally to the lungs, is also common. METHODS: The aim of this study is to evaluate the effectiveness of F18-fluorodeoxyglucose (FDG) positron emission tomography (PET) to detect metastatic lesions in patients with papillary thyroid carcinomas (PTC) after nearly total thyroidectomy and I-131 treatments who present with elevated human serum thyroglobulin (hTg) levels but negative 1-131 whole body scan (WBS). Twenty patients with PTC who underwent nearly total thyroidectomy and radioiodine treatments were included in this study. RESULTS: All of the 20 patients had negative I-131 WBS results and elevated hTg levels (hTg > or = 2.0 microIU/mL) under thyroid-stimulating hormone (TSH) stimulation (TSH > or = 30 microIU/mL). CONCLUSIONS: FDG-PET was perform to detect metastatic lesions. F18-fluorodeoxyglucose-PET could detect hypermetabolic lesions in 17 patients but failed to demonstrate miliary pulmonary metastases in two patients. No definite lesion was found in FDG-PET, x-ray chest computed tomography (CT) and other imaging studies of the remaining one patient This study showed that FDG-PET is a useful tool in detecting metastatic lesions in PTC with elevated hTg but negative I-131 WBS. However, miliary lung metastases may be missed in FDG-PET. In this circumstance, chest CT should be included in the follow-up protocol.