Successful laparoscopic cholecystectomy for acute cholecystitis with kyphoscoliosis by the devised placement of trocar ports: A case report.

INTRODUCTION: Kyphoscoliosis, which is a deformity of the spine caused by aging and osteoporosis, results in various surgical difficulties for laparoscopic cholecystectomy (LC) due to low-lying costal arches, such as a small abdominal working space, disturbance of the surgical view and decreased controllability of the surgical instrument. PRESENTATION OF CASE: We herein report the case of a 92-year old woman with severe kyphoscoliosis who was diagnosed with Grade II acute cholecystitis. Taking her general status into consideration, emergency percutaneous transhepatic gallbladder drainage (PTGBD) was initially performed. After PTGBD, the patient's physical status and systemic inflammation markedly improved. She then underwent interval LC. The surgical view of the upper abdomen including the gallbladder was entirely interrupted by bilateral low-lying costal arches with adhesion to the greater omentum. To access the gallbladder without interruption by the low-lying costal arch, the first umbilical port was changed to a multi-port with surgical glove and an additional port was added in the left abdomen. Consequently, LC was safely accomplished with the creation of the critical view. DISCUSSION: A low-lying costal arch due to kyphoscoliosis can prevent surgeons from accessing the gallbladder. LC with the standard 4-port method could not be accomplished because of insufficient lifting of the low-lying costal arch. Devised placement of the ports is needed to access the gallbladder between bilateral low-lying costal arches. CONCLUSION: A transumbilical multi-port and left abdominal port may be effective for successful LC of acute cholecystitis with kyphoscoliosis.

A case of hepatic inflammatory pseudotumor protruding from the liver surface.

We report a case of a resected hepatic inflammatory pseudotumor (IPT) protruding from the liver surface. A 69-year-old male with diabetes mellitus was admitted to hospital for investigation of an hepatic mass. An irregularly shaped, low-echoic mass measuring 21 × 18 mm was identified by ultrasound in S6. On computed tomography, the tumor appeared to be growing extrahepatically. After contrast enhancement, the lesion showed persistent peripheral enhancement, while the central part was hypoenhanced. On T2-weighted magnetic resonance imaging (MRI), the central portion of the lesion was hyperintense compared with the periphery. EOB-enhanced MRI revealed the mass to be being hypointense in contrast to the surrounding liver parenchyma in the hepatobiliary phase. On diffusion-weighted images, the lesion was hyperintense. Percutaneous biopsy was not attempted to avoid tumor cell dissemination. The patient underwent partial hepatectomy because of suspected malignancy. Histopathological examination of the resected specimen revealed fibrotic tissue and abundant vessels in the periphery, while a massive infiltration of inflammatory cells and fewer vessels were observed in the center. The patient was finally diagnosed with hepatic IPT of the fibrohistiocytic type.

Expression and characterization of PKL01, an Ndr kinase homolog in Lotus japonicus.

We isolated cDNA clones for novel protein kinases by expression cloning from Lotus japonicus. The LNZ001, one of the isolated clones, encodes a protein of 547 amino acids with a predicted molecular weight of 63,349. Since the protein contains 12 highly conserved subdomains specific to Ser/Thr protein kinases, we designated it PKL01. When homology searches based on the PKL01 sequence were carried out, the protein was found to show sequence homology with nuclear Dbf2-related kinases (Ndr kinases). When PKL01 was produced using an Escherichia coli expression system and purified to homogeneity, it underwent intermolecular autophosphorylation. The major autophosphorylation site was identified as Ser-317 by using various point mutants, and phosphorylation at this site was found to be critical for the kinase activity. PKL01 was found to be widely distributed in the leaves, stems, roots and root nodules by northern hybridization experiments. When endogenous substrates were screened using fractionated preparations from various parts of plants, PKL01 preferentially phosphorylated basic proteins in tissue extracts. These results suggest that PKL01 is an Ndr kinase homolog in L. japonicus and may be involved in the regulation of cellular functions through phosphorylation of basic protein substrates such as histones.