Non-clip laparoscopic colectomy using electrothermal bipolar vessel sealer clinical experiences.

BACKGROUND/AIMS: An electrothermal bipolar vessel sealer (EBVS) has been developed as an alternative to suture vessels, hemostatic clips, staplers and ultrasonic coagulators for ligating vessels and tissue bundles. To leave the artificial material in the abdominal cavity, such as hemostatic clips or staplers, is undesirable because some complications have been reported and their long-term effects are not well known. We have performed laparoscopic colectomy without any metastatic clips using EBVS to divide all vessels. METHODOLOGY: From 2001 through 2002, ten consecutive patients underwent laparoscopic colectomy for colon cancer and ulcerative colitis with non-use of hemostatic clip technique in Kobe University Hospital, Kobe, Japan. RESULTS: All procedures were performed successfully without any kind of trouble. The average blood loss was 103.1 +/- 42.6mL. The average operation time was 234.0 +/- 11.1 min. There were no postoperative complications or death. In addition to the minimal blood loss and procedure time, the merit of EBVS is to leave no artificial material behind in contrast to the application of hemostatic clips or staplers. CONCLUSIONS: The use of EBVS is safe and easy in laparoscopic colectomy. This non-clip technique using EBVS will reduce the opportunity to leave artificial materials in the abdominal cavity.

Molecular analysis for differential diagnosis of small bowel obstruction: expression of proinflammatory cytokines and diamine oxidase activity.

BACKGROUND: A small bowel obstruction is classified as simple (nonstrangulated) or strangulated. The early recognition with correct diagnosis of small bowel obstruction is a critical issue as the release from strangulation requires surgical emergency. METHODS: To evaluate the physiological effect on small bowel obstruction, a metallic ring was put in the small intestine (simple ileus) and a loop obstruction was made with keeping the blood flow (strangulated obstruction). Serum level of cytokines, IL-6, TNF-α, and IL-1ß as well as endotoxin and seromuscular enzymes, CPK and LDH, were serially analyzed. Serum and mucosal DAO activity were also assessed. RESULTS: Endotoxin was increased at 18 h through 48 h in strangulated obstruction, but not detected in the simple ileus. Early proinflammatory cytokines were significantly elevated in strangulated obstruction. High expression of IL-6 prolonged after 12h. Transiently expressed IL-1ß peaked at 12h, TNF-α was increased at 18 h. In simple ileus, these expressions of cytokines were low and slow. LDH and CPK were significantly elevated at 48h, but there were no difference between simple ileus and strangulated obstruction. Serum DAO activity was significantly increased in simple ileus, but gradually decreased in strangulated obstruction, while mucosal DAO activity was decreased in both groups. CONCLUSIONS: High level of serum IL-6 is an early marker for strangulated obstruction. The pattern of serum DAO activity, decrease in strangulated obstruction and increase in simple ileus, might be useful molecular parameter in the early and proper diagnosis of small bowel obstruction.

Identification of hiatal ligament for laparoscopic total mesorectal excision.

Total mesorectal excision (TME) based operation is now established as a standard procedure for patients with lower or middle third rectal cancer. Laparoscopic surgery has a great advantage in colorectal surgery, with good operative views, as well as benefit to the patients owing to less invasiveness, early recovery and shorter hospitalization. From April 2001 through March 2002, we assessed the laparoscopic TME for eight consecutive patients with rectal cancer in Kobe University Hospital (median age: 65.3). The procedure included sharp mesorectal dissection with high vascular ligation and preservation of autonomic pelvic nerves. During the laparoscopic TME, the hiatal ligament that is the sequence of anococcygeal raphe body can be identified with the traction of the rectum upward, and this fixes the posterior wall of the rectum to the levator hiatus. Resection of the hiatal ligament enables us to isolate the recto-anal canal up to the level of the internal anal sphincter. We conclude that identification of the hiatus ligament is essential to achieve the appropriate laparoscopic TME.

Intraoperative continuous external bile drainage during pancreaticoduodenectomy.

PURPOSE: The common hepatic duct is usually divided during the early stage of pancreaticoduodenectomy. However, abrupt, complete, and prolonged closure of the proximal common duct stump can cause liver damage in the course of this long operation, resulting in postoperative liver dysfunction and associated complications. Here, we investigate this phenomenon further. METHODS: We performed intraoperative continuous external bile drainage (IBD) in 43 consecutive patients (drainage group) and compared postoperative liver enzyme levels, morbidity including liver dysfunction, and outcomes with those of a control group (n = 41). RESULTS: There were no complications associated with IBD catheter insertion in this series. The drainage group had significantly lower transaminase levels within the first 7 postoperative days (PODs) than the control group. Postoperative liver dysfunction was confirmed in six patients from the control group and in one patient from the drainage group (P = 0.04). However, there were no significant differences between these two groups in terms of postoperative morbidity (other than liver dysfunction), relaparotomy, and in-hospital mortality rates. CONCLUSION: Intraoperative continuous external bile drainage failed to improve the overall morbidity and mortality rates in this series. However, our findings showed that prolonged intraoperative complete closure of the common hepatic duct contributed to postoperative liver dysfunction in most patients and that IBD, which is easy and safe to perform, could reduce intra-operative liver damage and prevent postoperative liver dysfunction.

Retroperitoneoscopic laparoscopic distal pancreatectomy with spleen salvage.

BACKGROUND/AIMS: Laparoscopic pancreatic surgery has now developed as a clinical practice. In urological surgery, direct extraperitoneal surgery has become popular in laparoscopic adrenalectomy and nephrectomy. As the pancreas is also an organ located in the retroperitoneal cavity, we evaluate the efficacy of retroperitoneoscopic laparoscopic distal pancreatectomy. METHODOLOGY: Specific-pathogen-free Large Yorkshire pigs were studied. No major bleeding episodes were encountered. After carbon dioxide insufflation, the abdominal viscera were inspected with a laparoscope. Below the left costal convexity, the balloon dissector was introduced and the second port was inserted in the retroperitoneal cavity. The scope was inserted using that port and additional two ports were inserted into the retroperitoneal cavity. RESULTS: The tail to body of the pancreas were easily mobilized from the retroperitoneum. The identified splenic artery and vein were carefully isolated from the pancreas. After lap-disk was applied to a 4-cm incision, the tail of the pancreas was pulled out to resect using various devices. The cut surface of the pancreas resected with ultrasonic dissector showed a less damaged area than that with monopolar electrocautery and bipolar electrocautery. CONCLUSIONS: Retroperitoneoscopic laparoscopic distal pancreatectomy is a rational procedure and is safe. As the pancreatic parenchyma has greater water content, the devices of ultrasonic dissector seem to be helpful.

Expression of receptor for advanced glycation end products (RAGE) and MMP-9 in human pancreatic cancer cells.

BACKGROUND/AIMS: Amphoterin is considered as a regulator for the ability of invasion and migration in tumor cells and embryonic neurons through binding to receptor for advanced glycation end products (RAGE), a multiligand cell surface molecule of the immunoglobulin superfamily. As matrix metalloproteinase-9 (MMP-9, gelatinase B) has been reported to play a critical role in tumor progression and metastasis, we have examined the relation of RAGE and MMP in human pancreatic cancer. METHODOLOGY: Three representative human pancreatic carcinoma cells were rendered for the study which show different metastatic potential, PANC-1 and MIA PaCa-2 as the cells with high ability, BxPC-3 as with low. The expression of RAGE was examined by RT-PCR. The expression of MMP-9 protein was examined by Western blotting. RESULTS: RAGE was strongly expressed in MIA PaCa-2 and PANC-1 that have high metastatic ability. On the contrary, RAGE was expressed little in BxPC-3 that has low ability. Similarly, expression of MMP-9 showed almost the same tendency. RAGE and MMP-9 are expressed concordant with the metastatic ability of the human pancreatic cancer cells. CONCLUSIONS: Control of these molecules could be a key to regulating the metastatic ability of pancreatic cancer and this may be exploited in targeted therapy of this cancer.

Tape ligature of cystic duct and fundus-down approach for safety laparoscopic cholecystectomy: outcome of 500 patients.

It is important to identify the structure of Calot's triangle at the time of cystic duct isolation to decrease intraoperative bile duct injury. Isolation of the cystic duct is the first dangerous technique in laparoscopic cholecystectomy. In conventional open cholecystectomy, the fundus-down approach (retrograde) is a more common procedure than the approach in the reverse direction. Similarly, the fundus-down approach is safe and has benefits of reducing common bile duct injury. We report the easy and safe contrivance for laparoscopic cholecystectomy with taping of the cystic duct followed by resection of the gallbladder with the fundus-down approach, performed for 500 patients. The identified cystic duct was ligatured temporarily with Teflon tape. Then, fundus of the gallbladder was isolated with the fundus-down approach except for Calot's triangle. The tape was used for pulling down the cystic duct and Calot's triangle was easily visible. The cystic duct was cut off only after the confirmation of no bile duct injury. Thanks to this tape procedure, there was no bile duct injury in our 500 cases. We recommend this tape ligature of the cystic duct with the fundus-down approach to decrease the incidence of common bile duct injury.

Lymphadenectomy along the middle colic artery in laparoscopic resection of transverse colon.

BACKGROUND/AIMS: Although laparoscopic-assisted colectomy has been replacing open colectomy, dissection of lymph nodes along the main artery is sometimes difficult and dangerous in laparoscopic-assisted colectomy, especially, lymph nodes at the origin of the middle colic artery in laparoscopic resection of the transverse colon. METHODOLOGY: After the isolation of colon, meso-colon in both ends was excised. Then, the colon was rotated clockwise 90 degrees by centering at the base of the meso-colon. This procedure made it easier to isolate the anterior and posterior leaf of the meso-colon at its base. The middle colic artery was divided at the root with the dissection of lymph nodes around the base of the meso-colon. RESULTS: Successful lymphadenectomy of the lymph node along the origin of the middle colic artery was performed. Twelve patients with early transverse colon cancer underwent laparoscopic transverse colon resection using this method. CONCLUSIONS: This method may contribute to the easy and safe laparoscopic transverse colectomy by improving the limited view of the laparoscope and raises the possibility for laparoscopic resection of advanced colon cancer.

A novel technique of finger-assisted laparoscopic surgery.

BACKGROUND: Although advanced and complex laparoscopic procedures are now being performed, tactile sensation is limited with available laparoscopic instrumentation. For immediate hemostasis, it sometimes is necessary to convert laparoscopic into open surgery. METHODS: We improved the procedure with the aid of an abdominal wall sealing device, a Lap protector, and a surgical grove. With this simple apparatus, we can easily switch from laparoscopic to open surgery and vice versa. RESULTS: Only 4 cm of skin incision was made. The operator can use his or her finger and most of the usual surgical instruments during the laparoscopic surgery. CONCLUSIONS: Finger-assisted laparoscopic surgery is affordable to perform the advanced laparoscopic procedure. This new technique made laparoscopic abdominal surgery easier and safer for beginners in laparoscopic surgery and skilled surgeons in open surgery. For the experts, this technique set up the safety door for the emergency in laparoscopic surgery.

Brain death-induced expression of ICAM-1 and VCAM-1 on rat hepatocytes.

BACKGROUND/AIMS: Brain death is a significant risk factor for donor organs used for transplantation. Adhesion molecules, ICAM-1 and VCAM-1 are induced in the liver of brain-dead patients, which have important roles in allograft rejection. However, the role of these molecules on hepatocytes has not been investigated. To investigate morphological changes and expression of ICAM-1 and VCAM-1 on hepatocytes, we employed a standardized rat model of brain death. METHODOLOGY: Isolated hepatocytes were examined by histology and immunohistology. RESULTS: The hepatocytes of brain-dead rats were less stained with eosin indicating the decreased permeability and impaired integrity of the cell membranes. Immunohistologically, expression of ICAM-1 was weak on hepatocytes of normal rats, and clearly enhanced and after brain death. Similarly, expression of VCAM-1 was not identified in the normal, but strongly induced after brain death. CONCLUSIONS: These findings indicate the increased immunogenicity of donor hepatocytes after brain death. Immunomodulation before engraftment of cellular grafts to diminish or decrease the immunogenicity may result in better outcome of hepatocytes from brain-dead donor.

Expression of receptor for advanced glycation end products (RAGE) in human biliary cancer cells.

BACKGROUND/AIMS: Amphoterin is considered as a regulator for the ability of invasion and migration in tumor cells and embryonic neurons through binding to RAGE (receptor for advanced glycation end products), a mult-iligand cell surface molecule of the immunoglobulin superfamily. METHODOLOGY: To see the involvement of RAGE in biliary cancer, three representative human biliary cancer cells (SK-ChA-1, TGBC-1 and NOZC-1) were rendered for the study. Cell invasion ability was determined using Matrigel invasion assay. The expression of RAGE protein was studied by Western blotting. RESULTS: Cell invasion assay through Matrigel showed high invasion potential in SK-ChA-1 and NOZC-1 (40.3 +/- 3.27, 48.7 +/- 4.8); low invasion potential in TGBC-1 (25.7 +/- 2.8). RAGE was strongly expressed in SK-ChA-1 and NOZC-1 that have high invasion ability. On the contrary, RAGE was faintly expressed in TGBC-1 that has low ability. CONCLUSIONS: RAGE is expressed in concordance to the invasion ability of the human biliary cancer cells. Control of this molecule could be a key to regulate the invasion ability of biliary cancers.

Apoptosis in Helicobacter pylori gastritis and residual gastritis after distal gastrectomy.

BACKGROUND/AIMS: Active gastritis, accelerated cell turnover followed by apoptosis, DNA damage and hyperplasia are often seen in the anastomosis area after gastrectomy. Recently, it has been reported that H. pylori induces apoptosis on gastric cells. Until now, the surgical effect itself and H. pylori infection have not been well differentiated as causes of apoptosis associated with gastritis. Our aim is to clarify the relationship of residual gastritis after gastrectomy and H. pylori gastritis. METHODOLOGY: Residual gastritis model using the Mongolian gerbil has been established with microsurgical technique. Residual gastritis with and without H. pylori infection was studied by histopathological examination and quantitated by Rauws' score. Elevation of pH in gastric juice after surgery was confirmed. Stimulation of downstream events leading to apoptosis, cleavage of poly-ADP-ribose polymerase as a result of activation of caspase-3, was evaluated using Western blotting. RESULTS: Histopathologically, H. pylori infection led to deterioration after surgery. The postoperative Rauws' score with infection was higher than without infection. Cleavage of poly-ADP-ribose polymerase was increased after surgery in gerbils with and without H. pylori infection. Densitometric study showed a greater increase in the animals with H. pylori infection than those without infection that was enhanced after surgery (0.59 vs. 1.04, 0.73 vs. 1.17, respectively). CONCLUSIONS: Apoptosis is increased both in residual gastritis and H. pylori gastritis. Both enterogastric reflux and H. pylori infection may be linked to tumorigenesis in anastomosis sites followed by accelerated epithelial cell turnover followed by apoptosis.

Laparoscopy-assisted colon resection for mucosa-associated lymphoid tissue (MALT) lymphoma in the cecum.

Colonic MALToma (mucosa-associated lymphoid tissue lymphoma) has not been well investigated compared to stomach MALToma which is related to Helicobacter pylori infection. We report the uncommon case of MALToma in the cecum initially identified as submucosal tumor, successfully treated by laparoscopy-assisted resection with systemic lymphadectomy. As the metastatic ability and sensitivity against chemotherapy of colonic MALToma is not known, temporally, this treatment seems to be the best choice.

Genetic analysis of cancer occurring in the ileocecal valve.

The ileocecal valve consists of an upper and lower segment formed by a duplication of the wall of the small and large bowels. The origin of tumor that occurs in the ileocecal valve is often difficult to prove. The tumor in the ileocecal valve was found with endoscopic examination in a 74-year-old man. The resected specimen of the tumor was genetically studied by using PCR-SSCP (polymerase chain reaction amplification, single strand conformational polymorphism) analysis to determine the origin and direction of the tumor. PCR-SSCP analysis of p53 showed a mutation of exon 8 only in the ileum side of the tumor. This suggests that the tumor has grown towards the ileum. The cancer in the ileocecal valve is derived from the colonic part of the valve which acquired the additional genetic change of p53 mutation.

Activation of macrophage-associated molecules after brain death in islets.

Islet transplantation is now established as an optional treatment for type I diabetes. However, rates of insulin independence in islet transplant recipients are still low. Although the major source of allograft is derived from brain-dead patient, the nonphysiologic state of brain death (BD) deteriorates organs such as liver and kidney. To determine the effects of BD on islets, a rodent model of BD has been used. Histologically, islets of BD rats showed decreased permeability and impaired integrity of the cell membranes. Flow cytometric analysis showed that CD11b/c-positive cells within islets were slightly increased in BD. This result suggests that BD induces macrophage infiltration into the islets. Moreover, RT-PCR revealed significant augmentation of macrophages-associated inflammatory molecules (IL-1beta, IL-6, TNF-alpha, and MCP-1) in islets from a BD donor. Inducible nitric oxide synthase (iNOS) was weakly expressed, although not reaching statistical significance compared with control. Our results indicate that islets from a BD donor are immunologically activated and have a potential risk factor for early graft loss and a poor long-term function of grafts in clinical setting of islet transplantation. Immunomodulation, to eliminate intraislet immunocytes and/or activated macro phage-associated molecules, might be necessary for the better outcome after islet graft from BD donors.

Expression of cyclooxygenases in Helicobacter pylori gastritis and residual gastritis after distal gastrectomy.

It has long been thought that duodenal reflux induces residual gastritis after distal gastrectomy. H. pylori infection appears to be another factor in residual gastritis; and H. pylori induced gastritis may exist preoperatively or may have been introduced postoperatively. Up until now, the surgical effect itself and H. pylori infection have not been well differentiated as causes of residual gastritis. Our aim in this study was to clarify the relationship between the surgical effect and H. pylori infection in residual gastritis. A residual gastritis model using the Mongolian gerbil has been established with microsurgical technique. Residual gastritis with and without H. pylori infection has been studied by histopathological examination and quantitated by Rauws' score. The expression of cyclooxygenase (both COX-1 and COX-2) has also been examined immunohistologically. Elevation of pH in gastric juice after surgery was confirmed. H. pylori infection led to deterioration after surgery. The postoperative Rauws' score with infection is higher than without infection. Levels of COX-1 were higher after surgery in both animals. COX-2 was not expressed in the animals without infection and only a little was expressed in the animals with infection. COX-2 was strongly expressed in the operated animals with infection, but the surgical effect was minute in the animals without infection. Residual gastritis consisted of both surgical gastritis and H. pylori gastritis. H. pylori gastritis is curable with eradication of the organism, but surgical gastritis is not. The COX inhibitor can be a good candidate in preventing residual gastritis after eradication of the H. pylori organism. The clinical implications of COX expression for patients with residual gastritis might deserve further study in the point of treatment of surgical and H. pylori gastritis.

Factors influencing hepaticojejunostomy leak following pancreaticoduodenal resection; importance of anastomotic leak test.

BACKGROUND/AIMS: Pancreatic fistula is a common complication after pancreaticoduodenostomy. Prevention of a concomitant bile leak from hepaticojejunostomy is important because it could lead to more serious complications including intraperitoneal abscess, subsequent sepsis and massive hemorrhage by activating pancreatic fistula. This study was designed to determine perioperative risk factors of the hepaticojejunostomy leak for the purpose of decreasing this morbidity. METHODOLOGY: Clinical records of 107 consecutive pancreaticoduodenal resections were reviewed. hepaticojejunostomy anastomoses were performed using absorbable sutures in an end-to-side, single-layer and interrupted fashion. A total of 8 presumed perioperative risk factors were analyzed. They included advanced age, low serum albumin, low serum total cholesterol, impaired glucose tolerance and placement of a biliary drainage catheter as preoperative factors, and dilated common hepatic duct and undone anastomotic leak test as intraoperative factors. In addition, transanastomotic stenting techniques including retrograde transhepatic bile drainage, T-tube and transjejunal drainage were compared with respect to hepaticojejunostomy leak rates. RESULTS: Hepaticojejunostomy leak was demonstrated in 9 patients (8%). Anastomotic leak testing only achieved statistical significance (p = 0.04). It is noteworthy that no hepaticojejunostomy leak developed among 28 patients who underwent this test through a retrograde transhepatic bile drainage catheter. In addition, the frequency of bile leaks (14/107) associated with the transanastomotic stenting techniques urged the necessity of appropriate intraperitoneal drain placement. CONCLUSIONS: Careful anastomotic procedures with a subsequent anastomotic leak test most effectively prevent hepaticojejunostomy leak after pancreaticoduodenal resection.

Does radical resection improve the survival in patients with carcinoma of the gallbladder who are 75 years old and older?

Radical resections have been reported to improve the surgical outcome for patients with carcinoma of the gallbladder. In recent years surgeons have had more opportunities to operate on elderly patients. We investigated whether the survival rate of aged patients who had radical resections were better than rates for those who had simple cholecystectomy. Of the 300 patients treated for carcinoma of the gallbladder between 1971 and 1999, 206 resected cases (except pancreaticoduodenectomy and hepatectomy) were divided into two groups: age 75 years or older, 54 patients (the older group), and age less than 75 years, 152 patients (the younger group). Clinical features and progression of the carcinomas did not differ between the two groups. In the older group, 22 patients (40.7%) had simple cholecystectomy, 32 (59.3%) had radical resections; in the younger group, 65 patients (42.8%) had simple cholecystectomy, and 87 (57.3%) had radical resection. None of the older patients who had radical resection died postoperatively. Postoperative survival was not different between the two groups. In the older group the 5-year survival rate for patients who had radical resections was better (60.9%) than the rate for those who had simple cholecystectomy (14.1%) (p = 0.0098). Radical resection is effective for the aged patients with the carcinoma of gallbladder.

Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size.

HYPOTHESIS: Selection of proper pancreaticojejunostomy techniques according to pancreatic texture and the main duct size reduces the pancreatic fistula rate. DESIGN AND PATIENTS: Data from 50 consecutive patients undergoing pancreatoduodenectomy with 3 different anastomotic techniques prospectively used according to pancreatic texture and the main duct size were analyzed. Duct-invagination anastomosis was selected for pancreata with a small duct (n = 34 [29 with a soft texture and 5 with a hard texture]). Stitches between the stump parenchyma and the jejunal seromuscular layer were added to this anastomosis procedure only for the hard pancreata. Pancreata with a large duct were reconstructed with a conventional duct-to-mucosa anastomosis (n = 16). SETTING: A university hospital department of digestive surgery. RESULTS: The morbidity was 40% (20 of 50 patients) in this series. Four patients (8%) with a soft pancreas and a small duct developed a pancreatic stump leak after duct-invagination anastomosis, but all of them were removed without sequelae. No pancreatic anastomotic leak was seen in this series, which resulted in no mortality, no remnant pancreatectomy, and only 1 relaparotomy in the consecutive 50 patients. CONCLUSION: The proper selection of pancreatic reconstruction techniques according to our criteria may reduce the pancreatic fistula rate, eliminate risky pancreatic anastomotic leaks, and result in excellent outcomes for those undergoing pancreatoduodenectomy.

Suppressive effects of tea polyphenol and conformational changes with receptor for advanced glycation end products (RAGE) expression in human hepatoma cells.

BACKGROUND/AIMS: It is reported that polyphenol is associated with low risk of hepatoma and that RAGE (receptor for advanced glycation end products) is important for cancer invasion. METHODOLOGY: Effects of teapolyphenol, EGCG (epigallocatechin-3-gallate) were studied. Proliferation of on human hepatoma cells, HLF, was measured with the use of WST-1 colorimetric assay. Cell invasion was analyzed by the Matrigel invasion assay. Morphology and immunohistological staining of expression of RAGE were also performed. RESULTS: Proliferation was inhibited with the addition of EGCG in a dose-dependent manner. EGCG (200 mumol/L) produced a profound growth suppression of HLF cells (24.5%). Cell invasion was also inhibited with preincubation of 100 mumol/L of EGCG (10.2%). In addition to the antitumor effects, neurite-like conformational changes of HLF cells were observed. Addition of EGCG (100 mumol/L) showed the expression of RAGE on cell surface in accordance to the morphological changes. CONCLUSIONS: The pathway associated to cell movement might be activated with RAGE expression. Although EGCG inhibits the growth and invasion, the cells which expressed RAGE seem to survive. Thus, the enrollment of RAGE should be analyzed to clarify the mechanisms of cancer resistance.