Computed tomography virtual endoscopy with angiographic imaging for the treatment of type IV-A choledochal cyst.

Type IV-A choledochal cysts (CCs) are a congenital biliary anomaly which involve dilatation of the extrahepatic and intrahepatic bile ducts. We present the case of a 30-year-old woman with type IV-A CC, on whom three-dimensional computed tomography (3D CT) and virtual endoscopy were performed. 3D CT revealed partial dilatation in the posterior branch of the intrahepatic bile duct and a relative stricture between it and the extrahepatic bile duct. Virtual endoscopy showed that this stricture was membrane-like and separated from the surrounding blood vessels. Based on these image findings, complete cyst resection, bile duct plasty for the stricture, and hepaticojejunostomy were safely performed. To the best of our knowledge, there are no reports of imaging by virtual endoscopy of the biliary tract which show the surrounding blood vessels running along the bile duct.

Reconsideration of laparoscopic cholecystectomy.

We describe the surgical method of cases showing a distended gallbladder. Because the most important thing does not cause biliary tract injury, it is to find orientation carefully. The frequency of incidental gallbladder cancer was in 7 (0.7%) of the 983. Only cholecystectomy is necessary to be performed for Tis or T1 cancer, and surgery has to be changed to radical surgery for T2 cancer or deeper invasion. Laparoscopic cholecystectomy is already an established standard operation. In the presence of acute or severe chronic inflammation, special attention should be paid to these points.

Chemoprevention of chemically-induced biliary carcinogenesis in hamsters by vitamin K2.

BACKGROUND/AIMS: Pancreaticobiliary maljunction (PBM) is a high risk factor of biliary tract cancer. The chemopreventive effects of Vitamin K2 (menaquinone-4: MK4) in a hamster PBM model were investigated. METHODOLOGY: The extrahepatic bile duct at the distal end of the common duct was ligated and cholecystoduodenostomy was performed (Group I). The same surgery was performed and from 4 weeks after surgery, 10 mg/kg of N-nitrosobis (2-oxopropyl) amine was subcutaneously injected once a week with a one-week interval (Group II). In addition of Group II, MK4 was orally administered once a day, five times with every week (Group III). The hamsters were sacrificed 20 weeks after surgery and histopathological findings of gallbladder were investigated. RESULTS: Group I showed predominantly proper epithelium without cancer. In Group II, atypical epithelium (AE) was observed in 75% of animals and early cancer was observed in 25%. Group III showed less AE and no cancer. The PCNA labeling index in Group III was statistically significantly lower than in Group II. In addition, no statistically significant differences were noted among the groups in terms of the apoptosis labeling index. CONCLUSIONS: MK4 suppressed biliary carcinogenesis by the induction of cell cycle arrest in a hamster biliary carcinogenetic model.

Ultrasonography-guided hepatic tumor resection using a real-time virtual sonography with indocyanine green navigation (with videos).

PURPOSE: For hepatic tumors that cannot be identified on routine ultrasonography (US), we marked the target area using real-time virtual sonography (RVS) with indocyanine green (ICG)-ethanol (1:100) during surgery, and performed hepatic resection while observing the fluorescence. EXPERIMENT: An ICG-ethanol mixture locally injected into mouse liver was retained in the same area for more than 4 h. The same mixture locally injected into pig liver at a depth of 3 cm could be observed using an infrared camera. CASE: An ICG-ethanol mixture (500 µl) was locally injected under RVS guidance into a metastatic hepatic tumor that was visible only on magnetic resonance imaging (MRI), and hepatic resection was performed while Photodynamic Eye (PDE) images were being observed. The metastatic lesion (3 mm in diameter in a pathological specimen) could be successfully resected. CONCLUSION: This method was useful for resecting US-invisible hepatic tumors.

The VIO soft-coagulation system can prevent pancreatic fistula following pancreatectomy.

BACKGROUND/PURPOSE: The VIO soft-coagulation system (SC) is a new device for tissue coagulation. We hypothesized that this device would be an effective tool for sealing small pancreatic ducts, thus reducing pancreatic fistula following pancreatectomy. METHODS: To confirm whether the SC could be used to seal small pancreatic ducts, we measured the burst pressure in sealed ducts in mongrel dogs. Eight dogs underwent distal pancreatectomy, with the remnant stump coagulated by using the SC. The animals were necropsied on postoperative day 10. In a clinical trial, 11 patients who underwent pancreatoduodenectomy with SC treatment (SC group), and 24 patients who underwent pancreatoduodenectomy without SC treatment (non-SC group) were compared. RESULTS: In the experimental study, the burst-pressure test revealed that the SC had efficiently sealed the small pancreatic ducts. Histological examination revealed completely obstructed pancreatic ductal structures, ranging from large pancreatic ducts (diameter, 500 microm) to microscopic ducts. No pancreatic leakage was observed following distal pancreatectomy without main pancreatic duct (MPD) suturing in dogs that had an MPD diameter of less than 500 microm. In the clinical trial, pancreatic fistula developed in only one patient (9.1%) in the SC group, but a pancreatic fistula developed in five patients (20.8%) in the non-SC group. CONCLUSIONS: This novel technique using the SC is an effective procedure for preventing the development of pancreatic fistula following pancreatectomy.