On-Site Monitoring of Postoperative Bile Leakage Using Bilirubin-Inducible Fluorescent Protein.

BACKGROUND: Bile leakage is the most common postoperative complication associated with hepatobiliary and pancreatic surgery. Until now, however, a rapid, accurate diagnostic method for monitoring intraoperative and postoperative bile leakage had not been established. METHOD: Bilirubin levels in drained abdominal fluids collected from 23 patients who had undergone hepatectomy (n = 22) or liver transplantation (n = 1) were measured using a microplate reader with excitation/emission wavelengths of 497/527 nm after applying 5 µM of UnaG to the samples. UnaG was also sprayed directly on hepatic raw surfaces in swine hepatectomy models to identify bile leaks by fluorescence imaging. RESULTS: The bilirubin levels measured by UnaG fluorescence imaging showed favorable correlations with the results of the conventional light-absorptiometric methods (indirect bilirubin: rs = 0.939, p < 0.001; direct bilirubin: rs = 0.929, p < 0.001). Approximate time required for bilirubin measurements with UnaG was 15 min, whereas it took about 40 min with the conventional method at a hospital laboratory. Following administration of UnaG on hepatic surfaces, the fluorescence imaging identified bile leaks not only on the resected specimens but also in the abdominal cavity of the swine hepatectomy models. CONCLUSION: Fluorescence imaging techniques using UnaG may enable real-time identification of bile leaks during hepatectomy and on-site rapid diagnosis of bile leaks after surgery.

Timing for removing prophylactic drains after liver resection: an evaluation of drain removal on the third and first postoperative days.

BACKGROUND: Conventionally, drains are removed from postoperative day (POD) 7 to POD 14 at our institute after hepatectomy (control group). This study was conducted to evaluate the outcomes of drain removal in the early postoperative period. METHODS: Recently, we defined criteria for the early removal of drains: (I) a drain-fluid bilirubin level of below 3 mg/dL; (II) a drain discharge volume of less than 500 mL/day; and (III) no macroscopic signs of bleeding or infection. For patients meeting these criteria, drains were removed on POD 3 between January 2012 and February 2013 (POD 3 group) and on POD 1 between February and December 2013 (POD 1 group). The outcomes of these groups were then retrospectively compared. RESULTS: The median duration of the postoperative hospital stay was shorter in the POD 3 group (11 days) than in the control group (14 days) (P<0.0001). The incidence of drain infection was lower in the POD 3 group (1.2%) than in the control group (5.7%). Meanwhile, the incidences of bile leakage and complications were higher in the POD 1 group than in the POD 3 group. However, the incidences were almost the same when patients whose drains were actually removed on the predefined POD were compared. The intraoperative findings were also considered when removing the drains. CONCLUSIONS: Drain removal on POD 3 may reduce the length of the postoperative hospital stay and the incidence of drain infection without impairing safety. To remove drains safely on POD 1, however, the intraoperative findings should also be considered.

A scoring system based on computed tomography for the correct diagnosis of xanthogranulomatous cholecystitis.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The differential diagnoses of XGC include gallbladder cancer (GBC), adenomyomatosis, and actinomycosis of the gallbladder. PURPOSE: To assess the usefulness of computed tomography (CT) findings in the diagnosis of XGC and differentiation from GBC. MATERIAL AND METHODS: We retrospectively assessed the pathological and radiological records of 13 patients with pathologically proven XGC and 33 patients with GBC. RESULTS: Significant differences were observed for the following five CT findings: diffuse wall thickening (XGC = 85%, GBC = 15%, P < 0.01); absence of polypoid lesions (XGC = 100%, GBC = 48%, P < 0.01); intramural nodules or bands (XGC = 54%, GBC = 9%, P < 0.01); pericholecystic infiltration (XGC = 69%, GBC = 9%, P < 0.01); and pericholecystic abscess (XGC = 23%, GBC = 0%, P = 0.018). We defined the scoring system based on how many of the five CT findings were observed. Our scoring system, which included these findings, revealed that patients with three or more findings had sensitivity of 77% (95% confidence interval [CI] = 57-87) and specificity of 94% (95% CI = 86-98). CONCLUSION: Our scoring system can assist in the differentiation of XGC from GBC.

A case of Lymphoepithelioma-like carcinoma (LELC) developed in the rectum.

Lymphoepithelioma-like carcinoma (LELC) is histologically similar in form to nasopharyngeal carcinoma (NPC) and is an epithelial tumor that is suggested to be involved in infection with Epstein-Barr virus (EBV), but it is rare to occur in the colon. A 35-year-old woman was found to have a rectal wall thickening by follow-up computed tomography (CT) image after sigmoidectomy and left salpingo-oophorectomy. Biopsy under colonoscopy revealed recurrence of ovarian cancer, and she underwent a low anterior resection. Pathological diagnosis was LELC. Although LELC of the stomach has been reported to have a high EBV infection rate as NPC, EBV infection was not detected in our case. Pelvic lymph node dissection was also performed, and metastasis was recognized around the iliac artery. There have been few reports of LELC occurring in the rectum, and there are no reports of distant metastasis only to the pelvic lymph node. We consider it a very valuable case, and report it with literature references.

Techniques of Fluorescence Cholangiography During Laparoscopic Cholecystectomy for Better Delineation of the Bile Duct Anatomy.

To evaluate the clinical and technical factors affecting the ability of fluorescence cholangiography (FC) using indocyanine green (ICG) to delineate the bile duct anatomy during laparoscopic cholecystectomy (LC).Application of FC during LC began after laparoscopic fluorescence imaging systems became commercially available.In 108 patients undergoing LC, FC was performed by preoperative intravenous injection of ICG (2.5  mg) during dissection of Calot's triangle, and clinical factors affecting the ability of FC to delineate the extrahepatic bile ducts were evaluated. Equipment-related factors associated with bile duct detectability were also assessed among 5 laparoscopic systems and 1 open fluorescence imaging system in ex vivo studies.FC delineated the confluence between the cystic duct and common hepatic duct (CyD-CHD) before and after dissection of Calot's triangle in 80 patients (74%) and 99 patients (92%), respectively. The interval between ICG injection and FC before dissection of Calot's triangle was significantly longer in the 80 patients in whom the CyD-CHD confluence was detected by fluorescence imaging before dissection (median, 90  min; range, 15-165  min) than in the remaining 28 patients in whom the confluence was undetectable (median, 47  min; range, 21-205  min; P < 0.01). The signal contrast on the fluorescence images of the bile duct samples was significantly different among the laparoscopic imaging systems and tended to decrease more steeply than those of the open imaging system as the target-laparoscope distance increased and porcine tissues covering the samples became thicker.FC is a simple navigation tool for obtaining a biliary roadmap to reach the "critical view of safety" during LC. Key factors for better bile duct identification by FC are administration of ICG as far in advance as possible before surgery, sufficient extension of connective tissues around the bile ducts, and placement of the tip of laparoscope close and vertically to Calot's triangle.

Mucinous cystadenocarcinoma of the appendix in which contrast-enhanced ultrasonography was useful for assessing blood flow in a focal nodular lesion in the tumor cavity: A case report.

A 63-year-old woman was admitted to hospital with pain in the right lower quadrant. Abdominal computed tomography (CT) revealed a 60-mm cystic mass at a site corresponding to the appendix. The mass wall on the appendicular ostium was thickened and enhanced by contrast, while calcification was observed in the mass wall on the appendicular tip. No projection was observed in the mass cavity. On abdominal ultrasonography (US), the mass wall on the appendicular ostium was thickened and projections were observed at two sites in the mass cavity. On contrast-enhanced US (CEUS), only one of these projections was enhanced. Based on the thickened and contrast-enhanced wall of the mass on the appendicular ostium on CT and US, as well as the contrast enhancement of a projection on US, the mass was diagnosed as mucinous cystadenocarcinoma of the appendix. Ileocecal resection was subsequently performed on day 10. A detailed examination of the surgical specimen revealed carcinoma cells in the mass wall on the appendicular ostium. The contrast-enhanced projection was identified as granulation tissue that had grown to come into contact with the tumor, while the non-contrast-enhanced projection was identified as solidified mucus. US enabled successful visualization of projections in the mass cavity that were not visible on abdominal CT. CEUS also proved useful for assessing blood flow in these projections.

Disease progression from mucosal to mucocutaneous involvement in a patient with desquamative gingivitis associated with pemphigus vulgaris.

BACKGROUND: Pemphigus vulgaris (PV) frequently begins with oral lesions and progresses to skin lesions. A patient is described who developed skin lesions during follow-up and whose only initial symptom was desquamative gingivitis (DG). METHODS: A 31-year-old woman presented with a 2-month history of painful gingiva. The diagnosis of PV was made according to clinical, histopathological, and immunofluorescent criteria. Topical corticosteroid (0.1% triamcinolone acetonide) was provided for the treatment of DG. Evaluation of the circulating autoantibody titers to desmoglein (Dsg)1 and Dsg3 was conducted by enzyme-linked immunosorbent assay (ELISA). RESULTS: The gingival PV lesions went into remission with the use of topical corticosteroid, although the patient experienced occasional recurrent oral lesions that required retreatment. She had regular follow-ups and remained relatively stable for several months. However, relapse and worsening of the oral lesions and the onset of skin lesions occurred after 26 months. Using ELISA, a change in the autoantibody profile corresponding to the transition from mucosal PV to mucocutaneous PV was confirmed. In all ELISA studies conducted throughout the course of the patient's disease, the Dsg3 ELISA was consistently high ranging from 150 to 200. However, the Dsg1 ELISA remained low, ranging from 10 to 30. After 26 months, Dsg3 (index value of 150) and Dsg1 (index value of 114) ELISA levels were elevated, consistent with the transition to mucocutaneous PV. CONCLUSIONS: In cases in which the lesions are limited to the oral cavity, PV sometimes may be managed successfully using only topical corticosteroids. However, it may not be possible to reduce the circulating Dsg autoantibody titers without systemic immunosuppression. The sustained high Dsg3 antibody level may cause "epitope spreading" and induce skin lesions. It may be prudent to determine post-treatment levels of Dsg using ELISA and, in consultation with the physician, recommend the addition of systemic therapy if Dsg3 levels remain elevated.

Clinical and diagnostic features of mucous membrane pemphigoid.

The aim of this study was to characterize the clinical and diagnostic features of mucous membrane pemphigoid (MMP). Five MMP patients were evaluated, and biopsies were obtained for routine histopathology and direct immunofluorescence. Circulating autoantibodies were verified by indirect immunofluorescence. Circulating immunoglobulin G autoantibody specific for 180 kDa bullous pemphigoid antigen (BP180) was evaluated by enzyme-linked immunosorbent assay (ELISA). All 5 patients complained of erythematous gingiva. Two patients had extraoral lesions involving the nasal mucosa, eyes, and skin. Histopathological confirmation was established for 4 of the patients, while direct immunofluorescence findings were positive in all 5. Although circulating autoantibodies were not identified by indirect immunofluorescence, the BP180 ELISA was positive in 3 cases. Both histopathological and direct immunofluorescence examinations are essential to establish a definitive diagnosis. Identification of circulating BP180 specific autoantibody shows promise.

Feasibility of eradication of mutans streptococci from oral cavities.

OBJECTIVES: Dental caries prevention programs using chlorhexidine (CHX) have been proposed, but CHX's effect in reducing levels of mutans streptococci (S. mutans and S. sobrinus) appears to last for only a few months. The aim of this study was to attempt to eradicate mutans streptococci from the oral cavity using intensive professional mechanical tooth cleaning (PMTC) and topical application of CHX in custom-made trays. METHODS: Seven adult dentate subjects participated in this study (mean age 53.7+/-5.6, age range 46 to 62, mean DMFT, 9.1+/-4.2). For each subject, PMTC was carried out eight times within ten days. After each PMTC, 1% CHX was applied twice to the tooth surface using custom-made trays. In addition, as home treatment, subjects were required to carry out tooth brushing three times a day, and apply 0.2% CHX in custom trays after brushing in the morning and evening. In addition, subjects rinsed with 0.2% CHX solution after lunch. Salivary levels of mutans streptococci were evaluated using Dentocult-SM at baseline and on days 9, 20, 70, 120. RESULTS: Mutans streptococci were eradicated by day 120 from 4 of the 7 seven subjects participating in this study. Those 3 subjects still harboring mutans streptococci exhibited deep periodontal pocketing. CONCLUSIONS: Eradication of mutans streptococci from the oral cavity is feasible using a combination of CHX application in custom-made trays and intensive PMTC.