Laparoscopic cholecystectomy with an ultrasound surgical aspirator.

Laparoscopic cholecystectomy using an ultrasound surgical aspirator has been performed in our department since March 1991. The horn cover was altered in order to be inserted through a trocar 10 mm in diameter. The main purpose of this device is to explore Calot's triangle by fragmentation and aspiration of the fatty tissue without damaging the nerves, vessels, and cystic duct. First the serosa of the Calot's triangle is cut via electrocautery with the sharp-angle hook dissector we designed. Then the cystic duct and cystic artery are efficiently exposed by the ultrasound surgical aspirator. This procedure is perfectly adapted for laparoscopic cholecystectomy. We obtained favorable results with the ultrasound surgical aspirator in 135 cases including 40 cases with a negative gallbladder, as evaluated by endoscopic retrograde cholangiography. In conclusion, the ultrasound surgical aspirator is suitable for skeletonizing the cystic duct and cystic artery, and the procedure is perfectly safe.

Percutaneous stenting for malignant biliary stenosis.

Percutaneous stenting for malignant biliary stenosis is quite beneficial to patients with unresectable or recurrent disease, tremendously improving the quality of their lives. Percutaneous transhepatic biliary drainage (PTBD) was attempted in 92 patients with obstructive jaundice during the period between January 1986 and July 1989. Implantation of an endoprosthesis was performed in 14 cases (15.2%) and succeeded in 12 (85.7%). When a guide wire could not be passed distally across the stricture site, percutaneous transhepatic cholangioscopy (PTCS) through the dilated PTBD fistula was carried out to enable its passage. PTCS is also valuable in the preoperative diagnosis of obstructive jaundice. The patients who are not candidates for surgery are suitable for this procedure. A Miller double-mushroom stent is used as the endoprosthesis in the majority of cases. One patient with recurrent hepatoma has lived at home with this stent for greater than 3 years due to repeated transarterial embolization and chemotherapy and does not need to wash or change the stent.

[Treatment of secondary empyema following lung resection complicated with internal fistula].

To clarify the results of treatment of secondary empyema following lung resection complicated with internal fistula, 81 cases treated at 31 different institutions during the 5 years period from 1983 to 1987 were analysed. 1) All cases of thoracic empyema treated surgically and secondary empyema following lung resection complicated with internal fistula did not decreased during the study period, in spite of the remarkable decrease of surgical cases for pulmonary tuberculosis. 2) The highest rate was observed in males over 50 years of age. 3) Bacteriologically positive case in empyema space was occupied about 70%. 4) 196 operations (including drainage) of 17 types were performed on 81 patients. Only 16% of the cases were successfully treated with one stage of operation. 5) Principal surgical procedure applied in cases under this study was drainage followed by closure of fistula with muscle plombage and with or without thoracoplasty. Case of air plombage and omental pedicle flap plombage have increased recently in Japan. 6) Success rate was 55.6%, failure rate was 32.1% and the mortality was 12.3%. These results indicate the difficulty involved in treatment. Therefore, to avoid occurrence of secondary empyema cases, careful selection of surgical indication, sufficient training in surgical technique and good preoperative and postoperative management are crucial.

[Treatment of thoracic empyema in recent 6 years; analysis of 944 cases in Japan].

944 cases of thoracic empyema were treated surgically in a 6-year period (from 1981 through 1986) in 37 institutions under supervision of Ryoken. Preoperative backgrounds, operative modes and surgical results are evaluated. Preoperative backgrounds are as follows; Acute cases comprised only 5.5% of the total. Primary cases outnumbered postoperative ones, the former occupying 65.8% of the total. Fistulous empyema comprised 68.6% of the total. Extension of the empyema; total empyema 56.0%, partial empyema 44.0%. Concerning respiratory reserve, those with FEV1/VCpr (to be denominated RI) less than 40 comprised 44.3% of the total. As to bacteriological findings; positive 49.9%, negative 40.0%, unknown 10.1%. Surgical modes; Pleuroresection 20.8%, decortication 22.4%, space-reducing 28.6%, air-plombage 9.7%, open drainage 6.8%, closed drainage 4.3%, others 7.4%. Overall results; success 83.8%, unsuccess 11.5%, death 4.7%. Those with positive microorganisms and RI less than 40 fared most poorly; success 73.2%, unsuccess 19.7% death 7.1%. Those with negative microorganisms and RI more than 41 fared most well; success 97.9%, unsuccess 1.5%, death 0.5%. Success rate with regard to surgical modes; air-plombage 95.7%, decortication 95.3% pleuroresection 92.6%, space-reducing 80.0%, closed drainage 68.3%, open drainage 29.7%.

Extraneural metastasis of choriocarcinomatous element in pineal germ-cell tumor. Case report.

A case of pineal germ-cell tumor producing human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) is reported in a 23-year-old man. Extraneural metastasis developed during a course of combined chemotherapy after radiation therapy. Postmortem examination revealed that the metastatic pulmonary tumor was a choriocarcinoma, producing only HCG.

Wilms' tumor with intracranial metastases presenting with intracranial hemorrhage.

Intracranial metastasis of Wilms' tumor is very rare. Furthermore, intracerebral hemorrhage is an unusual presentation of metastases. We report the case of a 4-year-old girl who had multiple intracranial metastatic lesions, initially presenting as an intracranial hemorrhage. Removal of the tumors and hematoma was followed by radiation therapy and chemotherapy. Thereafter, complete remission occurred. It is thought that this malignant tumor with metastases may be curable through combined therapy.

Characteristic findings of metrizamide CT cisternography in epidermoids.

The characteristic findings of metrizamide CT cisternography in two cases of epidermoid are reported. The main finding was a "cauliflower-like" appearance and was thought to be caused by the irregular interstices of epidermoids. Metrizamide CT cisternography may be helpful in making a diagnosis of an epidermoid.