The use of ultrasound in central vascular ligation during laparoscopic right-sided colon cancer surgery: technical notes

BACKGROUND

Complete mesocolic excision (CME) with central vascular ligation (CVL) requires the surgeon to sharply dissect the mesocolon and approach the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) for ligation of the supplying vessels relating to right-sided colon cancer at their origin. Even with preoperative images, it can still be challenging to identify these structures during laparoscopic surgery because of various intraoperative conditions. The aim of this study was to assess the efficacy of intraoperative ultrasound (IOUS) for identification of blood vessels during right-sided colon cancer surgery.

METHODS

We performed IOUS on 19 patients diagnosed with right-sided colon cancer at our institution, in January-October 2020. Preoperatively, a three-dimensional computed tomography (3D-CT) angiogram was obtained for the majority of patients to visualize the SMA, SMV, and their respective branches. The running position of the ileocolic artery (ICA) and right colic artery (RCA) related to the SMV and the presence of the middle colic artery were identified and compared using preoperative 3D-CT, IOUS, and intraoperative findings.

RESULTS

Nineteen patients [seven men and 12 women with a mean age of 73.9 ± 8.4 years (range 58-82 years)] were studied, including some with a body mass index of > 30 kg/m², locally advanced cancer, and severe adhesion. There were IOUSs that detected the SMA, SMV, and their tributaries in all patients. The positional relationships between the SMV and the ICA and RCA revealed by IOUS were consistent with the preoperative and intraoperative findings.

CONCLUSION

IOUS is a safe, feasible, and reproducible technique that can assist in detecting the branching of the SMA and SMV during CME with CVL in laparoscopic right-sided colon cancer surgery, regardless of individual conditions.

[Surgery for aortic valvular disease with congenital quadricuspid aortic valve]

A case of quadricuspid aortic valve is reported. A 69-year-old man was hospitalized with chest oppression at rest and abnormal electrocardiogram and diagnosed aortic regurgitation by echocardiography and aortic angiography. Aortic regurgitation was grade III according to Seller. Aortic valve replacement was performed successfully with a 21 mm St. Jude Medical valve. The aortic valve showed four cusps consisting of two equal larger cusps and two equal smaller cusps which was type C according to Hurwitz. Each valve was thickened and adhered, and fenestrations were found at each commissure. The right coronary ostium was small but not displaced. Twenty five cases in literature which were corrected surgically are also reviewed. Quadricuspid aortic valve is a rare anomaly but must be considered as a malformation which leads to severe valve failure in later life.

[Reconstructive surgery for acquired mitral regurgitation]

Between December, 1967, and July, 1994, 96 patients underwent repair of the mitral valve for acquired mitral valve regurgitation. According to Carpentier's classification, mitral valve pathology resulting in valve regurgitation was classified into three types; 4 patients assigned to type I, 63 type II, and 29 type III. The operative mortality rate was 1.0%. Follow-up data were available in 95 patients from 0.5 year to 25.3 years (mean average 8.8 years). The late mortality rate were not different between patients with valve pathology of type I, II and those with valve pathology of type III. Thromboembolism occurred on three patients for an embolic rate of 0.4% per patient-years. Twenty-eight patients required reoperation for residual MR and dehiscence of suture lines (type II; 10 cases, reoperation-free rate at 20 years, 83.2%) or recurrent MR due to progression of valve deformity (type III, 18 cases, reoperation-free rate at 20 years, 14.8%). These results demonstrate that patients with type I and II valve are good candidates for MVP, and that high incidence of reoperation for recurrent MR may limit the application of MVP to selected patients with type III valve.

Changes in the mononuclear cell subpopulations of rat cardiac transplant recipients administered FK506 for the treatment of ongoing rejection

The inhibitory effect of ongoing rejection and the changes that occurred in mononuclear cell subpopulations were compared between four groups of rats treated with FK506 or steroids. Group 1 was given no immunosuppressive drugs, group 2 was given FK506 from the day of grafting, group 3 was commenced on FK506 on the 4th day after grafting, and group 4 was commenced on methylprednisolone (MP) on the 4th day after grafting. The graft survival times in groups 2 and 3 were significantly longer than those in groups 1 and 4, and there were fewer CD3+ and CD4+ T lymphocytes in the peripheral blood in the groups treated with immunosuppressive drugs than in group 1. In group 4, the levels in both the peripheral blood and thymus were significantly lower than those in the groups treated with FK506 despite the fact that graft rejection occurred soon after the discontinuation of steroid administration. Moreover, the levels of interleukin-2 receptors and macrophages in groups 2, 3, and 4 were significantly lower than that in group 1 postoperatively; however, the number of macrophages in groups 2 and 3 was significantly lower than that in group 4 on the 10th day after transplantation. The findings of this study demonstrated that FK506, even if administered after rejection has begun, might inhibit the subsequent extensive allograft rejection more specifically and effectively than steroids, and that the measurement of a marker for macrophages in the peripheral blood could be useful for the detection of rejection following allograft transplantation in rats.

Effect of dose of cyclosporine or FK506 and antithrombotic agents on cardiac allograft vascular disease in heterotopically transplanted hearts in rats

BACKGROUND

We compared the severity of cardiac allograft vascular disease in rats treated with cyclosporine or FK506 and studied the effect of antithrombotic agents on cardiac allograft vascular disease.

METHODS

One group each was treated with 2 and 5 mg/kg/day of cyclosporine. Two other groups were injected with heparin and dipyridamole, respectively, in addition to cyclosporine. Four other groups were similarly divided by dose of FK506 (0.1 or 0.25 mg/kg/day) and concomitant anticoagulant treatment.

RESULTS

Grade of rejection and percentage stenosis of coronary arteries were lower in groups with high doses of immunosuppressive agents or with heparin. Major histocompatibility class II antigens were expressed by the endothelium of grafted hearts, and IgM and C3 were deposited in the intimal and medial layers in all groups except those administered the higher doses of immunosuppressive drugs. However, no remarkable differences in density of major histocompatibility class II antigens were found between groups demonstrating expression of these antigens. On the other hand, the intensity of IgM or C3 expression grew significantly as coronary stenosis increased in severity.

CONCLUSIONS

A significant difference in severity of cardiac allograft vascular disease was not found between the groups treated with cyclosporine and FK506, and cardiac allograft vascular disease was almost entirely suppressed when doses of cyclosporine and FK506 sufficient to suppress graft rejection were administered. Our findings also showed that concomitant heparin administration reduced the extent of allograft rejection and the incidence of cardiac allograft vascular disease.