Living related liver transplantation for biliary atresia with portopulmonary hypertension: Case report

Portopulmonary hypertension is a complication of end-stage liver disease that adversely affects the outcome of liver transplantation (LT). We report a case of living related LT who developed severe pulmonary hypertension during and after LT. This 16-year-old girl suffered from biliary atresia, having undergone a portoenterostomy at 60 days of age, at the time of discovery of liver cirrhosis. She had been admitted to a local hospital several times for episodes of esophageal variceal bleeding. Neither dyspnea nor cyanosis was discerned until LT. Although pulmonary hypertension (PH) was disclosed by echocardiogram upon preoperative evaluation, we did not consider this a contraindication for LT, because the PH was mild. She underwent living LT from her father (graft volume/recipient body weight ratio: 0.99%). After induction of anesthesia for LT, a pulmonary flotation catheterization showed severe PH (>40 mm Hg). The pulmonary artery pressure continued to be elevated during surgery, although it was possible that her severe scoliosis affected the data. Hyperbilirubinemia was observed after LT, despite good liver function tests. On postoperative day 12, a portal vein thrombosis was detected requiring emergency thrombectomy and splenectomy. Her general condition worsened after the second surgery. She died due to cardiopulmonary failure. Autopsy showed marked hypertrophy of the right ventricle with intimal thickening in the pulmonary artery. In this case, the underestimated PH might have resulted in the unfortunate outcome. Before LT, PH should be carefully evaluated by measures including invasive assessment.

Results of kidney transplantation in patients receiving MMF- or MMF and basiliximab-containing immunosuppression

Mycophenolate mofetil (MMF) is a more potent immunosuppressive drug than azathioprine or mizoribine in combination with cyclosporine (CsA) and steroids. Recently, basiliximab (BA), an interleukin-2 receptor antagonist, has become available in Japan. The purpose of this study was to evaluate the efficacy of an extremely low CsA dose immunosuppressive protocol with MMF versus MMF plus BA after renal transplantation (RTx).

PATIENTS

Between September 2001 and March 2003, we performed 79 RTx with CsA-based immunosuppression, including nine from cadavers and 70 from living donors with 15 ABO-incompatible RTx. Immunosuppression consisted of methylprednisolone (MP), CsA and MMF (group 1; n = 24) versus added BA during the induction phase (group 2; n = 55). In group 2, MP was withdrawn on postoperative day 14. Supplementary MP, muromonab-CD3, or gusperimus was administered if rejection was suspected clinically or diagnosed by biopsy.

RESULTS

The incidence of biopsy-proven acute rejection (AR) was significantly higher among group 1 than group 2 patients (P < .05). CsA C2 levels in group 1 were significantly higher than group 2 at each time (P < .01). The incidence of infection was comparable. Patient and graft survival rates in group 1 were 100% and 100%; in group 2, they were 98% and 98%, respectively.

CONCLUSION

The short-term results of RTx were favorable in both the MMF, and the MMF plus BA immunosuppression. In addition, BA significantly reduced the number of AR episodes. Early steroid withdrawal in recipients receiving BA induction was not associated with an increased risk of AR.

Hand-assisted laparoscopic live donor nephrectomy: Report of 100 cases

INTRODUCTION

Laparoscopic live donor nephrectomy is not yet widespread in Japan. After our first hand-assisted laparoscopic live donor nephrectomy (HALapNx) in 2001, we report our 100 cases and examine the possibility of making this technique widely available in Japan.

METHODS

HALapNx was performed in 100 cases (44 males and 56 females) from February 2001 through July 2003. The operative procedure for HALapNx was briefly described here. First, 2 12-mm ports were placed in the midaxillary line at the superior and inferior level of the umbilicus. Next, a 5-cm incision was made in the midline periumbilicus and the hand port system was fitted through the abdominal incision. After 10 mm Hg pneumoperitoneum, HALapNx begins with mobilization of the left colon.

RESULTS

HALapNx was completed successfully in all cases and no patients required conversion to laparotomy. The estimated blood loss was 33.5 +/- 40.3 g and no patient required blood transfusion. The mean operative time was 168.8 +/- 47.6 minutes, and there was no major complication in a donor.

CONCLUSIONS

HALapNx is technically feasible and may offer several advantages over open donor nephrectomy in terms of less blood loss, less postoperative pain, and minimal cosmetic disfigurement. In Japan, laparoscopic donor nephrectomy is not yet widespread, possibly due to the need for surgical laparoscopic skills. We believe that the best way to make laparoscopic donor naphrectomy widely available is through hand-assisted laparoscopic surgery.

[2.2](2,7)-Fluorenophanediene, [2.2.2](2,7)-fluorenophanetriene, and their fluorenide ions

The McMurry coupling of 2,7-diformylfluorene affords a dimer, anti-[2.2](2,7)-fluorenophanediene, and a trimer, [2.2.2](2,7)-fluorenophanetriene, as cyclic oligomers. X-Ray crystallography of the dimer establishes its strained, layered structure with anti-conformation. While the fluorenyl groups of the dimer do not show any sign of rotation in the variable temperature 1H NMR spectra up to 120 degrees C, those of the trimer are fast rotating even at -50 degrees C. Treatment of the dimer and trimer with KH in DMSO furnished the respective dianion and trianion that are stable at room temperature in the solutions. While the trianion shows substantial conjugation through the etheno bridges, the dianion shows little conjugation through the etheno bridges and almost no proton-deuterium exchange of the fluorenyl C9-H with the solvent DMSO-d6 probably due to stereospecific protonation-deprotonation associated with the tightly layered structure.

Possible harmful effects on central nervous system cells in the use of physiological saline as an irrigant during neurosurgical procedures

BACKGROUND

Physiologic saline is routinely used as an irrigant in neurosurgery especially in Japan. Cerebrospinal fluid (CSF) differs from physiologic saline in its concentration of inorganic salts, osmolality, and pH and is completely different insofar as it contains glucose, protein, cholesterol, and other lipids. The present study was designed to compare the possible functional and morphologic deleterious influence of these differences on cultured rat neural cells using saline (S), Ringer's solution with glucose (Lactec G, LG; Otsuka Pharmaceutical Co.; Tokyo, Japan) and without glucose (Lactec, L; Otsuka Pharmaceutical Co.), and an artificial CSF (ACSF).

METHODS

Primary cultured rat neurons and astrocytes were divided into five groups according to the medium used, the four experimental groups (ACSF, L, LG, and S) and one control group (C). At various time points up to 24 hours, the rhodamine 123 uptake by neuronal or astrocytic cellular mitochondria was evaluated as cell function assessment. Morphologic assessment for both neuron and astrocyte culture was carried out with scanning electron microscopy (SEM) at the 24-hour time point.

RESULTS

SEM showed little difference between the C and ACSF groups, whereas morphologic deterioration was particularly severe in the S group for both neurons and astrocytes. In the case of neuronal mitochondrial activity, the L and S groups demonstrated respectively severe and some deterioration, particularly in the mitochondria of the neuronal processes. The deleterious effects in mitochondrial activity of the S group were even more apparent in the astrocytic cells.

CONCLUSION

These results suggest that physiologic saline, when used as an irrigant in neurologic surgery, might in some circumstances cause damage to exposed and compromised neural cells.

Granulocyte colony-stimulating factor synergistically augments 1,25-dihydroxyvitamin D3-induced monocytic differentiation in murine bone marrow cell cultures

In a series of studies, we have reported that 1,25-dihydroxyvitamin D (3), a known stimulator of monocytic differentiation, primes bone marrow progenitor cells or promyelocytic HL-60 cells to the actions of several factors involved in both monocytic and granulocytic differentiation. In the present study, we have further examined the combinational effects of 1,25-dihydroxyvitamin D (3) and the other inducer of granulopoiesis, granulocyte colony-stimulating factor, on non-fractionated native murine bone-marrow cell culture. Over 6 days of treatment, human granulocyte colony-stimulating factor sustained cell viability, increased the size of small rounded non-adherent cells, and induced granulocytic differentiation, while 1,25-dihydroxyvitamin D (3) decreased cell viability, promoted the development of large adherent flattened cells, and upregulated some monocytic differentiation markers. Combining these two factors over 6 days synergistically upregulated phagocyte activity, membrane-bound interleukin-1alpha, NAD(P)H oxidase, monocytic Mac-1, and non-specific esterase. Similar effects were observed in successive treatment with granulocyte colony-stimulating factor followed by 1,25-dihydroxyvitamin D (3), but successive treatment in reverse order was somewhat less effective. No combinational treatment upregulated granulocytic lactate dehydrogenase, Gr-1, or chloroacetate esterase to as great an extent as was obtained with granulocyte colony-stimulating factor alone, indicating that granulocytic differentiation is attenuated by addition of 1,25-dihydroxyvitamin D (3). Therefore, in contrast to our previous data, the present findings suggest that granulocyte colony-stimulating factor synergistically augments 1,25-dihydroxyvitamin D (3)-induced monocytic differentiation in our murine bone-marrow cell cultures. Considering previously published data, we also suggest that these synergistic effects may be mainly due to the combination of two distinct effects such as the primary proliferative effects of granulocyte colony-stimulating factor on multipotent stem cells and the subsequent differentiative effects of 1,25-dihydroxyvitamin D (3) on proliferating cells.

Abducens schwannoma inside the cavernous sinus proper: case report

BACKGROUND

Only 2 cases of abducens nerve schwannoma solely inside the cavernous sinus have been reported. In both cases, abducens nerve palsy remained after operation. We report the first case of abducens nerve schwannoma inside the cavernous sinus proper with postoperative recovery from abducens nerve palsy.

CASE DESCRIPTION

The patient was a 47-year-old female who developed left abducens and trigeminal nerve palsies. Neuroradiological examination revealed left intra-cavernous sinus tumor. Total removal of the tumor was performed. The location of the tumor was confirmed intraoperatively inside the cavernous sinus itself, with no relation to the trigeminal nerve. Further, the relation of the tumor to one particular nerve fiber within the abducens nerve bundle was confirmed inside the cavernous sinus. After surgery, the patient had transient abducens nerve palsy. It had totally disappeared by 6 months.

CONCLUSION

When the tumor origin is just within the spacious cavernous sinus rather than more posterior in the narrow dural tunnel of Dorello's canal, successful preservation of the nerve function is possible postoperatively through a thorough knowledge of the membranous anatomy and careful preoperative study of the radiographic findings.

Spinal accessory schwannoma mimicking a tumor of the fourth ventricle: case report

OBJECTIVE AND IMPORTANCE

Spinal accessory schwannomas unassociated with neurofibromatosis are very rare, and only 30 cases have been reported in the literature. To our knowledge, this is the first report of a spinal accessory schwannoma mimicking a tumor of the fourth ventricle.

CLINICAL PRESENTATION

A 50-year-old man presented with neck pain after being involved in a motor vehicle accident. There were no neurological deficits, but a computed tomographic scan revealed a large hypodense mass with punctuate calcifications in the fourth ventricle. The tumor exhibited low intensity on the T1-weighted magnetic resonance imaging scan and high intensity on the T2-weighted scan, and it showed inhomogeneous contrast enhancement.

INTERVENTION

The tumor was totally removed by a bilateral suboccipital craniectomy and C1 laminectomy. Dissection of the surgical specimen revealed that the tumor had originated from the left spinal accessory nerve. Histopathological examination confirmed the diagnosis of schwannoma. The patient experienced transient postoperative cerebellar ataxia but recovered completely.

CONCLUSION

Intracisternal-type spinal accessory schwannomas sometimes mimic a tumor of the fourth ventricle. Total surgical resection can be achieved with good outcome.

Identification of a human glioma antigen, SOX6, recognized by patients' sera

To identify tumor antigens for glioma, a human testis cDNA library was screened by serological identification of antigens by recombinant expression cloning with sera from glioma patients. In this screening, the most frequently isolated antigen was SOX6, an Sry-related high-mobility group (HMG) box-containing gene. SOX6 is a transcriptional factor that is specifically expressed in the developing central nervous system and in the early stages of chondrogenesis in mouse embryos. IgG antibodies against SOX6 were detected in sera from 12 of 36 glioma patients (33.3%), 0 of 14 patients with other brain disease (0%), and one of 54 other cancer patients (1.9%). In sera from 37 healthy individuals, no IgG responses against SOX6 were detected, except in an elderly female. Furthermore, Western blot and ELISA analyses with sera from glioma patients revealed that the DNA-binding domain, the HMG box of SOX6, might be a dominant epitope of IgGs against SOX6. RT-PCR and Northern blot analysis revealed that the SOX6 gene was more highly expressed in glioma tissues than in normal adult tissues, except testis. Western blot analysis with an anti-SOX6 antibody demonstrated that the SOX6 protein was expressed in glioma tissues, but not in normal adult brain tissue. Immunohistochemical analysis with the anti-SOX6 antibody showed that all the glioma tissues analysed expressed SOX6 in tumor cells, but only a few SOX6-positive cells were detected in non-neoplastic tissues from the cerebral cortex. In summary, these results indicate that the developmentally regulated transcription factor SOX6 is aberrantly expressed in glioma and specifically recognized by IgGs from glioma patients' sera.

Metastatic Adenocarcinoma of the Dura Mimicking Petroclival Meningioma-Case Report-

A 27-year-old female presented with gait disturbance and left facial paresthesia. She had a history of breast and lung masses not yet identified. Magnetic resonance (MR) imaging revealed a tumor suggesting a petroclival meningioma. Her symptoms worsened rapidly. MR imaging showed enlargement of the tumor. Subtotal removal of the tumor was performed. Histological examination revealed metastatic adenocarcinoma. Examination of the other masses confirmed adenocarcinoma originating from lung carcinoma. Dural metastases can be difficult to preoperatively differentiate from meningioma clinically or radiographically. MR spectroscopy and laboratory examinations such as cytologic and serologic studies are valuable for differential diagnosis. The final diagnosis of the tumor depends on the histological findings. However, careful monitoring of the patient's course is very important to detect rapid growth of metastases.

Tuberculoma Mimicking Falx Meningioma-Case Report-

A 25-year-old male presented with an intracranial tuberculoma mimicking falx meningioma manifesting as right lower monoparesis. The patient had a past history of pulmonary tuberculosis, cured by antituberculous therapy. Computed tomography and magnetic resonance (MR) imaging showed a lesion mimicking a falx meningioma. Surgery achieved subtotal resection. Histological and biochemical examinations revealed the surgical specimen was tuberculoma. He was treated with antituberculous therapy, and his gait disturbance disappeared. Follow-up MR imaging showed no regrowth.

Angiographic manifestations and operative findings with 70 cases of hemifacial spasm: relation of common trunk anomalies

The relations between angiographic manifestations and operative findings of hemifacial spasm were studied in 70 cases between 1988 and 2001. Vertebral angiography was performed, and Towne, straight AP, and lateral projections were routinely examined. The dominant anterior inferior cerebellar artery (AICA) directly compressed the facial nerve root exit zone in 26 cases, the dominant posterior inferior cerebellar artery (PICA) in 20, the AICA in 13, the PICA in 2, and the vertebral artery (VA) in 9. Compression by multiple vessels was observed in 11 cases. Anatomical variations of the affected AICA and PICA were classified into 3 groups according to their origins and distributions of blood supply: normal distribution of AICA and PICA in 18%, common trunk anomaly with dominant AICA (basilar artery origin) in 48% and common trunk anomaly with dominant PICA (vertebral artery origin) in 34%. Analyses of the angiograms revealed significantly increased numbers of common trunk anomalies compared with cases with normal angiograms. In 18 of the 20 cases of unilateral common trunk anomalies, facial nerves were compressed by the dominant artery. Preoperative vertebral angiograms may clarify the offending vessels and their sites in most hemifacial spasm cases, thus increasing the safety of surgical interventions.