Concomitant laparoscopic splenectomy and cholecystectomy as an effective and minimally invasive treatment of pyruvate kinase deficiency with gallstones

A 4-year-old girl with pyruvate kinase deficiency underwent partial splenic embolization initially. However, even after this procedure, she still had to be transfused every 2 months and then every month. At 5 years of age, she was admitted to our hospital to undergo splenectomy. She underwent laparoscopic splenectomy and concomitant cholecystectomy for gallstones. The hemogram recovered to the normal range after surgery, and her postoperative course was uneventful. Considering the absence of morbidity, the short hospitalization, the quick return to normal activity, the good cosmetic result, and the improved clinical and hematologic results, we consider that simultaneous laparoscopic splenectomy and cholecystectomy is safe and effective for the management of hemolytic anemia resulting from pyruvatre kinase deficiency and associated with cholelithiasis.

Fluid-dynamic characteristics of a bristled wing

Thrips fly at a chord-based Reynolds number of approximately 10 using bristled rather than solid wings. We tested two dynamically scaled mechanical models of a thrips forewing. In the bristled design, cylindrical rods model the bristles of the forewing; the solid design was identical to the bristled one in shape, but the spaces between the `bristles' were filled in by membrane. We studied four different motion patterns: (i) forward motion at a constant forward velocity, (ii) forward motion at a translational acceleration, (iii) rotational motion at a constant angular velocity and (iv)rotational motion at an angular acceleration. Fluid-dynamic forces acting on the bristled model wing were a little smaller than those on the solid wing. Therefore, the bristled wing of a thrips cannot be explained in terms of increased fluid-dynamic forces.

Protective effects of anti-neutrophil antibody against myocardial ischemia/reperfusion injury in rats

Neutrophil activation initiates myocardial ischemia/reperfusion (I/R) injuries. The aim of this study is to evaluate the in vitro functions of an anti-neutrophil monoclonal antibody, Urge-8, and its therapeutic efficacy against myocardial ischemia (MI) in rats. We measured in vitro functions of rat neutrophils including chemotactic activity, superoxide production, phagocytic function, and neutrophil degranulation. MI was induced in Wistar rats by clamping the left coronary artery for 1 h. Rats received either isotype-negative control IgG(1) (control group, n = 20), 250 microg/kg of Urge-8 before (pre-treatment group, n = 20) or after (post-treatment group, n = 20) MI. The three groups were compared during the first 24 h after reperfusion with respect to changes in mean arterial pressure, heart rate, body temperature, biochemistry, serum cytokines, myocardial neutrophil infiltration, survival rate, and size of MI. Urge-8 effectively suppressed in vitro functions of rat neutrophils including chemotactic activity, superoxide production, phagocytic function, and neutrophil degranulation. The Urge-8 treated groups showed higher levels of arterial pressure and survival rate, lower values of interleukin-6 and interleukin-8, lower grade of myocardial neutrophil infiltration, and smaller MI size as compared to the control group. In conclusion, Urge-8 is effective against myocardial I/R injury by suppressing certain functions and myocardial infiltration of neutrophils in rats.

Interdigitating dendritic cell sarcoma of the spleen: report of a case with a review of the literature

Interdigitating dendritic cell sarcoma is an extremely rare neoplasm that mainly occurs in the lymph nodes. We report a case of interdigitating dendritic cell sarcoma arising from the spleen, a previously unreported site for interdigitating dendritic cell sarcoma. An 87-year-old woman, visiting Ashigara Hospital with complaints of palpitation and dyspnea, was found to have pancytopenia and low proteinemia. Abdominal ultrasonography and CT scanning demonstrated severe splenomegaly with heterogeneous enhancement. She received a splenectomy under the clinical diagnosis of a splenic tumor. Grossly, the spleen was markedly enlarged, with confluent massive nodules. Microscopically, the normal architecture was effaced with diffuse proliferation of large pleomorphic cells arrayed in a somewhat sheet-like pattern. Erythrophagocytosis was commonly observed. Immunohistochemical studies showed that the tumor cells were positive for S-100 protein, fascin, vimentin, and CD68, but uniformly negative for CD45, B- and T-cell markers, CD1a, CD30, complement receptors, CD34, Factor VIII, HMB-45, and lysozyme. Ultrastructurally, the tumor cells possessed complex interdigitating cytoplasmic dendritic processes. Birbeck granules were absent. Based on these findings, the present case was diagnosed as interdigitating dendritic cell sarcoma. The patient died of multiple liver metastases 3 months postoperatively.

[A case of emergency coronary artery bypass graft for the patient using chronic hemodialysis, where in blood volume was measurable in the perioperative period]

An emergency coronary artery bypass graft (CABG) was given to a 66 year-old patient due to acute myocardial infarction (AMI). Circulating blood volume (BV) was measured to study in the perioperative period. Three coronary artery bypasses were made under cardiopulmonary bypass, being managed by ultrafiltration when the pump-oxygenator was in action and by peritoneal dialysis in the early postoperative period. Preoperative BV reduced immediately after the operation. It showed an increasing trend 4 hours after the operation, but after that BV reduced from that before the operation while water balance was kept positive. Cardiac output after the operation was higher than before. It suggested that in this patient using hemodialysis BV levels turned to be lower compared with that before the operation, as excessive water leaked out of the blood vessel, although water balance was kept positive due to improved cardiac functions after the operation.

An autopsy case of intravascular lymphomatosis with dermatomyositis

A 62-year-old man was admitted to hospital with general malaise, arthralgia, edema, and high-grade fever. He was diagnosed as dermatomyositis because of typical skin rashes and muscle weakness. His symptoms were improved by high-doses of prednisolone and cyclosporin A, with the exception of the skin rash over the back. High-grade fever developed again when tapering prednisolone. His condition deteriorated gradually. Paresthesia, hypothyroidism, metabolic acidosis, and disseminated intravascular coagulopathy occurred, and he died eight months after the first admission. Postmortem examination revealed intravascular proliferation of atypical mononuclear cells in the lumens of small vessels in all organs. Intravascular lymphomatosis (B cell type) was diagnosed.

Antiinflammatory effect of heparin-coated circuits with leukocyte-depleting filters in coronary bypass surgery

Cardiac surgery with cardiopulmonary bypass is associated with a systemic inflammatory response. We examined combined use of heparin coating of the cardiopulmonary bypass circuit and a leukocyte-depleting arterial line filter to reduce this response. Thirty patients were allocated randomly to equal groups with a conventional circuit and arterial line filter (C group), a heparin-coated circuit with a conventional filter (H group), or a heparin-coated circuit with a leukocyte-depleting arterial line filter (HF group). Cytokines and respiratory function were repeatedly measured perioperatively. Plasma interleukin (IL)-6 concentrations in the HF group were lower than in the C group immediately following bypass and operation, at 4 h, and 12 h (p < 0.05). Plasma IL-8 was lower in the HF group than in the C group at 4 h (p < 0.05). The respiratory index was lower immediately after bypass in the HF group than the C group (0.61 +/- 0.2 versus 1.05 +/- 0.4, p < 0.05). Heparin-coated circuits with leukocyte-depleting filters decrease inflammatory responses and improve pulmonary function during operation.

[Blood transfusion under cardiopulmonary bypass is a possible inducer for inflammation?]

To investigate that blood transfusion under cardiopulmonary bypass is a possible inducer for inflammation, a retrospective study was made with 20 adult patients who underwent coronary artery bypass grafting. The subjects were divided into two groups; transfusion group (group T) including 9 patients who received blood transfusion during cardiopulmonary bypass and the control group (group C) including 11 patients who did not undergo perioperative transfusion. Respiratory index as an indicator of respiratory functions was determined before and immediately after cardiopulmonary bypass, at the end of surgery and 4 hours thereafter. Cardiac index and arterial pressure were determined as the indicator of cardiac function. Moreover, interleukin 6 and 8 (IL-6 and IL-8), inflammatory cytokines were measured and compared between the two groups. The mean amount of blood transfusion was 2.1 units per individual of group T. The minimum value of hematocrit during cardiopulmonary bypass was significantly lower in group T (15.8 +/- 1.8%) than group C (19.1 +/- 1.4%), but the difference became not significant after cardiopulmonary bypass. There were no significant differences either in aortic pressure or cardiac index between two groups. The respiratory index at the end of surgery was higher in group T but the difference was not significant. Meanwhile IL-8 level at the end of cardiopulmonary bypass was significantly higher in group T (67.9 +/- 36 pg/ml) than group C (35.1 +/- 21 pg/ml). However, there was no difference in IL-6 level between the two. These results suggested that inflammation might be aggravated by an increase of IL-8 induced by blood transfusion.

Calculation of the absorbed dose for the overexposed patients at the JCO criticality accident in Tokai-mura

The doses for the overexposed patients were estimated by the measurement result of specific activity of 24Na in blood. The present method is almost based on documents of the International Atomic Energy Agency (IAEA) and the Oak Ridge National Laboratory. The neutron energy spectrum obtained using the ANISN code (Multigroup One-Dimensional Discrete Ordinates Transport Code System with Anisotropic Scattering) was assumed. The values in ICRP Publication 74 were applied for the doses in each organ per unit neutron fluence. Gamma-ray dose was indirectly estimated based on (a) the result of environmental monitoring around the accident site and (b) a graph in IAEA manual, which gives the kerma ratio of neutrons and gamma-rays as a function of the critical volume or the atomic ratio of hydrogen to 235U. The estimated neutron doses were 5.4 Gy for patient A. 2.9 Gy for patient B and 0.81 Gy for patient C. The estimated gamma-ray doses were 8.5 or 13 Gy for patient A, 4.5 or 6.9 Gy for patient B, and 1.3 or 2.0 Gy for patient C.

Surgical technique for combined intestine-auxiliary liver transplantation in rats: development of a new microsurgical model

Combined liver-intestine transplantation is an evolving procedure, and auxiliary liver transplantation has several advantages over standard orthotopic liver transplantation. We present a new model of combined intestine-auxiliary liver transplantation in rats. Total small bowel and 60% liver were harvested en bloc. An aortic segment that contained the celiac axis and superior mesenteric artery ensured blood supply to the graft. Venous drainage of the grafted intestine was achieved via the intact portal vein of the graft. The infrahepatic vena cava was cut at different levels during the modification period and at the oblique level of the left renal vein in consecutive series. Revascularization was accomplished by end-to-side anastomosis of the aorta and of the infrahepatic vena cava. The recipient small bowel was resected and the intestine continuity restored by anastomosis. Total operation time averaged 130 min. The overall survival rate of 3 months in the consecutive series was 80% (16/20). Exploratory laparatomy and histologic study in 3 rats on 90 days after transplantation revealed normal and viable grafts. Liver function was normal and both grafted liver and intestine showed normal histologic architectures in 5 rats observed for 12 months after transplantation. The present model is reproducible and allows preclinical research on several aspects of experimental combined intestine-auxiliary liver transplantation.

Surgical technique for combined intestine-auxiliary liver transplantation in rats: development of a new microsurgical model

Combined liver-intestine transplantation is an evolving procedure, and auxiliary liver transplantation has several advantages over standard orthotopic liver transplantation. We present a new model of combined intestine-auxiliary liver transplantation in rats. Total small bowel and 60% liver were harvested en bloc. An aortic segment that contained the celiac axis and superior mesenteric artery ensured blood supply to the graft. Venous drainage of the grafted intestine was achieved via the intact portal vein of the graft. The infrahepatic vena cava was cut at different levels during the modification period and at the oblique level of the left renal vein in consecutive series. Revascularization was accomplished by end-to-side anastomosis of the aorta and of the infrahepatic vena cava. The recipient small bowel was resected and the intestine continuity restored by anastomosis. Total operation time averaged 130 min. The overall survival rate of 3 months in the consecutive series was 80% (16/20). Exploratory laparatomy and histologic study in 3 rats on 90 days after transplantation revealed normal and viable grafts. Liver function was normal and both grafted liver and intestine showed normal histologic architectures in 5 rats observed for 12 months after transplantation. The present model is reproducible and allows preclinical research on several aspects of experimental combined intestine-auxiliary liver transplantation.

Effects of a phosphodiesterase III inhibitor on circulating blood volume after cardiopulmonary bypass

Using a new method based on pulse dye densitometry, circulating blood volume (BV) was measured without direct sampling in patients undergoing open-heart surgery, and the effects of phosphodiesterase (PDE) III inhibitor administration during cardiopulmonary bypass (CPB) were evaluated. Sixteen patients scheduled for elective coronary artery bypass grafting were randomly assigned to the PDE III inhibitor group or control group. BV was determined before CPB, and immediately, and 4 and 12h after operation. After declamping of the aorta, the PDE III inhibitor amrinone (1 mg/kg) was infused as a single bolus into the venous reservoir in the PDE III inhibitor group. BV decreased significantly soon after the operation in the control group. It did not decrease in the PDE III inhibitor group (48.6 +/- 44 and 60.6 +/- 8.0 ml/kg for the control and PDE III inhibitor groups. respectively). Four hours after surgery and beyond no significant changes in BV were observed in either group. The body fluid balance was negative in both groups. In conclusion, a single administration of PDE III inhibitor during CPB was found to sustain BV soon after operation and, therefore, is useful for postoperative management of open-heart surgery.

Intragastric endoscopic mucosal resection through a temporary gastrostomy for early gastric cancer: usefulness of Buess-type endoscope

OBJECTIVE

To assess the feasibility of cure of early gastric cancer by the endoscopic procedure done through a temporary gastrostomy and to use it to treat patients with various severe complications.

DESIGN

Prospective study.

SETTING

University hospital, Japan.

SUBJECTS

Four patients who required gastric mucosal resection for early gastric cancer.

MAIN OUTCOME MEASURES

Ease of the procedure, cure rate, safety under epidural anaesthesia, and outcome.

RESULTS

All patients had the procedure under epidural anaesthesia without pain or complaints during operation. Mean operation time was 120 minutes (60-200). Histological examination showed that the surgical margin was free of tumour in 3 of the cases. One patient who had microscopic invasion of lymph nodes subsequently underwent second-look conventional gastrectomy with lymphadenectomy. Postoperative recovery was rapid, and all patients were discharged from the hospital uneventfully.

CONCLUSION

This organ-preserving procedure enables good visualisation of the tumour and is useful even for high-risk patients.

Myocardial ischemia induced by anomalous aortic origin of the right coronary artery in a patient with atrial septal defect

A 27-year-old woman with atrial septal defect (ASD) and a sensation of squeezing in the anterior chest by effort was admitted to our hospital. In addition to the ASD, the coronary angiogram showed an abnormal anomalous position of the right coronary artery. Exercise thallium (Tl)-201 cardiac scintigram with an electrocardiogram clearly detected myocardial ischemia in the inferior area. In the operative findings, the orifice of the right coronary artery was positioned high above the commissure between the right and left sinuses of Valsalva, and it ran between the aorta and pulmonary trunk. Considering myocardial ischemia possibly caused by the anomalous origin of the right coronary artery, a coronary artery bypass graft (CABG) was simultaneously performed to the right coronary artery with direct closure of ASD. The myocardial ischemic finding in the inferior area disappeared after the operation, and she was also relieved from the chest pain. In view of these findings, we suggest that an active combination treatment such as CABG and ASD closure is highly successful in a patient with a threatening coronary anomaly and congenital heart disease.

Effect of coronary artery bypass grafting on native coronary artery stenosis. Comparison of internal thoracic artery and saphenous vein grafts

BACKGROUND

The purpose of this study was to investigate the influence of coronary artery bypass grafting on the degree of stenosis of the native coronary artery.

METHODS

EXPERIMENTAL DESIGN

retrospective data analysis.

SETTING

University hospital.

PATIENTS

consecutive patients undergoing coronary artery bypass grafting (n=52). Bypasses using internal thoracic artery grafts (n=26) and saphenous vein grafts (n=37) to incompletely occluded coronary arteries were studied.

INTERVENTIONS

coronary artery bypass grafting using internal thoracic artery or saphenous vein grafts.

MEASURES

stenosis of the native coronary artery on angiography.

RESULTS

Three recipient coronary arteries bypassed with internal thoracic artery grafts (12%) and 14 recipient coronary arteries bypassed with saphenous vein grafts (38%) showed progression of narrowing (p=0.024). Two recipient coronary arteries bypassed with internal thoracic artery grafts (8%) and 13 recipient coronary arteries bypassed with saphenous vein grafts (35%) showed total occlusion (p=0.016). Hypertension, hyperlipidemia, diabetes mellitus, and smoking history did not correlate with progression of stenosis of the native coronary arteries. Graft flow measured during surgery in the saphenous vein grafts was not significantly different between the group that exhibited progression of the native stenosis and the group that did not.

CONCLUSIONS

Coronary artery bypass grafting with saphenous vein grafts may result in progression of stenosis of the recipient coronary artery. This is less likely after coronary artery bypass grafting with internal thoracic artery grafts. This difference may be due to the ability of the pedicled internal thoracic artery graft to regulate flow. Thus competitive flow in the native coronary artery is minimized. This has significant clinical implications.

Carcinoma of the cystic duct associated with pancreaticobiliary maljunction

We report a rare case of carcinoma of the cystic duct (CCD) associated with pancreaticobiliary maljunction (PBM). A 63-year-old man had presented with relapsing cholecystitis of 4 months, duration. Computed tomography showed a distended gallbladder: however, small mass in the cystic duct was overlooked. Endoscopic retrograde cholangiopancreatography demonstrated a long common channel (20-mm-long) and fusiform dilatation of the common bile duct, findings, which were consistent with PBM. At laparotomy, we found a papillary tumor, 20 mm in diameter, that obstructed the cystic duct. The patient underwent resection of the gallbladder and the common bile duct, lymph node dissection in the hepatoduodenal ligament, and hepaticojejunostomy. Histologic study revealed a papillary adenocarcinoma confined within the subserosal space. There was no lymphatic or perineural invasion of cancer cells. The surrounding cystic ductal mucosa showed dysplasia and hyperplasia, and the gallbladder and common bile duct showed severe inflammation. The patient has been doing well for 16 months after surgery, without tumor recurrence. This case suggests a relationship between CCD and chronic biliary inflammation caused by PBM, as in cases of gallbladder carcinoma.

Cardiac surgery in patients with end-stage renal disease. Utility of continuous ambulatory peritoneal dialysis

OBJECTIVES

The number of patients with end-stage renal disease undergoing open heart surgery continues to grow. We evaluated continuous ambulatory peritoneal dialysis and the extracorporeal ultrafiltration method during cardiopulmonary bypass in the management of these difficult patients.

METHODS

These 2 methods were used in 4 patients with renal failure who underwent open heart surgery between July 1997 and March 1999. Preoperative continuous ambulatory peritoneal dialysis was conducted using standard protocols. Extracorporeal ultrafiltration method was used only during cardiopulmonary bypass. Continuous ambulatory peritoneal dialysis was initiated upon arrival at the intensive care unit. Mean follow-up was 12 months.

RESULTS

Postoperative blood urea nitrogen and creatinine concentrations were lower than preoperative concentrations. No patients required hemodialysis. All 4 patients were discharged to their homes. No deaths occurred.

CONCLUSIONS

Continuous ambulatory peritoneal dialysis and extracorporeal ultrafiltration method are combined to treat patients with end-stage renal disease who require open heart surgery. This combination is simple, and does not require specialized personnel, and obviates the hemodynamic instability associated with hemodialysis.

CT-guided treatment of ultrasonically invisible hepatocellular carcinoma

New techniques of CT-guided management were introduced to ablate ultrasonically invisible hepatocellular carcinomas. In six patients with HCC, a total of six nodules (8-30 mm in diameter) were treated under the guidance of CT. These lesions were not visualized by sonography but were visualized as Lipiodol spots on CT after chemoembolization. Tumor localization was successful in all patients without difficulty, using a thin needle or hookwire under the guidance of CT. Two patients underwent subsequent hepatic resection and/or microwave coagulation therapy (MCT) through a small incision after hookwire placement. Four patients received percutaneous MCT (n = 2) or ethanol injection (PEI) (n = 2) at the time of localization. The postoperative CT with contrast enhancement indicated that tumor ablation was complete in four of the five nodules treated with MCT or PEI. However, in one nodule (30 mm in diameter) treated with PEI, tumor ablation was not complete. There were no complications. There has been no local tumor recurrence 6-46 months after treatment in any of the patients. In conclusion, these CT-guided procedures were effective in treating ultrasonically invisible hepatocellular carcinomas that otherwise would have remained untreated.

Multiendoscope-assisted treatment for blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome is characterized by gastrointestinal and cutaneous hemangiomas and gastrointestinal bleeding causing anemia. We report a unique case of this syndrome in an adult woman. It was associated with congenital heart disease, for which the patient underwent surgery at 12 months of age, and cutaneous hemangiomas, for which surgery was performed later in childhood. Gastrointestinal bleeding was diagnosed and treated when she was 21 years of age after a workup for iron deficiency anemia. Successful total resection of all gastrointestinal hemangiomas was performed by minimally invasive surgery with gastric, small intestinal, and colonic fiberscopy and laparoscopy. The postoperative course was uneventful. The patient could walk the day after surgery, and she was discharged from the hospital 14 days after surgery. Our experience and findings given in other reports suggest that total resection of hemangiomas should be the final goal and that minimal skin incision is preferable for this benign disease, with multiendoscope-assisted treatment to ensure that any hemangiomas remaining in the gastrointestinal tract are not overlooked.

Painless lithotripsy by flashlamp-excited dye laser for impacted biliary stones: an experimental and clinical study

OBJECTIVE

To find out the appropriate dye laser output and frequency for each kind of stone experimentally, and to use flashlamp-excited dye laser for impacted biliary stones.

DESIGN

Prospective study.

SETTING

University hospital, Japan.

SUBJECTS

12 patients undergoing lithotripsy for both intrahepatic and extrahepatic impacted biliary stones.

MAIN OUTCOME MEASURES

Appropriate dye laser output and frequency, histological changes in the bile duct wall, and outcome.

RESULTS

Stones were pulverised, and required a median 155 pulses (range 80-205) at 40 mJ for bilirubin stones and 355 pulses (range 205-405) at 50 mJ for cholesterol stones. At the standard energies used, the laser caused only superficial damage to the serosa of the common bile duct. It was successful in fragmenting 133/135 stones (99%), and in addition pulverised 125/135 stones (93%). No patients complained of pain during laser lithotripsy even under local anaesthesia. All patients were discharged from the hospital after an uneventful recovery, and no recurrent stones have been found at outpatient follow-up ranging between 2 and 85 months.

CONCLUSION

Flashlamp-excited dye laser with a small choledochoscope seems to be safe and painless way of treating biliary stones, even if they are impacted in the peripheral biliary tree and patients are at high risk.