Single-port laparoscopic Heller myotomy and Dor fundoplication: initial experience with a new approach for the treatment of pediatric achalasia

PURPOSE

The aim of this report was to evaluate the safety and feasibility of single-port laparoscopic Heller myotomy and Dor fundoplication (SPLHD) as treatment of pediatric esophageal achalasia.

METHODS

A 9-year-old boy with a significant history of achalasia underwent SPLHD. The single-port was inserted using an umbilical incision. The falciform ligament and left liver lobe were raised using an elevating suture, providing good visualization of the operative field at the cardia. The Heller myotomy was planned to be 4 cm long, extending 1 cm onto the gastric wall.

RESULTS

The SPLHD was successfully accomplished without the need for any skin incisions or additional ports. Oral intake was resumed on the first postoperative day, and the length of hospital stay was 8 days. The patient had complete resolution of dysphagia and regurgitation. No complications were noted, and the patient had an excellent cosmetic result.

CONCLUSIONS

The SPLHD is a safe and feasible procedure for symptomatic pediatric achalasia when performed by a surgeon experienced in laparoscopic and esophageal surgery.

Auditory findings after stereotactic radiosurgery in acoustic neurinoma

Auditory function after gamma knife stereotactic radiosurgery (GK) was evaluated in 22 patients with newly diagnosed unilateral acoustic neurinoma who had had some measurable hearing preoperatively. No tumor growth was observed in any patients. The preservation rates for useful hearing (n = 13) and any measurable hearing (n = 22) were 62% and 86%, respectively, at 2 years after GK. Postoperative hearing dysfunction was attributed to progressive cochlear impairment in 13 patients and to progressive injury in the retrocochlear auditory pathway in 5 patients. Hearing tended to be well preserved when caloric response was unchanged postoperatively. Preservation of hearing was not associated with the initial tumor volume, decrease of tumor size, maximum tumor dose, or peripheral tumor dose.

[Surgical strategy and treatment for pediatric surgical diseases accompanied with congenital heart diseases]

Advances in perinatal care in recent years have resulted in improved outcomes in both pediatric diseases treated surgically and congenital heart disease. However, aggressive surgical treatment is sometimes not performed because of a lack of knowledge of cardiac and pediatric surgeons. Lives may be saved if current pediatric surgical and pediatric cardiovascular surgical skills are combined. In complicated cases, a medical team is formed in our institution consisting of representatives of various departments, and the best treatment strategy tailored for individual patients is determined. We have treated 17 patients under this system, and 12 including 2 patients who had both severe pediatric diseases requiring surgery and congenital heart disease survived without major complications. Two patients died due to intestinal ischemia after cardiac surgery. To improve the survival rate of complicated cases, early detection or prevention of intestinal ischemia is required.

Laparoscopy-assisted appendectomy through an umbilical port in children

INTRODUCTION

We report surgical techniques for single-incision laparoscopy-assisted surgery (SILAS) in the treatment of pediatric acute appendicitis.

METHODS

We performed SILAS in 15 cases of acute appendicitis between January and September of 2009. SILAS is a surgical method that involves making the incision at the umbilicus, inserting a wound retractor XS, suspending the abdominal wall with a hook, and appendectomy with the same procedures as conventional appendectomy.

RESULTS

SILAS appendectomy was performed in all 15 cases with the exception of one case where one 3-mm port was added. Compared to open appendectomy, blood loss was significantly lower and postoperative hospitalization time was shorter, although there was no significant decrease in operative time, or postoperative fasting time. No postoperative complications, such as wound infection, intestinal obstruction, intra-abdominal abscess, or bleeding, were encountered.

CONCLUSION

SILAS was safely performed and is superior to open appendectomy with regard to cosmetic outcome.

[A novel formulation of cisplatin (CDDP)]

The study aimed to assess our newly devised CDDP delivery system designed to provide targeting potential and a sustained release of the anticancer agent. Seventy percent deacetylated chitin was applied as a drug carrier. We prepared two different types of systems with two different procedures: namely, system A with direct method and system B with indirect method. The targeting property of the system was evaluated ex vivo with measuring adhesive force between each system and human colonic mucosa. The release behavior of the CDDP from the system was examined in vitro. The anticancer activities of the released CDDP were also examined in vitro using human gastric cancer cell line, MKN-45. Each system was a viscose elastic solution. The adhesive forces of the novel systems were stronger at 37 degrees C than that of 25 degrees C. Each system provided a sustained release of CDDP. The released CDDP demonstrated effective growth suppression activity against the MKN-45 cancer cells. The novel systems basically showed a favorable targeting function and a sustained release of CDDP, which effectively provided a growth inhibition potential against human cancer cell line. Our newly devised CDDP delivery systems are promising as a novel approach to cancer chemotherapy.

Dyke-Davidoff-Masson Syndrome Demonstrated by Current MR Images

Current magnetic resonance imaging techniques demonstrated MR findings of Dyke-Davidoff-Masson syndrome in a 44-year-old man. Statistical parametric mapping analysis of the T1-weighted images showed focal atrophy in the basal ganglia. Three-dimensional white matter fibers of corticospinal tracts, corpus callosum and cingulate bundle were demonstrated using diffusion tensor data correlated to the patient's clinical conditions.

Transport and strong-correlation phenomena in carbon nanotube quantum dots in a magnetic field

Transport through carbon nanotube (CNT) quantum dots (QDs) in a magnetic field is discussed. The evolution of the system from the ultraviolet to the infrared is analyzed; the strongly correlated (SC) states arising in the infrared are investigated. Experimental consequences of the physics are presented-the SC states arising at various fillings are shown to be drastically different, with distinct signatures in the conductance and, in particular, the noise. Besides CNT QDs, our results are also relevant to double-QD systems.

Calcium ion release from calcium hydroxide stimulated fibronectin gene expression in dental pulp cells and the differentiation of dental pulp cells to mineralized tissue forming cells by fibronectin

AIM

The effect of calcium ions on dental pulp cells was examined and the mechanism of dentine bridge formation by calcium hydroxide was investigated.

METHODOLOGY

Human dental pulp cells were treated with high concentration of calcium or magnesium ions for 24 h and fibronectin gene expression was measured by the quantitative PCR method. Human dental pulp cells were then cultured on fibronecin-coated dishes for 24 h, and osteocalcin and osteopontin gene expression, which are typical phenotypes of mineralized tissue forming cells, were measured by the quantitative PCR method.

RESULTS

Fibronectin gene expression was stimulated by calcium ions dose-dependently. On the other hand, magnesium ions did not influence fibronectin gene expression. Furthermore, pulp cells cultured on fibronectin-coated dishes enhanced the expression of phenotypes of mineralized tissue forming cells.

CONCLUSIONS

Calcium ions released from calcium hydroxide stimulates fibronectin synthesis in dental pulp cells. Fibronectin might induce the differentiation of dental pulp cells to mineralized tissue forming cells that are the main cells to form dentine bridges, via contact with cells.

Significance of radio-pathological correlations: differentiating severe central nervous system infection from acute embolic infarction

We describe two educational autopsy cases of severe central nervous system (CNS) infection and septic emboli, such cases having been difficult to differentiate from acute infarctions via emergency MR imaging studies. We briefly discuss the pathology and MR findings along with radiopathological correlation.

Asymptomatic self-limiting diffuse white matter lesions in subacute to chronic stage of herpes simplex encephalitis

This study evaluated white matter changes in the subacute and chronic stages of herpes simplex encephalitis (HSE). Subjects comprised 15 patients with HSE. All patients were examined using MRI at onset, and then at seven to ten days, three to five weeks and two to three months after onset. In addition, the six patients who displayed white matter signal abnormalities were examined at six months and <one year after onset. Cell count, protein levels, polymerase chain reaction (PCR) of herpes simplex virus in cerebrospinal fluid (CSF), and exacerbation of neurological symptoms as well as dose of acyclovir were compared between patients with and without white matter abnormalities. Diffuse white matter signal changes were identified at the subacute stage (3-5 weeks after onset) of HSE in six patients (6/15, 40%). No significant relationship was observed between the presence of white matter signal abnormalities and laboratory data, acyclovir dose or clinical symptoms. These signal abnormalities disappeared or improved by two years without any clinical treatment. Diffuse white matter signal abnormalities occur frequently in the subacute stage of HSE. Although the mechanisms underlying these white matter lesions have not been elucidated, subclinical immune-mediated processes may be considered. Repeat MRI studies over a long period are necessary for evaluating the clinical process of patients with HSE.

The cellular and behavioral consequences of interleukin-1 alpha penetration through the blood-brain barrier of neonatal rats: a critical period for efficacy

Proinflammatory cytokines circulating in the periphery of early postnatal animals exert marked influences on their subsequent cognitive and behavioral traits and are therefore implicated in developmental psychiatric diseases such as schizophrenia. Here we examined the relationship between the permeability of the blood-brain barrier to interleukin-1 alpha (IL-1 alpha) in neonatal and juvenile rats and their later behavioral performance. Following s.c. injection of IL-1 alpha into rat neonates, IL-1 alpha immunoreactivity was first detected in the choroid plexus, brain microvessels, and olfactory cortex, and later diffused to many brain regions such as neocortex and hippocampus. In agreement, IL-1 alpha administration to the periphery resulted in a marked increase in brain IL-1 alpha content of neonates. Repeatedly injecting IL-1 alpha to neonates triggered astrocyte proliferation and microglial activation, followed by behavioral abnormalities in startle response and putative prepulse inhibition at the adult stage. Analysis of covariance with a covariate of startle amplitude suggested that IL-1 alpha administration may influence prepulse inhibition. However, adult rats treated with IL-1 alpha as neonates exhibited normal learning ability as measured by contextual fear conditioning, two-way passive shock avoidance, and a radial maze task and had no apparent sign of structural abnormality in the brain. In comparison, when IL-1 alpha was administered to juveniles, the blood-brain barrier permeation was limited. The increases in brain IL-1 alpha content and immunoreactivity were less pronounced following IL-1 alpha administration and behavioral abnormalities were not manifested at the adult stage. During early development, therefore, circulating IL-1 alpha efficiently crosses the blood-brain barrier to induce inflammatory reactions in the brain and influences later behavioral traits.

Branched-chain Amino Acids and Arginine Supplementation Attenuates Skeletal Muscle Proteolysis Induced by Moderate Exercise in Young Individuals

This study aimed at evaluating the effect of a single oral intake of branched-chain amino acids (BCAA) with Arg on skeletal muscle protein metabolism during moderate exercise in young individuals. Eight healthy volunteers (4 males and 4 females, means +/- SEM, 26 +/- 1 yrs, 177.8 +/- 3.7 cm, 72.6 +/- 3.9 kg) were studied in a randomized double-blind placebo-controlled cross-over trial. The subjects performed 3 bouts of 20-min cycling exercise (5-min break between each bout) at 126 +/- 13 W corresponding to 50 % of the maximal work intensity. A single oral supplement of either a BCAA drink containing 2 g of BCAA and 0.5 g of Arg or an isocaloric placebo drink was given at 10 min of the 1st exercise bout. Both arterial and venous blood samples were simultaneously taken from the radial artery and the femoral vein, respectively. Blood flow in the femoral artery was determined using the ultrasound Doppler technique. The blood sampling and blood flow measurements were performed at rest, every 10 min during each exercise bout. Net balance of BCAA and Phe across the leg muscles were measured by the arteriovenous difference method. The BCAA ingestion resulted in increases in both the plasma BCAA concentration and BCAA uptake into the working leg. The Phe release from the leg during exercise significantly increased as compared to the basal level in the placebo trial (0.97 +/- 0.28 vs. 0.23 +/- 0.22 micromol/min, p < 0.05). In the BCAA trial, the cumulative Phe release from the leg during the 3rd exercise bout was significantly lower than that in the placebo trial (5.0 +/- 7.4 vs. 35.9 +/- 13.2 micromol/25 min, p < 0.05). These results suggest that endurance exercise at moderate intensity enhances proteolysis in working muscles, and a single oral intake of 2 g of BCAA with Arg at onset of exercise effectively suppresses exercise-induced skeletal muscle proteolysis.

Successful repair using innominate vein flap, pericardial flap and thymus pedicle flap for tracheo-innominate artery fistula

Tracheo-innominate artery fistula (TIF) is a rare but frequently fatal complication after tracheostomy. Without operation, the mortality is nearly 100% because of acute massive tracheal hemorrhage. Although the survival rate is extremely low, survival is possible only when an immediate operation is performed. Many surgeons have chosen ligation or resection of the innominate artery because repair with blood flow maintained in the innominate artery carries a high risk of postoperative fatal recurrent bleeding. We report on a successful surgical management of one case by patch closure with an innominate vein flap, wrapping of the innominate artery with a pericardial flap, and interposition of a thymus pedicle flap between the innominate artery and the trachea. Our surgical procedure is effective in maintaining the patency of the innominate artery preventing neurological deficits, and in preventing postoperative recurrent bleeding.

Therapeutic efficacy of leukocytapheresis in a pregnant woman with severe active ulcerative colitis

Leukocytapheresis has recently been used to induce remission in patients with ulcerative colitis (UC) who fail to respond to corticosteroids. We could not find a report in the literature on leukocytapheresis for UC with gestational exacerbation. We have recently encountered this unique condition and report the details here. A 30-year-old Japanese woman with left-sided severe UC was corticosteroid-dependent and had recurrence of the active disease during tapering of corticosteroid. She declined any dose increase and the use of any immunosuppressive agent because she was in the 13th week of pregnancy. Then, concomitant leukocytapheresis was performed without increasing the corticosteroid dose. Recovery was rapid and dramatic. Mucous and bloody stool decreased after the first session, and she had remission 2 weeks later. She underwent a total of four sessions without complications. After 6 weeks, she was discharged from our hospital and underwent maintenance treatment as an outpatient with mesalazine and corticosteroid tapering. Subsequently, she gave birth to a healthy baby girl by an uncomplicated vaginal delivery while keeping the remitted stage of UC.

Complement membrane attack is required for endplate damage and clinical disease in passive experimental myasthenia gravis in Lewis rats

Myasthenia gravis (MG) is a debilitating and potentially fatal neuromuscular disease characterized by the generation of autoantibodies reactive with nicotinic acetylcholine receptors (AChR) that cause loss of AChR from the neuromuscular endplate with resultant failure of neuromuscular transmission. A role for complement (C) in the pathology of human MG has been suggested based upon identification of C activation products in plasma and deposited at the endplate in MG. In the rat model, experimental autoimmune MG (EAMG), C depletion or inhibition restricts clinical disease, further implicating C in pathology. The mechanisms by which C activation drives pathology in MG and EAMG are unclear. Here we provide further evidence implicating C and specifically the membrane attack complex (MAC) in the Lewis rat passive EAMG model of MG. Rats deficient in C6, an essential component of the MAC, were resistant to disease induction and endplate destruction was reduced markedly compared to C6-sufficient controls. After reconstitution with C6, disease severity and endplate destruction in the C6-deficient rats was equivalent to that in controls. The data confirm the essential role of the MAC in the destruction of the endplate in EAMG and raise the prospect of specific MAC inhibition as an alternative therapy in MG patients resistant to conventional treatments.