Rectal duplication cyst successfully treated by laparoscopic total mesorectal excision using the prolapsing technique

Congenital alimentary tract duplication is a rare disease. It most frequently occurs in the ileum, with the rectum being the rarest site. Herein, we report a 38-year-old woman who was referred to our hospital because of severe anal pain. On digital examination, a smooth, round, rubbery mass was palpable; it was located 5 cm from the anal verge in the posterior rectal wall. A CT scan demonstrated a 5-cm cystic lesion located anterior to the sacrum that was displacing the rectum anteriorly. Spontaneous remission of the tumor was evident; however, after 5 months of follow-up, the patient experienced the same severe anal pain. MRI demonstrated a recurrent cystic lesion. To prevent further complications and to confirm or deny malignancy, laparoscopic total mesorectal excision using the prolapsing technique was performed. Pathologically, the cystic lesion was diagnosed as a rectal duplication cyst. This is the first report of a rectal duplication cyst successfully treated by laparoscopic total mesorectal excision.

A design of backing seat and gasket assembly in diamond anvil cell for accurate single crystal x-ray diffraction to 5 GPa

We designed a new cell assembly of diamond anvil cells for single crystal x-ray diffraction under pressure and demonstrate the application of the cell to the crystallographic studies for ice VI and ethanol high-pressure (HP) phase at 0.95(5) GPa and 1.95(2) GPa, respectively. The features of the assembly are: (1) the platy anvil and unique-shaped backing seat (called as "Wing seat") allowing the extremely wide opening angle up to ±65°, (2) the PFA-bulk metallic glass composite gasket allowing the easy attenuation correction and less background. Thanks to the designed assembly, the R(int) values after attenuation corrections are fairly good (0.0125 and 0.0460 for ice VI and ethanol HP phase, respectively), and the errors of the refined parameters are satisfactory small even for hydrogen positions, those are comparable to the results which obtained at ambient conditions. The result for ice VI is in excellent agreement with the previous study, and that for ethanol HP phase has remarkable contributions to the revision to its structure; the H12 site, which makes gauche molecules with O1, C2, and C3 sites, may not exist so that only trans conformers are present at least at 1.95(2) GPa. The accurate intensities using the cell assembly allow us to extract the electron density for ethanol HP phase by the maximum entropy method.

Presentation of a patient with pT2bN1M0 small cell carcinoma of the uterine cervix who obtained long-term survival with maintenance chemotherapy, and literature-based discussion

BACKGROUND

Small cell carcinoma of the uterine cervix is a rare cervical carcinoma that advances early and is associated with a poor prognosis. We present a case of this disease which invaded the parametrium and metastasized to the pelvic lymph node. The patient underwent postoperative concurrent chemoradiotherapy (CCRT) followed by maintenance chemotherapy and obtained long-term survival.

CASE

A 26-year-old patient, who had conceived on two occasions without giving birth and had smoked for ten years, underwent radical hysterectomy with a diagnosis of Stage Ibl cervical carcinoma in December 2006. The patient showed parametrial invasion, and metastasis to the left external iliac node and vaginal stump. With a diagnosis of pT2bN1M0, the patient underwent CCRT with weekly nedaplatin as postoperative therapy. For the maintenance chemotherapy, from May 2007, ten courses of PE therapy (CDDP, 15 mg/body; VP-16, 100 mg/body x 3) were performed. No recurrent signs have been observed for 39 months after the first operation.

CONCLUSION

PE therapy may be useful as maintenance therapy, although there are no established treatments for small cell carcinoma of the uterine cervix.

Value of indocyanine green clearance of the future liver remnant in predicting outcome after resection for biliary cancer

BACKGROUND

It is difficult to predict hepatic functional reserve accurately before major hepatectomy. The aim of this study was to analyse the usefulness of the future liver remnant plasma clearance rate of indocyanine green (ICGK-F, calculated as plasma clearance rate of indocyanine green (ICGK) x proportion of the future liver remnant) in predicting death after major hepatectomy.

METHODS

Data on ICGK and ICGK-F were collected prospectively and analysed retrospectively for 274 patients who underwent right hepatectomy, right trisectionectomy or left trisectionectomy for biliary cancer between 1991 and 2008. The mortality rate and incidence of postoperative complications were analysed. Patients were separated into two groups according to year of operation (85 patients operated on between 1991 and 2000; 189 from 2001 to 2008).

RESULTS

In multiple logistic regression analyses, an ICGK-F less than 0.05 had the strongest impact on the incidence of postoperative mortality (odds ratio 8.06; P < 0.001). The postoperative mortality rate was significantly lower in the later period (P < 0.001). In patients with an ICGK-F value between 0.040 and 0.049, the mortality rate in the early period was 30 per cent, whereas it was only 8 per cent in the later period.

CONCLUSION

An ICGK-F of 0.05 is a useful cut-off value for predicting mortality and morbidity. With careful perioperative patient management in an experienced institution, this cut-off value can be lowered further.

He/Ar-atom scattering from molecular monolayers: C60/Pt(111) and graphene/Pt(111)

Supersonic He and Ar atomic beam scattering from C(60) and graphene monolayers adsorbed on a Pt(111) surface are demonstrated in order to obtain detailed insight into a gas-molecule collision that has not been studied in detail so far. The effective masses and phonon spectral densities of the monolayers seen by different projectiles are discussed based on classical models such as the hard cube model and the recently developed smooth surface model. Large effective masses are deduced for both the monolayers, suggesting collective effects of surface atoms in the single collision event. The effective Debye temperature of graphene was found to be similar to that reported in highly oriented pyrolytic graphite (HOPG), indicating that the graphene is decoupled well from the Pt substrate. A much smaller Debye-Waller factor was found for the C(60) layer, probably reflecting the strong C(60)-Pt(111) interaction.

Oceanic Residence Times of Dissolved Beryllium and Aluminum Deduced from Cosmogenic Tracers 10Be and 26Al

The residence times of the soluble fractions of beryllium and aluminum in seawater are estimated to be 1500 years or more. These residence times are estimated from a comparison of the annual deposition rates of cosmogenic beryllium-10 and aluminum-26 with the concentrations of beryllium-10 and aluminum-26 in seawater estimated from the specific activities of these radionuclides in an authigenic mineral assembly such as a manganese nodule. These residence times are greater by an order of magnitude than the mean residence times of beryllium and aluminum estimated from the geochemical balance.

A case of recurrent yolk sac tumor as spindle cell sarcoma of the abdominal wall

Few studies report on tissue morphology in recurrence of yolk sac tumor. The case of the recurrence of a yolk sac tumor as a spindle cell sarcoma of the abdominal wall is presented. A 27-year-old woman was referred to our hospital due to suspicion of an ovarian tumor. Right salpingo-oophorectomy, partial omentectomy, and extirpation of disseminated foci as fertility-preserving surgery was done since the intraoperative pathological diagnosis was yolk sac tumor. Final pathological examination showed a germ cell tumor of which yolk sac tumor formed the major component including a small area that appeared to be immature nerve tissue. Although residual tumor was not less than 1 cm, clinical complete remission was reached after the sixth course of BEP regimen. However, the recurrence of a yolk sac tumor as an unclassified spindle cell sarcoma of the abdominal wall was found about two years after the initial surgery. Thereafter, the patient expired due to progression of the intraperitoneal disseminated lesions. The mesenchyme-like component of the yolk sac tumor is characterized by spindle cells originating from epithelial elements, and is likely to give rise to a chemoresistant, diversely differentiated sarcoma. This report suggests that the sarcoma reported in the case here also arose when spindle cells of the mesenchyme-like component underwent sarcomatous change during or after chemotherapy, subsequently relapsed as a chemoresistant tumor, and metastasized.

A phase II trial of combination irinotecan and oral etoposide chemotherapy in recurrent ovarian cancer: A Tohoku Gynecologic Cancer Unit (TGCU) study

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Background: Various problems still exist in the management of recurrent ovarian cancer and there are limited treatment options especially for the platinum resistant patients (pts). We conducted a phase II study to evaluate the efficacy and safety of the combination irinotecan/oral etoposide chemotherapy. Methods: Eligibility criteria included recurrent ovarian cancer with measurable disease or positive CA125, preserved organ function, and aged 20–75. Treatment was conducted with irinotecan (60 mg/m2 iv, day 1, 15) and oral etoposide (50 mg/body day 1–21), q 28 days until disease progression or unacceptable toxicity. Primary endpoint was response rate (RR) and secondary endpoints included toxicity, progression-free survival (PFS), and overall survival (OS). Results: 38pts were enrolled on this study from May 2003 to April 2007, and all pts were eligible. Median age was 57 yrs (range 37–74). PS 0 in 24 pts, 1 in 10 pts, and 2 in 4 pts. Median number of previous regimen was 2 (range 1–4). Median treatment cycles were 6 (range 2–27). RR (CR+PR) was 18/38 (47.4%), and CR+PR+SD rate was 31/38 (81.6%). Grade 3/4 adverse effect included leukopenia (50.0%), neutropenia (52.6%), anemia (18.4%) and thrombocytopenia (2.6%), nausea/vomiting (7.9%) and diarrhea (2.6%). Treatment-related death was not observed. Median PFS was 7 months (range 1–33) and OS was 19 months (range 4–60). Among 20 pts with platinum resistant cases, RR was 6/20 (30.0%), CR+PR+SD rate was 14/20 (70.0%), median PFS was 6 months (range 1–33), and OS was 24 months (range 5–60). Conclusions: Combination irinotecan/oral etoposide chemotherapy can achieve a superior management for the recurrent ovarian cancer without declining QOL, and also has the possibility to be one of the most effective regimens as second-line chemotherapy.

No significant financial relationships to disclose.

The expression profile of functional regulatory T cells, CD4+CD25high+/forkhead box protein P3+, in patients with ulcerative colitis during active and quiescent disease

Regulatory T cells (T(reg)) have an essential role in maintaining immune tolerance in the gut. The functional CD4(+) T(reg) express the transcription factor forkhead box protein 3 (FoxP3) or a CD25(high) in humans. Further, depletion of elevated granulocytes/monocytes by extracorporeal adsorption (GMA) induces immunomodulation in patients with ulcerative colitis (UC). We investigated the impact of GMA on T(reg). Thirty-one UC patients, clinical activity index (CAI) 12.1 +/- 2.97, refractory to conventional medications including intravenous corticosteroid and 13 healthy controls (HC), were included. Patients received five GMA sessions over 5 weeks. Biopsies from the rectal mucosa and blood samples at baseline and post-GMA were immunostained with anti-CD4/FoxP3 and anti-CD4/CD25 antibodies for immunohistochemistry and flow cytometry. Following GMA, 22 of 31 patients achieved remission (CAI <or= 4, P < 0.01) and their endoscopic activity index decreased from 10.6 +/- 2.32 to 4.75 +/- 1.48 (P = 0.003). The circulating CD4(+)CD25(high+) T(reg) level was low and increased markedly in responders (P < 0.02). In the nine non-responders, the baseline CD4(+)CD25(high+) T(reg) level was about 50% of the level in the responders (P < 0.03) or in the HC (P < 0.01), and all nine had to undergo colectomy. Conversely, the number of CD4(+)/FoxP3(+) mucosal T(reg) in GMA responders decreased significantly after the fifth GMA session compared with the baseline level (P < 0.05). It is believed that the CD4(+) T(reg) has an essential role in the control of immune pathology in UC patients and a net influx of these cells from the circulation into the mucosa may proceed to suppress inflammation. GMA can impact the circulating as well as the mucosal levels of T(reg).

[Surgical removal of native aortic valve thrombosis associated with acute myocardial infarction and protein C deficiency; report of a case]

Native aortic valve thrombosis is an uncommon event. We describe the case of a 76-year-old man who suffered acute myocardial infarction associated with native aortic valve thrombosis diagnosed by cardiac catheterization. Since the thrombus was localized on the right coronary cusp and occluded right coronary artery, rescue revascularization was performed using perfusion catheter, which was continuously engaged to the right coronary artery. Operation was immediately performed under cardiopulmonary bypass. After incision of ascending aorta, thrombus was removed easily and aortic valve was preserved without degenerative change. Histological study showed a typical thrombus without any specific findings. He had a good clinical course and discharged 9 days after the operation. He had no history of heart valve disease, left heart catheterization or bacterial endocarditis. Since laboratory data showed 41% in protein C antigen and 32% of protein C activity, he was diagnosed of protein C deficiency. Our report emphasize that this thrombus formation may be caused by protein C deficiency.

Erythrocyte magnesium and prostaglandin dynamics in chronic sleep deprivation

BACKGROUND AND HYPOTHESIS

The mechanism of sudden cardiac death occurring in patients with chronic fatigue is controversial. This study was designed to define a hypothesis that coronary arterial spasm and thrombus formation can occur during chronic fatigue.

METHODS

For evaluating the feasibility of coronary arterial spasm, erythrocyte magnesium (Mg) was measured. Blood coagulability was evaluated by the change of prostaglandin concentration. Subjects included 16 healthy male volunteers (mean age 21.6 +/- 2.5 years). Test conditions were as follows: (A) control state: a day following a night of good sleep; (B) temporary sleep deprivation: a day preceded by < 3 h of sleep; (C) chronic sleep deprivation: a day preceded by a month during which sleep lasted < 60% of that in condition (A) above. The erythrocyte Mg concentration was measured by the atomic absorption method. The plasma concentration of thromboxane B2 and 6-keto-prostaglandin F1 alpha were measured in eight subjects by radioimmunoassay method.

RESULTS

(1) Mean erythrocyte Mg concentration was significantly less in chronic sleep deprivation (1.1 +/- 0.4 mg/dl) than in the control state (1.8 +/- 0.4 mg/dl, p < 0.01) or in temporary sleep deprivation (1.6 +/- 0.4, p < 0.01). (2) The level of thromboxane B2 was significantly higher during chronic sleep deprivation than under control conditions (104.4 +/- 78.0 vs. 20.4 +/- 9.0 pg/ml, p < 0.05). (3) There were no significant intergroup differences in 6-keto-prostaglandin F1 alpha level.

CONCLUSION

These findings could support the hypothesis that coronary arterial spasm and thrombus formation occur in chronic sleep deprivation.

Two cases of ovarian cancer at an early stage incidentally detected using transvaginal ultrasonography in screening: importance of interval for ovarian cancer screening and selection of population with a high risk of ovarian cancer

Interval of ovarian cancer screening using transvaginal ultrasonography (TVS) and selection of populations with a high risk of this disease are an important issue in detecting early stage-disease. We report two cases of ovarian cancer patients incidentally detected at FIGO Stage I using TVS in the obligatory staff health check. They had undergone other ovarian cancer screening by TVS six months before and received a carefree result at that time. One patient had risk factors (RFs) for ovarian cancer such as obesity and a familal history of ovarian cancer in a first degree relative, and the other had RFs such as obesity and endometrial malignancy. Although cost-effective screening may be important, we recommend that while normal and asymptomatic populations are screened annually, women with any high RFs for ovarian cancer should be screened every six months.

[Emergency off-pump coronary artery bypass grafting for a nonagenarian with acute myocardial infarction; report of a case]

A 92-year-old man was presented with chest pain in home clinic. And he was transferred to our hospital for emergent operation of the acute myocardial infarction. Emergent coronary angiography (CAG) revealed the occlusion of left main trunk (LMT) and 2 vessels disorder. The patent was indicated of an emergency off-pump cardiac artery bypass graft (OPCAB). Our patient had a favorable post-operative course without severe complications, and discharged on post-operative day 23. It is difficult to standarlize the cardiac operation technique and indication of advanced elderly patients. In spite of lower safety margin of nonagenarians, we have to reevaluate the indication considering with physical defect, post-operative quality of life (QOL), the will of patients and their families themselves.