Pulmonary staple granuloma mimicking lung cancer; report of a case

A 67-year-old man was referred to our hospital with chief complaints of bloody sputum and an abnormal chest shadow. He had a history of chronic renal failure and surgery for right pneumothorax. During dialysis treatment 2 years ago, an examination revealed a mass shadow with spiculation in the apex of the right lung. Subsequently, he noted bloody sputum, and the shadow became larger. Serum Progastrin-releasing-peptide (GRP) levels remained within the range of 70-80 pg/ml at the previous clinic, but were elevated to 109 pg/ml on admission to our hospital. These findings suggested lung cancer developing around the scar due to pneumothorax surgery, and we performed an operation. The resected tumor was a granuloma formed around a staple with a polytetra-fluoroethylene (PTFE) sheet, showing no evidence of malignancy. The patient's postoperative course was uneventful, and the serum Pro-GRP level fell to 60 pg/ml.     

Craniopharyngioma of the posterior fossa

A case of craniopharyngioma originating in the very unusual location of the posterior fossa is presented. The patient, a 23-year-old man, was operated on at another hospital when he was 3 years old for craniopharyngioma in the suprasellar area. There was no complaint for several years after this initial operation. Three months before he was admitted to our hospital, he had complaints of headache, vomiting, nausea, and ataxia. A computed tomographic scan revealed a mass with a cyst and calcifications in the posterior fossa. The tumor was removed totally.     

Historical vignette: Dr Charles Robson; pioneer Canadian pediatric anesthetist

Charles Robson (Figure 1) was born in New Westminster, British Columbia (now a suburb of Vancouver), in 1884 and graduated in medicine from McGill University in Montreal in 1913. Having interned and with some anesthesia training at the Royal Victoria Hospital in Montreal, he was sent overseas to work in a Canadian Army Hospital where he founded a school to train military anesthetists. Returning to Canada in 1919, he joined the staff of the Hospital for Sick Children in Toronto as chief anesthetist, a position he held until 1951 (1). During most of this time, he was the sole full-time anesthetist at the hospital; administration of anesthesia at this hospital was not limited to staff anesthetists until 1950 (1).     

局麻下免逆行插管应用Y型负压吸引鞘行经皮肾镜术疗效分析

目的探讨局部麻醉免逆行插管下运用Y型负压吸引鞘行经皮肾镜碎石取石术（PCNL）的效果。 方法通过倾向性评分匹配肾门或第三腰椎横突以上输尿管单颗或简单多颗结石120例,分为观察组60例和对照组60例。观察组采用局麻下免逆行插管并Y型负压吸引鞘行PCNL治疗,对照组采用椎管内麻醉下普通常压鞘下行PCNL治疗。比较两种不同麻醉及治疗方式下手术出血量、麻醉及手术时间、清石率、疼痛分级、术后进食时间、术后住院时间、治疗费用及并发症等。 结果观察组麻醉及手术时间、术后进食时间、术后住院时间及治疗费用等明显少于对照组（P<0.05）;两组间手术出血量、疼痛分级、清石率及并发症的比较,差异无统计学意义（P>0.05）。 结论对于肾及输尿管上段单颗或简单多颗结石,采用局麻免逆行插管Y型负压吸引鞘行PCNL优于椎管内麻下普通鞘行PCNL,值得在临床推广应用。     

Relationship between symptoms of ischemic heart disease and upper abdominal digestive organ disease

We previously reported that percutaneous trans-arterial coronary angioplasty (PTCA) seemed to decrease cardiac complications in patients with ischemic heart disease (IHD) who underwent abdominal surgery. After the report, 1293 PTCAs were performed for patients with IHD in our institute. Of these 1293 patients, 6 patients underwent abdominal surgery under general anesthesia within 14–150 days after successful PTCA. We observed the relationship between symptoms of IHD and upper abdominal digestive organ disease (ADOD), which sometimes occurs concomitantly in IHD patients. In conclusion, the present study identified some features of the chief complaints and symptoms of IHD patients with concomitant upper ADOD. This information should prove useful for making a differential diagnosis and deciding treatment.An abstract of this study was presented at the annual meeting of the Japanese Society of Internal Medicine, Nagoya, Japan, 2002.     

Munchausen syndrome, a factitious injury, presenting brain abscess and intraventricular hemorrhage: a case report

Munchausen syndrome is a factitious disorder. Patients sometimes inflict injury on themselves in order to assume a sick role. The authors report a patient with Munchausen syndrome suffered from brain abscess, reopened wound and intraventricular hemorrhage. A 64-year-old male was admitted to our hospital after head injury. CT and MR imaging revealed a mass with surrounding edema in the right frontal lobe. The mass was surgically removed, and diagnosed as brain abscess. During the surgery, the authors noticed a small bone defect in the frontal bone above the brain abscess; therefore, we considered that head injury just concerned this lesion. There were no particular clues leading to other possible pathologies. After the first surgery, the patient presented atypical seizures several times. Once we discharged him from our hospital, we hospitalized him again because the wound had reopened. A subsequent operation was needed, and we removed the bone flap which we considered the origin of the infection. After the second surgery, he stabbed a nail into his head where the bone had been removed due to the previous surgery, and presented intraventricular hemorrhage. The hemorrhage decreased in size through non-surgical treatment and he was referred to the psychiatry department under a diagnosis of Munchausen syndrome. Diagnosis of this entity is difficult and often made at the later stage of hospitalization, because patients present a variety of complaints and clinical symptoms, which are hardly proved factitious. Early consideration of this syndrome will offer an early and accurate diagnosis, and is mandatory for a good prognosis.     

Testicular cancer metastatic to multiple organs including the stomach, kidneys, and skin: a case report

A 39-year-old man whose chief complaints were general fatigue and bloody phlegm was diagnosed with testicular cancer and underwent left high orchiectomy at an affiliated hospital. The histopathologic diagnosis was chorio carcinoma. Several imaging examinations revealed the metastases in the lung, liver, brain, stomach, kidneys and skin. In spite of various chemotherapies, he died 17 months after the operation. Skin metastasis of testicular cancer is very rare and this is the twelfth case reported in the world, to our knowledge. The significance of skin metastasis in testicular cancer is discussed.     

使用筋膜扩张器治疗单纯性男性尿道狭窄(附18例报告)

目的:探讨应用输尿管镜联合筋膜扩张器进行尿道扩张治疗男性尿道狭窄的临床疗效。方法:18例尿道狭窄患者在输尿管镜直视下置入斑马导丝通过狭窄处进入膀胱,沿留置的斑马导丝逐号置入筋膜扩张器扩张尿道,儿童患者可根据年龄用筋膜扩张器扩张至适当型号即可;而成人用筋膜扩张器扩张至F18号后,可根据需要再用F20号以上的金属扩张器进行扩张。然后留置合适型号的导尿管1周至1个月,随访6~24个月。结果:18例患者均一次扩张成功,无尿道穿孔、撕裂及假道形成等并发症。其中16例经定期尿道扩张治愈,其余2例因尿道狭窄复发而转为开放手术治疗。术后最大尿流率(Qmax)为13.6~30.2(18.1±3.5)ml/s。结论:输尿管镜直视和斑马导丝引导下用筋膜扩张器进行尿道扩张方法简单,安全有效,是治疗男性尿道狭窄的一个较好的选择。     

Intraperitoneal spontaneous rupture of the bladder subsequent to irradiation of the uterus: a case report

We report a case of spontaneous intraperitoneal rupture of the bladder. A 54-year-old woman was admitted to our hospital with the chief complaints of severe lower abdominal pain, dysuria and macroscopic hematuria in October, 1985. In 1969, she had had a radical hysterectomy and postoperative irradiation for cancer of the uterus. Two years later she had undergone additional irradiation. On physical examination, the abdomen was tender with guarding and signs of peritonitis. Laboratory data revealed a blood urea nitrogen of 32.8 mg/dl and all electrolytes were normal. Excretory urogram showed normal upper urinary tract but irregularity of the bladder dome. Cystoscopy revealed acute inflammation of the bladder mucosa. Consequently, we made a presumptive diagnosis of radiation cystitis and she was treated with antibiotics and drip infusion. Within a week her general condition was improved and she had discharged. In June, 1986 she was admitted again with the same chief complaints as at her first admission. Cystoscopic findings showed a hole on the postero-superior wall and retrograde cystogram revealed an intraperitoneal rupture of the bladder. At exploration a necrotic bladder wall was resected and closed in 3 layers. The post operative course was uneventful.     

A successful one stage treatment in angina pectoris and intermittent claudication of both legs

A successful surgical case of concomitant aorto-coronary bypass grafting and aorto-right iliac, left femoral bypass grafting was presented. A sixty-two years old male admitted to our institution with complaints of angina pectoris and intermittent claudication of both legs who had a history of acute inferior myocardial infarction for which emergency percutaneous coronary balloon dilatation was carried out prior to this admission. In this admission, he was found out to have diabetes mellitus moreover and he hoped to have one staged operation for two different type of the disease. After general anesthesia, at first, aorto-right coronary bypass grafting with saphenous vein graft was carried out under cardio-pulmonary bypass, then aorto-right iliac, left femoral bypass grafting with a dacron bifurcated graft was made only with one time of systemic heparinization. His postoperative course was uneventful and discharged in good condition. We conclude that simultaneous aorto-coronary bypass and revascularization of both legs can be done with minimal risk.     

三种扩皮送鞘法在肿瘤患者PICC置管中的应用效果观察

目的 探讨三种扩皮送鞘法在超声引导下改良塞丁格技术PICC置管中的应用效果,为临床操作提供参考。方法 将384例肿瘤科行PICC置管患者随机分为A、B、C三组,各128例。A组采用微插管鞘中的扩张器与传统穿刺针的外鞘组装后直接扩张穿刺点后送鞘的钝性分离法;B组采用扩张器与导管鞘组件扩张穿刺点后送鞘的钝性分离法;C组采用扩皮刀扩张穿刺点后推进血管鞘的方法。比较三组患者一次性送鞘成功率、置管后24 h穿刺点渗血情况及置管术中疼痛评分。结果 A组和C组一次性送鞘成功率100%,B组一次性送鞘成功率95.31%。三组穿刺点渗血情况、局部渗液发生率比较,差异有统计学意义（均P<0.01）,A组和B组显著低于C组。A组和B组术中疼痛评分低于C组。结论 采用微插管鞘中的扩张器与传统穿刺针的外鞘组装后直接扩张穿刺点后送鞘的钝性分离法行PICC置管,不仅一次性送鞘成功率高,且患者置管术中疼痛及术后穿刺点局部渗血渗液等并发症发生率较低。     

Extramedullary relapse of acute lymphoblastic leukemia in childhood to the prostate

A 6-year-old boy presented with the chief complaints of miction pain and pollakisuria. He had a past history of acute lymphoblastic leukemia (ALL), which subsided in response to chemotherapy at 3 years of age. Ultrasonography revealed urinary retention associated with bilateral hydronephrosis secondary to the prostate enlargement. Computed tomography and magnetic resonance imaging showed no other abnormal finding. Transrectal needle biopsy showed infiltration of leukemic cells in the prostate. Bone marrow puncture and cerebrospinal fluid aspiration revealed no leukemic cells, resulting in a diagnosis of extramedullary relapse of ALL in the prostate. Although he was successfully treated by chemotherapy, irradiation and his voiding function was improved, ALL relapsed in the left testis 1 year later. In spite of left orchiectomy, irradiation and additional chemotherapy, he died of bone marrow relapse and multiple organ failure. Extramedullary relapse of ALL in the prostate is very rare. To our knowledge, our case is the first well-documented report in the published work.     

Perforation of the superior vena cava and hemothorax caused by insertion of a pulmonary artery catheter

A 70-year-old woman with aortic regurgitation was scheduled for aortic valve replacement. After induction of anesthesia resistance was encountered when attempting to remove the guide wire with a sheath dilator prior to insertion of a pulmonary artery (PA) catheter through the right internal jugular vein. Ten hours after catheter insertion, chest X-ray examination in ICU showed poorly delineated right lung field, and hemothorax was suspected, as a large amount of fluid was also seen draining from the chest drain tube. Twenty two hours after catheter insertion, we opened her chest and found that the superior vena cava (SVC) had been perforated. After surgical closure of the hole on the SVC, the hemodynamics because stabilized and active bleeding was controlled. The patient was subsequently discharged from the hospital without any further complications. This perforation was thought to be caused by carelessness during insertion of the PA catheter. To prevent serious complications, such as perforation of the great vessels or heart by a catheter, the results of the present case suggest that careful attention is required during catheterization, especially when resistance is encountered.     

A case of myxofibrosarcoma of the bladder

A 43-year-old woman presented to our hospital with the chief complaints of gross hematuria and dysuria. Cystoscopy and magnetic resonance imaging showed a tumor on the dome of the bladder and large blood clots. Computed tomography demonstrated no findings of distant metastasis. Following transurethral resection of the tumor, the tumor was histologically diagnosed as myxofibrosarcoma with muscular invasion, and partial cystectomy was performed in September 2009. There has been no evidence of recurrence or metastasis for 24 months postoperatively. In addition, the Japanese literature on myxofibrosarcoma of the bladder was reviewed and discussed.     

Torsion of the spermatic cord in undescended testis: report of two cases

We report two cases of torsion of the spermatic cord in undescended testis. Case 1: A 23-year-old man was admitted to our hospital with the complaints of fever and left inguinal pain. He had cerebral palsy in his past history. Tentative diagnosis of acute epididymitis of left undescended testis was made, and antibacterial drugs were given. Response was poor, and torsion of the spermatic cord was suspected strongly. Torsion of the spermatic cord in undescended testis and severe testicular infarction were seen in surgery after 13-day conservative treatment. Orchiectomy was performed. Case 2: A 6-year-old boy was admitted to our hospital with the chief complaints of left inguinal mass and pain. He had felt abdominal pain for 3 days. Scrotal contents were impalpable and the diagnosis of torsion of the spermatic cord was made. Orchiectomy was performed due to severe testicular infarction.     

A case of prostatic hyperplasia in a young male

Prostatic hyperplasia in young males is a very rare disease. A 28-year-old man was admitted to our hospital on June 24, 1989, with the chief complaints of intermittent macrohematuria and dysuria. Endoscopic examination revealed two papillary tumors in the prostatic urethra; no urinary bladder tumor was found. A transurethral resection was done for the urethral tumors. Pathological examination revealed prostatic hyperplasia. These lesions were considered ectopic prostatic tissue at first. However, imaging showed that this may in fact be prostatic hyperplasia of the apical region near the capsule. The post-operative course was uneventful and he is presently observed as an outpatient. This patient represents the seventh case reported in the literature.     

Anesthetic management of parturients with cerebrovascular diseases]

From January 1992 to December 1997, 13 parturients with cerebrovascular diseases had childbirth at our institution. Among them, 8 patients received anesthesia for delivery. Five patients had a history of ruptured arteriovenous malformation (AVM), cerebral aneurysm, or intraventricular bleeding due to moyamoya disease, and they had radical operations. Of these 5 patients after radical operations, three had a repeat cesarean section under spinal anesthesia, and two had a vaginal delivery under epidural anesthesia to avoid excessive hypertension and hyperventilation. There were two patients with a history of cerebrovascular diseases but had no radical operations. Of these two, one patient who was diagnosed as having aneurysm underwent elective cesarean section under spinal anesthesia, and another patient with a history of cerebral bleeding underwent cesarean section under general anesthesia for abruptio placentae. These 7 patients did well during pregnancy and puerperium. The eighth patient experienced severe headache followed by loss of consciousness caused by ruptured AVM, and required an emergency operation. Simultaneous cesarean section and craniotomy were performed at another hospital. Intrauterine fetal death (IUFD) occurred, but mother survived.     

A case of chronic subdural hematoma associated with idiopathic thrombocytopenic purpura (ITP)

A 41-year-old male was admitted to our service with right occipital pain as his chief complaint. CT and MRI examinations revealed bilateral chronic subdural hematomas. The patient had also been affected with ITP since the age of 28. Since emergency operation was thought to be dangerous, he was transferred to Tokushima University Hospital, and treated preoperatively by administration of steroids and a large dose of immunoglobulin. When his platelet count had returned to 146,000/mm3, evacuation of the hematoma through burr holes was performed successfully under local anesthesia. The postoperative course was uneventful. So far as we have been able to find in the literature, only 3 cases of ITP complicated by chronic subdural hematoma have been reported. The characteristic clinical feature of these 4 cases including our own case was noted as the absence of a history of trauma. However, the etiological relationship between ITP and chronic subdural hematoma was controversial. Occurrence of chronic subdural hematoma in patients with ITP and in patients under hemodialyzer treatment is very rare. However, intracerebral hemorrhages are rather common among such patients. So it was suggested that the tendency to bleeding among patients with ITP, and among hemodialyzer patients may contribute little as an etiological factor in the evolution of chronic subdural hematoma.     

Breast Biopsy: A Study of Cost-effectiveness

The entry of third party payors into the field of health care has brought about increasing awareness of cost-effectiveness. Since breast biopsy is among the most commonly performed operations and open to criticism, the purpose of this report is to provide data relative to cost-effectiveness of breast biopsies at the University of New Mexico and to compare such data with 1) cost-effectiveness of mammographic screening for breast cancer, and 2) cost-effectiveness of judicious use of mammography in patients with breast complaints. From 1972 through 1978, 1064 patients were seen because of complaints relative to the breasts and 516 breast biopsies were done. Seventy patients were found to have cancer (14% of the breast biopsies). Using the October 1978 through March 1979 cost schedules for hospital and professional fees, the average cost of a breast biopsy was $1,216.00 for general anesthesia, $751.00 for assisted local anesthesia, and $520.00 for local anesthesia. The major differences lay in 1) anesthesia and operating room average charges of $618.00 for general anesthesia, $451.00 for assisted local anesthesia, and $260.00 for local anesthesia; 2) room charge of $174.00 for general anesthesia; and 3) laboratory and x-ray charges of $256.00 for general anesthesia, $120.00 for assisted local anesthesia, and $91.00 for local anesthesia. In 1978 64% of breast biopsies were done under local anesthesia as opposed to 1972 when 22% were done under local anesthesia. For the 516 breast biopsies, 47% were done under local anesthesia, 4% under assisted local anesthesia and 49% under general anesthesia. The calculated overall cost of the 516 breast biopsies was $448,794.00 or $6411.00 per cancer. Comparing our data to those of Lewis at our 1978-79 cost schedules and assuming our anesthetic mix in his patients, his cost per cancer identified was $3973.00 in patients with breast complaints. His cost figure is considerably lower than ours because of a higher yield of cancer (41%). Making the same assumptions for cost and anesthetic mix, the cost per biopsy proved cancer diagnosed in mammographic screening for breast cancer is $11,175.00 (Feig), and $24,482 (Lewis). Thus, 1) use of local anesthesia rather than general anesthesia reduces cost of breast biopsies by $694.00 per breast biopsy, 2) greater precision in selection of patients for breast biopsies is mandatory to reduce cost of diagnosis of cancer, 3) present state of the surgical art is more cost-effective than is screening for breast cancer.     

Does a ureteral access sheath facilitate ureteroscopy?

PURPOSE: Ureteral access sheaths were initially developed to facilitate difficult ureteroscopic access. However, to our knowledge no formal evaluations have been performed to assess the routine use of ureteral access sheaths. Therefore, we prospectively analyzed intraoperative time, symptomatic outcome, major complications, stone-free rate and overall costs related to the routine use of a new ureteral access sheath during standard ureteroscopic procedures. MATERIALS AND METHODS: Patients undergoing 6.5Fr semirigid or 7.5Fr flexible ureteroscopy were prospectively randomized to unaided ureteroscopy with no access sheath or ureteroscopy via a 12-14Fr ureteral access sheath. Patients who required ureteral dilatation were randomized to the ureteral access sheath used as a dilator or a standard 18Fr ureteral balloon dilator. Patients were evaluated postoperatively on days 0, 1 and 6 with a questionnaire to assess pain, irritative symptoms and complications. The stone-free rate and long-term complications were determined by excretory urography or computerized tomography at 3 months. RESULTS: Enrolled in the study were 59 consecutive patients, who underwent a total of 62 ureteroscopic procedures. Of the 47 patients (76%) who did not require ureteral dilatation 23 (49%) underwent ureteroscopy via the ureteral access sheath and 24 (51%) underwent unaided ureteroscopy. Seven of the 15 patients (28%) who required ureteral dilatation underwent access sheath dilatation, while balloon dilatation was performed in 8. There was no significant difference in postoperative symptoms, complication rate or stone-free status in the access sheath and nonaccess sheath groups in patients not requiring ureteral dilatation (p <0.05). A significant increase in postoperative symptoms was noted when the balloon was used as a dilator compared to the access sheath. Operative time and costs in all patients who underwent access sheath dilatation were less than in those in whom the access sheath was not used. In the 15 patients who required dilatation 71% of access sheath and 100% of balloon dilatations were successful. CONCLUSIONS: Routine use of a ureteral access sheath appears to facilitate semirigid and flexible ureteroscopy by decreasing operative time and costs, allowing direct visualization of ureteroscope insertion with simple ureteral re-entry and assisting renal and ureteral access with minimal associated morbidity. A ureteral access sheath should be considered for routine ureteroscopic procedures.