Relation between small airways disease and parenchymal destruction in surgical lung specimens.

The relation between small airways disease and parenchymal destruction was investigated in lungs and lobes removed at surgery from 27 patients aged 15-70 years. Eight of the 27 patients were life-long non-smokers. The degree of small airways disease was assessed by semi-quantitative grading (SAD score) and by measuring diameter and wall thickness of membranous bronchioles. Parenchymal destruction was measured in three ways. Firstly, the number of alveolar attachments on membranous bronchioles per millimetre of circumference (AA/mm) was counted; the number of broken attachments was subtracted from the total AA/mm to give the numbers of intact attachments (normal AA/mm). Secondly, a point counting technique was used to give a destructive index (DI). Thirdly, the mean linear intercept (Lm) was determined. Total and normal AA/mm correlated negatively with the SAD score of membranous bronchioles (rs = -0.48 and -0.51) and with wall thickness (rs = -0.37 and -0.45) and DI correlated with wall thickness (rs = 0.5) and with the SAD score of respiratory bronchioles (rs = 0.53). Lm did not correlate with indices of small airway disease and total and normal AA/mm did not correlate with diameter. Multiple regression analyses showed that the correlation of total AA/mm with the SAD score of membranous and respiratory bronchioles and with wall thickness were not confounded by age or smoking. It is concluded that small airways disease is related to destruction of peribronchiolar alveoli, and it is postulated that small airways disease has a direct role in the causation of centrilobular emphysema.     

Posterior wall laceration of the thoracic trachea: the transcervical–transtracheal approach

A large membranous wall laceration of the thoracic trachea was surgically treated. The surgical approach consists on a low collar incision followed by a longitudinal tracheotomy. The membranous tear was repaired with a running suture and tracheotomy sutured with interrupted crossed stitches. The procedure was effective and endoscopic follow-up showed a perfect healing process with no signs of tracheal stenosis. This new technique proved to be a reliable, quick and safe procedure, which allows to repair membranous lacerations as far as the carina, avoiding thoracotomy.     

Tracheomalacia

Tracheomalacia is a rare tracheal problem that leads to collapse of the airway and expiratory flow obstruction. Expiratory CT scans are the diagnostic test of choice in adults. Chronic obstructive pulmonary disease is the most common cause of adult tracheomalacia. Plication of the membranous wall to polypropylene mesh to recreate the normal airway shape (membranous wall tracheoplasty) is an effective treatment in adults.     

Different erythrocyte and platelet surface electric charge in various types of glomerulonephritis

BACKGROUND: Some preliminary observations suggest that predisposition to a particular type of glomerulonephritis (GN) may be connected with the genetically determined charge of the glomerular capillary wall. A correlation between erythrocyte surface and the glomerular capillary wall charges has also been observed. The purpose of this study was to verify and extend previous investigations. Therefore we measured erythrocyte and platelet surface charge from patients with idiopathic membranous and mesangial GN as well as idiopathic membranoproliferative GN and lupus nephritis. METHODS: The erythrocyte and platelet surface charge was determined by the binding of the cationic dye, alcian blue (AB). A fresh alcoholic AB solution was made for each experiment, which were run in batches of four, each including cells from a healthy person and from patients each with a different type of GN. RESULTS: In patients with idiopathic membranous and membranoproliferative GN, a significant decrease in the erythrocyte and platelet charges was observed irrespective of their clinical state (remission or nephrotic syndrome). Erythrocyte charge was decreased despite the normal amount of membranous sialic acid. In contrast, patients with idiopathic mesangial GN, in complete or partial remission, exhibited normal erythrocyte and platelet surface charges. Exclusively in this type of GN, the appearance of nephrotic proteinuria was associated with a slight decrease, the erythrocyte charge, which was not statistically significant (P > 0.1). A reduction in the negative erythrocyte charge in lupus nephritis was less in magnitude than in idiopathic membranous or membranoproliferative GN, and occurred independently of the level of daily proteinuria, whereas the platelet charge was normal. CONCLUSION: The decrease of the erythrocyte and platelet charge in idiopathic membranous and mebranoproliferative GN seems to be a pre-morbid feature.      

Insulin deposits in membranous nephropathy associated with diabetes mellitus.

Seven diabetic patients with membranous nephropathy were immunohistologically studied in order to clarify the role of extrinsic insulin in membranous nephropathy. In three cases (group A), granular deposits of insulin were detected along the glomerular capillary wall with indirect immunoperoxidase technique using anti-porcine insulin antibody, where IgG and C3 were deposited in the identical pattern. The other four cases (group B), 8 of idiopathic membranous nephropathy, and 5 of diabetic glomerulosclerosis showed no insulin deposit in the glomerulus. Clinically, proteinuria was heavier in group A (mean +/- SE; 32.0 +/- 5.4 g/day) than in group B (5.5 +/- 0.5). Nephrotic syndrome developed after the beginning of the therapy with porcine insulin, and in two of them, proteinuria was ameliorated after porcine insulin was replaced by human insulin. Since porcine insulin is a heterologous peptide for human beings and has antigenicity when injected into patients, immune complex composed of insulin and anti-insulin antibody may cause membranous nephropathy in some diabetic patients treated with this animal insulin.     

Anatomical approach for surgery of the male posterior urethra

OBJECTIVE

To investigate, in a morphological study, the anatomy of the male rhabdosphincter and the relation between the membranous urethra, the rhabdosphincter and the neurovascular bundles (NVBs) to provide the anatomical basis for surgical approach of the posterior urethra as successful outcomes in urethral reconstructive surgery still remain a challenging issue.

MATERIALS AND METHODS

In all, 11 complete pelves and four tissue blocks of prostate, rectum, membranous urethra and the rhabdosphincter were studied. Besides anatomical preparations, the posterior urethra and their relationship were studied by means of serial histological sections.

RESULTS

In the histological cross‐sections, the rhabdosphincter forms an omega‐shaped loop around the anterior and lateral aspects of the membranous urethra. Ventrally and laterally, it is separated from the membranous urethra by a delicate sheath of connective tissue. Through a midline approach displacing the nerves and vessels laterally, injuries to the NVBs can be avoided. With meticulous dissection of the delicate ventral connective tissue sheath between the ventral wall of the membranous urethra and the rhabdosphincter, the two structures can be separated without damage to either of them. This anatomical approach can be used for dissection of the anterior urethral wall in urethral surgery.

CONCLUSIONS

Based on precise anatomical knowledge, the ventral wall of the posterior urethra can be dissected and exposed without injuring the rhabdosphincter and the NVBs. This approach provides the basis for sparing of the rhabdosphincter and for successful outcomes in urethral surgery for the treatment of bulbo‐membranous urethral strictures.     

Partial sleeve right pneumonectomy with carinal flap closure

We describe a technique used in 2 patients for resection of carcinoid tumor arising from the right main bronchus and extending along the lateral wall of the lower trachea. A flap was mobilized from the non-involved membranous posterior wall of the right main bronchus, which was left attached to the carina. This was used to close the defect in the lower trachea. Both patients did well after surgery and were followed-up for 10 to 17 years with no evidence of recurrence.     

前列腺癌患者根治术后尿失禁的预防

目的探讨保护尿道膜部括约肌和神经血管束及重建膀胱颈部对前列腺癌根治术后尿失禁的预防作用。方法对32例前列腺癌采用保护尿道膜部括约肌和前列腺旁神经血管束,并在重建膀胱颈部黏膜充分外翻后的后壁行折叠缝合1针的方法,进行前列腺癌根治术,观察术后尿失禁发生情况。结果经6～72个月随访,全部患者排尿通畅,无肿瘤复发,除2例发生轻度尿失禁外,其余30例在6个月内均恢复尿控能力。结论保护尿道膜部括约肌和前列腺旁神经血管束,在充分外翻膀胱黏膜的重建膀胱颈后壁折叠缝合,能减少前列腺癌根治术后尿失禁的发生。     

Tracheoplasty in a large tracheoesophageal fistula.

Postintubation tracheoesophageal fistulas (TEFs) are severe lesions that can be associated with tracheal stenosis and therapeutic difficulties. A case is reported of a woman with TEF and postintubation tracheal stenosis with 6.5 cm of affected trachea, and total esophageal exclusion. A tracheoplasty method is described patching the loss of the tracheal membranous wall with the posterior esophageal wall. In a final step, a self-expanded tracheal stent and esophagocolic bypass were added.     

Mechanical properties and innervation of the smooth muscle layers of the urethra of greyhounds

OBJECTIVE: To investigate the properties of the smooth muscle layers in the urethral wall of male and female greyhounds, and to consider their roles in continence and micturition. MATERIALS AND METHODS: The distribution and innervation of the smooth muscle layers of the prostate capsule and membranous urethra of male greyhounds were assessed. Strips of smooth muscle from these regions were used to determine the neuropharmacological properties by assessing the excitatory and inhibitory responses to nerve stimulation, and the effects of blocking agents. These were compared with strips from the proximal urethra and from the female urethra. RESULTS: The smooth muscle of the membranous urethra comprised 9% of the wall and received its innervation exclusively in branches from the pelvic plexus. The cholinergic innervation in the male produced 80% of the total contractile response in the longitudinal membranous urethra, 50% in the prostate capsule and 13% in the circular muscle of the proximal urethra. In the female all areas had poor contractile responses. Inhibitory fibres produced relaxation in all parts of male and female urethrae with the major effect caused by nitric oxide. Adrenergic nerves contributed to both residual excitation (alpha receptors) and inhibition (beta receptors). CONCLUSIONS: The longitudinal smooth muscle of the male membranous urethra probably shortens the urethra during micturition, through the activity of cholinergic nerves, whereas the circular smooth muscle of the proximal urethra, under adrenergic control, may be contracted during continence and ejaculation. In the female, the smooth muscle plays a minor role.     

Changes in heparan sulfate correlate with increased glomerular permeability

The glomerular capillary wall functions as both a size-selective and charge-selective barrier. Heparan sulfate is known to be an important component of the charge-selective barrier to filtration of polyanions. We studied the alterations in both the charge and size selectivity barriers in a model of experimental membranous nephropathy in the rabbit. The fractional clearance of both charged and uncharged dextrans compared to inulin was measured. Sulfate incorporation into glycosaminoglycans was measured and the glomerular heparan sulfate was isolated and biochemically characterized. Membranous nephropathy in the rabbit was induced with daily injections of cationic bovine serum albumin. After three weeks of injection animals had 735 +/- 196 mg/24 hours of protein excretion. There was no change in [35S] incorporation in 24 hours by experimental animals, 440 +/- 91 DPM/mg dry weight of glomeruli, N = 9 versus 410 +/- 98, N = 11 in controls. The percentage of [35S] incorporated into heparan sulfate versus chondroitin sulfate was decreased, 60% +/- 3 versus 79% +/- 2, P less than 0.001. Heparan sulfate from membranous nephropathy eluted from ion exchange chromatography in a lower molarity salt, indicating a lower effective charge. Fractional clearance of neutral dextrans was significantly increased in membranous nephropathy for dextrans greater than 48 A, while fractional clearance of dextran sulfates was significantly increased compared to controls for dextrans greater than 32 A. Thus, in membranous nephropathy there is loss of both charge selectivity and size selectivity. The loss of charge selectivity correlated with a change in the structure of the glomerular heparan sulfate.(ABSTRACT TRUNCATED AT 250 WORDS)     

Membranous glomerulonephritis in a patient with ankylosing spondylitis: a rare association

Ankylosing spondylitis is a chronic inflammatory disease of the vertebral joints and soft tissues. Renal involvement, apart from amyloidosis, is rare in this disorder. Of the various glomerulonephritides reported in association with ankylosing spondylitis, IgA nephropathy is the most common. Membranous glomerulonephritis occurs very rarely in patients with ankylosing spondylitis, and only four such cases have been reported in the available English literature. Due to the rarity of this association, membranous glomerulonephritis may not initially be considered in patients with ankylosing spondylitis and proteinuria. We report the case of a 29-year-old man with ankylosing spondylitis who presented with pedal edema and was detected to have nephrotic syndrome. A percutaneous renal biopsy showed features of membranous glomerulonephritis with capillary wall granular deposits of IgG and C3 on immunofluorescence and subepithelial immune complex deposits on electron microscopy. No other secondary cause of membranous glomerulopathy was found on extensive investigations. Membranous glomerulonephritis is extremely rare in association with ankylosing spondylitis, the present case being the fifth such report. The exact relationship of these two entities (etiological or coincidental) still needs to be elucidated. The occurrence of this rare association needs to be recognized and differentiated from other more common causes of renal involvement in ankylosing spondylitis.     

Tracheoplasty--a new operation for complete congenital tracheal stenosis

This is a report of a case of complete congenital tracheal stenosis confirmed by tracheobronchogram. The stenosis also involved the origin of the right main bronchus. The membranous portion of the trachea was absent. It was repaired through a sternotomy and right thoracotomy aided by partial cardiopulmonary bypass. The posterior trachea was opened from larynx to carina and on into the right main bronchus, and each posterior tracheal edge was sewn to the anterior wall of the esophagus with a running Prolene suture. Three months after repair bronchoscopy showed that the new membranous trachea was epithelialized and the entire airway was of good caliber; the only problem was a diffuse tracheomalacia. He died in his seventh postoperative month after a major airway complication due to tracheotomy, which occurred after an elective bronchoscopy. It is obvious that this operation is technically feasible. It was hoped that his airway would become sufficiently stable to allow the tracheotomy tube to be removed at some time in the future.     

Congenital bilateral diaphragmatic eventration with membranous chest wall hamartoma

The case of a 2-month-old girl with congenital bilateral eventration of the diaphragm is reported. After normal delivery from cephalic position, the patient developed respiratory distress. Mechanical ventilation started immediately but extubation was difficult A membranous lesion was found on computed tomography of the chest. Resection of the membrane between the right middle and lower lobes and bilateral diaphragmatic plication was performed. Histologically the membrane was a chest wall hamartoma. The patient was extubated on 6 day postoperatively and is alive and well 4 months after surgery.     

Repair of large, iatrogenic, tracheo-esophageal fistulae

Closure of large, iatrogenic, tracheo-esophageal fistulae present a formidable technical challenge. Our method of repair is presented, which describes the exposure and subsequent closure that relies on creating a new "membranous" trachea using remnant flaps of the esophageal wall of the fistula.     

An overlapping syndrome of IgA nephropathy and membranous nephropathy?

This is the first report of primary glomerular disease with both mesangial IgA and subepithelial IgG deposits in the glomeruli at the same time. This nephropathy, discovered in 3 patients, is either a new disease entity or an overlapping of IgA nephropathy and membranous nephropathy. Follow-up studies may clarify the pathogenesis of IgA nephropathy and/or membranous nephropathy. In 1 patient the clinical findings resembled those of IgA nephropathy, and in the other 2 they were those of membranous nephropathy. Light microscopy showed generalized diffuse increases in mesangial cells and matrix, and there was slight capillary wall thickening. In the glomeruli, immunofluorescence microscopy demonstrated both granular deposits of IgA in the mesangium and granular deposits of IgG along the capillary loops. On electron microscopy, electron-dense deposits were identified not only in the mesangium but also on the epithelial side of the glomerular basement membrane. These findings were confirmed by the immunoperoxidase technique in electron-microscopic studies of these antibody classes. These glomeruli contained both the dense reaction products of IgA deposits in the paramesangium and mesangial matrix and the dense reaction products of IgG deposits on the epithelial side of the basement membrane.     

Evaluation of tracheo-bronchial wall invasion using transbronchial ultrasonography (TBUS).

BACKGROUND: Whereas accurate evaluation of tumor invasion into the tracheo-bronchial wall is a critical factor in decision-making of therapy for intra-thoracic malignancies, it is sometimes difficult with usual thoracic imaging techniques such as computed tomography. As recent progress in technology of ultrasonography is marked, usefulness of transbronchial ultrasonography (TBUS) in evaluation of tracheo-bronchial wall invasion was assessed. METHODS: Following routine fiberoptic bronchoscopy, an ultrasound probe (20 MHz) covered with a balloon sheath was inserted through the bronchoscope. After air present between the ultrasound probe and the tracheo-bronchial wall was eliminated with filling the balloon with distilled water, TBUS imaging was taken. RESULTS: With TBUS, normal tracheo-bronchial wall was represented as a five-layer structure at the cartilagenous portion and a three-layer structure at the membranous portion. Based on this normal TBUS imaging, tumor extent was judged in 35 patients with intra-thoracic malignancies. Among 25 patients with extra-wall tumor including esophageal cancer (n=15) and metastatic lymph nodes (n=7), tracheo-bronchial wall invasion was clearly demonstrated in nine patients, and no invasion was demonstrated in the other 16 patients. Among ten patients with tumor originating from the tracheo-bronchial wall, tumor extent beyond outer border of the wall was demonstrated with TBUS in five patients. These diagnoses were examined pathologically in 15 patients who underwent the operation, and the accuracy was 93.3%. CONCLUSIONS: It is suggested TBUS can be a useful diagnostic tool in evaluation of tumor invasion to the tracheo-bronchial wall.     

保留神经血管束的耻骨后前列腺癌根治术的疗效观察

目的：小结开展保留神经血管束的耻骨后前列腺癌根治术（RRP）的经验和教训。方法：对40例穿刺活检证实的前列腺癌患者行RRP,术前采用新辅助治疗,术中采用保护尿道膜部括约肌和前列腺侧旁神经血管束,并在重建膀胱颈部粘膜充分外翻后的后壁行折叠缝合1针。间断、无张力行残留尿道和外翻的膀胱颈缝合。结果：经3～78个月随访,全部患者排尿通畅,无肿瘤复发;除2例发生轻度尿失禁外,余38例在6个月内均恢复尿控能力。结论：充分做好耻骨后前列腺癌根治术前的准备工作,有利于手术操作;术中保护好尿道膜部括约肌和前列腺侧旁神经血管束,在充分外翻膀胱粘膜的重建膀胱颈后壁折叠缝合,能减少前列腺癌根治术后尿失禁的发生。     

Anatomical study of total cystoprostatectomy

The authors describe an anatomical study of total cystoprostatectomy. They show that Denonvilliers' fascia is made up of many membranous layers starting at the bladder. They recall the fact that the preprostatic veins are attached at the bottom, not only to the venae dorsales penis, but also to the venae pudendae internae which runs under the levator ani muscle. These preprostatic veins lie inside a vessel-bearing blade of tissue made of muscular and collagenous tissue derived from the anterior vesical wall. This anatomical study recalls the fact that the interprostatorectal dissection line is behind Denonvilliers' fascia and that the preprostatic vein dissection line is on the anterior aspect of the membranous urethra.     

A case of tracheal benign mixed tumor]

A 44-year-old male was admitted because of dyspnea. Bronchoscopy revealed a tumor obstructing 85% of the tracheal lumen, at the site of the membranous portion, 3 cm below the vocal cords. The tumor was removed by sleeve tracheal resection with end to end anastomosis. Histological findings showed benign mixed tumor (pleomorphic adenoma) arising from the tracheal wall. Postoperative course was uneventful. Only 5 tracheal mixed tumors have been found in the Japanese literatures. Therapeutic approach to this tracheal tumor is discussed in this paper.