Traumatic carotid cavernous fistula complicated with intracerebral hemorrhage: case report

A 45-year-old woman presented with a rare case of traumatic carotid cavernous fistula (CCF) complicated with intracerebral hemorrhage after injury in a car accident. She had multiple injuries including facial bone fracture and slight subarachnoid hemorrhage around the left sylvian fissure. Emergent plastic surgery for the facial deformity was performed. Next day, she suffered intracerebral hemorrhage in the left frontal lobe. Angiography revealed CCF, predominantly draining to the left superficial sylvian vein. The left internal carotid artery was occluded by endovascular treatment. The clinical triad of traumatic CCF is orbital bruit, exophthalmos, and chemosis. Hemorrhagic complication such as subarachnoid hemorrhage, epistaxis, and otorrhagia may occur according to the venous drainage pattern. Traumatic CCF may be accompanied by intracerebral hemorrhage.     

Intravenous patient-controlled analgesia (IV-PCA) for relief of postoperative pain

Intravenous patient-controlled analgesia (IV-PCA) using opioids such as morphine and fentanyl can be an effective analgesic method for post-operative pain that is resistant to conventional administration of narcotic analgesics and nonsteroidal anti-inflammatory drugs, and where epidural block and peripheral nerve block are not feasible. In addition to post-operative pain relief, IV-PCA can facilitate early ambulation, reduce respiratory complications, and increase patient satis-faction. However, respiratory and circulatory depression, and post-operative nausea and vomiting (PONV) often occur as side effects of IV-PCA with opioids. Administration of droperidol can be an effective treatment for PON.     

Tumor scintigraphy by the method for subtracting the initial image with technetium-99m labeled antibody

The method for subtracting the initial image from the localization image was evaluated for radioimmunoscintigraphy of tumors with technetium-99m (Tc-99m) labeled antibodies. Monoclonal antibodies were parental mouse and mouse-human chimeric antibodies to carcinoembryonic antigen (CEA), designated F11-39 and ChF11-39, respectively, both of which have been found to discriminate CEA in tumor tissues from the CEA-related antigens. After reduction of the intrinsic disulfide bonds, these antibodies were labeled with Tc-99m. In vivo studies were performed on athymic nude mice bearing the human CEA-producing gastric carcinoma xenografts. Though biodistribution results showed selective and progressive accumulation of Tc-99m labeled antibodies at the tumor site, high radioactivity in blood was inappropriate for scintigraphic visualization of the tumors within a few hours. We examined the subtraction of the initial Tc-99m image from the Tc-99m localization image after a few hours. Subtracted images of the same count reflected the in vivo behavior of the Tc-99m radioactivity. The subtracted scintigrams revealed excellent tumor images with no significant extrarenal background. Visualization of the tumor site was dependent on antigen-specific binding and nonspecific exudation. These results demonstrate that a method of subtraction of the initial image may serve as a potentially useful diagnostic method for an abnormal site for agents with a low pharmacokinetic value.     

Comparison of the effects of aortic valve replacement using 19-mm Carpentier-Edwards Perimount bioprosthesis and 19-mm Medtronic Mosaic bioprosthesis.

OBJECTIVE: Short (< or =3 months)- and middle (> or =4 months)-term results of aortic valve replacement (AVR) using 19-mm Carpentier-Edwards Perimount (CEP) bioprosthetic valves and 19-mm Medtronic Mosaic (MM) bioprosthetic valves in patients with small aortic annulus were compared. PATIENTS AND METHODS: At our facility, AVR was performed using bioprostheses in 110 patients from April 1999 to March 2006. Of these patients, 40 were treated using 19-mm CEP (Group C), and 9 using 19-mm MM (Group M). Evaluation by inquiry, physical examination, and echocardiography was performed before, a short term after, and a middle term after surgery, and the effects of AVR were compared. RESULTS: The New York Heart Association (NYHA) functional class grade showed improvements in both groups. The aortic valve peak pressure gradient was 29.8 +/- 10.1 mmHg in Group C and 53.8 +/- 17.3 mmHg in Group M, being higher in Group M, a middle term after surgery. However, the left ventricular mass index (LVMI) showed improvements in both groups compared with the values before surgery, and the left ventricular ejection fraction (LVEF) was maintained. During the middle term after surgery, the frequency of cardiac events showed no significant difference between the two groups. CONCLUSIONS: In the patients treated with 19-mm MM, the aortic valve peak pressure gradient was higher than in those treated with 19-mm CEP, but acceptable improvements in the LVMI, maintenance of the LVEF, and avoidance of cardiac events were observed in both groups.     

Prevalence of Synchronous Colorectal Neoplasms Detected by Colonoscopy in Patients with Gastric Cancer

Purpose Our purpose was to study the characteristics of colorectal neoplasms in patients with gastric cancer (GC). Methods The study group comprised GC patients who underwent colonoscopy before resection of their GC. We examined the prevalence, site, and histology of colorectal neoplasms, as well as the clinicopathological features and treatment of the patients who had synchronous colorectal cancers (CRC). The logistic regression model was applied to investigate the features of the GC patients with concurrent CRC. Results We studied 466 GC patients (mean age 64.5 years; 147 women, 319 men), 143 (31%) of whom had a family history of gastrointestinal cancer. Synchronous colorectal adenoma and cancer were detected in 182 (39%) and 18 (4%) patients, respectively. Among the 18 synchronous CRCs, 11 were in the early stages and 10 of these were resected endoscopically. The other eight required simultaneous open radical surgery. All the GC patients with synchronous CRC were older than 50 years. Statistical analysis did not show a significant difference between the features of the patients with and those without concurrent CRC. Conclusions The possibility of synchronous colorectal neoplasms in GC patients cannot be disregarded in clinical practice; however, screening of the large bowel may not be necessary in GC patients younger than 50 years.     

Intracisternal infusion of magnesium sulfate solution improved reduced cerebral blood flow induced by experimental subarachnoid hemorrhage in the rat

Magnesium has neuroprotective and antivasospastic properties in the presence of subarachnoid hemorrhage (SAH). The present study investigated the effect of intracisternal administration of magnesium on cerebral vasospasm in the experimental SAH rat model. The rat double-SAH model (0.2 mL autologous blood injected twice into the cisterna magna) was used. Normal saline (SAH group, N = 8) or 10 mmol/L magnesium sulfate in normal saline (SAH + MG group, N = 8) was infused into the cisterna magna at 1.5 μL/min for 30 min on day 5. Control rats without SAH also received intracisternal infusion of normal saline (control group, N = 6). Local cerebral blood flow (CBF) at 24 locations and the weighted average were quantitatively measured by the autoradiographic technique using [¹⁴C]iodoantipyrine during infusion. The weighted average CBF was significantly reduced (P < 0.01, Student’s t-test) in the SAH group (0.78 ± 0.16 mL g⁻¹ min⁻¹) compared to the control group (1.0 ± 0.15 mL g⁻¹ min⁻¹) and was significantly improved (P < 0.01, Student’s t-test) in the SAH + MG group (0.98 ± 0.18 mL g⁻¹ min⁻¹). Local CBF was significantly reduced (P < 0.05, unpaired t test) in 16 locations in the SAH group and significantly improved (P < 0.05, unpaired t test) in 12 locations in the SAH + MG group. Intracisternal infusion of magnesium sulfate significantly improved reduced CBF induced by experimental SAH in the rat.     

Changes of D-dimer after total hip arthroplasty in patients with and without intraoperative heparin

Introduction Marked activation of thrombosis is common in patients undergoing total hip arthroplasty, especially during reaming of the femur and after insertion of the femoral prosthesis. This suggests that management designed to minimize deep vein thrombosis and fatal pulmonary embolism after total hip arthroplasty should be focused on the period during insertion of the femoral component. In some previous studies, a low dose of heparin administered intraoperatively was shown to suppress the formation of fibrin. Objective The present study was performed to evaluate the influence of intraoperative heparin administration on the D-dimer level and on the prevention of pulmonary embolism after total hip arthroplasty. Material/methods A total of 22 and 26 consecutive patients respectively underwent total hip arthroplasty with and without intraoperative administration of unfractionated heparin. Postoperatively, all patients wore knee-high elastic stockings and were fitted with calf-to-thigh intermittent pneumatic compression devices. Active ankle flexion and extension exercises were commenced as soon as motor function recovered. None of the 48 patients received prophylactic anticoagulants postoperatively. Results There was a significant difference of the mean D-dimer level on the 1st day between the patients with and without intraoperative administration of heparin (8.9 ± 6.6 vs. 15.7 ± 12.7, P < 0.05). Although there were no patients with symptomatic deep venous thrombosis and pulmonary embolism, asymptomatic pulmonary embolism was detected by pulmonary perfusion scintigraphy in three patients who did not receive intraoperative heparin. The operative blood loss and postoperative drainage were similar in both groups and no bleeding complications were observed. In conclusion, we recommend a safe and inexpensive regimen comprising 1,000 U of intravenous unfractionated heparin intraoperatively, postoperative pneumatic compression, and early active mobilization for prevention of thoromboembolic complications after total hip arthroplasty.     

Billroth I Gastrectomy Using a Circular Stapler to Treat Gastric Cancer

We describe herein our technique of performing gastrectomy followed by side-to-end gastroduodenostomy. Because the clamp is removed at the resection line of the greater curvature, there is no need to perform an additional gastrotomy for insertion of the instrument. This feature differentiates our technique from previous methods of anastomosis using the circular stapler. We believe that our technique is superior in simplicity and security to the traditional hand-sewn anastomosis. Moreover, it allows for a shorter operative time. This technique is recommended for practical surgery over conventional techniques. Received: February 23, 2000 / Accepted: July 25, 2000     

Persistent subclinical rejection associated with nodular B-cell infiltrates in a renal transplant recipient

Abstract:  Recently, B-cell infiltrates in acute rejection grafts have attracted interest as an indicator of refractory rejection. Here, we report a case of deceased donor renal transplantation in a Japanese recipient operated overseas in which the recipient suffered from persistent tubulointerstitial rejection episodes associated with B-cell infiltrates. A 59-yr-old man with end-stage renal disease caused by immunoglobulin A nephropathy underwent deceased donor renal transplantation overseas in December 2005. The initial post-operative course was uneventful. The patient was referred to our hospital one month after transplantation. He maintained stable renal function throughout the follow-up period. The maintenance immunosuppressive regimen consisted of tacrolimus, mycophenolate mofetil and methylprednisolone. His serum creatinine concentration remained around 1.0 mg/dL, with no evidence of proteinuria. However, a discrepancy was detected between the renal function and the pathological findings. The pathology showed subclinical tubulointerstitial rejection with nodular B-cell infiltrates refractory to aggressive antirejection therapy. A steroid pulse and 15-deoxyspergualin were ineffective and the patient developed interstitial fibrosis and tubular atrophy by one yr after the transplantation, with persistent tubulitis and B-cell infiltrates. We treated the refractory rejection with B-cell infiltrates with a single 200 mg/body dose of rituximab and obtained an improvement. The pathological findings after administering rituximab consisted of mild tubulitis classified as Banff borderline, and elimination of the nodular B-cell infiltrates. At present, 20 months after renal transplantation, the patient continues to maintain stable renal function, with a good serum creatinine concentration (0.87 mg/dL).