Gastric volvulus and giant Bochdalek hernia in an adult patient that were safely repaired by endoscopic reduction and elective laparoscopic surgery

A Bochdalek hernia (BH) is a congenital abnormality with incomplete closure of the diaphragm. It is usually manifested in infants but rarely in adults. Here, we report an adult patient with gastric volvulus and giant BH that were safely repaired by endoscopic reduction and elective laparoscopic surgery, respectively. A 79-year-old woman presented with left upper abdominal pain but no history of trauma. CT revealed a giant BH with gastric volvulus. After emergency endoscopic reduction of the volvulus, elective laparoscopic repair of the BH was performed. The 8 × 8-cm defect was repaired with interrupted nonabsorbable sutures and a mesh. The patient's postoperative course was uneventful, and no complications or recurrence were observed in the 6 months that followed.     

Long-term results of first-line sequential high-dose carboplatin, etoposide and ifosfamide chemotherapy with peripheral blood stem cell support for patients with advanced testicular germ cell tumor

OBJECTIVE: Standard chemotherapy shows relatively low long-term survival in patients with poor-risk testicular germ cell tumor (GCT). First-line high-dose chemotherapy (HD-CT) may improve the result. High-dose carboplatin, etoposide, ifosfamide chemotherapy followed by autologous peripheral blood stem cell transplantation (PBSCT) was investigated as first-line chemotherapy in patients with advanced testicular GCT. METHODS: Fifty-five previously untreated testicular GCT patients with Indiana 'advanced disease' criteria received three cycles of bleomycin, etoposide and cisplatin (BEP) followed by one cycle of HD-CT plus PBSCT, if elevated serum tumor markers were observed after three cycles of the BEP regimen. RESULTS: Thirty patients were treated with BEP alone, because the tumor marker(s) declined to normal range. Twenty-five patients received BEP and HD-CT. One patient died of rhabdomyolysis due to HD-CT. Three and six (13% and 25%) out of 24 patients treated with BEP and HD-CT achieved marker-negative and marker-positive partial responses, respectively. The other patients achieved no change. Fifteen (63%) are alive and 14 (58%) are free of disease at a median follow-up time of 54 months. Severe toxicity included treatment-related death (4%). CONCLUSIONS: HD-CT with peripheral stem cell support can be successfully applied in a multicenter setting. HD-CT demonstrated modest anticancer activity for Japanese patients with advanced testicular GCT and was well tolerated. This regimen might be examined for further investigation in randomized trials in first-line chemotherapy for patients with poor-risk testicular GCT.     

Clinical study of penile carcinoma in 38 cases

We retrospectively reviewed 38 patients with primary penile squamous cell carcinoma (stage 1 in 22, stage 2 in 7 and stage 3 in 9) who were treated in our institution from 1963 through 1987. The incidence of regional nodal metastasis was correlated with tumor category, local infiltration and tumor grade. The incidence rate of nodal metastasis of G2 and G3 tumors was statistically higher than that of G1 tumors. Of 27 patients initially treated by radiotherapy and/or chemotherapy, 11 patients achieved complete response. G1 tumors and T1 to 2 tumors had such high response rates as 58 and 50 per cent, respectively, but 5 patients (45 per cent) had local recurrence at an average of 74 months after initial treatment. The 5-year survival rates of over-all, stage 1, 2 and 3 were 73, 90, 75 and 25 per cent, respectively. Patients with stage 3 disease had a statistical lower survival rate than those with stage 1 or 2 disease. Among 13 patients with regional nodal metastasis, none with G2 tumor survived three years, although 3 patients (60 per cent) of those with G1 tumor survived five years. These results suggest that tumor grade is the most prognostic factor for the regional nodal metastasis, the response of conservative treatment and the survival of metastasized patients.     

A case of secondary bladder tumor the origin (gastric cancer) of which could not be identified before autopsy

Primary bladder tumor is the most frequent malignant tumor in the field of urology, whereas the incidence of secondary bladder tumor from a distant organ is quite rare. We report here a 21-year-old female patient with metastatic bladder tumor from gastric cancer. She came to our hospital with a complaint of only bladder irritability. Cystoscopical and cytological examinations revealed rhabdomyosarcoma of the bladder. She did not respond to radiation therapy and combined chemotherapy, consisting of actinomycin D, vincristine and cyclophosphamide, and died 91 days after admission. Autopsy revealed a primary tumor of poorly differentiated scirrhus carcinoma of the stomach. Thus this was a quite rare case of metastatic bladder carcinoma characterized by bladder irritability without gastrointestinal symptoms.     

Thallium-201 SPECT depicts radiologically occult lung cancer.

A case of radiologically occult lung cancer is presented in which 201TI SPECT of the chest clearly delineated the involved area. A 66-yr-old man underwent chest screening examinations for asymptomatic smokers and presented a positive sputum cytology for lung cancer. Conventional chest x-ray, tomography of computed radiography, and a CT scan failed to locate the lesion in the lung. Thallium-201 SPECT, however, was successful in depicting the area of the involvement.     

Case of dermatomyositis complicated with massive pleural effusion that preceded the myopathy]

A 36-year-old man was admitted to a hospital with complaints of fever, polyarthralgia and dyspnea. Erythema was observed on his face, extensor surface of the fingers and extremities, and a chest X-ray revealed massive bilateral pleural effusion. He had no sign of myopathy at this point. Pleural fluid was proved to be exudative and contained extremely high levels of hyaluronic acid. He was also complicated with interstitial pneumonitis and was given a pulse therapy with methyl prednisolone followed by daily administration of 55 mg prednisolone (PSL). Twenty days after the commencement of the therapy, pleural effusion decreased but muscle weakness gradually appeared, accompanied by elevation of myogenic enzymes. Myogenic changes on electromyogram, and irregularity of the muscle fibers with slight inflammatory cell infiltrates in a biopsy specimen were demonstrated. He was transferred to our hospital, and a diagnosis of dermatomyositis was made. Later, pleural effusion waxed and waned depending on the dosage of PSL, but no other causative disorder was demonstrated by extensive examinations. This case indicates that the pleuritis could be one of the vasculitic manifestations of dermatomyositis.     

Dynamic Interaction of Craniofacial Structures during Head Positioning and Direct Laryngoscopy in Anesthetized Patients with and without Difficult Laryngoscopy

Background: We lack fundamental knowledge of the mechanisms of difficult laryngoscopy despite its clinical significance. The aim of this study was to examine how head positioning and direct laryngoscopy alter arrangements of craniofacial structures.

Methods: Digital photographs of the lateral view of the head and neck were taken at each step of head positioning and direct laryngoscopy in age- and body mass index-matched patients with (n = 13) and without (n = 13) difficult laryngoscopy during general anesthesia with muscle paralysis. The images were used for measurements of various craniofacial dimensions.

Results: Both simple neck extension and the sniffing position produced a caudal shift of the mandible and a downward shift of the larynx, resulting in an increase of the submandibular space. Direct laryngoscopy during the sniffing position displaced the mandible and tongue base upward and caudally, and the larynx downward and caudally, increasing the submandibular space and facilitating vertical arrangement of the mandible, tongue base, and larynx to the facial line. These structural arrangements in response to direct laryngoscopy were not observed in patients with difficult laryngoscopy, whereas head positioning produced similar structural arrangements in patients with and without difficult laryngoscopy.     

Detection of beta-lactamase-producing strains isolated from urinary tract and their drug susceptibility

A total of 518 bacterial strains isolated from the urine of patients with various urological diseases in our Urological Department between November, 1987 and February, 1989 were studied for their beta-lactamase production and susceptibility to various antimicrobial agents was determined. beta-lactamase activity was determined by the acidometry disc method. There were 241 gram-positive cocci, 276 of gram-negative rods and 1 Neisseria gonorrhoeae. Thirty-four percent of the gram positive and 76.3% of gram negative rods produced beta-lactamase. S. aureus (81.3%), S. epidermidis (65.1%) in gram-positive cocci, E. cloacae (100%), S. marcescens (100%), C. freundii (100%), P. aeruginosa (97.2%), P. Rettgeri (88.9%), E. gergoviae (85.7%), K. oxytoca (84.6%), M. morganii (81.8%) and E. coli (69.0%) in gram-negative rods produced beta-lactamase at a higher rate. beta-lactamase produced by gram-positive cocci was entirely penicillinase, and that produced by gram-negative rods only penicillinase in 4.0%, only cephalosporinase in 44.2% and both in 25.4%. In S. aureus and S. epidermidis, the isolated rate of strains resistant to ampicillin (p less than 0.01) and piperacillin (p less than 0.05) in the beta-lactamase producing strains was significantly higher than that in the beta-lactamase non-producing strains. In E. coli, the isolation rate of strains resistant to ampicillin and piperacillin in the penicillinase-producing strains was significantly higher than in the penicillinase non-producing strains (p less than 0.01). But both cephalosporinase-producing strains and beta-lactamase non-producing strains showed high susceptibility to cephalothin. These results suggest that the penicillinase might present a clinical problem in the treatment of urinary tract infections by S. aureus, S. epidermidis and E. coli.