Laparoscopic distal gastrectomy with intracorporeal handsewn Billroth-I anastomosis (ICHSA)

Background

The number of cases of laparoscopic surgery has been increasing. Lymph node dissection has been standardized, and the enlarged view provided by laparoscopes allows for the procedure to be performed successfully entirely within the abdominal cavity, but many cases of reconstruction using the Billroth-I method are performed under direct vision through a small incision. In this study, by placing an anchor thread on a suture line on the lesser curvature of the stomach, we simplified the procedure for handsewn anastomosis and safely performed gastroduodenal anastomosis at low cost to obtain good results.

Methods

From January 2009 to December 2010, we performed handsewn gastroduodenal anastomosis in 18 cases. After performing lymph node dissection, the duodenum and the stomach were separated using an automatic stapling device. Anchor sutures were placed on the suture line of the lesser curvature of the stomach. First, the seromuscular layer of the stomach and the seromuscular layer of the duodenum were sutured by performing interrupted suturing using an extracorporeal knot-tying method. With the stomach and the duodenum in a fixed state, the anastomosis area was opened. The thread of the anchor suture was pulled toward the abdominal wall, and then all layers of the stomach and the duodenum at the posterior wall were continuously sutured. Similarly, for the anterior wall, all layers were continuously sutured from the lesser curvature toward the greater curvature.

Results

We performed this anastomotic procedure in 18 patients with early gastric carcinoma. The mean time required for the anastomosis was 64.6 ± 17.1 min, and the estimated blood loss was 53.1 ± 91 g. All operations were curative, and the mean number of retrieved lymph node was 27.1 ± 10.8. A nasogastric tube was removed on the first or second day. An upper gastrointestinal series performed on postoperative days 5–6 showed no anastomotic leakage and normal transit. Oral intake was started on days 6–7. Postoperative complications included one case of a ruptured suture, but this was resolved through a conservative approach. There was no mortality. Postoperative endoscopy revealed that the anastomosis area was extremely soft, and no abnormalities were observed. Moreover, the only costs related to the anastomosis were for the thread and needles, and although more time was required compared with mechanical anastomosis, the cost was extremely low.

Conclusions

We performed gastroduodenal anastomosis under a total laparoscopic approach by handsewn. This method is economical, because it does not require the use of machinery for anastomosis, and the duodenal stump is short. We believe that this method, which can be performed in a similar manner even for obese patients, can be used as a standard method of anastomosis.     

Cytochrome C Oxidase Deficiency and Neuronal Involvement in Menkes' Kinky Hair Disease: Immunohistochemical Study

Antibodies against subunits II and IV of cytochrome c oxidase (COX) and against complex III of the respiratory chain were used to study the expression of these proteins in the cerebellum, spinal cord, and other regions of the central nervous system in an autoptic case of Menkes' kinky hair disease (MKHD). We found a reduced expression of COX subunits in all examined areas whereas staining for complex III appeared normal. Immunostaining was altered in morphologically well-preserved neurons, suggesting that COX deficiency may have a pathogenetic role in the neuronal degeneration of MKHD.     

Heparan sulfate-like immunoreactivity in the spinal cord in motor neuron disease

Summary The spinal cords from eight autopsy cases of sporadic motor neuron disease (MND) and two control cases were immunohistochemically examined using anti-bodies directed to neurofilament proteins (anti-Nf) and to heparan sulfate (HepSS-1). Variable numbers of spheroids were observed in the anterior horns in the MND cases. In one case of MND, one third to half of the remaining anterior horn cells contained conglomerate inclusions in their perikarya. These pathological structures were not encountered in the control cases. The immunohistochemical study revealed that both anti-Nf and HepSS-1 intensely labelled all spheroids and conglomerate inclusions in the MND cases. The colocalization of heparan sulfate with neurofilamentous accumulation suggests that heparan sulfate is required for the aggregation of neurofilaments, resulting in the formation of spheroids and conglomerate inclusions in MND.Supported in part by the Amyotrophic Lateral Sclerosis Association (USA)     

Immunohistochemical Investigations on Cerebellar Purkinje Cells of Menkes' Kinky Hair Disease: Disappearance of Inositol 1, 4, 5-Triphosphate Receptor Protein,and Expression of Phosphorylated Neurofilament Proteins, αB-Crystallin and Stress-response Proteins

Immunohistochemical investigations were carried out on cerebellar Purkinje cells in patients with Menkes' kinky hair disease (MD) and normal control subjects (ages: 1–65 years). Six antibodies were used. They were specific to inositol 1,4,5-triphosphate receptor protein regarded as P₄₀₀ (P₄₀₀/IP₃R), phosphorylated neurofilament proteins (pNFP), αB-crystallin, stress-response protein (srp) 72, srp 27 and ubiquitin, respectively. In normal brains, all Purkinje cell bodies, axons, and dendrites including the spiny branchlets of dendrites were positive for anti-P₄₀₀/IP₃R antibody. In comparison, not every Purkinje cells in MD cases had P₄₀₀/IP₃R immunoreactivity. And some of the cells were more intensely stained than others. The immunoreaction products of P₄₀₀/IP₃R were frequently detected in cell bodies and proximal portions of the dendrites, but not in the peripheral dendrites including spiny branchlets. Most of the Purkinje cell bodies in MD reacted with anti-pNFP antibody, while only a small fraction of the cells was positive with anti-αB-crystallin and srp 72 and srp 27. Ubiquitin immunoreactivity was not detected. In contrast, Purkinje cell bodies from normal subjects were not recognized by antibody to pNFP, αB-crystallin, srp 72 and srp 27. Our results indicate that MD is associated with the loss of inositol 1,4,5-triphosphate receptor in Purkinje cells, and an aberrant phosphorylation of neurofilament proteins or aberrant distribution of normal phosphorylated neurofilament proteins. These impairments may lead to the expression of stress response proteins or αB-crystallin in some cells.     

A histopathological study of craniopharyngioma with special reference to its stroma and surrounding tissue

The numerous pathology reports on craniopharyngioma describe the classical features of squamous epithelium and keratin. Relatively little attention has been paid to its stroma and the surrounding tissue. We focused our observation on these two areas in a retrospective study of craniopharyngiomas in 36 operative cases and 5 autopsy cases. The tumor interdigitated with the brain and pituitary gland. At the interface, the brain was markedly gliotic with Rosenthal fibers simulating pilocytic astrocytoma. The tumor stroma had reactive changes and commonly showed cyst formation and calcification.     

Cerebellar superoxide dismutase expression in Menkes' kinky hair disease: an immunohistochemical investigation

This comparative immunohistochemical study deals with the expression of the cytosolic Cu/Zn-binding and mitochondrial Mn-dependent superoxide dismutases (SODs) in the cerebella of five patients with Menkes' kinky hair disease (MKHD) and five age-matched controls. Several cell types, including Purkinje cells and reactive astrocytes, of all MKHD patients examined were intensely stained by an antibody to Mn SOD, but not by an anti-Cu/Zn SOD antibody. By contrast, the cells of the five controls reacted very weakly or not at all with the anti-Mn SOD antibody, but were strongly reactive with the antibody to Cu/Zn SOD. These results suggest that the increased Mn SOD immunoreactivity in MKHD reflects enzyme induction as a protective mechanism against the highly toxic superoxide anion generated under the disease conditions.     

Correlation between colonic motility and defecatory disorders after anterior resection of the rectum in canine models

Abstract The objective of this study was to describe the correlation between changes in colonic motility and defecatory disorders in four experimental canine models, with an emphasis on denervation. Therefore, we constructed a model by dividing 20 healthy mongrel dogs into four groups, i.e. control, denervation, transection and anterior resection of the rectum (AR) (denervation plus transection), and focused on the correlation between colonic motility and defecatory disorders by counting the colonic migrating motor complexes (CMMCs) and colonic non‐migrating motor complexes (CNMCs). Gastrointestinal and colonic contractile activities were continuously recorded on a computer with strain gauge force transducers. The dogs’ feces were checked daily, and their consistency was recorded as normal, semisolid, or watery. Compared with the control group, the transection group showed elongation of the propagation time (P < 0.05), and the mean motility index of colonic contractile activity at C4 and C5 in the denervation group was greater than that in the control group (P < 0.05). The AR group showed three features of colonic motility: (i) elongation of the mean CMMC cycle (P < 0.05); (ii) shortening of the propagation time (P < 0.05); and (iii) increment of the number of CNMCs. Concerning fecal consistency, the AR group only showed watery diarrhoea. In conclusion, we revealed the existence of a correlation between defecatory disorders and changes in colonic motility. Increased knowledge among colorectal surgeons of the changes in colonic motility that occur following colorectal surgery is very important and could lead to the curtailment of defecatory disorders among patients.     

A case of urethral recurrence found 15 years after radical cystectomy

PURPOSE: A case of a urethral recurrence found 15 years after radical cystectomy is reported. METHODS/RESULTS: A 78-year-old man, who had undergone radical cystectomy at age 63, presented with urethral bleeding and positive cytology in urethral washing. The urethra was surgically resected. Pathologic examination revealed transitional cell carcinoma located in the distal and mid portion of the penile urethra. CONCLUSION: Evidence suggested that urethral recurrence resulted from the implantation from the primary bladder tumor; in addition, the urethral neoplasm had scarcely grown in the penile urethra for 15 years.     

Histological changes in the pituitary gland and adenomas following radiotherapy

To elucidate histological changes in the pituitary gland and adenomas following radiotherapy, two irradiated pituitary glands and seven irradiated non‐functioning adenomas were studied. The latter included four cases with conventional radiation (CR) and three cases with radiosurgery: two with gamma knife radiosurgery (GKR) and one with stereotactic fractionated radiotherapy (SRT). The specimens were obtained 10 months to 10 years (mean 58 months) after the radiotherapy. Irradiated pituitary glands showed diffuse fibrosis in the adenohypophysis, whereas irradiated adenomas showed either mild or no fibrosis in five CR/SRT cases and diffuse thick hyaline deposits in two GKR cases. No necrosis was observed. Stellate‐shaped S‐100 protein‐positive cells were greater in number in the irradiated pituitary glands than in the normal glands. Pituitary cells with dense granular reactivity for mitochondrial protein, cytochrome oxidase, and Mn‐SOD, mimicking oncocytes, were greater in number in the irradiated adenohypophysis but did not show any change in cell size. Many irradiated pituitary cells and some irradiated adenoma cells were densely positive with anticytokeratin 1,5,10,14 antibody whereas non‐irradiated counterparts were negative. In adenomas, MIB‐1 labeling index remained unchanged after the radiation. The results may indicate that radiation‐induced fibrosis was associated with an increased number of folliculo‐stellate cells, mitochondrial dysfunction, and squamous metaplasia. These findings were prominent in irradiated pituitary cells and may participate in delayed pituitary hypofunction following radiotherapy. In irradiated adenoma cells, similar findings were observed but diffuse fibrosis was absent. The histological changes were more intensive in adenomas following GKR than those following CR.     

A successful transcatheter embolization with occluding spring emboli for vertebral arteriovenous fistulas following insertion of Swan-Ganz catheter

Vertebral arteriovenous fistulas caused by insertion of percutaneous monitoring catheter through internal jugular vein are rare complications. This is a case report of a successful treatment by transcatheter embolization using spring occluder for the fistulas. Particular attention should be paid to the following: Normal basilar and contralateral vertebral arteriograms are prerequisites to this procedure in order to avoid its potential neurological hazards. For the complete elimination of the fistulas with retrograde filling, embolic material should be placed in the artery not only proximal but also distal to the fistulas opening.