Specific Antibiotic Prophylaxis Based on Bile Cultures Is Required to Prevent Postoperative Infectious Complications in Pancreatoduodenectomy Patients Who Have Undergone Preoperative Biliary Drainage

Background Preoperative biliary drainage (PBD) is associated with bacterial contamination of bile, but the effects of PBD on morbidity after pancreatoduodenectomy remain controversial. The aim of this study was to characterize bile contamination to develop successful specific antibiotic prophylactic strategies for pancreatoduodenectomy. Methods Ninety-one consecutive patients who underwent pancreatoduodenectomy for periampullary tumor were prospectively evaluated. Prophylactic antibiotics were selected based on preoperative bile cultures. Bile cultures and postoperative complications were compared in 46 patients who underwent PBD (drainage group) versus 45 patients who did not (nondrainage group). Results The incidence of positive bile cultures was higher in the drainage group (78%) than in the nondrainage group (36%) (P < 0.001). In the drainage group, positive bile cultures were frequently polymicrobial (61%) and demonstrated resistance to several antibiotics, including cefazolin (83%), cefmetazole (72%), and cefpirome (64%). Overall morbidity (30% and 22%) and infectious morbidity (13% and 11%) did not differ significantly between the drainage and nondrainage groups, respectively. Conclusions PBD had a notable influence on bile microbial contamination, including a higher rate of antibiotic resistance. Therefore, specific antibiotic prophylaxis based on bile culture is required for preventing infectious complications in pancreatoduodenectomy patients who undergo PBD.     

Inhibition of integrin alphavbeta3 reduces blood-brain barrier breakdown in focal ischemia in rats

Ischemic stroke is a major cause of morbidity and mortality in industrialized nations. We tested the effect of postischemic treatment of cyclo-RGDfV (cRGDfV), a selective inhibitor of integrin alphavbeta3, in the middle cerebral artery occlusion (MCAO) model of ischemic stroke in rats. Rats were randomly divided into three groups: sham operation (n = 13), MCAO with no treatment (n = 18), and MCAO with cRGDfV treatment (n = 28). Focal ischemia was induced with the suture occlusion method for 2 hr, and treatment was given 1 hr after reperfusion (3 hr after ischemia). All animals were sacrificed 24 hr after reperfusion. Assessment included neurological scores, infarction volumes, brain water content, Evans blue exudation, IgG exudation, histology, immunohistochemistry, and Western blotting. Treatment with cRGDfV ameliorated neurological deficits, reduced brain edema, and reduced exudation of Evans blue dye and IgG, but failed to reduce infarction volumes. Western blotting showed a reduction in phosphorylation of one subset of vascular endothelial growth factor (VEGF) receptors in the cRGDfV treatment group. Western blotting also demonstrated a significant reduction of fibrinogen in the cRGDfV treatment group. We conclude that poststroke treatment with cRGDfV reduces blood-brain barrier breakdown in focal ischemia, possibly through inhibition of VEGF-mediated vascular breakdown.     

High-grade invasive urothelial carcinoma with focal plasmacytoid differentiation successfully treated by transurethral resection followed by chemoradiotherapy

We report a case of high-grade invasive urothelial carcinoma with plasmacytoid differentiation of the urinary bladder. A 75-year-old woman was referred to our hospital because of macroscopic hematuria. Cystoscopy detected a solid pedunculated bladder tumor, and a transurethral resection of the bladder tumor (TUR-Bt) and the image findings showed pT1N0M0 bladder cancer. The histopathological examination revealed the coexistence of a large component of high-grade invasive urothelial carcinoma and a small component of plasmacytoid carcinoma. Following the TUR-Bt, external beam radiotherapy and chemotherapy with gemcitabine and nedaplatin were carried out. The bladder tumor has not recurred for 2 years after the TUR-Bt.     

Cricopharyngeal myotomy for primary cricopharyngeal dysfunction caused by a structural abnormality localized in the cricopharyngeus muscle: Report of a case

Primary cricopharyngeal dysfunction (PCD) is a rare idiopathic disorder of the upper esophageal sphincter (UES), characterized by oropharyngeal dysphagia, frequent aspiration, and narrowing at the level of the UES. Cricopharyngeal myotomy (CPM) has been used to treat oropharyngeal dysphagia of different causes including anatomic, neuromuscular, iatrogenic, inflammatory, neoplastic, and idiopathic; however, the indications for CPM and predictors of its outcome are not clearly defined. We report a case of PCD with hypertonic UES caused by a structural abnormality localized in the cricopharyngeus muscle, visualized as a cricopharyngeal bar, which we treated successfully by CPM, achieving long-term relief.     

Double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct

We report a case of double cancer of the cystic duct and gallbladder associated with low junction of the cystic duct. A 73-year-old woman was admitted to the hospital complaining of upper abdominal pain. Endoscopic retrograde cholangiography showed a stenotic lesion in the lower common bile duct and no visualization of the cystic duct or gallbladder. Enhanced computed tomography revealed a heterogeneously enhanced tumorous lesion around the lower bile duct in the pancreatic head. A diagnosis of cancer arising from the cystic duct that entered the lower part of the common hepatic duct was made by intraductal ultrasonography, which showed an intraluminal protruding lesion in the cystic duct. Isolated gallbladder cancer was also diagnosed, by abdominal computed tomography. She underwent pancreaticoduodenectomy with dissection of regional lymph nodes. Histological examination revealed moderately differentiated adenocarcinoma of the cystic duct and well-differentiated adenocarcinoma of the gallbladder. Double cancer of the cystic duct and gallbladder is extremely rare, and this case also suggests a relationship between a low junction of the cystic duct and neoplasm in the biliary tract.     

Idiopathic retroperitoneal fibrosis diagnosed by CT-guided needle biopsy: a case report

A 72-year-old man was admitted to another hospital because of general fatigue and dyspnea secondary to renal insufficiency. Abdominal computed tomography (CT) and magnetic resonance imaging showed left atrophic kidney, right hydronephrosis, and an intra-pelvic mass of soft-tissue density located anterior to the sacrum, involving the right ureter at the level between the 5th lumber vertebra and the sacrum. He was referred to our hospital after percutaneous nephrostomy was constructed into right kidney. CT-guided needle biopsy revealed the idiopathic retroperitoneal fibrosis, leading us to give him steroid therapy. Three weeks later, radiographic findings showed a remarkable reduction of the mass and the improvement of the right ureteral stricture.     

Modification of the Bentall operation using the proximal double sewing technique without excision of leaflets

We present a report on reinforcement of the proximal anastomosis during the Bentall operation. The aortic wall was excised with a 5-mm remnant, and aortic valve leaflets were preserved. Interrupted horizontal mattress sutures (2-0 Polyestel) reinforced with pledgets were placed. The composite graft was placed at the intraannular position inside of the preserved leaflets. The aortic valve leaflets were then pasted to the sewing cuff with fibrin glue. A running suture with 4-0 monofilament was placed between the remnant of the aortic wall and the peripheral side of the sewing cuff wrapped with native aortic valve leaflets.     

Failure of low-dose radiosurgery to control temporal lobe epilepsy.

Radiosurgical treatment of intractable epilepsy has emerged as a noninvasive alternative to resection. Although gamma knife surgery (GKS) reportedly is effective when the radiation dose is sufficient to cause a destructive reaction in the targeted medial temporal lobe, the optimal target area and dose distribution are largely unknown. Some investigators have suggested that focused irradiation from a nondestructive dose is also effective. In this article the authors report two cases of medial temporal lobe epilepsy in which the patients underwent GKS performed using a 50% marginal dose of 18 Gy covering the amygdala. hippocampal head and body, and parahippocampal gyrus. In both cases this procedure failed to control seizures. Both patients became seizure free after undergoing anterior temporal lobectomy 30 and 16 months, respectively, after radiosurgery.     

Influence of head and neck position on cuff position and oropharyngeal sealing pressure with the laryngeal mask airway in children

We studied how head and neck position affect the cuff positionand oropharyngeal sealing pressures of the laryngeal mask airways(LMAs) in children. We studied 39 non-paralyzed healthy childrenaged 1.5–8.0 yr, weighing 10.3–27.0 kg, managedwith size 2 or 2.5 LMAs during elective surgery. Head and neckmovements did not adversely affect airway patency in 97% ofpatients. One child developed apparent airway obstruction withhead and neck flexion, which was relieved in the neutral position.Oropharyngeal sealing pressure was significantly greater duringneck flexion compared with the neutral position (P<0.02).Fibreoptic examination revealed that the epiglottis covereda larger area of the LMA aperture during neck flexion, comparedwith the neutral position (P<0.02). Br J Anaesth 2001; 86: 122–4