Colonic transit time, sphincter EMG, and rectoanal videomanometry in multiple system atrophy.

Both constipation and fecal incontinence are prominent lower gastrointestinal tract (LGIT) dysfunctions that occur frequently in multiple system atrophy (MSA). We investigated the mechanism of constipation and fecal incontinence in MSA. Colonic transit time (CTT), sphincter electromyography (EMG), and rectoanal videomanometry were performed in 15 patients with MSA (10 men, 5 women; mean age, 63.5 years; mean duration of disease, 3 years; decreased bowel frequency [< 3 times a week] in 9; difficulty in expulsion in 11; fecal incontinence in 3) and 10 age-matched healthy control subjects (7 men and 3 women; mean age, 62 years; decreased bowel frequency in 2; mild difficulty in expulsion in 2; fecal incontinence in none). Compared to the control subjects, MSA patients had significantly prolonged CTT in the rectosigmoid segment and total colon. Sphincter EMG showed neurogenic motor unit potentials in none of control subjects but in 93% of MSA patients. At the resting state, MSA patients showed a lower anal squeeze pressure (external sphincter weakness) and a smaller increase in abdominal pressure on coughing. During rectal filling, MSA patients showed smaller amplitude in phasic rectal contraction, which was accompanied by an increase in anal pressure that normally decreased, together with leaking in 3 patients. During defecation, most MSA patients could not defecate completely and had larger postdefecation residuals. MSA patients had weak abdominal strain, smaller rectal contraction on defecation, and larger anal contraction on defecation (paradoxical sphincter contraction on defecation), although these differences were not statistically significant. These findings in MSA patients were similar to those in Parkinson's disease patients in our previous study, except for the sphincter denervation and weakness in MSA. Constipation in MSA most probably results from slow colonic transit, decreased phasic rectal contraction, and weak abdominal strain, and fecal incontinence results from weak anal sphincter due to denervation. The responsible sites for these dysfunctions seem to be both central and peripheral nervous systems that regulate the LGIT.     

The effectiveness of regional cerebral oxygen saturation monitoring using near-infrared spectroscopy in carotid endarterectomy.

Nineteen patients (20 operations) underwent elective carotid endarterectomy without arterial shunt. Carotid cross-clamping caused a significant decrease (from 61.2% to 49.5%, 19.1% decrease from the preclamp baseline) of the ipsilateral cerebral oxygen saturation and it increased to 65.6% after declamping. Cross-clamping also caused a significant decrease (from 2.9 Hz to 1.6 Hz) of the ipsilateral electroencephalogram main frequency and it increased to 3.6 Hz after declamping. Asymmetry of main frequency which was greater than 0.7 Hz was observed when that of oxygen saturation decreased more than 25% during cross-clamping. The reported data indicate that cerebral oxygen saturation less than 54-56.1% and its decrease more than 15.6-18.2% is found to be a predictor of neurologic compromise. In this study, the asymmetry of cerebral oxygen saturation more than 25% was also found to be a risk. Arterial shunt should be used in haemodynamically high risk cases.     

Analysis of unknown cause subarachnoid hemorrhage with repeated negative angiogram]

Seven hundred and fifty five cases of acute non-traumatic subarachnoid hemorrhage were admitted to the department of neurosurgery of our hospital from July, 1995 to March, 2004. In 555 patients cerebral angiography was conducted but initial angiography was negative in 30 patients. Except 10 general condition poor patients, in 20 initial angiogram-negative patients were undergone repeated angiography. The cause of SAH could not be demonstrated in 13 cases. The SAH in perimesencephalic and non-perimesencephalic cisturns was seen in 7 and 6 cases, respectively. Occipital and/or neck pain on admission was statistically more common among patients with perimesencephalic SAH than those with non-perimesencephalic SAH (p = 0.029), and the prognosis of perimesencephalic SAH was good. We conclude that repeat angiography should not be recommended in patients with perimesencephalic SAH. Patients with non-perimesencephalic SAH had a higher rate of complication. In the non-perimesencephalic group, 3 patients developed hydrocephalus and 3 patients had vasospasm, which were found by repeated angiography. Therefore, repeated angiography is recommended for better clinical outcome by early detection and management of serious complications in this group of patients.     

Predictive factors for pancreatic fistula after pancreaticosplenectomy for advanced gastric cancer in the upper third of the stomach

This study aimed to retrospectively investigate the predictive factors for pancreatic fistula following pancreaticosplenectomy. Pancreatic fistula is a major lethal complication of pancreaticosplenectomy. However, predictive factors for this condition have not yet been established. Between April 1992 and March 2000, 147 patients with advanced gastric cancer that was located predominantly in the upper third of the stomach were enrolled in this study. Predictive factors for pancreatic fistula were investigated using univariate and multivariate analyses. Pancreatic fistula, as de.ned according to our criteria, was observed in 73 (49.7%) patients. In the univariate analysis, age, body mass index, serum zinc level, hyperlipidemia, and comorbid disease all signi.cantly affected the incidence of pancreatic fistula. In the multivariate analysis, body mass index, hyperlipidemia, and comorbid disease independently predicted the occurrence of pancreatic fistula. By contrast, the experience of the operating surgeon had no significant effect on the frequency of this condition. Our results suggest that pancreaticosplenectomy, the surgical merit of which is not apparent, should be avoided whenever possible. If this operative procedure must be used (e.g., in patients with extensive tumor presence), careful manipulation and appropriate drainage are essential, particularly in cases showing predictive factors of pancreatic fistula.     

A case of splenic vein occlusion caused by the intravenous tumor thrombus of nonfunctioning islet cell carcinoma

We report herein a case of successfully treated advanced, nonfunctioning islet cell carcinoma associated with left-sided portal hypertension. The splenic vein was obstructed by a huge intravenous tumor thrombus developing from the main pancreatic tumor. Direct invasion to adjacent organs such as the spleen, colon, left kidney and stomach was also observed, although liver metastasis was not present. Radical resection was carried out with removal of these five involved organs and the patient is alive without recurrence more than 5 years after surgery.     

Simple method of hyperthermo-chemo-hypoxic isolated liver perfusion for hepatic metastases

As a regional therapy for hepatic malignancy, we developed a simple method of isolated liver perfusion (hyperthermo-chemo-hypoxic). In the present study, the influence of this method on the hepatic tissue and other organs was experimentally evaluated and applied it to seven patients. Experimentally, all dogs survived without hepatic insufficiency and systemic toxicity. Clinically, one patient died on postoperative day 14 of hepatic failure. The reason was that liver temperature reached 43°C, which seemed to be the maximum limit for thermal toxic effect to the human liver. The other six patients well tolerated the perfusion with mild increases of serum aminotransferase and total bilirubin levels and decreases of hepaprastin levels. Serum aminotransferase and total bilirubin and hepaprastin levels returned to normal levels by postoperative day 14. There were no significant differences between the isolated liver perfusion group (n=7) and hepatectomy-only group (n=27). Six patients were discase-free during the observation period after the perfusion. This system is a simple, useful method for treating patients with metastatic cancer limited to the liver.

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Resumen Hemos desarrollado un modelo simple de perfusión aislada del higado (Hyperthermo-Chemo-Hypoxic) como forma de terapia regional en neoplasias malignas del hígado. En el presente estudio se hizo la evaluación experimental del efecto de este método sobre el tejido hepático y otros órganos, el cual fue aplicado a un Grupo de 7 pacientes. Experimentalmente todos los perros sobrevivieron sin insuficiencia hepática ni toxicidad sistémica. Clínicamente, un paciente murió en el día 14 postoperatorio por falla hepática. La razón fue que la temperature del hígado alcanzó los 43°C, lo que pareció sobrepasar el límite del efecto térmico tóxico sobre el hígado humano. Otros 6 pacientes toleraron bien la perfusión con leves aumentos de los niveles de aminotransferasa y de bilirrubina total y disminución de los niveles de hepaprastina. Los niveles de aminotrasferasa, bilirrubina total y hepaprastina regresaron a valores normales en el día 14 postoperatorio. No se encoutratron diferencias significativas entre el Grupo sometido a perfusión aislada del hígado (n=7) y el Grupo sometido a hepatectomía sola (n=27). Seis pacientes aparecieron libres de enfermedad en el período de observación luego de la perfusión. Este sistema puede ser un método simple y útil para el tratamiento de pacientes con cáncer metastásico limitado al hígado.

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Résumé Nous avons développé une méthode simple de perfusion hépatique isolée (hyperthermie chimiothérapie hypoxie) comme traitement locorégional des lésions malignes du foie. Le retentissement de cette thérapeutique sur le tissu hépatique et sur les autres organes a été évalué expérimentalement et ensuite, elle a été appliquée à sept patients. Au cours de la partic expérimentale de cette étude, tous les chiens ont survécu sans insuffisance hépatique ni toxicité systémique. Un patient est décédé à J 14 d'insuffisance hépatique. La cause a été une hyperthermie hépatique à 43°C, ce qui semble être la limite supéricure de température supportée par le foie humain. Les six autres patients ont bien toléré la perfusion avec seulement une légère augmentation des transaminases, de la bilirubine et une diminution des taux de l'hépaprastine. Les taux de transaminases, de la bilirubine et de l'hépaprastine sont revenus à la normale au J 14 postopératoire. Il n'y avait aucune différence significative entre le groupe recevant une perfusion isolée (n=7) et le groupe ayant eu une hépatectomie (n=27). Six patients sont sans maladie pendant la période d'observation. Ce système, simple, peut être utile dans le traitement des patients ayant un foie métastatique.

     

Intraoperative removal of common bile duct stone through the intact papilla by flushing with saline solution combined with pharmacologic sphincter relaxation

In two patients with bile duct stones in the distal common bile duct the stones were successfully removed through the intact papilla without choledochotomy. In both patients, the stone was discovered on the intraoperative cholangiogram just after cholecystectomy. The stone was removed by intraoperative flushing with saline solution, combined with pharmacologic sphincter relaxation. This new technique employs glyceryl trinitrate and butylscopolamine bromide to relax the sphincter of Oddi, followed by intermittent flushing with saline solution to augment pressure in the the distal common bile duct. The saline flushing was initiated 3 min after the agents were administered. This technique is simple and less invasive than conventional methods of choledocholithotomy. We recommend this method as the first choice for the removal of common bile duct stones.