原发性十二指肠恶性肿瘤的X 线诊断

目的　探讨X线诊断原发性十二指肠恶性肿瘤的价值。方法　回顾性分析 2 1例原发性十二指肠恶性肿瘤的X线所见并与手术病理对照。结果　X线表现包括充盈缺损、黏膜改变、肠腔狭窄和龛影。结论　根据临床及X线表现 ,术前可以正确诊断原发性十二指肠恶性肿瘤。     

Sagittal osteotomy of the patella after Morscher

The aim of this study was to present long-term results of sagittal osteotomy of the patella after Morscher. The study included 70 patients treated for patellar dysplasia with a postoperative follow-up from nine to 20 years. There were 59 females and 11 males with an average age of 21 years at the time of operation. Results were evaluated for the entire group of 70 patients and then presented separately for the 30 patients in whom sagittal osteotomy of the patella was performed as a single procedure and 40 patients in whom, in addition to sagittal osteotomy of the patella, medialisation and ventralisation or distalisation of the tibial tuberosity were also performed. The mean value of the Wiberg patellar angle was 112 degrees preoperatively and 140 degrees postoperatively. In the whole group of patients excellent results were obtained in 24 (35%), good results in 30 (42%), fair results in 13 (19%) and poor results in three (4%) patients. In 30 patients with sagittal osteotomy as a single operation excellent results were obtained in 13 (43%), good results in 14 (47%) and fair results in three (10%) patients, while in the 40 patients with sagittal osteotomy and additional surgical procedures, 11 (27%) were excellent, 16 (40%) good, ten (25%) fair and three (8%) had poor results. Sagittal osteotomy of the patella after Morscher is an enrichment of the spectrum of the secondary-causal and preventive procedures for the treatment of patello-femoral disorders.     

口服氨基葡萄糖联合关节腔内注射治疗膝骨性关节炎

目的 探讨口服氨基葡萄糖联合关节腔内注射治疗膝骨性关节炎的疗效.方法 门诊选取膝骨性关节炎患者402例,将患者按第1次关节腔内注射药物的不同分为透明质酸钠关节腔内注射组(214例)和三联针(透明质酸钠、醋酸曲安奈德、盐酸利多卡因)关节腔内注射组(188例),并在治疗后1、2、3、5周对患者按预先设定的疗效评价标准进行随访.结果 治疗后两组患者西安大略麦马斯特大学骨性关节炎指标可视化量表 (WOMAC) 疼痛指标和机体功能指标均明显下降,而且随观察时间延长,呈逐渐下降趋势,组间比较差异无统计学意义(P>0.05),但治疗后第1周随访,三联针关节腔内注射组疼痛指标下降趋势更明显,两组治疗期间塞来昔布用量比?差异有统计学意义(P<0.05).两组的不良反应发生率分别为8.9%(19/214)和8.5%(16/188),主要表现为轻中度的胃肠道不适和便秘.结论 口服氨基葡萄糖联合关节腔内注射在短期内能有效减轻膝骨性关节炎患者疼痛,改善关节功能,第1次关节腔内注射三联针能更快、更有效地缓解疼痛,减少了塞来昔布的用量.     

Renal damage caused by warm ischaemia during laparoscopic and robot-assisted partial nephrectomy: an assessment using Tc 99m-DTPA glomerular filtration rate

Background

Few studies assessing the functional change of each kidney following warm ischaemia after partial nephrectomy are available.

Objectives

Our aim was to identify the effects of the warm ischaemic time (WIT) on renal function after partial nephrectomy under the pneumoperitoneum.

Design, setting, and participants

Forty-four consecutive patients who underwent laparoscopic partial nephrectomy (LPN) or robot-assisted partial nephrectomy (RAPN) from June 2008 to May 2009 for a single cT1 renal tumour were included in this prospective protocol.

Measurements

Technetium Tc 99m-diethylenetriaminepentaacetic acid (Tc 99m-DTPA) renal scintigraphy was used to determine the glomerular filtration rate (GFR) of both kidneys and each kidney individually. Tc 99m-DTPA GFR was performed preoperatively and 3 mo postoperatively. In addition, we analysed Tc 99m-DTPA scintigraphy GFR regionally in the healthy areas of the affected kidney.

Results and limitations

Patients with WIT >28 min had a significantly greater decrease in the GFR of the affected kidney (p = 0.031). The GFR of the affected kidney showed a significant decrease perioperatively (46.4 ± 14.3 to 37.9 ± 11.9 ml/min per 1.73 m²; p = 0.003). The functional change of the nonaffected kidney showed an increasing trend (47.5 ± 13.8 to 51.4 ± 14.3 ml/min per 1.73 m²), although it was not statistically significant (p = 0.103). Regional Tc 99m-DTPA GFR of both affected kidney and nonaffected kidney showed no significant differences perioperatively (6.3 ± 1.8 to 6.1 ± 1.9 ml/min per 1.73 m²; p = 0.641; 6.6 ± 1.9 to 7.1 ± 2.0 ml/min per 1.73 m²; p = 0.200). On multivariate analysis, preoperative GFR, resected volume of marginal healthy tissue, and WIT were independent predictors for functional reduction of the affected kidney (p < 0.05). The study was limited by small numbers and short follow-up periods.

Conclusions

Stationary overall renal function after LPN or RAPN is masked possibly by functional compensation of the contralateral healthy kidney. The damage of the affected kidney estimated by scintigraphy occurs when WIT exceeds 28 min during partial nephrectomy under the pneumoperitoneum.     

Analysis of anatomical variations of bone and vascular structures around the posterior atlantal arch using three-dimensional computed tomography angiography

OBJECT: The current study evaluates the incidence of anatomical variations of the V(3) segment of the vertebral artery (VA) and the posterior arch of the atlas (C-1). Failure to appreciate these types of anatomical variations can cause catastrophic injury to the VA during posterior approaches to the upper cervical spine. METHODS: In the present study, the authors analyzed the records of 1013 Korean patients who underwent computed tomography (CT) angiography to evaluate the incidence of anomalous variations in the third segment of the VA and to determine the incidence and morphometric characteristics of any detected posterior ponticuli. The authors also hoped to determine any specific imaging features that might indicate a VA anomaly around the craniovertebral junction. RESULTS: The mean age of the patients was approximately 55.7 years and the prevalence of a posterior ponticulus was 15.6%. The incidence rate of a posterior ponticulus in the male population was 19.3%, whereas in the female population it was 12.8%. The incomplete type of posterior ponticulus was more common than the complete type. The mean age of the patients with an incomplete posterior ponticulus (55.7 years) was significantly younger (p = 0.018) than the mean age of patients with a complete posterior ponticulus (57.6 years). The incidence rate of a persistent first inter-segmental artery was 4.7% and the incidence rate of a fenestrated VA was 0.6%. The area of the C-1 transverse foramen on the abnormal side was significantly smaller than that of the contralateral normal side. CONCLUSIONS: The shape of the C-1 posterior arch and the third segment of the VA are heterogeneous. Therefore, preoperative radiological studies should be performed to identify any anatomical variations. Using preoperative 3D CT angiography, we can precisely identify an anomalous VA and significantly reduce the risk of VA injury.     

Atypical presentation of distal renal tubular acidosis in two siblings

Primary distal renal tubular acidosis (dRTA) is an inherited disease characterized by the inability of the distal tubule to lower urine pH <5.50 during systemic acidosis. We report two male siblings who presented with severe hyperchloremic metabolic acidosis, high urinary pH, nephrocalcinosis, growth retardation, sensorineural hearing loss, and hypokalemic paralysis. Laboratory investigations revealed proximal tubular dysfunction (low molecular weight proteinuria, generalized hyperaminoaciduria, hypophosphatemia with hyperphosphaturia, and hypouricemia with hyperuricosuria). There was significant hyperoxaluria and laboratory evidence for mild rhabdomyolysis. Under potassium and alkali therapy, proximal tubular abnormalities, muscular enzymes, and oxaluria normalized. A homozygous mutation in the ATP6V1B1 gene, which is responsible for dRTA with early hearing loss, was detected in both siblings. In conclusion, proximal tubular dysfunction and hyperoxaluria may be found in children with dRTA and are reversible under appropriate therapy.     

Successful colonoscopic decompression of colon after development of an early postoperative obstruction at the stapled anastomosis after an anterior colectomy and early chemotherapy: a case report

A case report describing the successful colonoscopic decompression and catheter drainage of an early postoperative large bowel obstruction caused by swelling at the stapled anastomosis after the initiation of chemotherapy. Our case illustrates that colonoscopy can be successful in managing early postoperative bowel obstruction secondary to swelling at the stapled colonic anastomosis.     

Surgical Indication for Non-curative Endoscopic Resection in Early Gastric Cancer

Background Endoscopic resection (ER) is an effective treatment for early gastric cancer (EGC) without lymph node metastasis. However, after ER additional surgery may be needed to manage the risks presented by residual cancer or lymph node metastasis. Methods ER was performed on 344 gastric adenocarcinomas between November 2001 and April 2006 at the Korean National Cancer Center under the strict pre-procedural indication. The authors performed operations in 43 patients due to: residual mucosal cancer, a mucosal cancer larger than 3 cm, or a submucosal cancer regardless of size or margin involvement. ER and surgical specimens were reviewed and analyzed for residual cancer and lymph node metastasis. Results Based on examinations of ER specimens, cancer was confined to the mucosal layer in 15 patients (34.9%) and invaded the submucosal layer in 28 patients (65.1%). Surgical specimens showed residual cancer in 17 patients (39.5%) and lymph node metastasis in four (9.3%). Neither residual cancer nor lymph node metastasis was found in patients with less than 500 μm submucosal invasion without margin involvement in ER specimens. In three of four patients with lymph node metastasis, the depth of submucosal invasion was 500 μm or more; the remaining patient had a 4-cm-sized differentiated mucosal cancer. Conclusions When a pathologic evaluation of an ER specimen reveals more than 500 μm of submucosal invasion or a mucosal cancer of larger than 3 cm, surgery should be considered due to the risk of lymph node metastasis.     

Proposal of the Surgical Options for Primary Tumor Control During Sentinel Node Navigation Surgery Based on the Discrepancy Between Preoperative and Postoperative Early Gastric Cancer Diagnoses

Background

There is no consensus on the optimal method of primary tumor control, determined by preoperative clinical factors, during sentinel node (SN) navigation surgery for early gastric cancer (EGC). In this study, we investigated the accuracy of clinical diagnosis based on preoperative examination in patients with EGC and proposed surgical options for primary tumor control during SN navigation surgery.

Methods

We analyzed 815 patients with clinical stage IA gastric cancer who underwent gastrectomy at the National Cancer Center in Korea between March 2001 and February 2011. The clinical stage was determined by endoscopy, endoscopic ultrasonography, and abdominal computed tomography.

Results

The preoperative assessment of tumor depth and tumor size was accurate in 57.5 and 70.8 % of patients, respectively. Tumor depth and size were underestimated in 8 and 25.3 % of patients. The overall accuracy of histologic diagnosis by endoscopic biopsy was 87.2 %. Of those tumors diagnosed preoperatively as differentiated, 20.5 % revealed mixed histology of undifferentiated type.

Conclusions

The recommendation for SN biopsy may be limited to tumors sized 3 cm or smaller to avoid positive lateral margins and to minimize the risk of skip metastases. Endoscopic resection may safely be applied to small mucosal cancers, but other surgical options should be employed for undifferentiated large mucosal lesions, given their tendency for diffuse invasion. Full-thickness resection is preferable for submucosal cancers, to secure clear vertical margins.     

Prognostic Impact of Microscopic Tumor Involved Resection Margin in Advanced Gastric Cancer Patients after Gastric Resection

Background

The prognosis of patients with positive surgical resection margins is dismal in gastric cancer. However, the influence of positive margin itself on prognosis is still uncertain, especially in advanced gastric cancer (AGC). The aims of the present study were to evaluate the prognostic impact of microscopic tumor involved resection margins in stage III–IV AGC after gastric resection in comparison with other well-known factors.

Methods

Among 1,536 consecutive gastric cancer patients who received intentional curative resection for stage III–IV AGC between April 2001 and December 2011 at the National Cancer Center, 35 patients (2.28 %) had positive resection margins on their final histology. A comparison of clinicopathologic characteristics, recurrence pattern, overall survival (OS), and disease-free survival (DFS) was made between positive margin (PM) patients and negative margin (NM) patients.

Results

Among the 35 PM patients, 15 (42.9 %) had proximal involved margins, 21 (60.0 %) had distal involved margins, and one (2.9 %) had both involved margins. Twenty-eight PM patients (80.0 %) were stage III, and 7 (20.0 %) were stage IV. Recurrence was significantly higher in PM than NM (63.6 % vs. 39.7 %, respectively; p = 0.005). The OS and DFS rates were significantly lower in the PM group than in the NM group (14.9 vs. 36.3 months, p < 0.001 and 11.6 vs. 27.1 months, p = 0.005, respectively). The presence of PM was an independent risk factor for both OS and DFS.

Conclusions

The presence of PM is an independent risk factor for OS and DFS. Considering the prognostic impact of PM, a sufficient resection margin should be ensured when determining the resection line in gastrectomy with curative intent. The reoperation to secure clear resection margins should be considered as a treatment of choice in the case of PM.