Improved quality of life with jejunal pouch reconstruction after total gastrectomy

BACKGROUND: There is increasing evidence that the effect of jejunal pouch reconstruction is satisfactory for reservoir function in several randomized control studies. However, these studies were performed in patients with advanced gastric cancer, where significant numbers of the patients died of disease recurrence. In order to exclude the influence of disease recurrence, we performed jejunal pouch reconstruction after total gastrectomy in patients with early gastric cancer in a randomized controlled study and investigated whether or not an improved quality of life (QOL) was observed with jejunal pouch reconstruction. METHODS: Fifty consecutive patients receiving total gastrectomy for early gastric cancer were prospectively divided into the Roux-en-Y reconstruction group without pouch (RY group) or the jejunal pouch reconstruction group (pouch group). Body weight, eating capacity, QOL assessment by gastrointestinal symptom rating scale (GSRS), nutritional parameters, endoscopical examination, 24-hour pH monitoring and Bilitec monitoring were evaluated at 3, 12, and 48 months after surgery. RESULTS: Jejunal pouch reconstruction provided the better QOL than Roux-en-Y reconstruction without pouch both at short-term and long-term periods in a randomized control study. Moreover, as a new finding, pouch reconstruction provided less bile reflux into the esophagus compared with Roux-en-Y reconstruction. CONCLUSIONS: Jejunal pouch reconstruction provided improvement of QOL in patients receiving total gastrectomy.     

Detection of pannus by multidetector-row computed tomography

Prosthetic valve dysfunction (PVD) due to pannus formation is an infrequent but serious complication. A 72-year-old man who underwent aortic valve replacement was diagnosed with PVD and aneurysm of the Sinus of Valsalva. Multidetector-row computed tomography (MDCT) was used to examine the cause of PVD before reoperation. MDCT demonstrated that tissue regarded as pannus extended from the left ventricular septum into the pivot guard. These findings were confirmed by observations during reoperation. MDCT can be a useful diagnostic technique for the anatomical and functional evaluation of PVD.     

A prospective study of indications for mediastinoscopy in lung cancer with CT findings,tumor size,and tumor markers

BACKGROUND: Biopsies by mediastinoscopy remain the most reliable preoperative staging method for N2 lung cancer. Because it is neither practical nor economical to recommend mediastinoscopy for all candidates for surgery, we developed indicational criteria for video-assisted mediastinoscopy (VAM) and carried out a prospective study to validate its usefulness. METHODS: Patients with resectable primary lung cancer were chosen for VAM when at least one of three clinical indicators was present: (1) computed tomographic evidence of mediastinal adenopathy, (2) elevated levels of serologic tumor markers, and (3) diameters of primary cancers (> 2 to 3 cm). Patients without positive nodes (group 2) underwent thoracotomy, and patients with positive nodes (group 3) received induction therapy. When none of these criteria were met (group 1), thoracotomy with R2b lymph node dissection was performed without VAM. RESULTS: One hundred twenty-one men and 82 women (total, 203) were eligible for the study. The mean age of the patients was 64.4 years (range, 39 to 75 years) with primary lung cancer. The patients were comprised of 135 adenocarcinomas, 46 squamous cell cancers, and 22 other carcinomas. There were 78 patients in group 1, 87 in group 2, and 38 in group 3. The stages of group 2 patients were more advanced (chi2 = 63.2668; p < 0.001) than those of group 1. As the incidence of positive indicators for VAM increased, the ratios of N2 patients increased from 2.5% (all negative) to 90.4% (triple positive: p < 0.001). The correlation of our criteria with the pathology findings revealed a diagnostic sensitivity of 95.8% and a negative predictive value of 97.4%. Using three indicators for N2 prediction, we selected 96% (46 of 48) pN2, N3 patients and avoided 37% (76 of 203) unnecessary VAMs. CONCLUSIONS: We established and validated currently useful criteria for VAMs in the management of primary lung cancer.     

Thromboembolic events associated with Guglielmi detachable coil embolization with use of diffusion-weighted MR imaging. Part II. Detection of the microemboli proximal to cerebral aneurysm

BACKGROUND AND PURPOSE: The purpose of this study was to document the incidence and radiologic appearance of thromboembolic events during Guglielmi detachable coil (GDC) embolization for asymptomatic basilar artery (BA) bifurcation and BA-superior cerebellar artery (SCA) aneurysms by using diffusion-weighted (DW) MR imaging, with special emphasis on the evidence of thromboembolic events in vascular territories proximal from the treated aneurysm, which cause cerebellar infarction, and to discuss which step of the procedure (aneurysm or catheter manipulation) may play a role for most thromboembolic events. METHODS: Since 1999, 38 asymptomatic BA bifurcation and BA-SCA aneurysms were treated with GDCs at the National Cardiovascular Center. DW studies were performed for 26 patients between 2 and 5 days after GDC embolizations. All DW images were reviewed by two radiologists for depiction of abnormalities. These findings were retrospectively evaluated with clinical and technical factors of thromboembolic events. RESULTS: DW images showed new hyperintense lesions in 18 patients (69%), with seven (27%) incurring neurologic deteriorations. All symptomatic patients fully recovered by discharge. Fourteen (78%) of 18 patients showed new lesions proximal to the treated aneurysm; that is, in the cerebellar hemispheres. In three cases treated with the balloon-assisted technique, new hyperintense lesions were seen. CONCLUSION: In our experience, most thromboembolic events related to the use of the GDC embolization may be caused by catheter manipulation, especially in the case of the balloon-assisted technique. Caution should be exercised in the handling of catheters. Furthermore, a softer and smaller caliber catheter and simple GDC technique should be considered.     

Accidental fatal hypothermia in elderly people with Alzheimer's disease

We report two forensic autopsy cases of fatal accidental hypothermia in an 89-year-old woman and a 76-year-old man who were found dead and unclothed. In both cases, Alzheimer's disease (AD) was diagnosed by neuropathological examination. Wandering due to AD was determined as the cause of these accidents. Although paradoxical undressing in hypothermic victims is known to occur as a result of cold exposure, in our patients, undressing was attributed to dementia due to AD before they became hypothermic. These cases indicate that neuropathological examination is crucial to determining the cause of such accidents and that undressing is not always the result of hypothermia in elderly victims.     

Thromboembolic events associated with Guglielmi detachable coil embolization of asymptomatic cerebral aneurysms: evaluation of 66 consecutive cases with use of diffusion-weighted MR imaging

BACKGROUND AND PURPOSE: Although Guglielmi detachable coil (GDC) endovascular treatment of intracranial aneurysms has become an accepted alternative to surgery, the main complication continues to be thromboembolic events. We sought to determine the frequency and radiologic appearance of thromboembolic events during GDC embolization for asymptomatic cerebral aneurysms by using diffusion-weighted (DW) MR imaging and to determine whether aneurysmal anatomic factors or use of the balloon-assisted technique affected the frequency. METHODS: In 74 patients, 79 asymptomatic cerebral aneurysms were treated with GDC embolizations at the National Cardiovascular Center from 1999 to 2001. Thirty-nine of these aneurysms (49%) were treated with the balloon-assisted technique. DW imaging was performed in 66 patients at 2-5 days after GDC embolization. All DW images were reviewed by two radiologists for depiction of abnormalities. RESULTS: DW images showed hyperintense lesions in 40 patients (61%), with 16 of these patients (40%) incurring neurologic deteriorations. Fifteen of the symptomatic patients (94%) fully recovered by discharge, and the remaining one experienced permanent deficits. Hyperintense lesions were detected more frequently in wide-neck (73%) or large (100%) aneurysms and in procedures that used the balloon-assisted technique (73%) than in small aneurysms (50%) or in procedures with the simple GDC method (49%). The occurrence of new lesions was significantly associated with use of the balloon-assisted technique and with aneurysm diameter in multivariate analysis (P <.05). CONCLUSION: In our experience, thromboembolic events related to the use of GDC embolization are relatively common, especially in wide-neck or large aneurysms or in association with the balloon-assisted technique. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique such as the addition of antiplatelet agents and the development of new embolic materials are mandatory.     

Detection of stunned myocardium in post-reperfusion cases of acute myocardial infarction

OBJECTIVE: This study was designed to evaluate the correlation between improvements in serial images obtained by SPECT imaging with Tc-99m MIBI (MIBI) and I-123 BMIPP (BMIPP) and the recovery of cardiac function in acute myocardial infarction (AMI) patients after reperfusion therapy. METHODS: Twenty five patients who were admitted to the emergency room within 24 hours after the onset of the first event of AMI were enrolled in this study. The culprit coronary arteries were identified by CAG and were treated with direct percutaneous transluminal coronary angiography (PTCA), followed by stent implantation. To determine risk areas, initial image at the onset was acquired by the freeze method, in which MIBI was injected before the treatment and the image was collected after the reperfusion therapy. After the reperfusion treatment was completed, MIBI SPECT images at rest were performed on days 7 and 60. Both early and late images, including gated SPECT images were acquired after 30-60 minutes and 6 hours post injection, respectively. In addition, BMIPP SPECT images at rest were obtained 30 minutes after injection of 148 MBq BMIPP on days 7 and 60 (BMIPP image). The obtained image was divided into 48 segments and percent uptake of each segment was calculated. The number of abnormal areas (NAA) was defined as the segment with a % uptake less than 60% of normal uptake, and the change of NAA over time was evaluated. RESULTS: The NAA on the MIBI-early image significantly improved between thepre image and the day 7 image (p < 0.001), but no similar improvement was observed between day 7 and day 60. On the other hand, the NAA of the MIBI-delayed image did not significantly improve up to day 7, but a slight improvement was observed on days 7 and 60 (p < 0.05). A significant improvement in the NAA of the BMIPP image was observed between day 7 and day 60, as shown in the delayed image (p < 0.05). An excellent correlation on the NAA between the MIBI-delayed image and the BMIPP image was observed with r = 0.983 (p < 0.001) at day 7 and r = 0.984 (p < 0.001) at day 60 resulting in a consistent diagnosis. Analysis of the myocardial function by means of gated SPECT indicated that the wall motion significantly improved as the myocardial perfusion improved up to day 7 and thereafter a steady improvement was observed up to day 60. The improvement in the NAA in MIBI-delayed images in the subacute phase (day 7) and in the chronic phase (day 60) as well as BMIPP images showed excellent correlation with the improvement in RWM and RWT (MIBI-delayed image: r = 0.550 (RWM), r = 0.647 (RWT)), (BMIPP image: r = 0.536 (RWM), r = 0.565 (RWT)). CONCLUSION: We conclude that insufficient ATP production caused by mitochondrial dysfunction in stunned myocardium is closely related to MIBI delayed and BMIPP image Furthermore, MIBI delayed imaging as well as BMIPP imaging will provide a clue to the state of stunned myocardium after reperfusion therapy in patients with AMI.     

Proliferative status is a risk index for recurrence in primary superficial (pTa/T1) low-grade urothelial bladder carcinoma

The current clinicopathologic study for evaluation of superficial bladder cancer still has limitations in predicting the true behavior of recurrence. To determine the high-risk recurrence factors, we studied the influence of Ki-67, c-erbB-2, p53 and multidrug resistance-associated protein (MRP) expression. Samples were obtained from 33 pTa and 46pT1 diagnosed bladder cancer patients with a mean follow-up of 48.7 +/- 30.6 months. The contingency table method, Kaplan-Meier curve and multivariate analysis were used to evaluate the association among the immunohistochemical factors expression, clinicopathologic parameters with tumor recurrence. Stage pT1 tumors, sessile tumors and large tumors (> 3 cm) showed a significantly high recurrence rate (p = 0.0158, p = 0.0162, p = 0.0001 respectively). Tumors with overexpression of Ki-67, c-erbB-2 and p53 were more likely to recur (p = 0.0035, p = 0.0027, p = 0.0076 respectively), MRP expression was not associated with recurrence. Multivariate analysis showed that large tumors and high Ki-67 expression were independent indicators of recurrence. On the other hand, in tumors less than 1 cm, recurrence was significantly correlated with overexpression of Ki-67 and p53. High Ki-67 expression could discriminate higher recurrence cases in grade 2, pT1 and single tumors. The c-erbB-2 overexpression was more frequently associated with recurrence in sessile tumors, large tumors, multiple and grade 1 tumors. The p53 overexpression also predicted a higher risk of recurrence in pTa tumors. These data demonstrated that the use of proliferative related proteins yields significant prognostic information in addition to clinicopathological factors, high Ki-67 expression is a reliable indicator of recurrence. A combination rather than any factor alone could more accurately predict tumor recurrence.     

Oral chemolysis of uric acid stones

Oral chemolysis of uric acid stones was performed retrospectively. Twenty-one patients with upper urinary uric acid stones were given alkaline citrate (Uralyt-U) orally. In the case of hyperuicemia, allopirinol was combined. In 11 out of 15 patients (73.3%) treated with oral chemolysis alone, stones were dissolved. In 4 out of 6 cases (66.7%) combined with extracorporeal shock-wave lithotripsy, administration of alkaline citrate shortened the period to be stone-free. In conclusion, we successfully treated 15 out of 21 cases (71.4%) with the administration of alkaline citrate.