Sagittal flexion of the femoral component affects flexion gap and sizing in total knee arthroplasty

The purpose of this study was to determine how much sagittal rotation of the femoral component affects the flexion gap and femoral component sizing using a computer-simulation technique. The study comprised 25 knees scheduled for total knee arthroplasty (TKA). The femoral component was positioned at -2°, 0°, 2°, 4°, or 6° of flexion to the anterior femoral cortex, and the resected portion of the posterior medial femoral condyle was measured for 3 total knee systems. The amount of the resected bone of the posterior medial condyle decreased approximately 1 mm for every 2° of additional flexion in all TKA systems. Intentional sagittal flexion of the femoral component by several degrees during TKA can be a useful downsizing technique for the femoral component without excessively increasing the flexion gap.     

A case of minimal change nephrotic syndrome with immunoglobulin A nephropathy transitioned to focal segmental glomerulosclerosis

A 50-year-old woman with a 1-month history of lower extremity edema and a 5 kg weight increase was admitted to our hospital with suspected nephrotic syndrome in October 1999. Urine protein level was 3.5 g per day, 10-15 erythrocytes in urine per high-power field, and serum albumin level 2.5 g/dl. Furthermore, an accumulation of pleural effusion was confirmed by chest X-ray. The results of a renal biopsy indicated slight mesangial proliferation in the glomeruli by light microscopy, and an immunofluorescence study confirmed the deposition of immunoglobulin (Ig) A and C3 in the mesangial area. Diffuse attenuation of foot processes and dense deposits in the mesangial area were observed by electron microscopy. Treatment with 40 mg/day of prednisolone was effective, and proteinuria was negative 1 month later. Because of this course, we diagnosed minimal change nephrotic syndrome complicated by mild-proliferative IgA nephropathy. In November 2000, there was a relapse of nephrotic syndrome, which was believed to be induced by an influenza vaccination, but response to increased steroid treatment was favorable, and proteinuria disappeared on day 13 of steroid increase. A second relapse in May 2001, showed steroid resistance with renal insufficiency, and an increase in the selectivity index to 0.195. Light microscopy revealed focal sclerotic lesions of the glomeruli, and an immunofluorescence study revealed attenuation of mesangial IgA and C3 deposition. These findings led to the diagnosis that minimal change nephrotic syndrome had transitioned to focal segmental glomerulosclerosis, whereby mesangial IgA deposition was reduced by immunosuppressive treatment. Subsequently, her renal function gradually worsened to the point of end-stage renal failure by 27 months after the second relapse of nephrotic syndrome.     

Insulin secretion and glucose utilization are impaired under general anesthesia with sevoflurane as well as isoflurane in a concentration-independent manner

Purpose The dose-dependent effects of sevoflurane and isoflurane anesthesia on glucose tolerance were compared in humans. Methods A prospective, randomized clinical study was conducted in 30 patients. The 30 patients were divided randomly into three sevoflurane anesthesia groups (0.5, 1.0, and 1.5 minimum alveolar concentration [MAC]) and three isoflurane anesthesia groups (0.5, 1.0, and 1.5 MAC). Induction of anesthesia was accomplished by inhalation of the volatile agent and nitrous oxide. After induction, anesthesia was maintained at the designated MAC for 15 min without surgical stimulation. The intravenous glucose tolerance test (IVGTT) was performed in these 30 patients while they were under general anesthesia and again several days after surgery in 5 of these patients while they were awake, as a control. Results The insulinogenic index (change in concentration of immunoreactive insulin/change in glucose concentration), the acute insulin response, and rates of glucose disappearance were significantly lower in all anesthesia groups than in the control group. However, the insulinogenic index, acute insulin response, and the glucose disappearance rate did not differ significantly among the six anesthesia groups. Conclusion Sevoflurane anesthesia impairs glucose tolerance to the same degree as does isoflurane anesthesia. Glucose intolerance during sevoflurane or isoflurane anesthesia is independent of agent and dosage up to 1.5 MAC.     

Repair of mitral regurgitation caused by prolapse of the anterior mitral leaflet

Mitral regurgitation caused by prolapse of the anterior mitral leaflet has been considered to be difficult for reconstruction. In Japan, these cases have been repaired mainly by replacement of chordae with artificil sutures. We have repaired them by Carpentier’s technique. We report a series of 9 patients with pure mitral regurgitation caused by ruptured or elongated chordae of the anterior mitral leaflet. Two of them had lesions at both anterior and posterior leaflet. All patients underwent mitral valve repair by segmental transposition of the posterior leaflet. As for associated procedures, there were ring annuloplasty with Carpenter rings (9 cases), sliding technique (8 cases) reported by Carpentier, reinforcement by transposition of secondary chordae of the posterior leaflet (6 cases), commissuroplasty (1 case), and closure of leaflet perforation. All patients survived operations and all patients except one underwent left ventriculography postoperatively. In only 2 patients, residual mitral regurgitatin classed as I/IV was observed. All patients returned home in New York Heart Association class I. Follow-up ranged from 7 to 45 months (mean follow-up 20 months). All patients were free from reoperation or thromboembolism. Although longer follow-up is necessary, this technique appears to be adequate for the repir of patients with anterior leaflet prolapse.     

Treatment strategy for malignant solid tumors in childhood

The prognosis for children with malignant solid tumors has improved dramatically in Japan. During the last two decades, various groups have conducted sequential studies of the treatment of children with neuroblastoma, Wilms' tumor, and hepatoblastoma. Most institutes participated in nonrandomized trials designed to evaluate the safety and efficacy of combination chemotherapy, surgery, and radiotherapy in each group study and treated children with these tumors The results are reviewed and areas for future investigation are identified.     

Results of laparoscopic liver resection: retrospective study of 68 patients

Background  Although an increasing number of reports and publications have dealt with the laparoscopic approach to liver resection, this procedure remains uncommon, and its feasibility, safety and effectiveness are still not established. There are few reports of the advantages of this approach on postoperative recovery. Methods  From December 1997 to March 2007, laparoscopic hepatic resection were performed in 68 patients. Results  There were 52 malignant tumors (36 hepatocellular carcinomas, three intrahepatic cholangiocarcinomas, one cystadenocarcinoma, liver metastases from ten colorectal carcinomas and two other organs) and 16 benign lesions among our 68 patients. Fifteen patients with hepatocellular carcinoma had cirrhosis. The mean tumor size was 3.1 ± 1.8 cm (range 1.0–14.0 cm), and the tumors were located in every liver segment except segment I. Liver resection was anatomical in 17 patients and consisted of a lobectomy in four patients and a lateral segmentectomy in 13 patients. Non-anatomical resections were performed in 51 patients. The operative time was 214 ± 93 min. Mean blood loss was 393 ± 564 g. A hand-assisted laparoscopic method or mini-laparotomy method was required in 35 patients (51.4%). Operative complications occurred mainly in our early cases and included three patients (4.4%) with operative bleeding, 2 of whom (2.9%) requiring a conversion to open surgery. Postoperative complications occurred in seven patients (10.0%), and two of then eventually required a re-operation. The mean hospital stay was 17 days. There were no complications in the more recent cases. Conclusions  The laparoscopic approach for liver tumors is feasible, if the indication is carefully selected. The safety of this procedure depends on the surgical experience of the surgeon and team and the availability of the necessary technology.     

An intestinal volvulus caused by multiple magnet ingestion: an unexpected risk in children

It has been reported that ingested magnets can cause intestinal fistula formation or perforation, leading to intestinal obstruction. However, there are no previous case reports that magnet ingestion additionally caused an intestinal volvulus. We report herein the case of a 1-year-old boy in whom the ingested magnets caused a volvulus of part of the small intestine leading to the resection of the necrotic portion. We think that if more than one magnet is found as a foreign body in the intestine, they should be removed immediately by laparotomy. Clinicians who care for children should be aware of this unexpected risk.     

A case of Sertoli cell tumor

We report a case of Sertoli cell tumor. A 33-year-old man visited our clinic with a complaint of painless left scrotal swelling on September 29th, 2003. An elastic firm induration larger than a hen's egg in size was palpable on the surface of the left testis. Tumor markers for testicular tumor such as human chorionic gonadotropin-beta, alpha fetoprotein, and lactate dehydrogenase were not elevated. However, ultrasound showed a low echoic mass in the left testis. Therefore, we performed left high orchiectomy under the diagnosis of left testicular tumor. Its histology showed Sertoli cell tumor. Neither recurrence nor metastasis has been detected for about 8 months after the operation.     

Bladder outlet obstruction accelerates bladder carcinogenesis

OBJECTIVE

To examine the correlation between partial bladder outlet obstruction (PBOO) and bladder carcinogenesis.

MATERIALS AND METHODS

Female Wistar rats (6 weeks old) were divided into three groups of 10 each: group 1 was exposed to n‐butyl‐n‐butanol nitrosamine (BBN, a carcinogen) in drinking water for 8 weeks; group 2 had PBOO induced surgically after exposure to BBN for 8 weeks; group 3 had a sham operation and the rats drank normal water (control group). After 20 weeks, all of the rats were killed humanely and their bladders analysed.

RESULTS

There were no significant differences in body weight among the groups. The bladder weight of group 2 was significantly greater than either group 1 or group 3. Histopathologically, bladder smooth muscle hypertrophy was the major cause of the increased bladder weight for group 2. In group 2 there were increases in bladder wall thickness and many nipple‐shaped urothelial tumours. Basic fibroblast growth factor and hypoxia‐inducible factor‐1α expression were significantly greater in group 2 than in groups 1 and 3.

CONCLUSIONS

Exposure of the bladder to carcinogens during bladder hyperplasia and hypertrophy induced by PBOO results in a greater incidence of superficial bladder carcinoma.