Pancreas-Sparing Duodenectomy for a Recurrent Retroperitoneal Liposarcoma: Report of a Case

Pancreas-sparing duodenectomy (PSD), which allows preservation of the pancreas in its entirety, is a promising procedure for low-grade malignancies of the duodenum, the periampullary region, and the neighboring retroperitoneum. We report a case of recurrent retroperitoneal liposarcoma involving the second and third parts of the duodenum, which was extirpated using PSD, after a right hemicolectomy for tumor invasion of part of the colonic hepatic flexura. The Roux-en-Y jejunal limb was sutured to the duodenal bulb in an end-to-end fashion, and the biliary and pancreatic duct systems were reconstructed with end-to-side anastomoses, placing the jejunal limb distal to the bulbo-jejunostomy after a septoplasty to repair the adjacent pancreatic and biliary ducts. Because retroperitoneal liposarcoma has a low incidence of lymph node metastasis, pancreaticoduodenectomy may be inappropriate, especially if minimally extensive surgery can ensure organ preservation. Pancreas-sparing duodenectomy could be the most appropriate procedure for nonepithelial malignant tumors located around the duodenum distal to the pylorus, which have no involvement with the pancreatic parenchyma or periduodenal lymph nodes.     

Post-parturition infectious endocarditis in a patient with a normal mitral valve.

A 29-year-old woman with no history of heart disease was admitted for the treatment of congestive heart failure. Six months earlier, she had given birth, then 20 days later developed a fever and cardiac failure ensued. An echocardiogram demonstrated severe mitral valve regurgitation. Her blood cultures were positive, and we made a diagnosis of mitral valve regurgitation due to infectious endocarditis. Despite treatment for congestive heart failure and antibiotic therapy, resulting in negative blood cultures, her congestive heart failure did not improve, and vegetation on the mitral valve was observed by echocardiography. We successfully removed the infected tissue with mitral valve plasty.     

The effect of fibrin glue on inhibition of pericardial adhesions

The effect of fibrin glue on inhibition of pericardial adhesions was tested using 26 beagle dogs. Dacron patches were sutured to the heart and tincture of iodine was applied to promote adhesions. Fibrin glue (3 ml) was sprayed over the patches in 15 dogs (test group), and was not sprated in the remaining 11 dogs (control group). All animals in the test group had minimal adhesions between the pericardium and the epicardium or patched region, and an accumulation of gelatinous material was found in the subpericardial space. Marked fibrosis and a poor demarcation of the subpericardial space were found in the control group. The adhesion score and the visibility of coronary anatomy in the test group were significantly better than in the control group. The tension strength in the test group was significantly less than in the control group. We concluded, therefore, that fibrin glue may also be useful as an adhesion inhibitor.     

Full-thickness skin graft from the ulnar aspect of the wrist to cover defects on the hand and digits

Skin defects on the volar surface of the hand and digits are commonly treated with skin grafts. Many donor sites capable of providing adequate skin have already been reported. Ideal conditions for the donor site depend on skin color, texture, durability, and size. The authors describe the use of a new donor site for harvesting skin grafts to repair relatively small skin defects on the hand and digits. They used full-thickness skin grafts from the ulnar aspect of the wrist to reconstruct burn contractures and syndactyly in 20 patients. Their grafts provided an ideal color and texture match, and normal function of the hand and digits was restored. The donor site was closed directly, and the resulting scar was inconspicuous.     

Magnetic resonance imaging for preoperative evaluation of breast cancer: a comparative study with mammography and ultrasonography

BACKGROUND: The widespread use of mammographic screening has led to increased detection of small tumors that are often difficult to diagnose with conventional imaging modalities such as mammography and ultrasonography. Intraductal spread of breast cancer, a principle risk factor for local recurrence, is also difficult to diagnose with mammography and ultrasonography. We investigated the clinical usefulness of magnetic resonance imaging of the breast in the therapy of breast cancer and we compared it with mammography and ultrasonography. STUDY DESIGN: A total of 183 patients with primary breast cancer underwent surgery at our institute between September 1, 1999, and November 30, 2002. They were examined preoperatively with magnetic resonance imaging, mammography, and ultrasonography. Magnetic resonance imaging evaluation included contrast-enhanced dynamic studies using IV injection of gadolinium-diethylenetriamine pentaacetic acid. RESULTS: Detection rates of breast cancers by magnetic resonance imaging, mammography, and ultrasonography were 93.7%, 84.6%, and 97.3%, respectively (magnetic resonance imaging versus mammography, p < 0.05). Patterns of time-intensity curves in dynamic magnetic resonance imaging differed with histologic types. Sensitivity, specificity, and accuracy of detection of intraductal spread were 66.7%, 64.2%, and 65.6% with MRI; 22.2%, 85.7%, and 50% with mammography; and 20.6%, 85.2%, and 50% with ultrasonography, respectively (sensitivity, specificity, and accuracy; p < 0.05, respectively). CONCLUSIONS: Magnetic resonance imaging can diagnose breast cancer as accurately as ultrasonography and more accurately than mammography. Patterns of time-intensity curves correlated with tumor histology. In addition, magnetic resonance imaging can detect intraductal spread more accurately than the other two methods. Magnetic resonance imaging appears to be indispensable in breast-conserving surgery to minimize local recurrence.     

Differences in spatial and temporal frequency interactions between central and peripheral parts of the feline area 18

The visual system demonstrates significant differences in information processing abilities between the central and peripheral parts of the visual field. Optical imaging based on intrinsic signals was used to investigate the difference in stimulus spatial and temporal frequency interactions related to receptive field eccentricity in the cat area 18. Changing either the spatial or the temporal frequency of grating stimuli had a significant impact on responses in the cortical areas corresponding to the centre of the visual field and more peripheral parts at 10 degrees eccentricity. The cortical region corresponding to the centre of the gaze was tuned to 0.4 cycles per degree (c/deg) for spatial frequency and 2 Hz for temporal frequency. In contrast, the cortical region corresponding to the periphery of the visual field was tuned to a lower spatial frequency of 0.15 c/deg and a higher temporal frequency of 4 Hz. Interestingly, when we simultaneously changed both the spatial frequency and the temporal frequency of the grating stimuli, the responses were significantly different from those estimated with an assumption of independence between the spatial and temporal frequency in the cortical region corresponding to the periphery of the visual field. However, in the cortical area corresponding to the centre of the gaze, spatial frequency showed significant independence from temporal frequency. These properties support the notion of relative specialization of visual information processing for peripheral representations in cortical areas.     

Concomitant aortic valve and ascending aorta replacement with moderate hypothermic circulatory arrest to treat an aortic bicuspid valve with post-stenotic dilatation

We recommend concomitant surgery for aortic valve replacement (AVR) and ascending aortic replacement using moderate hypothermic circulatory arrest (CA) for post-stenotic dilatation complicated by an aortic bicuspid valve. Cardiopulmonary bypass (CPB) was established from the right atrium to the dilated ascending aorta. As soon as the rectal temperature decreased to 28?°C, CA was commenced and the open distal anastomosis of a polyester prosthesis, without any cerebral perfusion, was completed. AVR was then carried out during rapid re-warming with CPB using a side arm of the prosthesis. This procedure exhibited safe and satisfactory results. There are many benefits of carrying out the procedure in this way; it avoids the requirement for cannulation to a calcified aortic arch, provides a good operative field, for an easier distal anastomosis and suturing at the valve site, and reduces the risk of further dilatation or dissection of the residual ascending aorta in the later phase.     

Vascular Endothelial Growth Factor C Promotes Lymph Node Metastasis in a Rectal Cancer Orthotopic Model

Purpose Vascular endothelial growth factor C (VEGF-C), a novel member of the vascular endothelial growth factor family, is a relatively specific lymphangiogenic growth factor. It has been suggested that increased expression of VEGF-C in primary tumors is correlated with lymph node metastasis. We conducted this study to determine whether VEGF-C directly affects lymphangiogenesis and lymph node metastasis in colorectal cancer.Methods For an accurate analysis and clear visualization of metastases, the rectal cancer cell line, DLD1, was engineered to stably express green fluorescent protein (GFP) (DLD1/GFP). We implanted DLD1/GFP cells overexpressing VEGF-C orthotopically into the rectal walls of nude mice.Results Lymph node metastasis was confirmed in all (100%) of the mice bearing DLD1/GFP-VEGF-C tumors, but in only 25% of the mice bearing control tumors. There were more lymph node metastases per mouse in the mice bearing DLD1/GFP-VEGF-C tumors than in the mice bearing control tumors. There were no differences in cell growth and motility in vitro or in the resulting tumor volume from the implanted cells between the two groups. Immunohistochemical staining revealed that VEGF-C induced the growth of lymphatic vessels, which were enlarged in the tumor periphery and contained tumor cell emboli.Conclusion These results suggest that VEGF-C-induced lymphangiogenesis mediates tumor spread and the formation of lymph node metastasis.     

Microcirculation of kidney and skin during left ventricular assisted circulation--comparative studies of pulsatile and nonpulsatile assists]

We examined microcirculation of the kidney and skin over a six-hour period in an acute myocardial infarction model in pigs. The outflow cannula was placed in the ascending aorta, the inflow cannula was placed the in left atrium, and a pump was connected to each (pulsatile group, Zeon Medical pneumatic pump; nonpulsatile group, Nikkiso HPM-15). Items examined included the regional blood flow of the cortex and medulla in the kidney and skin, renal and carotid arterial flow, arterial ketone body ratio (AKBR), lactate/pyruvic acid (L/P), BUN, creatinine, and beta 2-microglobulin. After the experimental study, the major organs were removed and a pathological study was performed. The mean aortic pressure after the assist could be maintained at about 100 mmHg. There were no significant differences between the two groups in mean aortic pressure and total cardiac output. Under assisted circulation, the pulse pressure was maintained at about 15 mmHg in the nonpulsatile group and about 40 mmHg in the pulsatile group. After the assist, there were no significant differences in the carotid arterial blood flow between the two groups. However, there were significant differences between the two groups in the renal arterial, renal cortical, and regional skin blood flows. In the laboratory data, there were significant differences between the two groups in AKBR, L/P, and beta 2-microglobulin. Pathological findings on the kidney in the nonpulsatile group showed expansion of the proximal tubes, retention of red blood cells, and expansion of blood capillaries within the glomerulus. On the other hand, the pulsatile group showed almost normal formation. In the lungs, the nonpulsatile group showed edematous change in the air cells and the pulsatile group showed almost normal formation. The results of the previous and current study indicated that the pulsatile assist produced superior circulation in the kidney and peripheral organs and superior cellular metabolism in the early treatment of acute left cardiac failure. On the other hand, nonpulsatile assisted circulation was found to be ineffective in maintaining the circulation in the body, and to be potentially capable of causing irreversible damage of major organs if continuous for more than three hours. The results also indicated that pulsatility was necessary to maintain normal circulation in the peripheral organs and cellular metabolism in the early treatment of acute left cardiac failure.