Successful choledochojejunostomy for choledochal stricture with preservation of the collateral parabiliary venous system following iatrogenic portal occlusion

We surgically treated a patient with biliary stricture and portal vein occlusion, after operation for gastric cancer with lymphadenectomy along the hepatoduodenal ligament, that had led to choledochal stone formation and a dilatated parabiliary venous system. A 57-year-old man without hepatic dysfunction exhibited hepatic duct dilatation with choledochal stone on ultrasonography and percutaneous transhepatic cholangiography, respectively. Pharmacoportography revealed occlusion of the portal vein and dilatation of the parabiliary venous system. Of various preoperative imaging studies used, enhanced computed tomography was most useful for delineating the surgical anatomy of the hepatoduodenal ligament. Complete preservation of the dilatated vessels, which functioned as the main portal collateral pathway, resulted in a successful choledocho-jejunostomy, with an uneventful postoperative course.     

Cibenzoline-induced respiratory muscular paralysis in a hemodialysis patient

A 69-year-old man was admitted to our kidney center with endstage renal failure. We started intermittent peritoneal dialysis immediately because of severe azotemia, hyperkalemia, and metabolic acidosis. Two weeks after admission, he developed uremic pericarditis with frequent ventricular premature contractions and supraventricular premature contractions. The intermittent peritoneal dialysis was then replaced by intensive hemodialysis, and oral administration of 300 mg/d of cibenzoline was started. Four days later, he developed thirst, weakness, and dyspnea due to respiratory muscular paralysis. We initiated respiratory support with a respirator because analysis of his blood gases revealed marked hypercapnia and hypoxia. He also developed hypoglycemia and prolonged PQ and QRS intervals on the electrocardiogram, which we believed were due to cibenzoline intoxication; we discontinued the cibenzoline immediately. All symptoms improved, and he was extubated 5 days later. After 2 months, his pericardial effusion disappeared. He now continues maintenance hemodialysis as an outpatient. We suspect that the cibenzoline induced the respiratory muscular paralysis for 2 reasons: 1) the patient experienced the respiratory muscular paralysis, at the same time he also experienced thirst, weakness, hypoglycemia, and prolonged PQ and QRS intervals on electrocardiogram, and all of these symptoms improved after the discontinuation of cibenzoline, and 2) his plasma concentration of cibenzoline became remarkably elevated, to 20 times above the standard therapeutic level. This patient's clinical course indicates that hemodialysis might be superior to intermittent peritoneal dialysis for treatment of cibenzoline intoxication.     

Micro-shear bond strength of dual-cured resin cement to glass ceramics.

OBJECTIVES: The aim of this study was to investigate the effects of sandblasting, etching, and a silane coupling agent on the ability of dual-cured resin cement to bond to glass ceramics designed for in indirect adhesive restoration. METHODS: A cast glass ceramic (Olympus Castable Ceramics) with a crystalline phase consisting of mica and beta-spondumene was selected as the substrate material. The glass surfaces, which were sandblasted, polished, or etched with phosphoric acid or hydrofluoric acid (HF), were bonded with a dual-cured resin cement (Panavia Fluoro Cement) using a dentin adhesive system (Clearfil SE Bond), both with and without a silane coupling agent. A micro-shear bond test was carried out to measure the bond strength of the resin cement to the glass surface. Each glass surface was bonded and tested using the shear test. In addition, surfaces with the bonding removed after the shear bond test, the adhesive interface between the glass and cement, and an etched glass surface without any bonding, were studied morphologically using scanning electron microscopy or field emission scanning electron microscopy. RESULTS: Usage of a silane coupling agent effectively raised the bond-strength values of resin cement (Fisher's PLSD, P<0.01). The effectiveness of using phosphoric acid etching to improve bonding was not clear (Fisher's PLSD, P>0.01). HF-etching for 30s seemed to over-etch the glass surface, resulting in adverse effects on bonding (Fisher's PLSD, P<0.01). SIGNIFICANCE: The micro-shear bond strength between Olympus Castable Ceramics and resin cement can be increased by the silane coupling agent used along with an acidic primer.     

A case of transient bioprosthetic valve regurgitation and hemolysis devoloping early after surgery using Carpentier-Edwards valve.

The Carpentier-Edwards pericardial bioprosthesis has been markedly improved in the long-term results and valve-related complications including valve dysfunction, compared to the previous generation bioprosthesis. We report a patient in whom transient prosthetic valve regurgitation and hemolysis occurred early after mitral valve replacement using a Carpentier-Edwards pericardial bioprosthesis and were resolved by preservative therapy. The patient was a 77-year-old female diagnosed with severe mitral valve stenosis and insufficiency. She underwent mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis. Opening and closing of the three leaflets looked good on intraoperative transesophageal echocardiography (TEE). The only prosthetic valve regurgitation was evident at the central region where the leaflets form coaptation, and no abnormal findings were seen. Serum lactate dehydrogenase (LDH) was decreased to 405 U/l after surgery. However, LDH again began to increase on the 3rd day after surgery and it increased to 1,830 U/l on the 14th day after surgery. Hemolytic urine was detected on 10th day after surgery. PVL was not detected, but moderate abnormal regurgitation from the outside of the stent pocket was detected on TEE. Revision of valve replacement was considered, but LDH thereafter to 393 U/l on 41st day after surgery. The TEE was repeated, and only a trace of central jet was detected without abnormal regurgitation, unlike the previous examination. The patient did not develop any complications thereafter and was discharged on 47th day after surgery. LDH was nearly normal at the time of discharge.     

Abnormal fluorine-18-fluorodeoxyglucose uptake in benign esophageal leiomyoma

A benign esophageal leiomyoma with abnormally increased fluorine-18-fluorodeoxyglucose uptake on positron emission tomography (PET) was resected thoracoscopically. The tumor, of which the maximum standardized uptake value of the lesion was 4.7, was well defined and 38 mm in diameter. Neither mitotic activity nor degeneration was found histologically; and immunoreactivity for CD34, CD117, MIB-1, and glucose transporter-1 was negative immunohistochemically. A diagnosis of gastrointestinal stromal tumor was ruled out by an oncogenic kinase gene mutation study. This case cautions against PET-dependent evaluation for malignant potential of esophageal submucosal tumors.     

Golgi study on brain of macular mutant mouse as a model of Menkes kinky hair disease

Summary This study was undertaken to elucidate, using the Golgi method, the neuropathological change in the brain of the macular mutant mouse, whose hemizygote (Ml/y) is considered to be a model of Menkes kinky hair disease (MKHD). The hemizygote mice gradually lost weight after 10 days of age and died with emaciation and seizure around day 15. The normal littermate (+/y) was well developed. In the cerebrum, the arborization of pyramidal neurons in the layer V of the Ml/y was the same as that in the +/y on day 10. However, development of arborization in the Ml/y was delayed in comparison with that in the +/y on days 12 and 14. Purkinje cells with several somal sprouts were observed in the cerebellum in both the Ml/y and +/y on day 7. The somal sprouts in the +/y had regressed gradually by day 12, while they were still in the anterior and middle lobes of the Ml/y on day 14. Additionally, the trunks of Ml/y stem dendrites became thicker and a cactus formation was recognized on the branching portion of the dendrites on day 14. Arborization of these abnormal Purkinje cells was distinctly poor compared with that in the +/y. These results suggest that the growth of the neurons is delayed in the Ml/y and simultaneously their cytoskeletal developments are disturbed, especially in the Purkinje cells. There is a close similarity in many respects to the neuropathological change in MKHD.     

Correlation between scalp-recorded electroencephalographic and electrocorticographic activities during ictal period.

OBJECTIVE: To investigate the correlation between scalp-recorded electroencephalographic (EEG) and electrocorticographic (ECoG) activities during ictal periods. METHODS: Simultaneous EEG and ECoG recordings with chronic subdural electrodes were performed in eight patients with partial epilepsy. RESULTS: In two cases where the ictal ECoG discharges originated in deep brain structures such as the hippocampus and interhemispheric surface of the frontal lobe, ictal discharges could not be detected on EEG until they expanded to the cortex of convexity. In four cases, the ictal onset zones were located in the lateral convexity. When synchronous or near synchronous ictal ECoG discharges with amplitudes of 200-2000muV were recorded on more than 8-15cm(2) of cortex, corresponding discharges were recorded on EEG in these four cases. However, in a case of frontal lobe epilepsy, asynchronous ictal ECoG discharges were recorded on 10 electrodes of convexity but no ictal EEG activity was recorded. Furthermore, in two frontal lobe epilepsy cases, ictal EEG discharges did not always reflect the ictal ECoG spike, but occasionally reflected slow background ECoG activity around the ictal discharges. CONCLUSIONS: Multiple factors such as the width of the cortical area involved, amplitude of ictal discharges and degree of synchronization of electrical potentials play important roles in the appearance of ictal EEG recordings, and the relationship between ictal EEG and ECoG is not straightforward.