Laparoscopic radical nephrectomy in ACDK-associated renal cell carcinoma accompanied by duplicated IVC: a case report

A 59-year-old male patent who had undergone chronic dialysis for 13 years presented with gross hematuria. Radiological examinations showed a cystic renal tumor in the left kidney, multiple renal cysts due to acquired cystic disease of the kidney (ACDK), and a duplicated inferior vena cava (IVC). Although we suspected that the branches of the left IVC might be anormalous with regard to number and location, we could not obtain information about the left renal vein by 3-dimensional computed tomography because of the decreased blood flow in the end-stage kidney. Laparoscopic radical nephrectomy was performed using a transperitoneal approach. We first identified the left IVC and then exposed its surface widely so that we could identify the veins draining into it. We identified and divided two renal veins and also identified an adrenal vein and a gonadal vein draining directly into the left IVC. The enlarged kidney with multiple renal cysts was removed in a purely laparoscopic procedure.     

Locally applied cilostazol suppresses neointimal hyperplasia and medial thickening in a vein graft model.

BACKGROUND: Pathological changes in vein grafts begin immediately after arterial circulation is applied to the grafts. Chemical mediator stimulation and mechanical strain induce neointimal hyperplasia and medial thickening of the vein grafts, resulting in their failure. We investigated the inhibitory effect of locally applied cilostazol, an inhibitor of cyclic adenosine monophosphate phosphodiesterase III, on neointimal hyperplasia and medial thickening of the grafts. METHODS AND RESULTS: We established a distal anastomotic stricture model of femoral vein-abdominal aorta interposition grafting in rats. In this model, neointimal hyperplasia was observed not only at the distal anastomotic sites, but also in the graft body at postoperative day 14 and was markedly progressed at day 28. A strong expression of tenascin-C was found in the media and neointima of the graft body. In the grafts around which cilostazol was administered locally using Pluronic gel, neointimal hyperplasia was significantly suppressed compared with control grafts treated with the gel alone, with the mean neointimal cross-sectional area reduced by 87.1% for the graft body and by 78.9% for the distal anastomotic sites and mean medial cross-sectional area of the graft body reduced by 54.2% at day 28 versus the control. Cilostazol treatment decreased cell proliferation and the number of tenascin-C-producing cells seen by in situ hybridization, but the expression of tenascin-C protein was not suppressed. CONCLUSION: We concluded that a single perivascular application of cilostazol inhibits neointimal hyperplasia and medial thickening of vein grafts in a rat model.     

A novel approach to restore atrial function after the maze procedure in patients with an enlarged left atrium.

OBJECTIVE: Left atrial (LA) volume reduction surgery concomitant with the maze procedure has been reported to facilitate sinus rhythm recovery even in patients with refractory atrial fibrillation (AF) with an enlarged LA. However, it is unknown whether the procedures can also restore effective atrial function of the enlarged LA with over-stretched myocardium. METHODS: The maze procedures in association with mitral valve surgery were performed to 57 AF patients with an enlarged LA (LA diameter >or=60mm). Among them, 32 patients had concomitant LA volume reduction surgery (VR group). Another 25 patients did not have the volume reduction (control group). RESULTS: Three months postoperatively LA end-diastolic volume (LAEDV, ml) assessed by magnetic resonance (MR) imaging was larger in the VR group than that in the control group (291+/-117 vs 223+/-81 ml, p<0.05). Postoperatively, sinus rhythm recovery rate was better (84 vs 68%, p<0.05) and LAEDV was drastically smaller (118+/-48 vs 203+/-76 ml, p<0.001) in the VR group than those in the control group. Among the patients with sinus rhythm recovery in both groups, LA contraction ejection fraction (%) improved in the VR group but not in the control group (22.3+/-7.8 vs 10.3+/-4.7%, p<0.001). CONCLUSIONS: The LA volume reduction surgery concomitant with the maze procedure restored contraction of the enlarged LA; however, the maze procedure alone did not restore LA contraction in spite of successful sinus rhythm recovery. LA volume reduction surgery may be desirable to the patients with refractory AF with over-stretched LA.     

Validation and reliability of a Japanese version of the Shoulder Pain and Disability Index: A cross-sectional study

BackgroundThe Shoulder Pain and Disability Index (SPADI) is a simple disease specific questionnaire that is used to evaluate the impact of shoulder disorders. The purpose of this study was to translate the SPADI into Japanese (SPADI-Jp) and evaluate its reliability and validity in Japanese patients with shoulder disorders.MethodsCross-cultural adaptation of the SPADI was performed according to international guidelines. A total of 100 patients with shoulder disorders participated in this study. Each participant was asked to finish the SPADI-Jp, Disability of Arm, Shoulder and Hand (DASH), and the Short-Form 36 (SF-36) at the initial visit. Thirty-four patients repeated the SPADI-Jp to assess the test–retest reliability. The test–retest reliability was quantified using the interclass correlation coefficient (ICC), while Cronbach's alpha was calculated to assess the internal consistency. The construct validity was assessed using Spearman's rank correlation coefficients.ResultsInternal consistency in the SPADI-Jp was very high (0.969), as measured by the Cronbach's alpha. The ICC of the SPADI-Jp was 0.930. There was a strong, positive correlation between the DASH and the SPADI-Jp (r = 0.837, p < 0.001). The SPADI-Jp was significantly correlated with most of the SF-36 subscales. The correlations of the SPADI-Jp with physical subscales of the SF-36 were stronger than those with the other subscales.ConclusionsWe demonstrated that the SPADI-Jp is a reliable and valid self-assessment tool. Because cross-cultural adaptation, validation, and reliability of the disease-specific questionnaire for shoulder pain and disability have not been evaluated in Japan, the SPADI-Jp can be useful for evaluating such patients in the Japanese population.     

Blood flow energy loss: a predictor for the recovery of left ventricular function after bioprosthetic aortic valve replacement

 Open in a separate windowOBJECTIVESIt is difficult to estimate the improvement in left ventricular (LV) function after aortic valve replacement (AVR). The present study aimed to evaluate whether energy loss (EL) can predict the postoperative LV function after AVR.METHODSNine patients who underwent AVR with a bioprosthetic valve were enrolled in the present study. Porcine prostheses were used in 5 patients and bovine pericardial prostheses were used in 4 patients. The aortic flow pattern was visualized and EL and cardiac output (CO) were measured using 4-dimensional flow magnetic resonance imaging from the LV to the descending aorta; the EL/CO ratio in the extracted area was calculated as total EL/CO ratio.RESULTSWith a porcine valve, a severe helical flow was observed in the ascending aorta during the holosystolic phase. In contrast, with a bovine pericardial valve, straight transvalvular aortic flow was observed in the early systolic phase and 2 large vortical flows occurred on both sides of the greater and lesser curvature of the ascending aorta after the mid-systolic period. The total EL/CO ratio was strongly correlated with LV ejection fraction improvement after AVR (r = 0.74, P = 0.02).CONCLUSIONSThe aortic flow pattern is different between the porcine valve and bovine pericardial valve. The total EL/CO ratio is a valuable tool for evaluating the postoperative LV ejection fraction improvement after AVR. Optimization of total EL/CO ratio would have potential to improve haemodynamic performances after AVR.     

Intramuscular hemangioma of the upper extremity in infants and children

PURPOSE: Intramuscular hemangiomas (IMHs) are benign tumors comprising just 0.8% of all hemangiomas and are extremely rare in the upper limbs. These tumors can pose diagnostic as well as therapeutic challenges for orthopaedic surgeons, especially in younger children. We reviewed cases of IMH of the upper extremity in infants and children from our institute. METHODS: Six consecutive patients underwent surgical treatment for IMH in our hospital. There were 4 girls and 2 boys. Long-standing pain and swelling were common symptoms except in a 1-year-old boy. Tumors were evaluated by radiography, computed tomography, magnetic resonance imaging, and angiography. RESULTS: After a mean follow-up of 42 months, all patients except one were free of pain and without tumor recurrence or functional impairment. Minimal symptoms remained in a 6-year-old boy who underwent biopsy only. CONCLUSION: Magnetic resonance imaging is the most useful evaluation for IMH because it not only delineates the extent of tumor but also reveals characteristic structures. For young children with IMH, wide excision is the treatment of choice to prevent local recurrence, but every patient should be treated individually after evaluating the patient's age, tumor location and invasion, and cosmetic considerations. LEVEL OF EVIDENCE: Therapeutic study-level III.     

Simultaneous coronary arterial bypass surgery using mini-sternotomy and off-pump methods and abdominal aneurysm repair

A technique of combined minimally invasive coronary artery surgery and abdominal aneurysm repair is described. A mini-sternotomy and off-pump coronary artery bypasses to the left descending branch and right coronary arteries are conducted before abdominal aneurysm repair in a simultaneous operation.     

A case of amphetamine-induced down-regulation of beta-adrenoceptor]

A 29-year-old man with severe pyloric stenosis confessed that he had been a chronic amphetamine abuser just after awakening from anesthesia for partial gastrectomy. Anesthesia was maintained with thoracic epidural bupivacaine combined with continuous i.v. infusion of propofol. Decreased arterial blood pressure was observed 10 min after starting epidural anesthesia, and remained stable at 80-90 mmHg of systolic blood pressure in spite of massive fluid resuscitation in addition to repeated i.v. administration of ephedrine/methoxamine and continuous i.v. infusion of dopamine at a rate of 8 micrograms.kg-1.min-1. Finally, arterial blood pressure rose gradually after i.v. administration of methylpredonisolone 500 mg. We speculate that the down-regulation of beta-adrenoceptor induced by the sympathomimetic action of amphetamine, might be a major cause of refractory hypotension.     

Treatment of metastatic bone lesions in the upper extremity: indications for surgery

Pathological fractures caused by metastatic malignant disease have been the subject of increasing interest in recent years. This article describes our experience with the treatment of metastatic bone disease of the upper extremity and our attempt to clarify the indications for different surgical procedures. Of 53 patients with metastatic lesions to the upper extremity, 20 who had been surgically treated were analyzed retrospectively. These comprised 13 men and 7 women with a mean patient age of 62 years. The most common primary tumors to metastasize were lung and liver, with the humerus involved in 12 cases and the scapula and forearm in 4 cases each. Four patients with scapula and forearm involvement underwent tumor resection due to uncontrollable tumor size, while 3 were successfully treated by selective arterial embolization. Three metastases to the humeral head were reconstructed with endoprosthesis, but functional restriction was noted. Five cases with metastases to the humeral shaft were treated with tumor curettage, internal fixation using intramedullary nailing, adjuvant cryosurgery, and cementing. This achieved good results for pain relief and functional restoration with minimal complications. Two metastases to the humeral condyle were unable to be stabilized with plate and locking screws. Metastatic lesions to the scapula and forearm are commonly treated nonsurgically, but some patients with uncontrollable tumor mass require surgical resection. Endoprosthetic replacement is recommended if the lesion involves the humeral head or condyle. Most patients with the humeral shaft lesion are likely to benefit from tumor curettage, intramedullary nailing with locking screw, and cementing.