Curious complication after oroesophageal reconstruction with free jejunal flap: intussusception-like deformity of transferred jejunum

Regions of oropharyngeal cancer, hypopharyngeal cancer, and cervical esophageal cancer in a 70-year-old man were surgically resected and reconstructed with a free jejunal flap. Postoperatively the patient showed severe dysphagia and a chimneylike protrusion in the oral cavity. In a second operation, a dorsal, longitudinal incision for phimosis was made to release the stenosis; however, the dysphagia persisted, and peristalis seemed to interfere with deglutition. Here, we discuss the cause of the dysphagia, a complication of total reconstruction of oroesophageal defects with a single free jejunal flap, and the procedures of reconstruction.     

Cecal volvulus in cerebral palsy: Report of a case

A rare case of cecal volvulus in cerebral palsy that was preoperatively diagnosed and surgically treated without complications is herein reported. A 45-year old man, who had been treated for cerebral palsy as a result of a neonatal cerebral hemorrhage, was admitted to our hospital because of abdominal pain and vomiting. A plain abdominal X-ray film showed evidence of a huge quantity of gas in the left abdomen. Using a gastrographin enema from the colonoscope, an obstruction of the ascending colon was revealed with tapering of the lumen. A computed tomography scan showed a grossly dilated air-distended bowel in the left abdomen and soft tissue with internal architecture containing swirling strands of soft tissue and fat attenuation. An emergency laparotomy was performed. During the laparotomy the ileocecal region, which was unfixed at the retroperitoneum, was found to be twisted counterclockwise by 360° around the mesentery with the terminal ileum, thus resulting in a diagnosis of cecal volvulus. We therefore conducted an ileocecal resection. Cecal volvulus is an uncommon form of intestinal obstruction with a high mortality rate and may present considerable difficulty in diagnosis. Although cecal volvulus is rare as a cause of intestinal obstruction, it should be included in the differential diagnosis of bowel obstruction in cerebral palsy.     

Orthotopic intestinal transplantation using the cuff method in rats: a histopathological evaluation of the anastomosis.

Segmental small intestine transplantation (SIT) in rats, using a cuff technique, has achieved a high success rate. However, there have been few reports on the influence of the foreign body reaction to polyethylene cuff on vessel anastomoses and graft after SIT. This study involves the histopathological examination of the site of cuff anastomosis and grafts in the short- and long-term survival of segmental SIT. The data obtained from the suture anastomosis model also served as a control. One week after heterotopic segmental SIT using the cuff technique, orthotopic continuations were carried out in syngeneic combination. Twenty-five of 30 rats surviving >200 days (83.3%) were examined for vessel anastomosis. All arterial anastomoses were patent, but the portovenous anastomoses in 10 grafts (33%) were totally occluded and were associated with the formation of collateral vessels. Histopathological examination demonstrated good patency of the artery and vein anastomotic site in the short term, but granulation, fibrosis, and neovascularization at the anastomosis site surrounding the cuffs in the long-surviving group. However, the grafts appeared to be intact, with normal features of the villi. On the contrary, the site of the sutured anastomosis in the long-survival rats showed no inflammatory reaction. Although a polyethylene cuff caused foreign body reaction, the graft blood supplies were maintained by collateral vessels. Considering the low mortality and high success rate, polyethylene cuff is good for short-term study and an alternative method for long-term SIT experiments.     

Apatite cement containing cis-diamminedichloroplatinum implanted in rabbit femur for sustained release of the anticancer drug and bone formation

To treat malignant bone tumors, anticancer drugs are administered systemically, simultaneously with surgical therapy. However, drugs administered systemically have considerable invasive action on bone and other organs, and are also associated with various side effects. A bone-cementing material that can maintain high concentrations of anticancer drug at local sites and which can improve local structural weakness after tumor resection would constitute an ideal therapeutic means of treating malignant bone tumors. We therefore applied the concept of a drug delivery system and developed an implant containing calcium phosphate cement and the anticancer drug, cis-diamminedichloroplatinum (CDDP). The results of a sustained release test showed that the in-vitro cumulative release ratio of an implant containing 20% CDDP was over 60%, and a release rate of 0.1 mg/day was maintained. Experiments in vivo, using adult rabbits implanted with 10% CDDP, showed that the platinum (Pt) concentration in local bone marrow was an average 3200 μg/tissue·g 6 weeks after implantation. The concentration of Pt in the systemically administered group was 0.2 μg/tissue·g at 6 weeks. The Pt concentrations in other organs of the implanted group were: 3 μg/tissue·g or less in the kidney, and 2 μg/tissue·g or less in liver. These values were lower than those in the systemically administered group (3.5 and 2.1 μg/tissue·g, respectively). Local bone formation was observed by 12 weeks after implantation. Our implant maintained high Pt concentrations at local sites and the bone that formed reinforced the implant. Received: February 7, 2001 / Accepted: July 23, 2001     

Multiple Hepatic Vein Reconstruction Using an All-in-one Sleeve Patch Graft Technique in Living Donor Liver Transplantation: A Case Report

Maintaining hepatic inflow and appropriate venous drainage is important for maximizing the capacity of the retrieved graft in liver transplantation. Here, we report a successful case of multiple hepatic vein (HV) reconstruction using an all-in-one sleeve patch graft of the autologous great saphenous vein to ensure adequate blood flow through the HV. A patient with hepatocellular carcinoma caused by hepatitis C virus–induced cirrhosis underwent living donor liver transplantation using a right lobe graft. A preoperative dynamic computed tomography scan and intraoperative findings revealed that the graft had three middle HV tributaries, a superficial vein, segment VIII HV (V8), and segment V HV (V5). The openings of the superficial vein and V8 were located very close to that of the right hepatic vein (RHV) in the cutting surface. Each HV had significant diameter and drainage territory requiring reconstruction. An autologous great saphenous vein was used to create a sleeve patch to incorporate the close-packed HV openings. The autologous sleeve patch graft was sutured to the openings of the RHV and the superficial vein and the hole created on the sleeve patch graft was anastomosed to the openings of V8 directly on the back table to create an all-in-one sleeve patch. For the V5 reconstruction, the recipient's intrahepatic portal vein graft was used to create an interpositional conduit from the recipient's V5 to the inferior vena cava. The postoperative course was uneventful and postoperative studies revealed good graft function with excellent blood flow in the HV.     

Risk Factors for Development of New-Onset Diabetes Mellitus and Progressive Impairment of Glucose Metabolism After Living-Donor Liver Transplantation

Background

New-onset diabetes mellitus (NODM) has a negative impact on graft and patient survivals. Hepatitis C virus (HCV) infection, high body mass index, increased donor and recipient ages, and calcineurin inhibitor (CNI) type have been identified as risk factors for the development of NODM. We aimed to elucidate the risk factors for the development of NODM and those for progressive glucose intolerance in adult living-donor liver transplant (LDLT) recipients.

Methods

We collected data from 188 primary liver transplant recipients (age > 16 years) who underwent LDLT from June 1991 to December 2011 at Hiroshima University Hospital. Risk factors for NODM and progressive impairment of glucose metabolism in pre-transplantation diabetes mellitus (DM) recipients were examined.

Results

Pre-transplantation DM was diagnosed in 32 recipients (19.3%). The overall incidence of NODM was 6.0% (8/134 recipients). Multivariate analysis revealed that old recipient age (≥55 years) is a unique predictive risk factor for developing NODM. The incident of pre-transplantation DM was significantly higher in recipients with HCV infection than in those without HCV. A high pre-transplantation triglyceride level was an independent risk factor for progressive impairment of glucose tolerance among 32 LDLT recipients with pre-transplantation DM. All of the NODM patients were being treated with tacrolimus at the time of diagnosis. Switching the CNI from tacrolimus to cyclosporine allowed one-half of the patients (4/8) to withdraw from insulin-dependent therapy. NODM and post-transplantation glucose intolerance had no negative impact on patient and graft outcomes.

Conclusions

Older age of the recipient (≥55 years) was a significant risk factor for NODM. Hypertriglyceridemia in the recipients with DM is an independent risk factor for post-transplantation progressive impairment of glucose metabolism. NODM had no negative impact on outcomes in the LDLT recipients.     

Holmium laser enucleation of the prostate versus transurethral resection of the prostate: a randomized clinical trial

Objective

To evaluate the efficacy and safety of holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP), for treatment of benign prostatic hyperplasia (BPH).

Methods

A total of 164 cases of BPH were selected from patients who were hospitalized between January 2010 and December 2011. Patients had received either HoLEP or TURP treatment. Clinical data were collected from the perioperative period, 1 month after surgery, and 12 months after surgery.

Results

There was no significant difference between the two groups in the maximum urinary flow rate (Q _max), postvoid residual volume (PVR), international prostate symptom score (IPSS), or quality-of-life score (QOL score) at 1 month after surgery (p = 0.56, p = 0.346, p = 0.536 and p = 0.145, respectively). However, after 12 months, patients from the HoLEP group demonstrated better scores in Q _max, PVR, IPSS, and QOL than those from the TURP group (p = 0.037, p = 0.003, p < 0.001 and p = 0.019, respectively). The two groups had comparable operation time (p = 0.105), catheterization time (p = 0.173), and length of hospital stay (p = 0.395), but were statistically different in the weight of resected prostate tissue (p < 0.001), bladder irrigation time (p < 0.001), hemoglobin levels (p = 0.011), and blood sodium levels (p = 0.002) after surgery.

Conclusions

Compared to TURP, HoLEP was safer and had better long-term efficacy as assessed by multiple quantitative measures. Therefore, HoLEP may present a better option in the treatment of BPH.     

Jugular Venous Oxygen Saturation During Mild Hypothermic Versus Normothermic Cardiopulmonary Bypass in Elderly Patients

Purpose. Age is known to be a major risk factor for adverse postoperative cognitive dysfunction after cardiac surgery. We conducted this study to determine if jugular venous oxygen saturation (SjvO₂) differed during mild hypothermic (32°C) and normothermic cardiopulmonary bypass (CPB) in elderly patients.Methods. Sixty patients aged over 70 years who underwent elective coronary artery bypass grafting were randomly divided into two groups. Group 1 (n = 30) underwent normothermic CPB (>35°C) and group 2 (n = 30) underwent mild hypothermic CPB (32°C). For the continuous monitoring of SjvO₂, a fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb after the induction of anesthesia. Hemodynamic parameters, and arterial and jugular venous blood gases were measured at seven time points.Results. The SjvO₂ in the normothermic group was lower at the onset of CPB and 20min after the onset, than from the time of induction of anesthesia until the start of surgery (period 1), the respective SjvO₂ values being 50.3% ± 1.0%, 50.1% ± 1.6%, and 59.5% ± 1.9% (P < 0.05). However, in the mild hypothermic group there were no changes in the SjvO₂ value throughout the study. The cerebral desaturation time (when the SjvO₂ value was <50%) and the ratio of the cerebral desaturation time to the total CPB time in the normothermic group differed significantly from those in the hypothermic group, being 19 ± 11min and 17% ± 10%, and 9 ± 3min and 8% ± 4%, respectively (P < 0.05).Conclusions. The SjvO₂ value was better during mild hypothermic CPB than during normothermic CPB in elderly patients.     

Arterial stiffness in predialysis patients with uremia

BACKGROUND: Hemodialysis patients have advanced arterial wall stiffening as shown by increased aortic pulse wave velocity (PWV), an independent predictor of cardiovascular mortality. We compared aortic PWV of uremic patients before starting hemodialysis treatment with that of patients on maintenance hemodialysis. METHODS: The subjects were 71 patients with end-stage renal disease (ESRD) before starting hemodialysis (predialysis group), 144 patients on maintenance hemodialysis, and 140 healthy control subjects. These three groups were all nondiabetic and comparable in age and gender. RESULTS: The hemodialysis group had greater aortic PWV than the healthy subjects, and the predialysis patients showed a still higher value than the hemodialysis group. Multiple regression analysis in the total subjects revealed that the presence of renal failure was significantly associated with increased aortic PWV independent of age, gender, blood pressure, body mass index, smoking, high-density lipoprotein (HDL) and nonhigh-density lipoprotein (non-HDL) cholesterol levels. In contrast, hemodialysis was associated with decreased aortic PWV independent of renal failure and the other factors. Further analyses in the combined uremic patients again indicated the favorable impact of hemodialysis on aortic PWV independent of the classical risk factors, use of antihypertensive medications, including angiotensin-converting enzyme inhibitors and calcium channel blockers, hematocrit, serum calcium, phosphorus, parathyroid hormone levels, and the use of calcium carbonate. Insulin resistance using homeostasis model assessment (HOMA-IR) was associated with increased aortic PWV. CONCLUSION: Aortic stiffening was present in uremic patients before starting hemodialysis treatment and no adverse effect of hemodialysis was observed, suggesting the important roles of renal failure and/or metabolic alterations secondary to renal failure in arterial stiffness in patients with uremia.