Reconstruction of a severely crushed leg with interpositional vessel grafts and latissimus dorsi flap

We present a case of a near total amputation at the distal tibial level, in which the patient emphatically wanted to save the leg. The anterior and posterior tibial nerves were intact, indicating a high possibility of sensory recovery after revascularization. The patient had open fractures at the tibia and fibula, but no bone shortening was performed. The posterior tibial vessels were reconstructed with an interposition saphenous vein graft from the contralateral side and a usable anterior tibial artery graft from the undamaged ipsilateral distal portions. The skin and soft tissue defects were covered using a subatmospheric pressure system for demarcating the wound, and a latissimus dorsi myocutaneous free flap for definite coverage of the wound. At 6 months after surgery, the patient was ambulatory without requiring additional procedures. Replantation without bone shortening, with use of vessel grafts and temporary coverage of the wound with subatmospheric pressure dressings before definite coverage, can shorten recovery time.     

A murine model of neurofibromatosis type 1 tibial pseudarthrosis featuring proliferative fibrous tissue and osteoclast‐like cells

Neurofibromatosis type 1 (NF1) is a common genetic condition caused by mutations in the NF1 gene. Patients often suffer from tissue‐specific lesions associated with local double‐inactivation of NF1. In this study, we generated a novel fracture model to investigate the mechanism underlying congenital pseudarthrosis of the tibia (CPT) associated with NF1. We used a Cre‐expressing adenovirus (AdCre) to inactivate Nf1 in vitro in cultured osteoprogenitors and osteoblasts, and in vivo in the fracture callus of Nf1^flox/flox and Nf1^flox/? mice. The effects of the presence of Nf1^null cells were extensively examined. Cultured Nf1^null‐committed osteoprogenitors from neonatal calvaria failed to differentiate and express mature osteoblastic markers, even with recombinant bone morphogenetic protein‐2 (rhBMP‐2) treatment. Similarly, Nf1^null‐inducible osteoprogenitors obtained from Nf1 mouse muscle were also unresponsive to rhBMP‐2. In both closed and open fracture models in Nf1^flox/flox and Nf1^flox/? mice, local AdCre injection significantly impaired bone healing, with fracture union being <50% that of wild type controls. No significant difference was seen between Nf1^flox/flox and Nf1^flox/? mice. Histological analyses showed invasion of the Nf1^null fractures by fibrous and highly proliferative tissue. Mean amounts of fibrous tissue were increased upward of 10‐fold in Nf1^null fractures and bromodeoxyuridine (BrdU) staining in closed fractures showed increased numbers of proliferating cells. In Nf1^null fractures, tartrate‐resistant acid phosphatase–positive (TRAP+) cells were frequently observed within the fibrous tissue, not lining a bone surface. In summary, we report that local Nf1 deletion in a fracture callus is sufficient to impair bony union and recapitulate histological features of clinical CPT. Cell culture findings support the concept that Nf1 double inactivation impairs early osteoblastic differentiation. This model provides valuable insight into the pathobiology of the disease, and will be helpful for trialing therapeutic compounds. © 2012 American Society for Bone and Mineral Research     

Extralobar Pulmonary Sequestration Mimicking an Adrenal Tumor

Pulmonary sequestration is a rare cystic malformation composed of bronchopulmonary tissue that is discontinuous from the tracheobronchial tree and has an anomalous systemic blood supply. We present a case of a 40-y-old male who presented with an extralobar pulmonary sequestration and underwent a laparoscopic retroperitoneal mass excision. Preoperative imaging revealed a large 11.3-cm retroperitoneal tumor consisting of a multiloculated cystic lesion. The patient was discharged home, and at 3-mo follow-up no complaints were reported.     

Preferential expression of insulin-like growth factor binding proteins-1, -3, and -5 during early diabetic renal hypertrophy in rats

The renal insulin-like growth factor-I (IGF-I) system has been implicated in the pathogenesis of renal hypertrophy, altered hemodynamics, and extracellular matrix expansion associated with early diabetes. The relative abundance of IGF binding proteins (IGFBPs) in the renal microenvironment may modulate IGF-I actions. However, the precise IGFBPs expressed in the glomerular and tubulointerstitial compartments during diabetic renal growth have not been characterized. In the present study, in situ hybridization studies were performed to examine the expression of IGFBP-1 to -6 messenger RNAs (mRNAs) 3, 7, and 14 days after streptozotocin (STZ) injection in rats. In control, nondiabetic kidneys, all six IGFBP mRNAs were differentially expressed with a predominance of IGFBP-5. The onset of renal hypertrophy in STZ-induced diabetes was associated with a rapid and site-specific induction of IGFBP-1, -3, and -5 mRNAs. In contrast, basal expression of IGFBP-2, -4, and -6 mRNAs was not altered in diabetic rats. IGFBP-5 mRNA expression increased in diabetic glomeruli, cortical, and inner medullary peritubular interstitial cells at days 3, 7, and 14. Although normal glomeruli failed to express IGFBP-3, it was induced concomitantly with IGFBP-5 in diabetic glomeruli and cortical peritubular interstitial cells. IGFBP-1 mRNA levels also increased in cortical tubular cells at each time point tested. Peak induction of IGFBP-3 and -5 was observed at day 3, whereas IGFBP-1 was delayed until day 7. IGFBP-1, -3, and -5 mRNA levels declined by day 14, but remained persistently elevated above control. By immunoperoxidase staining, similar alterations in the pattern of IGFBP-3 and -5 protein expression were observed at each time point. The preferential and site-specific increase in IGFBP-1, -3, and -5 suggest that these IGFBPs may regulate the local autocrine and/or paracrine actions of IGF-I and contribute to the pathogenesis of the early manifestations of diabetic nephropathy.     

Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35 kg/m2

Background  Many mildly to moderately obese individuals with a body mass index (BMI) lower than 35 kg/m² have serious diseases related to their obesity. Nonsurgical therapy is ineffective in the long term, yet surgery has never been made widely available to this population. Methods   Between 2002 and 2007, 53 patients with a BMI lower than 35 kg/m² underwent laparoscopic adjustable gastric banding at our institution. Data on all these patients were collected prospectively and entered into an institutional review board–approved electronic registry. The study parameters included preoperative age, gender, BMI, presence of comorbidities, percentage of excess weight loss (%EWL), and resolution of comorbidities. Results   The mean preoperative age of the patients was 46.9 years (range, 16–68 years), and the mean preoperative BMI was 33.1 kg/m² (range, 28.2–35.0 kg/m²). Of the 53 patients, 49 (92%) had at least one obesity-related comorbidity. The mean BMI decreased to 28.1 ± 2.4 kg/m², 25.8 ± 2.9 kg/m², and 25.8 ± 3.1 kg/m² and mean %EWL was 48.3 ± 17.6, 69.9 ± 28.0, and 69.7 ± 31.7 at 0.5, 1, and 2 years, respectively. Substantial improvement occurred for the following comorbidities evaluated: hypertension, depression, diabetes, asthma, hypertriglyceridemia, obstructive sleep apnea, hypercholesterolemia, and osteoarthritis. There was one slip, two cases of band obstruction (from food), two cases of esophagitis, and two port leaks, but no mortality. Conclusion   The authors are very encouraged by this series of low-BMI patients who underwent laparoscopic adjustable gastric banding. Their weight loss has been excellent, and their complications have been acceptable. Their comorbidities have partially or wholly resolved. With further study, it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m².     

Cyclosporin A therapy for severe Henoch-Schönlein nephritis with nephrotic syndrome

To evaluate the efficacy of cyclosporin A (CyA) for treating severe Henoch-Schönlein nephritis (HSN), seven patients with nephrotic syndrome, aged 3.9–13.8 years (mean 6.5 years), were analyzed retrospectively. Mean follow-up times were 5.5 years (range 2–9 years). All underwent renal biopsy before treatment, and follow-up renal biopsy was performed in six of the seven patients. All patients improved, with 24-h protein declining from a mean of 9.2 g/m²/day (range 1.5–16 g/m²/day) to 0.3 g/m²/day (range 0.03–1.2 g/m²/day) (p=0.016) and serum albumin increasing from a mean of 2.1 g/dl (range 1.5–2.4 g/dl) to 4.6 g/dl (range 3.5–5.3 g/dl) (p=0.016) after CyA therapy. The activity index decreased significantly at the second renal biopsies obtained at a mean interval of 11.7 months after the first (6.4±3.3 vs 3.5±1.2, p=0.042, respectively), while the chronicity index and the tubulointerstitial scores did not change. On the immunofluorescent findings at the second biopsies, the degree of deposits of immunoglobulins such as IgA, IgM, C3, and fibrinogen decreased in five of the six patients. Although this case series is without controls, our study suggests that CyA may be beneficial to a subset of HSN patients with nephrotic syndrome.     

Effects of tissue-cultured mountain ginseng （Panax ginseng CA Meyer） extract on male patients with erectile dysfunction

Korean ginseng and mountain ginseng （Panax ginseng CA Meyer） are important traditional herbal plants whose ginsenosides are generally accepted as serving to improve sexual functions, such as penile erection. We investigated the effects of tissue-cultured mountain ginseng extract （TMGE） on male patients with erectile dysfunction （ED）. A double-blind, placebo-controlled study was conducted with 143 patients experiencing ED. Over the course of 8 weeks, one group took 1 000 mg of TMGE twice a day, and the other group took 1 000 mg of placebo twice a day. The effects of the TMGE and the placebo were analyzed using the Korean version of the International Index of Erectile Function （IIEF） questionnaire. A total of 86 patients completed 8 weeks of treatment. The scores on the five domains of the IIEF after medication were significantly higher than the baseline scores in the group treated with TMGE （P 〈 0.05）, whereas no significant improvement was observed in the placebo group （P 〉 0.05）. Erectile function and overall satisfaction scores after medication were significantly higher in the TMGE group than in the placebo group （P 〈 0.05）. Erectile function of patients in the TMGE-treated group significantly improved, suggesting that TMGE could be utilized for improving erectile function in male patients.     

The difficult choice between total and proximal gastrectomy in proximal early gastric cancer

Background

Surgical results including postoperative complications, prognoses, body weight changes, and nutritional statuses were compared in patients with early gastric cancer in the upper third of the stomach who were treated by total gastrectomy or proximal gastrectomy.

Methods

The authors reviewed clinicopathologic features, postoperative complications, survivals, body weight changes, and biochemical markers after surgery in 423 patients who underwent total or proximal gastrectomy for early gastric cancer in the upper third of the stomach.

Results

The proximal gastrectomy group (n = 89) had smaller tumors, shorter resection margins, and smaller numbers of retrieved lymph nodes than the total gastrectomy group (n = 334). N stages and 5-year survival rates were similar after total and proximal gastrectomy. Postoperative complication rates after total gastrectomy and proximal gastrectomy were 12.6% and 61.8%, respectively, which was significant (P < .001). Rates of anastomotic stenosis and reflux esophagitis were 6.9% and 1.8% after total gastrectomy and 38.2% and 29.2% after proximal gastrectomy, respectively. The parameters that reflect nutritional status (ie, body weight, serum hemoglobin, total protein, albumin, glucose, and cholesterol) were similar in the proximal and total gastrectomy groups at 6, 12, 24, and 36 months postoperatively.

Conclusion

Although the surgical safeties and curabilities of proximal and total gastrectomy were similar, proximal gastrectomy was found to be associated with a markedly higher rate of complications such as anastomotic stenosis and reflux esophagitis and to provide no benefit in terms of postoperative weight loss. The authors conclude that proximal gastrectomy is not a better option for upper-third early gastric cancer than total gastrectomy.