Randomized controlled trial of bipolar diathermy vs ultrasonic scalpel for closed hemorrhoidectomy

AIM:To compare hemorrhoidectomy with a bipolar electrothermal device or hemorrhoidectomy using an ultrasonically activated scalpel.METHODS:Sixty patients with grade Ⅲ or Ⅳ hemorrhoids were prospectively randomized to undergo closed hemorrhoidectomy assisted by bipolar diathermy(group 1) or hemorrhoidectomy with the ultrasonic scalpel(group 2).Operative data were recorded,and patients were followed at 1,3,and 6 wk to evaluate complications.Independent assessors were assigned to obtain postoperative pain scores,oral analgesic requirement and satisfaction scores.RESULTS:Reduced intraoperative blood loss median 0.9 mL(95% CI:0.8-3.7) vs 4.6 mL(95% CI:3.8-7.0),P = 0.001 and a short operating time median 16(95% CI:14.6-18.2) min vs 31(95% CI:28.1-35.3) min,P < 0.0001 was observed in group 1 compared with group 2.There was a trend towards lower postoperative pain scores on day 1 group 1 median 2(95% CI:1.8-3.5) vs group 2 median 3(95% CI:2.6-4.2),P = 0.135.Reduced oral analgesic requirement during postoperative 24 h after operation median 1(95% CI:0.4-0.9) tablet vs 1(95% CI:0.9-1.3) tablet,P = 0.006 was observed in group 1 compared with group 2.There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications.CONCLUSION:Bipolar diathermy hemorrhoidectomy is quick and bloodless and,although as painful as closed hemorrhoidectomy with the ultrasonic scalpel,is associated with a reduced analgesic requirement immediately after operation.     

Quantitative analysis of cerebral microvascular hemodynamics with T2-weighted dynamic MR imaging

The purpose of this study was to quantify cerebral microvascular hemodynamics with T2-weighted dynamic susceptibility contrast-enhanced magnetic resonance imaging (DSC-MRI) using a half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence. We performed T2-weighted DSC-MRI with HASTE sequence in 19 normal subjects. After bolus injection of gadopentetate dimeglumine, HASTE images of two sections were acquired for the simultaneous creation of concentration-time curves in the internal carotid artery and in brain tissue. Absolute regional cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and mean transit time (MTT) values of brain tissue were calculated on a base of the indicator dilution theory, and all values were corrected on the assumption that rCBF of white matter is constant in 22 mL/100 g tissue/min without age-dependent alteration. A decrease in rCBV and rCBF of gray matter was age dependent, while rCBV of white matter did not show significant change with aging. The mean rCBF value in gray matter was 37.3 +/- 8.4 mL/100 g tissue/min. The mean rCBV value was 4.1 +/- 0.8 mL/100 g tissue in gray matter and 2.9 + 0.4 mL/100 g tissue in white matter. The rCBV and rCBF values of gray and white matter obtained from T2-weighted DSC-MRI with HASTE sequence were slightly lower than the published data calculated by gradient-echo sequence. We were able to perform absolute quantifications of the capillary blood volume and flow, using a HASTE sequence, which would not have been possible with a gradient-echo sequence. This technique provides a new method for estimating cerebral microvascular hemodynamics.     

Three cases of small cell carcinoma of the urinary bladder: a case report

We report three cases of small cell carcinoma of the urinary bladder. Case 1: A 69-year-old man showed microscopic hematuria during follow up of prostate cancer of stage D2. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage of pT2N0M0. Complete remission was achieved by three courses of chemotherapy consisting of irinotecan and carboplatin. The patient was died by prostate cancer 16 months after the chemotherapy. Case 2: An 83-year-old woman presented with macroscopic hematuria. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage of pT2N0M0 and partial cystectomy was performed. The patient has been alive without any evidence of tumor recurrence at 6 months after surgery. Case 3: An 84-year-old man presented with macroscopic hematuria. The patient was diagnosed with small cell carcinoma of the urinary bladder at the stage ofcT3bN0M1 with multiple liver metastases. Complete remission was achieved by three courses of chemotherapy consisting of etoposide and carboplatin.     

Evaluation of mouth opening exercise after pumping of the temporomandibular joint in patients with nonreducing disc displacement.

PURPOSE: The purpose of this study was to investigate whether an additional mouth opening exercise contributes to better outcome in patients with nonreducing disc displacement who underwent pumping of the temporomandibular joint (TMJ). PATIENTS AND METHODS: Twenty-three female patients with nonreducing disc displacement of the TMJ underwent pumping of the TMJ and did mouth opening exercise after this treatment (rehabilitation group). Thirty-six female patients with nonreducing disc displacement of the TMJ underwent pumping of the TMJ, but did not do mouth opening exercise (non-rehabilitation group). Patients' signs and symptoms were examined monthly. Clinical evaluation was conducted according to the criteria presented by the 1995 American Association of Oral and Maxillofacial Surgeons. Outcomes were compared between the 2 groups at 12-month follow-up. Chi-square tests were used to assess the difference in good resolution rate between the 2 groups. When significant difference was not found, a non-inferiority test (Delta = 0.1) was used. Level of significance was set on P values less than .05. RESULTS: In both groups, clinical signs and symptoms improved. There was a good resolution rate of 60.9% in the rehabilitation group and 75% in the non-rehabilitation group. No significant difference was observed between the 2 groups. The non-inferiority test showed that the good resolution rate of the non-rehabilitation group was significantly equivalent or more to that of the rehabilitation group (P < .05). CONCLUSIONS: Mouth opening exercise did not seem to contribute to better outcomes in patients with nonreducing disc displacement who underwent pumping of the TMJ.     

Characterization of K-ras gene mutations in association with mucinous hypersecretion in intraductal papillary-mucinous neoplasms

Background/Purpose Intraductal papillary-mucinous neoplasms (IPMNs) of the pancreas have a favorable prognosis. However, invasive ductal carcinomas of the pancreas show a rapid progression. The aim of this study was to investigate gene mutations in pure pancreatic juice from IPMN patients and to define these genetic mutations in relation to the histopathological and clinical features of IPMNs. Methods Twenty-two patients with IPMN, 21 patients with ductal carcinoma, and 20 patients with normal pancreas or chronic pancreatitis were recruited for this study. We measured the main pancreatic duct’s largest diameter and the maximum size of a dilated branch was assessed by ultrasonography or endoscopic ultrasonography. Pure pancreatic juice was collected and was investigated for K-ras, p16, and p53 mutations. Results Mutant K-ras gene was detected in 13 of the 22 patients (59.1%) with IPMNs. Different kinds of mutations were detected in the same patient in 4 cases. In the 13 patients with mutant K-ras gene, the diameter of the most dilated part of the main pancreatic duct was 2–8 mm (average, 4.5 mm) and in 7 patients with wild-type K-ras gene, the diameter was 2–5 mm (average, 2.7 mm). There was a significant difference in the diameter of the main pancreatic duct between patients with and without the mutant K-ras gene (P = 0.0323). Conclusions The incidence of K-ras mutation may be associated with the hypersecretion of mucin.     

Retrospective evaluation of PSA density for selection of biopsy candidates with prostate specific antigen in the gray zone

PURPOSE: We examined the usefulness of prostate specific antigen density (PSAD) for selection of biopsy candidate with prostate specific antigen levels between 4.1 and 10.0 ng./ml. in prostate cancer screening retrospectively. MATERIALS AND METHODS: The screening was conducted on male candidates in Natori city, aged 55 years or older, for 6 years from 1994 through 1999. We could analyze serum PSA levels and PSA density in 118 men with PSA levels between 4.1 and 10.0 ng./ml. All of 118 men underwent ultrasound guided systematic prostate biopsy regardless of findings of digital rectal examination and transrectal ultrasound. Prostate volume was estimated by transrectal ultrasound measurements using the prolate ellipse formula (pi/6 x length x width x height). PSAD was calculated by dividing serum PSA level by prostate volume. Serum PSA levels were determined by Tandem-R assay. RESULTS: In 118 men, twenty-five men had prostate cancer. There was no significant difference in mean PSA between those with prostate cancer and those without prostate cancer, but the difference was significant in the mean PSA density (mean 0.26 and 0.16, respectively, p < 0.0001). Receiver operating characteristic curves for PSA and PSAD demonstrated superior benefit for PSAD in 118 men. A sensitivity, a specificity, a positive predictive value and a negative predictive value of PSAD cut-off of 0.15 were 88%, 52.7%, 33.3% and 94.2%. PSAD cut-off of 0.18 showed the highest sum of sensitivity and specificity, which gave a sensitivity of 80%, a specificity of 72%, a positive predictive value of 43.5% and a negative predictive value of 93.1%. PSAD cut-off of 0.15 would seem to be preferable to cut-off of 0.18 because of less cancer missing. CONCLUSIONS: Although further studies are needed to determine optimal cut-off value to be used in clinical practice, PASD seems to be useful for the selection of biopsy candidates with PSA levels of 4.1 to 10.0 ng./ml. in the prostate cancer screening.     

Recurrent angina due to high grade re-stenosis of the left subclavian artery after coronary artery bypass grafting in a patient on hemodialysis for chronic renal failure: report of a case

A 49-year-old woman on hemodialysis for chronic renal failure was admitted to our hospital with chest pain. She had undergone quadruple coronary artery bypass grafting (CABG) including a left internal thoracic to left anterior descending coronary artery anastomosis 9 months earlier. The blood flow through the left internal thoracic artery had decreased due to high grade stenosis at the proximal portion of the left subclavian artery, and recurrent angina had developed. She was treated by the placement of Palmaz biliary stents in the left subclavian artery, but re-stenosis occurred after 9 months, causing recurrent angina again. There fore, an operation was proposed and bypass grafting from the descending aorta to the left subclavian artery was successfully performed, resulting in complete resolution of her recurrent angina. This case serves to reinforce that patients on dialysis must be carefully followed up after CABG.     

Factors affecting range of flexion after total knee arthroplasty

Many factors affect postoperative range of flexion after total knee arthroplasty (TKA). The purpose of this study was to identify the most important factors that affect range of knee flexion after TKA. Sixty-five patients (73 knees) were treated with Genesis II knee replacements. Minimum follow-up was 2 years. Patient demographics (sex, age, body mass index, previous surgery, component type, patella resurfacing, preoperative Knee Society score preoperative range of motion) and radiographic measurements (preoperative tibiofemoral varus/valgus angle, height of the joint line, length of the patellar tendon, shift and tilt angle of the patella) were analyzed statistically. Among these factors, preoperative range of flexion, positively, and preoperative varus/valgus tibiofemoral angle, negatively, affected postoperative range of flexion. The tilt angle of the patella and the tilt angle of the patellar button approached statistical significance in revealing a negative relation with postoperative range of flexion. TKAs in which the patella was not resurfaced tended to lose range of flexion, whereas TKAs in which the patella was resurfaced tended to have no loss of flexion, although the number of TKAs in which the patella was not resurfaced was small. In conclusion, preoperative range of flexion and preoperative varus/valgus tibiofemoral angle affected postoperative range of flexion. The tilt angle of the patella and tilt angle of the patellar button may be factors that affect postoperative range of flexion. Received: September 28, 2000 / Accepted: January 9, 2001     

Significance of Ductal Margin Status in Patients Undergoing Surgical Resection for Extrahepatic Cholangiocarcinoma

OBJECTIVES: The objective of this study was to determine whether carcinoma in situ at the bile duct margin is prognostically different from residual invasive carcinoma in patients with extrahepatic cholangiocarcinoma. Although there are many reports that the ductal margin status at bile duct resection stumps is a prognostic indicator in patients with extrahepatic cholangiocarcinoma, some patients who undergo resection with microscopic tumor involvement of the bile duct margin survive longer than expected. METHODS: A retrospective clinicopathological analysis of 128 patients who had undergone surgical resection for extrahepatic cholangiocarcinoma was conducted. The status of the bile duct resection margin was classified as negative in 105 patients (82.0%), positive for carcinoma in situ in 12 patients (9.4%), and positive for invasive carcinoma in 11 patients (8.6%). RESULTS: Ductal margin status was an independent prognostic indicator by both univariate (p = 0.0022) and multivariate (p = 0.0105) analyses, along with lymph node metastasis. There was no significant difference between patients with a negative ductal margin and those with a positive ductal margin with carcinoma in situ (p = 0.5247). The 5-year survival rate of patients with a positive ductal margin with carcinoma in situ (22.2%) was significantly better (p = 0.0241) than with invasive carcinoma (0%). There was a significant relationship between local recurrence and ductal margin status (p = 0.0401). CONCLUSIONS: Among patients undergoing surgical resection for extrahepatic cholangiocarcinoma, invasive carcinoma at the ductal resection margins appears to have a significant relation to local recurrence and also a significant negative impact on survival, whereas residual carcinoma in situ does not. Discrimination whether carcinoma in situ or invasive carcinoma is present is important in clinical setting in which the resection margin at the ductal stump is positive.     

Case of retroperitoneal solitary fibrous tumor

Solitary fibrous tumor (SFT) of the retroperitoneal space is rare. We report a case of retroperitoneal tumor, diagnosed as SFT. A 69-year-old woman presented with right lower abdominal swelling, and was referred to our hospital with suspicion of right renal tumor. Abdominal ultrasound and computerized tomography (CT) showed a mass (about 15 x 14 x 10 cm) in the right abdomen. The tumor was thought to be right renal rumor, and right radical nephrectomy was performed. In the excised specimen the tumor was not connected to gastrointestinal tract, peritoneum, or right kidney. The histological and immunohistochemical examination of the specimen revealed SFT. The tumor has malignant potential with partially increased mitotic activity and cellularity in the histological examination. The patient is healthy and without evidence of recurrence or metastasis 26 months from surgery.