Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.     

Short-term effects of di-（2-ethylhexyl） phthalate on testes,liver, kidneys and pancreas in mice

Aim： To determine the biochemical effect of di-（2-ethylhexyl） phthalate （DEHP） on testes, liver, kidneys and pancreas on day 10 in the process of degeneration of the seminiferous epithelium. Methods： Diets containing 2% DEHP were given to male Crlj：CDI（ICR） mice for 10 days. The dose of DEHP was 0.90±0.52 mg/mouse/day. Their testes, livers, kidneys and pancreata were examined for detection of mono-（2-ethylhexyl） phthalate （MEHP）, nitrogen oxides （NOx） produced by peroxidation of nitric oxide （NO） with free radicals, and lipid peroxidation induced by the chain reaction of free radicals. Results： Histological observation and serum analysis showed the presence of severe sperrnatogenic disturbance, Leydig cell dysfunction, liver dysfunction and dehydration. Unexpectedly, the concentration of MEHP in the testes was extremely low compared with that in the liver. However, the concentration of the NOx in the testes was as high as the hepatic concentration. Furthermore, free radical-induced lipid peroxidation was histochemically detected in the testes but not in the liver. Conclusion： The results indicate that DEHP-induced aspermatogenesis is caused by the high sensitivity of the testicular tissues to MEHP rather than the specific accumulation or uptake of circulating MEHP into the testes.     

Progressively Unstable C2 Spondylolysis Requiring Spinal Fusion: Case Report

Cervical spondylolysis is a rare condition defined as a corticated cleft at the pars interarticularis in the cervical spine. This is the case of C2 spondylolysis demonstrating progressive significant instability, which was successfully treated by anterior cervical discectomy and fusion (ACDF) with cervical anterior plate. We describe a 20-year-old female with C2 spondylolysis presenting with progressive worsening of neck pain associated with progressive instability at the C2/3 segment. The progression of instability was well-documented on flexion-extension cervical spine x-rays. She was successfully treated by C2/3 ACDF with anterior cervical plate. Her preoperative significant neck pain resolved immediately after the surgical intervention. She was completely free from neurological symptoms at 1-year postoperative follow-up. We also review the literature and discuss 24 reported cases with C2 spondylolysis. When planning treatment, we should make sure to differentiate this pathology from acute traumatic fracture, which is a hangman''s fracture. Assessment of C2/3 instability associated with neurological deficits is extremely important to consider management properly. C2/3 ACDF with cervical plate is biomechanically viable, less invasive, and provides adequate surgical stabilization for unstable C2 spondylolysis.     

Range of motion of thoracic spine in sagittal plane

Study design

Imaging study of thoracic spine.

Objective

The purpose of this study was to investigate dynamic alignment and range of motion (ROM) at all segmental levels of thoracic spine.

Summary of background data

Thoracic spine is considered to have restricted ROM because of restriction by the rib cage. However, angular movements of thoracic spine can induce thoracic compressive myelopathy in some patients. Although few previous studies have reported segmental ROM with regard to sagittal plane, these were based on cadaver specimens. No study has reported normal functional ROM of thoracic spine.

Methods

Fifty patients with cervical or lumbar spinal disease but neither thoracic spinal disease nor compression fracture were enrolled prospectively in this study (34 males, 16 females; mean age 55.4 ± 14.7 years; range 27–81 years). After preoperative myelography, multidetector-row computed tomography scanning was performed at passive maximum flexion and extension position. Total and segmental thoracic kyphotic angles were measured and ROM calculated.

Results

Total kyphotic angle (T1/L1) was 40.2° ± 11.4° and 8.5° ± 12.8° in flexion and extension, respectively (P < 0.0001). The apex of the kyphotic angle was at T6/7 in flexion. Total ROM (T1/L1) was 31.7° ± 11.3°. Segmental ROM decreased from T1/2 to T4/5 but increased gradually from T4/5 to T12/L1. Maximum ROM was at T12/L1 (4.2° ± 2.1°) and minimum at T4/5 (0.9° ± 3.0°).

Conclusions

Thoracic spine showed ROM in sagittal plane, despite being considered a stable region. These findings offer useful information in the diagnosis and selection of surgical intervention in thoracic spinal disease.     

Stent-supported coil embolization for carotid artery pseudoaneurysm as a complication of endovascular surgery--case report

A 57-year-old male presented with right amaurosis fugax and left transient ischemic attack caused by stenosis of the intracranial segment of the right internal carotid artery (ICA). Percutaneous transluminal angioplasty with stenting was successfully performed to dilate the stenosis. However, serial angiography revealed the development of a large pseudoaneurysm in the cervical ICA, probably as a result of carotid wall injury caused by the guiding catheter during the procedures. The patient underwent a second endovascular angioplasty. A Palmaz stent was placed across the aneurysm neck to stabilize the carotid wall. Guglielmi detachable coils were then inserted into the aneurysm cavity through the stent struts to successfully obliterate the aneurysm. Both the angiographical results and the patient's outcome were favorable. Stent-supported coil embolization is an effective and safe technique for medically refractory pseudoaneurysms, and may be a useful alternative to direct surgery.     

Age-related changes in osseous anatomy, alignment, and range of motion of the cervical spine. Part I: Radiographic data from over 1,200 asymptomatic subjects

Purpose

This study aimed to establish radiographic standard values for cervical spine morphometry, alignment, and range of motion (ROM) in both male and female in each decade of life between the 3rd and 8th and to elucidate these age-related changes.

Methods

A total of 1,230 asymptomatic volunteers underwent anteroposterior (AP), lateral, flexion, and extension radiography of the cervical spine. There were at least 100 men and 100 women in each decade of life between the 3rd and 8th. AP diameter of the spinal canal, vertebral body, and disc were measured at each level from the 2nd to 7th cervical vertebra (C2–C7). C2–C7 sagittal alignment and ROM during flexion and extension were calculated using a computer digitizer.

Results

The AP diameter of the spinal canal was 15.8 ± 1.5 [mean ± standard deviation (SD)] mm at the mid-C5 level, and 15.5 ± 2.0 mm at the C5/6 disc level. The disc height was 5.8 ± 1.3 mm at the C5/6 level, which was the minimum height, and the maximum height was at the C6/7 level. Both the AP diameter of the spinal canal and disc height decreased gradually with increasing age. The C2–C7 sagittal alignment and total ROM were 13.9 ± 12.3° in lordosis and 55.3 ± 16.0°, respectively. The C2–C7 lordotic angle was 8.0 ± 11.8° in the 3rd decade and increased to 19.7 ± 11.3 in the 8th decade, whereas the C2–C7 ROM was 67.7 ± 17.0° in the 3rd decade and decreased to 45.0 ± 12.5 in the 8th decade. The extension ROM decreased more than the flexion ROM, and lordotic alignment progressed with increasing age. There was a significant difference in C2–C7 alignment and ROM between men and women.

Conclusions

The standard values and age-related changes in cervical anatomy, alignment, and ROM for males and females in each decade between the 3rd and 8th were established. Cervical lordosis in the neutral position develops with aging, while extension ROM decreases gradually. These data will be useful as normal values for the sake of comparison in clinical practice.     

Usefulness of computed tomography during cholangiography for the diagnosis of multiple hepatic peribiliary cysts: a report of three cases with chronic liver disease

Hepatic peribiliary cysts are composed of multiple tiny cysts along the larger portal tracts and have been reported to be harmless. On clinical images, peribiliary cysts resemble other diseases such as biliary dilatations, cholangitis, or periportal edema. Therefore, it is important to distinguish peribiliary cysts from these diseases using a combination of several imaging modalities. Herein, we report three cases of peribiliary cysts. The first case underwent laparotomy for the presumptive diagnosis of intrahepatic cholangiocarcinoma. In the remaining two cases, hepatic peribiliary cysts were diagnosed and laparotomy was avoided. Magnetic resonance cholangiography contributed to the diagnosis, owing to their characteristic distribution. In addition, computed tomography during cholangiography (cholangio-CT) demonstrated that the cysts had no communication with the intrahepatic biliary system. Therefore, cholangio-CT is considered to be the most useful modality for the diagnosis of peribiliary cysts.     

Effects of immunosuppressants on induction of regulatory cells after intratracheal delivery of alloantigen

BACKGROUND: We previously reported that intratracheal delivery (ITD) of alloantigen generated regulatory cells in mice. Here, we examined the effect of various doses of conventional immunosuppressants (FK506, cyclosporine A, azathioprine, mycophenolate mofetil, and rapamycin) on inducing regulatory cells in our model. METHODS: CBA mice (primary recipients) were given C57BL/6 splenocytes by ITD and either no additional treatment or various doses of an immunosuppressant. Seven days later, splenocytes from these mice were adoptively transferred into naive secondary CBA recipients that underwent C57BL/6 cardiac grafting the same day. RESULTS: Adoptive transfer from primary recipients given ITD of splenocytes alone induced prolonged allograft survival in secondary recipients (median survival time [MST], 50 days), suggesting that regulatory cells were generated. When ITD of alloantigen was combined with daily administration of 0.1 mg/kg FK506 or 0.2 mg/kg rapamycin, graft survival was similarly prolonged (MST 55 and 50 days, respectively). When combined with 20 or 40 mg/kg MMF or 0.4 mg/kg rapamycin, the majority of recipients demonstrated indefinite survival (MST, >100 days in all groups). When ITD of alloantigen was combined with 0.3, 0.5, or 1.0 mg/kg FK506; 5, 10, or 25 mg/kg cyclosporine A; or 1.0 or 2.0 mg/kg azathioprine, allografts were rejected acutely (MST 7-13 days). CONCLUSION: Generation of regulatory cells by ITD of alloantigen was facilitated by mycophenolate mofetil and high doses of rapamycin but abrogated by cyclosporine A, azathioprine, and high doses of FK506. Low doses of rapamycin and of FK506 did not interfere with generation of regulatory cells.     

An atypical case of "Takotsubo cardiomyopathy" during alcohol withdrawal: abnormality in the transient left ventricular wall motion and a remarkable elevation in the ST segment

A 64-year-old man was admitted due to hypokalemia-related myopathy. He was heavy drinker. He felt the stress of alcohol withdrawal during his hospitalization. The patient suffered a cardiopulmonary arrest lasting approximately 5 minutes on the fifth hospital day. One day later, ST-segment elevation was observed in leads I, aV(L), and V(2-6). Emergent cardiac catheterization was performed for suspicion of acute myocardial infarction. Normal coronary arteries with anterior akinesis of the left ventricle were revealed during the procedure. The present case may be an atypical form of "Takotsubo cardiomyopathy" in which the left ventricular contraction is due to focal anterior wall motion abnormalities.     

Life‐threatening hemorrhage from the corona mortis after laparoscopic inguinal hernia repair: Report of a case

Along with the increased use of other laparoscopic procedures, laparoscopic inguinal hernia repair has become widely used because of its minimally invasive nature. Here, we report a case of 66‐year‐old man who underwent transabdominal preperitoneal laparoscopic hernioplasty and developed hemorrhagic shock on postoperative day 1. CT showed postoperative venous hemorrhage from the retropubic space. Successful hemostasis of the massive hemorrhage was achieved laparoscopically. The origin of the hemorrhage was assumed to be the corona mortis vein, which was slightly injured during the operation. Despite the rarity of this complication, surgeons must be aware of the need to carefully dissect and fix the mesh in the retropubic space to avoid injuring the corona mortis. Laparoscopic hemostasis may be an effective alternative to the open approach.