A latissimus dorsi muscle flap used for repair of the esophagus after enucleation of a giant leiomyoma--a case report

A giant leiomyoma of the esophagus, 11.5 X 5.0 cm in size, which occupied half of the esophageal circumference, was surgically enucleated. A small epithelial defect caused by the enucleation of the tumor was directly closed, and a large muscular defect was covered with a latissimus dorsi muscle flap, introduced into the thoracic cavity through the space where the second rib had been resected. Postoperatively, a leakage at the epithelial suture line was noted, however, it was localized by the muscle flap coverage and spontaneously healed two weeks postoperatively. During the follow-up period of 1.5 years, no diverticle formation or stenosis occurred, and the patient had no complaints. The present clinical experience indicates that this procedure may be a useful method of grafting after excision of giant leiomyoma of the esophagus.     

Comparative accuracy of operative ultrasonography and cholangiography in detecting common duct calculi

Operative ultrasonography and operative radiographic cholangiography were compared for diagnostic effectiveness with regard to their ability to screen the common bile duct for the presence of calculi. We performed real-time B-mode ultrasonography and cholangiography using two injections of contrast material. In 350 patients, 349 ultrasonic and 285 cholangiographic examinations were performed with technically satisfactory results. The sensitivity, specificity, efficiency, and predictability of a negative test were at a high and comparable level for the two diagnostic procedures. However, the predictability of a positive test for ultrasonography of 91.8% was significantly greater (P less than 0.02) than the predictability of 73.2% for cholangiography. Since predictability of a positive test is based on common duct exploration rather than presumptive evidence of a clinical course, this test may be more valid than the other measures to determine diagnostic effectiveness. The advantages of ultrasonography, which are superior accuracy, favorable image qualities, reduced invasiveness, increased safety, avoidance of contrast material, and lower cost, were contrasted with the problems of ultrasonography, which included a slow learning curve for performance and interpretation of the technique and the limited availability of dedicated ultrasound equipment for surgical operations. We concluded that the advantages outweighed the problems and that operative ultrasonography of the common duct warrants wider application in clinical surgery.     

Recurrent vitreous hemorrhage in boys with prepapillary arterial loops

We examined recurrent vitreous hemorrhage in two boys with prepapillary arterial loops. Both patients complained of visible floaters in the left eye during gymnastic exercise. Prepapillary arterial loops and vitreous hemorrhage were found in the left eye in both boys. The vitreous hemorrhage decreased gradually, but recurred. Prepapillary arterial loops may be a risk factor for recurrent vitreous hemorrhage in children. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article. The authors also do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.     

Diaphragmatic reconstruction using a latissimus dorsi muscle flap following wide resection of the diaphragm combined with esophago-gastrectomy for cardial cancer

In three patients with cardial cancer invading the esophagus and the diaphragm, wide resection of the left diaphragm and its reconstruction using a latissimus dorsi muscle flap were performed during radical esophago-gastrectomy. More than two thirds of the diaphragm could be resected because the muscle flap was large enough to be brought into the thoracic cavity without difficulty, to repair the diaphragmatic defect. The postoperative respiratory function of these patients was adequately maintained. A technique for diaphragmatic reconstruction by means of the latissimus dorsi muscle flap is described in this report.     

Ultrasonic detection of platelet aggregation at variable shear rates

We have observed that high-resolution ultrasonic imaging can be used to detect and measure the size and sedimentation of large human platelet aggregates formed in vitro. At progressively lower shear rates, individual platelet aggregates grew in cross-sectional area from the limit of ultrasonic detectability of less than 1 mm2 at moderate shear rates to an approximate mean area of 25 mm2 at zero shear. Platelet aggregates tended to sediment at mean shear rates higher than zero shear. At a shear rate of 5.5 s-1, 70% of platelet aggregates had settled, and at 1.6 s-1, 90% had settled to the dependent half of horizontal tubes in less than 15 s. Ultrasonic aggregometry of platelets may be a valuable technique for investigation of platelet dynamics under controlled flow conditions in vitro.     

Evaluation of seasonal changes in hemoglobin A1c in diabetic patients

In order to evaluate seasonal changes in hemoglobin A1c (HbA1c) values, we examined HbA1c values among 34,590 patients in 2010, and calculated the monthly average of HbA1c values through the year. HbA1c values were the highest in March and the lowest in October with a difference of 0.30%. The similar annual pattern was observed in HbA1c values from 2006 to 2009. Then we selected 453 diabetic patients whose treatment did not change through the year, and calculated average HbA1c values in four seasons each. There were also significant seasonal changes in diabetic patients, which were the highest in the spring and the lowest in the autumn, especially found in patients with insulin therapy. These effects may be caused by cold climate, decreased physical activity, over food intake and body weight gain in the winter. These seasonal changes in HbA1c should be concerned in the case of health service research, clinical trials and evaluation of the effects of medical treatment.     

Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy

Background The use of intraoperative cholangiography (IOC), routinely rather than selectively, during laparoscopic cholecystectomy (LC) is controversial. Recent findings have shown laparoscopic ultrasound (LUS) to be safe, quick, and effective not only for screening of the bile duct for stones, but also for evaluating the biliary anatomy. This study aimed to evaluate, on the basis of the LC outcome and the cost of LUS and IOC, whether and how much the routine use of LUS would be able to reduce the need for IOC. Methods During LC, LUS was used routinely to screen the bile duct for stones and to evaluate the biliary anatomy, whereas IOC was used selectively only when LUS was unsatisfactory or unsuccessful. Results For 193 (96.5%) of 200 patients, LUS was completed successfully, whereas IOC was needed for 7 patients (3.5%). Bile duct stones were identified in 20 patients (10%). For the detection of bile duct stones, LUS yielded 19 true-positive, 175 true-negative, 0 false-positive, and 1 false-negative results. It had a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 99.4%. The postoperative complications included bile leaks from the liver bed in two patients and a retained bile duct stone in one patient. If IOC had been used selectively in a traditional manner on the basis of preoperative risk factors, IOC would have been needed for 77 patients (38.5%). The total cost of LUS plus IOC for the current 200 patients was $26,256. The total estimated cost of selective IOC, if it had been performed for the 77 patients, would have been $31,416. Conclusions Routine LUS accurately diagnosed bile duct stones and significantly reduced the need for selective IOC from a potential 38.5% to an actual 3.5% without adversely affecting the outcome of the LC or increasing the overall cost. The routine use of LUS during LC is accurate and cost effective.