Changes in calcium homeostasis in acromegaly treated by pituitary adenomectomy

Patients with acromegaly have alterations in mineral metabolism. To determine the effect of correction of excess GH secretion on calcium metabolism, we studied 12 acromegalic patients before and 3-4 weeks after pituitary adenomectomy. Treatment of acromegaly resulted in significant decreases in both serum calcium [from 9.3 +/- 0.2 to 8.7 +/- 0.1 mg/dl (mean +/- SEM); P less than 0.01] and urinary calcium excretion (from 200 +/- 24 to 88 +/- 12 mg/24 h; P less than 0.0002). Serum phosphate also decreased significantly (P less than 0.01) from 4.8 +/- 0.2 to 4.3 +/- 0.2 mg/dl. Both serum immunoreactive PTH and calcitonin levels were normal initially and did not change after surgery. The mean serum 25-hydroxyvitamin D (25OHD) level was significantly (P less than 0.01) lower and the 1,25-dihydroxyvitamin D [1,25-(OH)2D] level was significantly (P less than 0.0001) higher in acromegaly compared with measurements in 25 normal subjects. After surgery, the serum 25OHD level did not change; however, the serum 1,25-(OH)2D concentration fell significantly (P less than 0.0001) from 60 +/- 4 to 43 +/- 2 pg/ml. A positive correlation was found between the decrements in urinary calcium excretion and the serum 1,25-(OH)2D level when the comparison was made between the decrements as percentages of pretreatment values (r = 0.64; P less than 0.05). The accumulated data suggest that the hypercalciuria in acromegaly might be due to intestinal calcium hyperabsorption, which could be attributed to the elevated circulating 1,25-(OH)2D level. Excessive GH secretion might stimulate the production of 1,25-(OH)2D and might also directly stimulate calcium absorption.     

Comparison of long-term prognosis of laparoscopy-assisted gastrectomy and conventional open gastrectomy with special reference to D2 lymph node dissection

Background

Laparoscopy-assisted gastrectomy (LAG) is becoming widely used for early gastric cancer. However, how the curability and long-term prognosis of LAG and open gastrectomy (OG) for early and advanced gastric cancer compare remains unclear. This study assessed short- and long-term outcomes after LAG with lymph node dissection in early and advanced gastric cancer.

Methods

A total of 332 patients who underwent LAG or OG for early and advanced gastric cancer from January 2001 through December 2010 were reviewed retrospectively. The mean operating time, estimated mean blood loss, number of dissected lymph nodes, and survival rates were compared between LAG and OG for early and advanced gastric cancer.

Results

Overall, 47.6% (158/332) of patients underwent LAG; D1, D1+ lymph node dissection was carried out in 77.2%, with D2 dissection in 22.8%. Only one patient required conversion to OG. Comparing LAG and OG with D1, D1+ lymph node dissection for early gastric cancer (EGC), mean operating time was significantly longer, estimated mean blood loss was significantly smaller, and the average number of retrieved lymph nodes was significantly greater with LAG. The rate of specific postoperative morbidity was 17.2% for LAG patients and 25.0% for OG patients, with no postoperative mortality. Survival and recurrence rates were not significantly different. Comparing LAG and OG with D2 lymph node dissection for advanced gastric cancer (AGC), mean operating time was significantly longer and estimated mean blood loss was significantly smaller with LAG, while the average number of retrieved lymph nodes, specific postoperative morbidity and mortality, and survival and recurrence rates were not significantly different.

Conclusions

LAG with D1, D1+ lymph node dissection for EGC is safe and equivalent to open gastrectomy in curability. Moreover, LAG with D2 lymph node dissection for AGC is comparable to OG with D2 lymph node dissection with regard to short- and long-term results.     

Effect of body fat percentage on estimated propofol concentrations at awakening from anesthesia using target controlled infusion

BACKGROUND: Target controlled infusion (TCI) for propofol allows anesthesiologists to target constant blood concentrations of propofol. However, the pharmacokinetic parameters in TCI system do not take account of the patient's age, make up and gender. We evaluated the relationship between body fat percentage and the estimated effect site propofol concentrations at awakening. METHODS: Anesthesia was induced in 37 patients with fentanyl and propofol by TCI. Patients's percentage of fat was evaluated by measuring the thickness of the three parts of the skin fat with Skyndex (Caldwell Justiss, USA). After surgery and discontinuation of anesthesia, the estimated effect site propofol concentrations (EPEC) were determined when the patient could respond to verbal command. RESULTS: The EPECs at awakening were 1.5 +/- 0.2 micrograms.ml-1 in male and 1.5 +/- 0.3 micrograms.ml-1 in female. In male, the percentage of fat and body mass index (BMI) correlated significantly with EPEC (r = 0.79 and 0.49 respectively). In female, the percentage of fat and BMI did not correlate with EPEC. The estimated fentanyl effect site concentrations at awakening did not correlate with the EPEC. CONCLUSIONS: Male patients who have high percentage of fat have a tendency to delayed of awakening from propofol anesthesia. In female, however, no correlation was seen between percentage of fat and awakening time from propofol anesthesia. Measuring the percentage of fat might bring a new insight into pharmacokinetics of propofol.     

Inferior mesenteric artery aneurysm in Behçet syndrome

We present a case report of an aneurysm of the inferior mesenteric artery, associated with occlusion of the celiac, superior mesenteric, and left renal arteries and severe stenosis in the right renal artery, in a 48-year-old patient with Beh?et syndrome. The meandering inferior mesenteric artery, with an aneurysm 28 mm in greatest dimension, was the blood supply source for the intraperitoneal viscera. Aneurysm resection and reimplantation of the inferior mesenteric artery, and right renal artery bypass grafting with saphenous vein was performed. To our knowledge, this is the first reported case of inferior mesenteric artery aneurysm caused by Beh?et syndrome.     

Nodal status of malignant lymphoma in pelvic and retroperitoneal lymphatic pathways: comparison of integrated PET/CT with or without contrast enhancement

AIM: To determine the diagnostic accuracy of integrated contrast-enhanced positron emission tomography (PET) and computed tomography (CT), as compared with non-contrasted PET/CT, in evaluating nodal status of malignant lymphoma in pelvic and retroperitoneal lymphatic pathways. MATERIALS AND METHODS: Sixty-six patients (33 men and 33 women) with malignant lymphoma underwent staging with integrated CT and fluorine-18-fluorodeoxyglucose ((18)FDG) PET. Tumor types were diffuse large B-cell lymphoma (n=26, 39%), follicular lymphoma (n=20, 30%), Hodgkin disease (n=16, 24%), and marginal zone B-cell lymphoma (n=4, 6%). Both non-contrasted PET/CT and contrast-enhanced PET/CT images were examined separately by two different qualified physicians for each imaging modality, and nodal status of pelvic and retroperitoneal lymphatic pathways was evaluated. Reference standard included follow-up with clinical, laboratory, and conventional CT findings. We compared diagnostic accuracy retrospectively on basis of per-patient and per-lesion analyses between two modalities using McNemar test, respectively. RESULTS: Nodal status of pelvic and retroperitoneal lymphatic pathways was more accurately determined on contrast-enhanced PET/CT (n=52, 79%) compared with non-contrasted PET/CT (n=47, 71%). Difference in the accuracy of nodal staging between non-contrasted PET/CT and contrast-enhanced PET/CT was significant (p=0.048). On basis of per-lesion analysis, contrast-enhanced PET/CT determined more accurately the status of external iliac lymph node (p=0.002), internal iliac lymph node (p<0.0001), and common iliac lymph node (p=0.002) compared with non-contrasted PET/CT. Diagnostic accuracies of paraaortic lymph node, aortocaval lymph node, and paracaval lymph node were similar by either non-contrasted PET/CT or contrast-enhanced PET/CT. CONCLUSION: Integrated contrast-enhanced PET/CT improves the diagnostic accuracy in evaluating nodal status of pelvic and retroperitoneal lymphatic pathways in patients with malignant lymphoma.     

Stent Fracture and Reocclusion After Placement of a Single Self-Expanding Stent in the Common Iliac Artery and Endovascular Treatment

We present a case of fracture of a single self-expanding stent placed in the common iliac artery (CIA). An 80-year-old woman underwent placement of a self-expanding stent for CIA occlusion. Stent fracture and reocclusion were detected after 18 months. Successful revascularization was achieved using a stent-in-stent maneuver. The possibility of stent fracture with reocclusion should be considered following treatment with a single self-expanding stent for CIA occlusion.     

Transarterial Chemoembolization Using Cisplatin Powder in a Rabbit Model of Liver Cancer

The purpose of this study was to investigate the pharmacological advantages of transarterial chemoembolization (TACE) with cisplatin powder for hypervascular hepatic tumors in animal experiments. VX2 tumors were transplanted to the livers of nine rabbits. Cisplatin (1 mg/kg) was infused into the proper hepatic artery. In the cisplatin-HAI group, cisplatin solution was infused. In the cisplatin-GS-TACE group, after infusion of cisplatin solution, gelatin sponge particles were used for embolization. In the cisplatin-Lp-TACE group, after infusion of a cisplatin powder and lipiodol (10 mg/ml) suspension, gelatin sponge particles were used for embolization. Before and after administration, platinum concentrations in plasma were measured. Using liver specimens that were excised 60 min after infusion, platinum concentrations in tumorous and nontumorous liver tissues were measured. The mean platinum concentration in tumorous tissue was 0.88 μg/ml for the cisplatin-HAI group, 1.23 μg/ml for the cisplatin-GS-TACE group, and 12.65 μg/ml for the cisplatin-Lp-TACE group. The platinum concentration for the cisplatin-Lp-TACE group was significantly higher than that for the cisplatin-HAI group (p = 0.004) and the cisplatin-GS-TAE group (p = 0.004). The mean platinum concentration in nontumorous liver tissue was 0.98 μg/ml for the cisplatin-HAI group, 1.13 μg/ml for the cisplatin-GS-TACE group, and 1.09 μg/ml for the cisplatin-Lp-TACE group; no significant differences were seen. At both 5 and 10 min after infusion, the platinum concentrations for the cisplatin-Lp-TACE group were lower than those for the other two groups. The present results suggest that TACE using cisplatin powder/lipiodol suspension and gelatin sponge for hypervascular hepatic tumors has a number of pharmacological advantages. This material was presented at 2007 CIRSE.     

A quantitative method for estimating hepatic blood flow using a dual-input single-compartment model

The purpose of this study was to investigate the accuracy of a quantitative method for estimating arterial hepatic blood flow and portal hepatic blood flow separately using a dual-input single-compartment model compared with the maximum slope method using computer simulations and clinical data. In computer simulations, the rate constants for the transfer of contrast agent (CA) from the hepatic artery to the liver (K(1a)), from the portal vein to the liver (K(1p)) and from the liver to the blood (k(2)) were estimated from simulated time-density curves with various transit times of CA from the aorta to the liver (tau(a)) and from the portal vein to the liver (tau(p)) using the linear least-squares (LLSQ) method. In clinical studies, dynamic CT data were acquired from 27 patients, and parametric maps of K(1a), K(1p) and k(2) were generated by applying the LLSQ method pixel by pixel. In simulation studies, tau(a) and tau(p) were found to have a large and a small effect on the estimates of K(1a) and K(1p), respectively. In clinical studies, the K(1a) and K(1p) values estimated with the maximum slope method were underestimated by 60+/-29% and 37+/-12%, respectively, compared with those estimated by the LLSQ method. In conclusion, our results suggest that correction of tau(a) is necessary for accurately estimating K(1a) and K(1p). Our method is therefore promising for the evaluation of hepatic blood flow in various liver diseases because it allows us to evaluate arterial hepatic blood flow and portal hepatic blood flow separately and visually.     

Optimal temperature for the management of severe traumatic brain injury: effect of hypothermia on intracranial pressure,systemic and intracranial hemodynamics,and metabolism

OBJECTIVE: We studied the effect of hypothermia on intracranial pressure, systemic and intracranial hemodynamics, and metabolism in patients with severe traumatic brain injury to clarify the optimal temperature for hypothermia, with a view toward establishing the proper management techniques for such patients. METHODS: The study was performed in 31 patients with severe head injury (Glasgow Coma Scale score as high as 5). All patients were sedated, paralyzed, ventilated, and cooled to 33 degrees C. Brain temperature, core temperature, intracranial pressure, cerebral perfusion pressure, jugular venous oxygen saturation, mixed venous oxygen saturation, cardiac output, oxygen delivery, oxygen consumption, and resting energy expenditure were monitored continuously. RESULTS: Intracranial pressure decreased significantly at brain temperatures below 37 degrees C and decreased more sharply at temperatures 35 to 36 degrees C, but no differences were observed at temperatures below 35 degrees C. Cerebral perfusion pressure peaked at 35.0 to 35.9 degrees C and decreased with further decreases in temperature. Jugular venous oxygen saturation and mixed venous oxygen saturation remained in the normal range during hypothermia. Resting energy expenditure and cardiac output decreased progressively with hypothermia. Oxygen delivery and oxygen consumption decreased to abnormally low levels at rectal temperatures below 35 degrees C, and the correlation between them became less significant at less than 35 degrees C than that when temperatures were 35 degrees C or higher. Brain temperature was consistently higher than rectal temperature by 0.5 +/- 0.3 degrees C. CONCLUSION: These results suggest that, after traumatic brain injury, decreasing body temperature to 35 to 35.5 degrees C can reduce intracranial hypertension while maintaining sufficient cerebral perfusion pressure without cardiac dysfunction or oxygen debt. Thus, 35 to 35.5 degrees C seems to be the optimal temperature at which to treat patients with severe traumatic brain injury.     

Primary aortoesophageal fistula secondary to thoracic aneurysm

Aortoesophageal fistula (AEF) secondary to thoracic aneurysm is rare, and is usually fatal without prompt surgical intervention, with few survivors reported. Here we report a case of a 68-year-old woman late-presenting AEF successfully treated by extra-anatomic bypass grafting. Since she had already a mediastinal infection caused by AEF on admission, we performed extra-anatomic bypass grafting from the ascending aorta to the infrarenal aorta, and primary esophageal repair. The extra-anatomic bypass grafting was performed to avoid the risk to secondary graft infection and to decrease the total ishemic time induced by intraoperative aortic clamping, which is necessary when in-situ graft replacement is chosen. Although only 17 cases (including the present case) have been reported as long-term survivors, most have involved in-situ repair of the thoracic aneurysm. To our knowledge, the present case was only the second treated successfully by extra-anatomic bypass grafting. We recommend extra-anatomic bypass grafting for a case with severe infection and prolonged hypoperfusion insult caused by massive bleeding due to rupture in an aneurysm.