Laparoscopic reintervention for residual gallstone disease

Laparoscopic reintervention is being increasingly performed in patients who have previously undergone surgery for gallstone disease. A few patients with gallbladder remnants or a cystic duct stump with residual stones have recurrent symptoms of biliary disease. Patients with bile duct injuries were excluded from the study. We reviewed our experience in treating such patients over a 4-year period, January 1998 through December 2001. Five patients underwent laparoscopic reintervention after previous surgery for gallstone disease performed elsewhere during the period mentioned above. Of these 5 patients, 3 had impacted stones in gallbladder remnants (laparoscopic cholecystectomy, 2; open cholecystectomy, 1) and 2 had recurrent symptoms after cholecystolithotomy and tube cholecystostomy (conventional surgery) performed elsewhere. Laparoscopic excision of the gall bladder remnants was done in 3 patients and a formal laparoscopic cholecystectomy was done in 2 patients who had previously undergone cholecystolithotomy and tube cholecystostomy. The mean operating time was 42 minutes. No drainage was required postoperatively. All patients were symptom-free during a mean follow-up of 2.3 years (range, 7 months to 4 years). Reintervention may be required for patients with residual gallstones whose symptoms recur after gallbladder surgery such as cholecystectomy, subtotal cholecystectomy, and tube cholecystostomy. It is safe and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.     

Immunopathologic and clinical studies in pulmonary hypertension associated with systemic lupus erythematosus

PH is an uncommon manifestation of SLE. The symptoms of PH develop within a few years after the onset of the multisystem disease. The most common presenting complaints of SLE patients with PH are dyspnea on exertion, chest pain, nonproductive cough, edema, and fatigue or weakness. The important physical findings are a loud second pulmonic heart sound and a right ventricular lift. The chest roentgenogram shows a cardiomegaly, a prominent pulmonary segment, and usually clear lung fields. Pulmonary function tests may show evidence of restrictive lung disease; however, the physiologic abnormalities are mild and out of proportion to the severity of the PH. The diagnosis of PH is established by cardiac catheterization showing elevated pulmonary artery pressure, normal capillary wedge pressure, and no evidence of intracardiac or extracardiac shunts. Pathologic examination of the lung demonstrates angiomatoid lesions involving muscular pulmonary arteries. There is a thickening of the media and subintima of the arterioles. Immunoglobulin and complement deposits are found in the walls of pulmonary arteries. Immunoglobulin eluted from the lung contains rheumatoid factor and antinuclear antibody including antibody to DNA activity. DNA antigen is also present in walls of blood vessels. These results suggest an immune complex deposition process as a mechanism in the pathogenesis of PH in SLE. The clinical course of PH in SLE is variable. Symptoms may be mild and the disease follows a stable and protracted course for several years. It can, however, develop a progressive course ending in death in a few years. The clinical response of SLE patients with PH to treatment with high doses of systemic corticosteroids is not consistent or predictable.     

Tetralogy of Fallot: anatomic variants and their impact on surgical management

Tetralogy of Fallot is the most common form of cyanotic congenital heart disease. In this condition, episodic worsening of hypoxemia results from dynamic shifts in physiology, so-called "Tet spells." The relative frequency of this lesion and the risks of exacerbating "Tet spells" make anesthetic management of this patient population challenging. The conduct of palliative and reparative cardiac surgery is determined in large part by the anatomic variations within the spectrum of this disorder, most notably the severity of right ventricular outflow tract obstruction. This review will address the impact that the anatomic substrate has on the perioperative management of this interesting patient population.     

Selective frontoinsular von Economo neuron and fork cell loss in early behavioral variant frontotemporal dementia

Behavioral variant frontotemporal dementia (bvFTD) erodes complex social-emotional functions as the anterior cingulate cortex (ACC) and frontoinsula (FI) degenerate, but the early vulnerable neuron within these regions has remained uncertain. Previously, we demonstrated selective loss of ACC von Economo neurons (VENs) in bvFTD. Unlike ACC, FI contains a second conspicuous layer 5 neuronal morphotype, the fork cell, which has not been previously examined. Here, we investigated the selectivity, disease-specificity, laterality, timing, and symptom relevance of frontoinsular VEN and fork cell loss in bvFTD. Blinded, unbiased, systematic sampling was used to quantify bilateral FI VENs, fork cells, and neighboring neurons in 7 neurologically unaffected controls (NC), 5 patients with Alzheimer's disease (AD), and 9 patients with bvFTD, including 3 who died of comorbid motor neuron disease during very mild bvFTD. bvFTD showed selective FI VEN and fork cell loss compared with NC and AD, whereas in AD no significant VEN or fork cell loss was detected. Although VEN and fork cell losses in bvFTD were often asymmetric, no group-level hemispheric laterality effects were identified. Right-sided VEN and fork cell losses, however, correlated with each other and with anatomical, functional, and behavioral severity. This work identifies region-specific neuronal targets in early bvFTD.     

Single-Incision Laparoscopic Surgery (SILS) in Biliary and Pancreatic Diseases

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. With the advent of laparoscopic surgery and its continuous development, the focus has shifted to ‘scarless’ surgery. In recent times, the innovative technique of single-incision laparoscopic surgery (SILS) has been applied in gallbladder removal and even more complex biliopancreatic procedures to further minimize the invasiveness of the surgery. Newer developments in laparoscopic equipments and instrumentation have helped to further evolve this field of minimally invasive surgery. Literature search was performed using the following online search engines: Google, Medline, PubMed, Cochrane, and the online Springer link library. The terms used for the search were as follows: SILS, LESS, single-incision laparoscopic surgery, single-port laparoscopic surgery, SILS cholecystectomy, and SILS pancreatic surgery. Articles that matched the search criteria were selected and extensively reviewed. Moreover, pertinent information on instrumentation and technology for SILS and LESS was obtained by accessing websites of manufacturers. Although SILS represents the search for an essentially scarless surgery, there is still not a widespread use and uniformity of this procedure. SILS is performed either by single- or multiple-port technique. In the present article, we present a review of the potential benefits, limitations, and risks of SILS in biliary and pancreatic diseases. There are many studies showing benefits in cholecystectomy. A few case reports have also emerged about its feasibility in procedures such as cystogastrostomy and limited pancreatic resection. Further research and development of this technique is needed to arrive at a tangible conclusion about the perceived benefits of SILS. Randomized studies to compare SILS with traditional laparoscopy are essential.     

Nonbursal lymphomas induced by nondefective reticuloendotheliosis virus

In previous studies we described bursal lymphomas similar to those of lymphoid leukosis in line 15x7 chickens inoculated with nondefective reticuloendotheliosis (RE) virus. A different type of neoplastic disease syndrome induced by nondefective RE virus is described in the present study. The tumours were characterised as lymphomas and most commonly involved the thymus, heart, liver, and spleen; the bursa invariably appeared normal or atrophied. Mortality from nonbursal lymphomas occurred as early as 6 weeks post-inoculation and was as high as 66%. The frequency of nonbursal lymphomas was markedly influenced both by the strain of RE virus and the line of chicken. Maximum tumour induction occurred in line 6(3) or line 0 chickens inoculated with RE viral strains SN or DIA. Histologically, the tumours were composed of a homogenous population of immature lymphoreticular cells. The tumours were often accompanied by enlarged peripheral nerves which were infiltrated with large, irregular cells with abundant cytoplasm. In an indirect membrane immunofluores-cent test, the tumour cells reacted weakly with anti-T cell serum but not with anti-B cell serum; the cells were refractory to treatment with . either serum in a complement-dependent antibody cytotoxicity assay. A proportion of the tumour cells contained membrane RE viral antigens. Although this syndrome superficially resembled Marek's disease (MD), nonbursal RE lymphomas lacked the MD tumour-associated surface antigen and the pleomorphic lymphocyte populations characteristic of MD. The nonbursal lymphomas appeared different from the previously-described RE virus-induced bursal lymphomas on the basis of latent period, cell surface antigens, and line susceptibility, and are probably induced by a different molecular mechanism.     

Nonenzymatic glycosylation of proteins and protease activities in granulation tissues in experimental diabetes

Serum proteins and hemoglobins show increased nonenzymatic glycosylation in diabetes mellitus. The measure of glycosylated proteins, particularly hemoglobin, is considered to be a preferred indicator in the control of diabetes. In a study of diabetes and inflammation, we assessed the extent of nonenzymatic glycosylation of proteins of granulation tissue from diabetic rats. Five, seven, and ten days after carrageenan injection, the granuloma proteins were extracted. Nonenzymatic glycosylation was measured in soluble and insoluble granuloma proteins by thiobarbituric acid assay. Protease activities and free amino groups were assayed in soluble extracts. Nonenzymatic glycosylation in soluble proteins of both groups reached a maximum on the seventh day. However, nonenzymatic glycosylation in soluble proteins of the diabetic granulomas was significantly greater than the controls on days five and seven. During the days after granuloma induction, nonenzymatic glycosylation in the insoluble granuloma tissue proteins gradually decreased without any significant differences between controls and diabetics. Significant decreases in the free amino groups in soluble proteins of the diabetic tissues were noted. Greater activities of cathepsins B and D were noted in diabetic tissues over controls. These observations suggest that, in addition to increased proteolysis, increased nonenzymatic glycosylation of tissue proteins could be associated with the impaired process of wound healing in diabetics.     

Extensive Infection of Face by Mycobacterium chelonae: An Unusual Presentation

Mycobacterium chelonae is a rapidly growing mycobacteria, causes cutaneous, soft tissue, and rarely lung infections. Here we present a rare case of extensive infection of face at multiple sites by Mycobacterium chelonae, with an unusual presentation, diagnosed by using conventional methods.     

Spontaneous mandibular regeneration: another option for mandibular reconstruction in children?

Treatment for conditions of the mandible may require resection of the affected segment, and this may need reconstruction. There are case reports of spontaneous regeneration of segments of excised mandibles that resulted in reduced or no need for reconstruction, and we present four such cases. The age at presentation ranged from 6 to 12 years. In all cases the periosteum was preserved during resection. All patients showed evidence of spontaneous regeneration, both clinically and radiographically, between 3 and 5 months after resection. The planned delayed reconstruction meant that these patients either did not need any bony reconstruction, or needed less than had originally been anticipated. Such regeneration is mostly reported in children, and is thought to be the result of an intact periosteal layer. In patients having planned mandibular resections, where the periosteum is preserved, some spontaneous regeneration should be anticipated and final reconstruction delayed until this is complete.