Intra-operative Total Enteroscopy for the Management of Peutz-Jegher's Syndrome

We present a case of Peutz-Jegher's syndrome in an 18 year old female who was followed for gastrointestinal polyps for 13 years from the age of 5 years. The patient was treated four times with surgical or endoscopic polypectomy for gastrointestinal polyps. At the age of 14 years, a combined surgical and endoscopic approach for the management of Peutz-Jegher's syndrome was carried out. A large polyp of the ileum required enterotomy for its removal, and another smaller polyp of the upper jejunum was identified and removed by intra-operative total enteroscopy via the anus. Intra-operative enteroscopy allows one to identify polyps that would previously have been missed. A more complete polypectomy can be performed using this technique, allowing the patient with Peutz-Jegher's syndrome a longer interval between laparotomies and a reduction in symptoms attributed to polyps.     

An Autopsied Case of Interferon Encephalopathy

Abstract: A 78-year-old male with renal carcinoma was treated with a high dose infusion of interferon-alpha (IFN-alpha) for eight months. The patient had evidence of organlc brain syndrome such 88 : dysfunction of memory, slowing of behavior, and development of mental confusion that appeared eight months after the treatment. MRI at the time of mental confusion revealed difise white matter lesions. Neuropathologic findings were compatible to Binswanger's disease and Senile Dementia of Alzheimer Type (SDAT), Preexisting neurologic abnormalities including intracerebral arteriosclerosis and cerebral atrophy may increase susceptibility to unacceptably severe IFN neurotoxicity.     

Papillary adenocarcinoma in a seminal vesicle cyst associated with ipsilateral renal agenesis: a case report.

Cysts and tumors of the seminal vesicle are uncommon, and their coexistence is extremely rare. We report a case of multiple papillary tumors inside a seminal vesicle cyst associated with ipsilateral renal agenesis in a 17-year-old man. Surgical excision of the cyst and tumors was performed without any morbidity and histology revealed well differentiated papillary adenocarcinoma.     

Effects of whole-body vibration exposure on DOPAC and VIP-like immunoreactivity in the rat brain]

In order to clarify the involvement of cerebral 3,4-dihydroxyphenylacetic acid (DOPAC) and vasoactive intestinal polypeptide (VIP) in whole-body vibration stress, DOPAC and VIP-like immunoreactivity (VIP-LI) in various discrete brain regions of rats exposed to whole-body vibration (4G, 20 Hz, 90 min) were assayed. The results showed that the whole-body vibration increased the DOPAC level in the frontal cortex and nucleus accumbens, but did not induce a concurrent change of VIP-LI in these regions. VIP-LI was significantly increased in the amygdala, and decreased in the hippocampus, accompanied by no significant change of DOPAC. These results show that whole-body vibration affects cerebral VIP neuron systems in addition to its nonspecific action, i.e. the activation of mesofrontal and mesoaccumbens dopamine neuron systems. It is assumed that the amygdalofugal VIP neuronal system is involved in the regulation of hypothalamic and pituitary hormone secretions, and that VIP in the hippocampus plays a part in modulating the blood circulation in the cortex in whole-body vibration stress.     

Clinical and hemodynamic sequelae of mitral prostheses evaluated by Doppler echocardiography]

To determine the relative superiority of a prosthesis in the mitral position, in vivo hemodynamics were examined by Doppler echocardiography, and the results were compared with other types of mechanical mitral valves including 63 Bj?rk-Shiley convexo-concave (BS) values, 30 Duromedics (DM) valves, and 58 Medtronic Hall (MH) valves. For this comparison, the following indices were evaluated: peak velocity of mitral flow (PV), mitral valve orifice area (MVA), mitral valvular regurgitation, New York Heart Association (NYHA) classification, pulmonary capillary wedge pressure (PC), cardiac index (CI) and valve-related complications. On Doppler echocardiograms, PV ranged from 1.2 to 2.0 m/sec with a mean of 1.6 m/sec. There was no evident relationship between the PV and the valve size in each type of prosthesis, and no significant difference in the PVs among the valves. The mean MVA was 2.6 cm2 (25 mm DM, 25 mm MH), which was regarded satisfactory from a clinical standpoint. MVA increased with the increase in the valve size in all types of valves, and of all sizes, MVA was larger in the DM and MH groups than in the BS group. Similarly, the incidence of valvular regurgitation was relatively low in all groups, and the degree of regurgitation proved to be grade II or less in all cases. As for the clinical results, clinical symptoms (NYHA) and hemodynamic states (PC, CI) improved postoperatively, with the differences among the types of prosthetic valves being insignificant. The incidences of thromboembolism, valvular thrombosis, valve failure and prosthetic endocarditis were relatively low in all groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: 1. Arthroscopic and anatomical investigation

An arthroscopic and anatomical investigation was performed to define the abnormal conditions of the popliteal tendon area in a lateral meniscus. Arthroscopic findings for 100 patients and anatomical observations of 10 amputated knees were analyzed. Five of the 10 dissected menisci were also examined histologically. Menisco-tibial coronary ligaments were classified into two types, as follows: type I--a coronary ligament covering an entire popliteal tendon beneath the meniscus; type II--a popliteal tendon visible beneath the meniscus through defects of the coronary ligament. Twenty-one of 100 cases were classified as type I, and 79 were classified as type II. Three of the 10 anatomical dissections were type I, and the remaining 7 were type II. Menisci in which the type I coronary ligaments were thought to be torn and menisci with type II coronary ligaments showed a rather marked mobility, but no conclusion could be reached.     

Ulnar recurrent adipofascial flap for reconstruction of massive defects around the elbow and forearm.

An ulnar recurrent adipofascial flap was raised and turned over to reconstruct massive defects around the elbow and forearm after wide resection of malignant tumours. Compared to the fasciocutaneous flap, the ulnar recurrent adipofascial flap has the following advantages: (1) a larger flap can be harvested without the problem of primary closure of the donor site, (2) the contour and scar of the donor site is reasonably acceptable since no tension is presented, (3) the flap can be turned over to cover a wider area, and (4) debulking of the flap can be performed during the operation if needed. The rotation arc of the ulnar recurrent adipofascial flap reaches a wide region, including the distal one-half of the upper arm, the elbow, and the proximal two-thirds of the forearm. Sensory deficit in the forearm was avoided in our patients because meticulous separation and preservation of the medial cutaneous nerve of the forearm was achieved without jeopardising the blood supply to the flap. The ulnar recurrent adipofascial flap is an easy and reliable option for one-stage reconstruction of massive defects around the elbow.     

Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually due to rupture of a visceral artery aneurysm in chronic pancreatitis. Other causes of HP are rare. We present a case of HP which occurred in a patient with chronic calcifying pancreatitis and a pancreatic pseudocyst documented by ultrasonography and computed tomography. With detectable fresh blood in the descending duodenum, an aneurysm in the pancreatic head was revealed by superior mesenteric angiography as the suspected origin of intermittent bleeding from the pancreatic duct. Because an artery feeding the pseudocyst could not be identified, angiographic embolization was not possible. Surgical resection or ligation was difficult by laparotomy; therefore, intraoperative packing of the pseudocyst with absorbable gelatin sponges was achieved via a cannula through a directly punctured site in the pseudocyst wall. The patient has been followed for 4.25 years with no further episodes of HP. It is possible that the packing of a pancreatic pseudocyst with gelatin sponges is a method that can be used in similar cases, where control of hemostasis is the primary concern. The packing of a pancreatic pseudocyst with gelatin sponges is a technique that can be performed not only via laparotomy but also via laparoscopy or concomitant angiography and ultrasonography.     

Clinical Course and Autopsy Findings of a Patient with Clival Chordoma Who Underwent Multiple Surgeries and Radiation during a 10-Year Period.

The management of clival chordoma remains problematic. We present the case of a 48-year-old woman with clival chordoma who underwent multiple surgeries and radiation therapy, including gamma knife stereotactic radiosurgery (GK-SRS), during a 10-year clinical course. The tumor was initially removed by gross total resection via the trans-sphenoidal approach, followed by external linac radiation therapy. The tumor recurred at the clivus 5 years after the initial operation. After repeated trans-sphenoidal removal of recurrent tumors, she twice underwent GK-SRS for a tumor remnant adjacent to the brainstem. Although this part of the tumor was controlled by GK-SRS, there was further tumor extension toward the sphenoid and maxillary sinuses. Ultimately, lower cranial nerve dysfunction developed due to tumor extension into the lower part of the clivus and the patient died of respiratory failure. Autopsy revealed the tumor to extend from the lower clivus to the bilateral middle fossae. The lower part of the tumor extended to the nasal cavity and to the posterior wall of the pharynx, resulting in compression of the upper pharyngeal region. The tumor around the jugular foramen compressed the lower cranial nerves bilaterally. Tumor cells did not, however, invade the intradural space microscopically. Although chordoma is not biologically malignant, this tumor can show massive extension with destruction of bony structures and extracranial invasion of connective tissues. Therefore, the optimal treatment strategy is to remove the tumor mass as extensively as possible, including normal bony structures and connective tissues surrounding the tumor, using skull base surgical techniques.     

Quadro-pulse stimulation is more effective than paired-pulse stimulation for plasticity induction of the human motor cortex

OBJECTIVE: Repetitive paired-pulse transcranial magnetic stimulation (TMS) at I-wave periodicity has been shown to induce a motor-evoked potential (MEP) facilitation. We hypothesized that a greater enhancement of motor cortical excitability is provoked by increasing the number of pulses per train beyond those by paired-pulse stimulation (PPS). METHODS: We explored motor cortical excitability changes induced by repetitive application of trains of four monophasic magnetic pulses (quadro-pulse stimulation: QPS) at 1.5-ms intervals, repeated every 5s over the motor cortex projecting to the hand muscles. The aftereffects of QPS were evaluated with MEPs to a single-pulse TMS, motor threshold (MT), and responses to brain-stem stimulation. These effects were compared to those after PPS. To evaluate the QPS safety, we also studied the spread of excitation and after discharge using surface electromyograms (EMGs) of hand and arm muscles. RESULTS: Sizes of MEPs from the hand muscle were enhanced for longer than 75min after QPS; they reverted to the baseline at 90min. Responses to brain-stem stimulation from the hand muscle and cortical MEPs from the forearm muscle were unchanged after QPS over the hand motor area. MT was unaffected by QPS. No spreads of excitation were detected after QPS. The appearance rate of after discharges during QPS was not different from that during sham stimulation. CONCLUSIONS: Results show that QPS can safely induce long-lasting, topographically specific enhancement of motor cortical excitability. SIGNIFICANCE: QPS is more effective than PPS for inducing motor cortical plasticity.