Role of diagnostic laparoscopy in managing acute mesenteric venous thrombosis

We describe two cases with acute mesenteric venous thrombosis in which diagnostic laparoscopy helped to diagnose the possible bowel infarction. These patients presented with abdominal pain out of proportion to physical findings, and computed tomography demonstrated thrombus in the superior mesenteric vein. Anticoagulation with heparin followed by diagnostic laparoscopy was done immediately after the diagnosis was established. According to the laparoscopic findings, one was managed with full anticoagulation without laparotomy and the other was managed with full anticoagulation and surgical resection. Considering that delay in diagnosis and surgical exploration is still frequent and is a significant contributory factor to the reported high mortality rate, diagnostic laparoscopy in an early position in the management algorithm for acute mesenteric venous thrombosis can furnish a rapid precise diagnosis of bowel infarction. It can also reduce the unnecessary laparotomies in these difficult cases.     

Duodenal-preserving resection of the head of the pancreas and pancreatic head resection with second-portion duodenectomy for benign lesions,low-grade malignancies,and early carcinoma involving the periampullary region

HYPOTHESIS: Duodenal-preserving resection of the head of the pancreas (DPRHP) and pancreas head resection with segmental duodenectomy (PHRSD) can be alternatives to standard pancreaticoduodenectomy for benign periampullary lesions. DESIGN: Retrospective analysis of patients requiring surgery for benign and borderline malignant tumors of the periampullary region. SETTING: Tertiary care referral center. PATIENTS: Duodenal-preserving resection of the head of the pancreas (n = 8) and PHRSD (n = 7) were performed in 15 patients with a preoperative diagnosis of benign and borderline malignant tumors of the periampullary region (ie, 11 pancreas head lesions [2 intraductal papillary mucinous tumors, 4 serous cystadenomas, 2 insulinomas, 1 epidermal cyst, 1 metastatic renal cell carcinoma, 1 nonfunctioning islet cell tumor/parapaillary] and 4 duodenal lesions [3 adenomas and 1 adenocarcinoma]). MAIN OUTCOME MEASURES: Surgical factors (operation time and blood loss), postoperative complication, postoperative pancreatic insufficiency (eg, development of diabetes mellitus and steatorrhea or elevated stool elastase values), weight change, and recurrence of disease. RESULTS: No differences were noted in the mean operation time and estimated blood loss between the 2 procedures. Major postoperative complication constituted the following: bile duct stricture (n = 1) in DPRHP and delayed gastric emptying (n = 1) and postoperative bleeding (n = 1) in PHRSD. Newly developed diabetes mellitus occurred in 1 patient. Exocrine pancreatic insufficiency (steatorrhea) was observed in 1 patient after PHRSD. Patients with early duodenal carcinoma and intraductal papillary mucinous tumors with a borderline malignancy are still alive without evidence of recurrence. There was no hospital or long-term mortality. CONCLUSIONS: Duodenal-preserving resection of the head of the pancreas is recommended first for a benign or low-grade, early malignant pancreatic head lesion; PHRSD can be an option for a lesion of the ampullary-parapapillary duodenal area as well as the pancreatic head. Duodenal-preserving resection of the head of the pancreas can be converted to PHRSD if ischemia of the second portion of the duodenum occurs. We found benign periampullary lesions could be conservatively treated with DPRHP and PHRSD, which could substitute for classic pancreaticoduodenectomy.     

Quantitatively assessed dynamic contrast-enhanced magnetic resonance imaging in patients with chronic obstructive pulmonary disease: correlation of perfusion parameters with pulmonary function test and quantitative computed tomography

OBJECTIVES: The purpose of this study is to evaluate the correlation of the perfusion parameters of 3-dimensional, contrast-enhanced magnetic resonance (MR) imaging (3D CEMRI) with pulmonary function test (PFT) and quantitative computed tomography (CT) parameters in patients with chronic obstructive pulmonary disease (COPD). MATERIALS AND METHODS: In 14 patients with COPD, 3D CEMRI was performed. From the signal intensity-time curves, pulmonary blood flow (PBF), pulmonary blood volume (PBV), and mean transit time of each pixel was calculated. From the volumetric CT data, the quantitative parameters including the volume fraction of the lung below -950 Housefield Units (V(-950)) and mean lung density were assessed. The correlation between the MR perfusion parameters and the parameters from quantitative CT and PFT was assessed using Spearman correlation analysis. The correspondence of the regional impairment of perfusion on MR perfusion maps to the areas of emphysema on quantitative CT maps in each patient was assessed qualitatively using a 4-class visual scoring method by 2 readers. RESULTS: All 3D CEMRI examinations were successfully completed and MR perfusion parameters were obtained in all patients. The Spearman correlation test showed that PBF positively correlated with forced expiratory volume in 1 second (FEV(1))/forced vital capacity (FVC) (R = 0.49, P = 0.044), PBV positively correlated with FEV(1)/FVC (R = 0.69, P = 0.006) and negatively correlated with V-950 (R = -0.61, P = 0.020), and mean transit time positively correlated with FEV(1) (R = 0.63, P = 0.017) and FEV(1)/FVC (R = 0.76, P = 0.002). The areas of perfusion impairment on PBF and PBV maps were relatively well correlated with the areas of emphysema on CT maps [very good or good: PBF 71.5% (reader 1) and 64.3% (reader 2) of the patients, kappa = 0.47 (P < 0.001); PBV 78.6% (reader 1) and 78.6% (reader 2) of the patients, kappa = 0.89 (P < 0.001)]. CONCLUSIONS: This study shows that the deterioration of perfusion parameters measured on MR in patients with COPD, correlates with worsening of airflow limitation on PFT and emphysema index on CT. Regional heterogeneity of emphysema on CT matches with the decreased perfusion on MR.     

Case report of post-traumatic arterial high-flow priapism

Priapism is rare and usually unpredictable. High-flow priapism is caused by unregulated arterial inflow. Antecedent trauma is the most commonly described etiology. This condition does not require emergent treatment. The initial management of high-flow priapism should be observation, because treatment-related erectile dysfunction may appear. We report a case of high-flow priapism by perineal trauma in a 27-year-old man. His corpora were typically tumescent, but not completely rigid. He could not have sexual intercourse. Blood from the corpus cavernosum was normally oxygenated. Color duplex ultrasonography was performed in the lithotomy position, scanned at the perineum, showed pseudoaneurysmal appearance. Selective internal pudendal arteriography showed a right cavernous arterial extravasation. Superselective embolization of right internal pudendal arteries was performed with an autologous clot. After the procedure, detumescence was achieved as well as erectile function. We recommend superselective arterial embolization as the management of high flow priapism to patients who request treatment.     

Treatment Guidelines for Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: When Can We Operate or Observe?

Background The objectives of this study were to investigate the clinicopathological features of branch intraductal papillary mucinous neoplasm (IPMN) and to determine safe criteria for its observation. Most clinicians agree that surgical resection is required to treat main duct-type IPMN because of its high malignancy rate. However, no definite treatment guideline (with respect to surgery or observation) has been issued on the management of branch duct type IPMN. Methods We retrospectively reviewed the clinicopathological data of 138 patients who underwent operations for IPMN between 1993 and 2006 at five institutes in Korea. Results Of 138 patients (mean age, 60.6 years; 87 men, 51 women), 76 underwent pancreatoduodenectomy, 39 distal pancreatectomy, 4 total pancreatectomy, and 20 limited pancreatic resection. There were 112 benign cases: 47 adenoma, 63 borderline cases, and 26 malignant cases, with 9 of these being noninvasive and 17 invasive. By univariate analysis, tumor size and the presence of a mural nodule were identified as meaningful predictors of malignancy. By receiver operating characteristic curve analysis, a tumor size of >2 cm was found to be the most valuable predictor of malignancy. When cases were classified according to tumor size and the presence of a mural nodule, the malignancy rate for a tumor ≤2 cm without a mural nodule was 9.2%, for a tumor of ≤2 cm plus a mural nodule was 25%, and for other conditions such as tumor >2 cm, >25%. Conclusions Many branch duct IPMNs are malignant. Surgical treatment is recommended, except in cases that are strongly suspected to be benign or cases that present a high operative risk. Observation is only recommended in patients with a tumor size of ≤2 cm without a mural nodule.     

尿道发育不良性阴茎弯曲的手术矫治

目的临床研究尿道发育不良性阴茎弯曲27例的手术方式和疗效。方法皮肤切口绕过菲薄尿道,脱蜕尿道表面阴茎皮肤,切断阴茎腹侧之深浅筋膜,伸直阴茎,手术不伤及尿道。结果27例阴茎下弯得以伸直,其中1例因留置橡胶导尿管导致阴茎部尿道狭窄,经尿扩治疗2年余,排尿尚通畅。结论采取保护菲薄尿道的切口脱蜕阴茎皮肤,切断增厚的阴茎筋膜能伸直Ⅰ型弯曲的阴茎。     

Diminished neuropeptide levels contribute to the impaired cutaneous healing response associated with diabetes mellitus

Background. Patients with diabetic sensory neuropathy have significant risk of chronic ulcers. Insufficient nerve-derived mediators such as substance P (SP) may contribute to the impaired response to injury. Mutant diabetic mice (db/db), which develop neuropathy and have delayed healing, may provide a model to study the role of nerves in cutaneous injury.Methods. Skin from human chronic nonhealing ulcers and age-matched control skin was immunohistochemically evaluated for nerves. Nerve counts were also compared in murine diabetic (C57BL/KsJ-m+/+ Lepr(db); db/db) and nondiabetic (db/-) skin. Excisional wounds on the backs of db/db and db/- mice were grouped as: (a) untreated db/- mice; (b) untreated db/db mice; (c) db/db mice with polyethylene glycol (PEG); (d) db/db mice with PEG and SP 10(-9) M; or (e) db/db mice with PEG and SP 10(-6) M.Results. We demonstrated fewer nerves in the epidermis and papillary dermis of skin from human subjects with diabetes. Likewise, db/db murine skin had significantly fewer epidermal nerves than nondiabetic littermates. We confirmed increased healing times in db/db mice (51.7 days) compared to db/- littermates (19.8 days; P 相似文献   

Efficacy of 3-dimensional endorectal ultrasonography compared with conventional ultrasonography and computed tomography in preoperative rectal cancer staging

BACKGROUND: This study was performed to verify reports of the decreased accuracy of endorectal ultrasonography (EUS) in preoperative staging of rectal cancer, and to compare the efficacy of 3-dimensional (3D) EUS with that of 2-dimensional (2D) EUS and computed tomography (CT). METHODS: Eighty-six consecutive rectal cancer patients undergoing curative surgery were evaluated by 2D EUS, 3D EUS, and CT scan. RESULTS: The accuracy in T-staging was 78% for 3D EUS, 69% for 2D EUS, and 57% for CT (P < .001-.002), whereas the accuracy in evaluating lymph node metastases was 65%, 56%, and 53%, respectively (P < .001-.006). Examiner errors were the most frequent cause of misinterpretation, occurring in 47% of 2D EUS examinations and in 65% of 3D EUS examinations. By eliminating examiner errors, the accuracy rates in T-staging and lymph node evaluation could be improved to 88% and 76%, respectively, for 2D EUS, and to 91% and 90%, respectively, for 3D EUS. Conical protrusions along the deep tumor border on 3D images were correlated closely with infiltration grade, advanced T-stage, and lymph node metastasis. CONCLUSIONS: We found that 3D EUS showed greater accuracy than 2D EUS or CT in rectal cancer staging and lymph node metastases. Concrete 3D images based on tumor biology appear to provide more accurate information on tumor progression.     

Relationship between expression of the sodium/iodide symporter and 131I uptake in recurrent lesions of differentiated thyroid carcinoma

The sodium/iodide symporter (NIS) is known to be responsible for the active accumulation of iodide within the thyroid gland. We evaluated the relationship between the expression of NIS in primary or lymph node lesions and iodine-131 uptake in recurrent lesions of differentiated thyroid cancer. In 67 patients with differentiated thyroid cancer (5 follicular and 62 papillary carcinomas), the expression of NIS was analysed by immunohistochemical staining using polyclonal antibodies against human NIS. We used paraffin block tissues of primary tumours or metastatic lesions, and also assessed 131I uptake in recurrent lesions of thyroid cancer on post-operative 131I whole-body scan. Immunohistochemical staining was positive in 22 patients (32.8%), including 2 of 5 follicular and 20 of 62 papillary carcinomas. Recurrence was confirmed in 40 patients pathologically or clinically by serum thyroglobulin, 131I scan, fluorine-18 fluorodeoxyglucose positron emission tomography and/or computed tomography. Among these 40 patients, 28 showed positive uptake on 131I scan. Fourteen tumour specimens out of 28 (50%) were positive by NIS immunohistochemical staining. The remaining 12 patients with recurrent cancer showed negative 131I scans, and all specimens were negative by NIS immunohistochemical staining. Thus, NIS immunohistochemical staining predicted 131I uptake in recurrent cancer with a 100% positive predictive value and a 46.2% negative predictive value. There was no difference in the positivity of NIS according to the site of recurrence on 131I scan. Outcome of 131I therapy could be assessed in 22 of the 28 patients who showed 131I uptake in recurrent lesions. Patients with positive NIS immunostaining responded to 131I therapy better than did patients with negative immunostaining (P<0.05). In conclusion, NIS immunohistochemical staining showed a high positive predictive value in predicting iodine uptake. Positive immunohistochemical staining of human NIS in primary or lymph node lesions may predict 131I accumulation and effectiveness of 131I therapy in recurrent lesions.