ENDOSCOPIC SUBMUCOSAL DISSECTION FOR RECURRENT GASTRIC TUMORS

Endoscopic resection has been accepted as the standard treatment for intramucosal gastric tumors of differentiated type. However, the indication was limited to small tumors to achieve en bloc resection and prevent local recurrence in cases of conventional endoscopic mucosal resection (EMR) such as the strip biopsy and the cap technique. To avoid multi‐fragmental resection, we have developed endoscopic submucosal dissection (ESD) as a new endoscopic resection technique. ESD is a remarkable technique, because we make it possible to remove the lesions en bloc regardless of size, shape, coexisting ulcer, and location. However, it is difficult or impossible to resect recurrent tumors en bloc in conventional EMR owing to hard fibrosis, and some patients need laparotomy. Using ESD, we can dissect the submucosal layer as we directly look at the submucosa, and remove the lesion safely and reliably even in cases of hard fibrosis. The key to treatment of recurrent tumors in ESD are as follows: (i) using enough submucosal injection solution (we use a mixture of Glyceol and 1% 1900 kDa hyaluronic acid preparation); (ii) incising the mucosa without fibrosis; (iii) understanding characteristics of various cutting devices, and changing other devices in difficult situations. In these ways we can remove the majority of the recurrent tumors en bloc. Hence, we consider that ESD is a very effective treatment which achieves excellent en bloc and complete resection rates and enables patients with intramucosal gastric tumors to a recurrent‐free survival even in recurrent tumors.     

Impact of Dialysis and Older Age on Survival after Liver Transplantation

Because creatinine is heavily weighed in the MELD (model for end-stage liver disease) score, we sought to determine the impact of MELD-based organ allocation on outcomes after transplantation in the pre- and post-MELD eras, focusing on recipients over age 65 on dialysis prior to transplant. A total of 20 196 patients from the UNOS database were analyzed. Comparing the pre-MELD to MELD era, there was a 41% increase in patients on dialysis (p<0.0001), and a 117% increase in combined liver/kidney transplants (p<0.0001). In the pre-MELD era, 1-year patient survival in recipients greater and less than age 65 on dialysis who received liver transplant alone was 56.8% and 76.4%, respectively (p=0.13). In the MELD era these rates were 50.7% and 77.8% (p=0.04). In the pre-MELD era, 1-year patient survival in recipients greater and less than age 65 on dialysis who underwent combined liver/kidney transplantation was 25.0% and 83.2%, respectively (p=0.0002). In the MELD era, these rates were 67.0% and 82.5% (p=0.18). In conclusion, a greater proportion of patients in the MELD era are on dialysis prior to transplant, and more receive combined liver/kidney transplants compared with the pre-MELD era. Candidates over age 65 who are on dialysis at the time of transplant have decreased survival after isolated liver transplantation.     

Ectopic cervico-mediastinal thymoma confirmed by flow cytometric analysis of tumor-derived lymphocytes

Ectopic cervical or cervico-mediastinal thymomas are very rare and most of them are asymptomatic, except for the presence of a cervical mass. We present the case of a 71-year-old man with an ectopic cervico-mediastinal thymoma threatening superior vena cava syndrome. He had a slight headache and presented with venous dilatation on the chest wall. A computed tomographic scan and magnetic resonance, imaging of the chest demonstrated a mass extending from the right neck to the hilum, that indented the trachea and compressed and displaced the brachiocephalic veins anteriorly. Under a right hemicollar incision and median sternotomy, the mass was resected en bloc together with the thymus. The resected specimen was an encapsulated mass measuring 11×7×4 cm. The pathological diagnosis was type AB, non-invasive thymoma, confirmed by 3-color flow, cytometry of tumor-derived lymphocytes. Flow cytometry using biopsy material may contribute to the preoperative diagnosis of ectopic thymoma.     

完全胸腔镜下心内直视手术的实验研究

目的　探索完全胸腔镜下心内直视手术可行性手术过程中的可能风险。方法　选取 6 0支杂种成年狗 ,雌雄不拘 ,按手术前后顺序分为A、B、C三组 ,每组 2 0例 ,行完全胸腔镜下心内直视手术。记录每例手术时间、术中出现的意外损伤 ,对各组结果进行比较。结果　手术平均时间分别为 :A组 (5 6± 1 2 )h ,B组 (3 4± 0 8)h ,C组 (2 1± 0 3)h ;手术失败三组分别为 3、0、0例 ;三组实验动物意外损伤发生率 ,A组明显高于B、C组 (P <0 0 5和 0 0 1) ,分别为 2 4、8、1处。结论　经过一定时间技能训练 ,行完全胸腔镜下心内直视手术是可行的     

The severity of airways obstruction as a determinant of treatment response in COPD

Guidelines recommend that patients with COPD are stratified arbitrarily by baseline severity (FEV₁) to decide when to initiate combination treatment with a long-acting β₂-agonist and an inhaled corticosteroid. Assessment of baseline FEV₁ as a continuous variable may provide a more reliable prediction of treatment effects. Patients from a 1-year, parallel-group, randomized controlled trial comparing 50 μg salmeterol (Sal), 500 μg fluticasone propionate (FP), the combination (Sal/FP) and placebo, (bid), were categorized post hoc into FEV₁ <50% and FEV₁ ≥50% predicted subgroups (n=949/513 respectively). Treatment effects on clinical outcomes – lung function, exacerbations, health status, diary card symptoms, and adverse events – were investigated. Treatment responses based on a pre-specified analysis explored treatment differences by severity as a continuous variable. Lung function improved with active treatment irrespective of FEV₁; Sal/FP had greatest effect. This improvement appeared additive in milder disease; synergistic in severe disease. Active therapy significantly reduced exacerbation rate in patients with FEV₁ <50% predicted, not in milder disease. Health status and breathlessness improved with Sal/FP irrespective of baseline FEV₁; adverse events were similar across subgroups. The spirometric response to Sal/FP varied with baseline FEV₁, and clinical benefits were not restricted to patients with severe disease. These data have implications for COPD management decisions, suggesting that arbitrary stratifications of baseline severity are not necessarily indicative of treatment efficacy and that the benefits of assessing baseline severity as a continuous variable should be assessed in future trials.     

Effects of Dopexamine on Lipid Peroxidation During Aortic Surgery in Pigs: Comparison with Dopamine

OBJECTIVE: We investigated the dose-related effect of dopexamine and dopamine on free radical production and lipid peroxidation estimated by MDA measurements in an ischaemia-reperfusion model of supraceliac aortic repair. DESIGN: Prospective, randomized, blinded experimental study. MATERIALS: Twenty-five healthy pigs. METHODS: All experiments were performed under general endotracheal anaesthesia. Supraceliac aortic cross clamping was performed in all pigs. The pigs were randomly assigned into five groups (n=5 in each group) and received a continuous intravenous infusion of normal saline (CTL), dopamine 2 microg kg(-1)min(-1) (dopa 2), dopamine 8 microg kg(-1)min(-1) (dopa 8), dopexamine 2 microg kg(-1)min(-1) (dopex 2), dopexamine 8 microg kg(-1)min(-1) (dopex 8). Cardiac output, mean arterial pressure, arterial blood gas analysis and blood sampling for plasma MDA measurements (to reveal lipid peroxidation) were recorded after induction of anaesthesia (baseline), 60 and 120 min after cross-clamping of aorta (ischaemia phase), and 60 and 120 min after restoration of flow (reperfusion phase). RESULTS: Dopexamine and dopamine at 8 microgkg(-1)min(-1) reduced MDA at 60 and 120 min after reperfusion. CONCLUSION: Dopexamine seems superior to dopamine in reducing oxygen free radicals and subsequent lipid peroxidation during reperfusion after supraceliac aortic cross clamping in pigs.     

Determination of the mean transit time for the transport of aerosolized 99mTc-DTPA across the pulmonary epithelial membrane. A plasma sample method

Summary. During the last decade it has been customary to estimate pulmonary epithelial permeability (P-P) as the pulmonary clearance of inhaled nebulized ^99mTc-DTPA from a time-activity (t-a) curve registered externally by monitoring over the chest. The t-a curve, however, is not defined by the degree of P-P alone but also by factors such as the deposition of the ^99mTc-DTPA in the lungs. To avoid these problems a plasma sample method was derived. It describes P-P by the mean transit time (t?) for the transport of ^99mTc-DTPA across the pulmonary epithelial membrane, t? (L). The calculation of t? (L) involves two steps. Following the inhalation of Tc-DTPA the plasma t-a curve is defined and used to calculate t? for the transport for ^99mTc-DTPA across the pulmonary epithelial membrane, through the E?V and until elimination by the kidneys, t? (L+ECV). Subsequently, ^99mTc-DTPA is injected as a bolus i.v. and the new t-a curve is used to calculate t? for the transport of ^99mTc-DTPA through ECV to the kidneys, t? (ECV). Finally t? (L) is calculated as t? (L) = -t? (L+ECV) t? (ECV). We applied the method in nine non-smoking individuals (median age 25–5 years, range 20–28) and compared the results to t? as calculated from the initial slope of an externally derived t-a curve. The individual t? (L) values were systematically greater than those of the external detection method (P<0·05). It is concluded that the initial slope method overestimates total PCI as measured by the plasma sample method. When choosing between the two methods, special interest should be paid to the inherent problems of the methods.     

Coexisting Endogenous and Exogenous Llpold Pneumonia and Pulmonary Alveolar Proteinosis in a Patient with Neurodevelopmental Disease

We report a unique case of coexistingexogenous lipoid pneumonia, endogenous lipoid pneumonia (EU), and pulmonary alveolar proteinosis (PAP) in a 5-year-old patient with severe neurodevelop mental disease. The patient presented with gastroesophageal reflux and presumed chronic lung disease resulting from recurrent aspiration pneumonias and succumbed to respiratory failure. The autopsy showed lipid-laden macrophages and periodic acid-SchiJf9ositive granular matm'al i n alveolar spaces and multilamellated structures within both alveolar macrophages and extracellular debris.

These findings were similar to those in previous reports of coexisting E I P and PAP in the setting of gastroesophageal refux [I] . However, the present case diJfered by the presence of scattered large osmiophilic extracellular lipid vacuob. Besides strengthening the association between EIP and PAP and their relationship to gastroesophageal refux, this case suggests that t h q may arise together with exogenous lipoid pneumonia, through related mechanisms, in the setting of neurodevelopmental disease.     

A ring electrode to record extraocular muscle activities during skull base surgery

Summary A ring-shaped electrode was developed and used in 20 patients to record evoked electromyographic responses directly from the extraocular muscles during skull base surgery. Intra-operative monitoring with this electrode helps the surgeon to localize the nerves that innervate the extraocular muscles precisely and to refrain from disturbing important neural structures during operations. Such monitoring also provides some insight into the pathophysiology of the dysfunction of these nerves resulting from skull base lesions.     

DAY-ONLY ADMISSION FOR VARICOSE VEIN SURGERY

Day-only admissions for surgery are strongly encouraged, in an effort to keep costs down. Varicose vein surgery has been considered too major for day-only management despite the fact that there have been studies from overseas showing that it can be done with a morbidity comparable to inpatient surgery. The morbidity of day-only surgery for varicose veins (both long and short saphenous procedures) was assessed and compared with the results of inpatient surgery. Patients were also asked whether they were satisfied with the surgery being done this way. There were 165 consecutive patients available for study, 64 day-only and 101 inpatient. All patients attending Shellharbour Hospital, Shellharbour, had surgery done as day-only (as it was a morning list and allowed adequate time for recovery). Patients attending Bulli Hospital, Bulli, had surgery done as an inpatient (afternoon list). All surgery was performed by one surgeon. There was no difference (Chi-squared) in the age distribution (mean 48 years for day-only, 51 years for inpatient) or sex proportion in either group (Chi-squared test of proportions with continuity correction). Assessment of the results was done by review of the surgeon's notes, as well as telephone interviews for day-only subjects. The complication rate in both groups was similar. Wound problems represented the main complication with an incidence of 10.5% in each group. There was one deep venous thrombosis (DVT) in each group (diagnosed by duplex scan). Response to the telephone interview suggested that most patients were happy to have the surgery done as a day-only procedure. Sixty-nine per cent responded that they would have it done this way again and 76% were satisfied with the result of the surgery. This study confirms the results of overseas studies, in that varicose vein surgery can be performed as day-only procedures with a complication rate similar to inpatient procedures and with a high degree of patient satisfaction. It is suggested that this should be used as the method of choice for the majority of patients requiring varicose vein surgery.