Thoracic duct lymphography by subcutaneous contrast agent injection in a dog with chylothorax.

A 4-year-old male Japanese Shiba Inu presented with recurrent chylothorax. The thoracic duct was successfully imaged using computed tomography after the injection of an iodine contrast agent into the subcutaneous tissue surrounding the anus. The thoracic duct was successfully ligated and pericardectomy performed via an open thoracotomy. Pleural effusion improved but relapsed a week after the surgery. A second lymphography revealed a collateral thoracic duct that was not detected during the first lymphography. The collateral duct was ligated and chylothorax was resolved after the second surgery. The lymphography applied in this study was minimally-invasive and easily provided images of the thoracic duct in a dog with chylothorax.

Evaluation of resectability after neoadjuvant chemotherapy for primary non-resectable colorectal liver metastases: A multicenter study.

BACKGROUND/AIM: The Kyushu Study Group of Clinical Cancer (KSCC) previously reported the safety and efficacy of neoadjuvant chemotherapy with mFOLFOX6 + bevacizumab for H2/H3 liver metastases of colorectal cancer. The aim of the current study was to evaluate the resectability of these metastases before and after chemotherapy as determined by independent liver surgeons. METHODS: Between May 2008 and April 2010, 40 patients were registered in a multicenter phase 2 trial of neoadjuvant chemotherapy (KSCC 0802). In Study 1, 5 independent liver surgeons from five different KSCC centers evaluated the resectability of liver metastases of colorectal cancer based on imaging studies performed before and after chemotherapy. Each surgeon was blinded to the other surgeons' evaluations. In addition, no information about the patients' characteristics was provided. In Study 2, 3 surgeons evaluated the resectability of these lesions based on imaging studies with discussion with each other, with the surgeons being provided with information on the patients' characteristics. RESULTS: In Study 1, 13 patients (36.1%) were evaluated to be resectable at baseline, whereas 17 patients (47.2%) were evaluated to be resectable after chemotherapy. In Study 2, 4 patients (11.1%) were evaluated to be resectable at baseline, compared to 23 patients (63.9%) after chemotherapy. CONCLUSION: Neoadjuvant chemotherapy with mFOLFOX6 + bevacizumab was confirmed to increase the resectability of non-resectable liver metastases of colorectal cancer according to the independent assessments of surgeons.

Confirmation of Intimal Tear in Thrombosed-Type Acute Aortic Dissection by Virtual Angioscopy.

INTRODUCTION: Therapeutic strategies for intramural hematoma (IMH) involving the ascending aorta remain controversial. REPORT: The patient was a 72 year old woman with a history of chest pain. Multidetector computed tomography (MDCT) showed an IMH involving the ascending aorta. Because virtual angioscopy revealed a punctate intimal tear in the ascending aorta, acute aortic dissection with an intimal tear and not IMH was diagnosed, and emergency surgery was performed. The post-operative course was uneventful. DISCUSSION: Virtual angioscopy allows the vascular lumen to be examined minimally invasively on the basis of images reconstructed from MDCT data. Even if MDCT does not clearly show an intimal tear associated with aortic dissection in a general view, virtual angioscopy can show the exact location and size of the tear before surgery. Virtual angioscopy is very useful for distinguishing thrombosed-type acute aortic dissection without clear ulcer like projections from an IMH, which may facilitate therapeutic planning.

Multipotency of equine mesenchymal stem cells derived from synovial fluid.

Cartilage regeneration with cell therapy following arthroscopic surgery could be used in racehorses with intra-articular fractures (IAF) and osteochondritis dissecans (OCD). The aims of this study were to investigate the origin and multipotency of stromal cells in the synovial fluid (SF) of horses with intra-articular injury and synovitis, and to provide a new strategy for regeneration of lost articular cartilage. Mesenchymal stromal cells were isolated from SF of horses with IAF and OCD. Multipotency was analysed by RT-PCR for specific mRNAs and staining for production of specific extracellular matrices after induction of differentiation. The total number of SF-derived mesenchymal stromal cells reached >1 × 10(7) by the fourth passage. SF-derived cells were strongly positive (>90% cells positive) for CD44, CD90 and major histocompatibility complex (MHC) class I, and moderately positive (60-80% cells positive) for CD11a/CD18, CD105 and MHC class II by flow cytometry. SF-derived cells were negative for CD34 and CD45. Under specific nutrient conditions, SF-derived cells differentiated into osteogenic, chondrogenic, adipogenic and tenogenic lineages, as indicated by the expression of specific marker genes and by the production of specific extracellular matrices. Chondrogenic induction in culture resulted in a change in cell shape to a 'stone-wall' appearance and formation of a gelatinous sheet that was intensely stained with Alcian blue. SF may be a novel source of multipotent mesenchymal stem cells with the ability to regenerate chondrocytes.

The influence of axillary reverse mapping related factors on lymphedema in breast cancer patients.

PURPOSE: Upper extremity lymphedema (LE) is a harmful breast cancer complication. It has been reported that patient- or treatment-related risk factors of LE. Axillary reverse mapping (ARM) has been performed to prevent LE during axillary lymph node dissection (ALND) by visualizing the upper extremity lymphatics. We investigated whether ARM related factors included novel predictive risk factors of LE. METHODS: ARM revealed fluorescent axillary nodes (ARM nodes) in 76 patients by fluorescence imaging. Only ARM nodes within the ALND field were removed. Twenty-four (32%) patients developed LE (LE+) and 52 did not (LE-) during a median 24-month post-surgical follow-up period. We retrospectively evaluated the clinical features and ARM factors of LE+ and LE-. RESULTS: The positive ARM node rate among LE+ was 42%, significantly greater frequency than that among LE- (13%: p ≤ 0.05). Cranial collectors (lymphatic ducts along or above the axillary vein) were significantly more frequent in LE- (44%) than in LE+ (21%: p ≤ 0.05). Multivariate analysis revealed postoperative radiation and positive ARM nodes to be positive risk factors and cranial collectors to be a negative risk factor of LE. CONCLUSIONS: ARM factors could predict the incidence of LE post-axillary surgeries in breast cancer patients.

A randomized multicenter phase II trial on the efficacy of a hydrocolloid dressing containing ceramide with a low-friction external surface for hand-foot skin reaction caused by sorafenib in patients with renal cell carcinoma.

BACKGROUND: The purpose of this study was to investigate the usefulness of a hydrocolloid dressing containing ceramide for hand-foot skin reaction (HFSR) on the soles of the feet in metastatic renal cell carcinoma (RCC) patients treated with sorafenib. PATIENTS AND METHODS: Patients with grade 1 HFSR on the soles of the feet were randomly assigned in to two groups. One group received a hydrocolloid dressing containing ceramide (arm A) and the other received 10% urea cream (arm B). Patients in both groups applied treatment to the affected sites on the soles of the feet, but not to the hands. The primary end point was the incidence of grade 2 or 3 HFSR on the soles of the feet in the first 4 weeks. RESULTS: Thirty-three patients were assessed (17 in arm A and 16 in arm B), and there were no significant differences in baseline characteristics between the two groups. During the observation period of this study, grade 2 or 3 HFSR on the soles of the feet was found in 29% of patients in arm A and was significantly less than the 69% in arm B (P=0.03). The incidence of HFSR on the hands, however, was similar in both arms. The median time to grade 2 or 3 HFSR on the soles of the feet was also significantly longer in arm A than in arm B (P=0.03). CONCLUSIONS: These results indicate that a hydrocolloid dressing containing ceramide prevented the worsening of HFSR caused by sorafenib in metastatic RCC patients. CLINICAL TRIAL REGISTRATION NUMBER: UMIN000002016.

Characteristic power Doppler sonographic images of tumorous and non-tumorous buccal space lesions.

OBJECTIVES: The aim of this study was to evaluate the characteristic power Doppler sonographic images of buccal space tumorous and non-tumorous lesions. METHODS: 48 patients with buccal space lesions were evaluated with greyscale sonography followed by power Doppler sonography with a 12 MHz linear transducer. On greyscale sonography, buccal space lesions were assessed for the boundary (clear or unclear), echogenicity (hypoechoic or isoechoic) and internal architecture (homogeneous or heterogeneous). Power Doppler sonography was performed to evaluate the vascular signals within the buccal space lesions. RESULTS: 48 lesions were found in the 48 patients; of these 48 lesions, 28 were tumourous and 20 were non-tumourous. In the 28 tumours, 15 cases showed clear boundaries, 15 cases were hypoechoic relative to adjacent tissues and 22 cases presented with a heterogeneous appearance on greyscale sonography. The internal vascularity of 19 tumours was shown using power Doppler sonography. In the 20 non-tumorous lesions, 11 cases showed clear boundaries, 17 cases were hypoechoic relative to adjacent tissues and 13 cases presented with a homogeneous appearance on greyscale sonography. 18 non-tumorous lesions showed no internal vascularity using power Doppler sonography. Logistic multivariate regression analysis between the tumour group and the non-tumorous lesions group demonstrated that the internal architecture (odds ratio = 8.270, p = 0.029) and vascular signals (odds ratio = 17.533, p = 0.003) were significant variables. CONCLUSIONS: Power Doppler sonography is a useful technique for the differential diagnosis of tumorous and non-tumorous buccal space lesions.

Transumbilical laparoscopic surgery using GelPort through an umbilical zigzag skin incision.

INTRODUCTION: We report herein a new method of transumbilical laparoscopic surgery using a GelPort through an umbilical zigzag skin incision. The method involves collaborating with plastic surgeons to ensure the procedure was minimally invasive. MATERIALS AND SURGICAL TECHNIQUE: After marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPort double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The Gelport was latched on the wound retractor ring, following the inflation of the pneumoperitoneum by CO (2). One or more additional ports were inserted as necessary. All operations were performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical incision, and anastomosis was performed. Using the above method, we performed the following procedures: one total gastrectomy, one distal gastrectomy, three gastric local resections, five right hemicolectomies, two high anterior resections, three cholecystectomies, and seven transabdominal preperitoneal hernioplasties. All cases were accomplished without any complications using this method. The wounds of the umbilical region were almost "scarless" in all cases. DISCUSSION: We developed an umbilical zigzag skin incision technique to perform abdominal laparoscopic operations using a GelPort, with a minimal number of skin incisions. We consider that our method reduces the technical difficulties associated with laparoscopic surgery and maintains cosmesis.

Assessment of ablative margin by MRI with ferucarbotran in radiofrequency ablation for liver cancer: comparison with enhanced CT.

OBJECTIVES: Our aim was to determine whether ablated liver parenchyma surrounding a tumour can be assessed by MRI with ferucarbotran administered prior to radiofrequency ablation (RFA) compared with enhanced CT. METHODS: 55 hepatocellular carcinomas (HCCs) in 42 patients and 5 metastatic liver cancers in 3 patients were treated by RFA after ferucarbotran administration. We then performed T(2)* weighted MRI after 1 week and enhanced CT after 1 month. T(2)* weighted MRI demonstrated the ablated parenchyma as a low-intensity rim around the high intensity of the ablated tumour in these cases. The assessment was allocated to one of three grades: margin (+), high-intensity area with continuous low-intensity rim; margin zero, high-intensity area with discontinuous low-intensity rim; and margin (-), high-intensity area extending beyond the low-intensity rim. RESULTS: Margin (+), margin zero and margin (-) were found in 17, 35 and 5 nodules, respectively. All 17 nodules with margin (+) and 13 of those with margin zero were assessed as having sufficient ablative margins on CT. The remaining 22 nodules with margin zero had insufficient margins on CT. The overall agreement between MRI and CT for the diagnosis of the ablative margin was moderate (κ = 0.507, p < 0.001). No local recurrence was found in 15 HCC nodules with margin (+), whereas local recurrence was found in 4 (11.8%) out of 34 HCC nodules with margin zero. CONCLUSION: Administration of ferucarbotran before RFA enables the ablative margin to be visualised as a low-intensity rim, and also enables the evaluation of the ablative margin to be made earlier and more easily than with enhanced CT.

Genetic variation of vascular endothelial growth factor pathway does not correlate with the severity of retinopathy of prematurity.

OBJECTIVE: The aim of this study was to assess the genetic effects of the vascular endothelial growth factor (VEGF) pathway on retinopathy of prematurity (ROP). STUDY DESIGN: A prospective study from a tertiary center that enrolled 204 Japanese infants (<35 weeks of gestational age (GA)) having no anomalies. ROP developed in 127, but not in 77 infants. The relative severity was defined as non-severe, moderate and severe ROP for GA, based on the staging criteria. VEGF (g.-634G>C, g.+13553C>T) and VEGF-receptor (KDR g.+4422(AC)11 to 14, Flt-1 c.+6724(TG)13 to 23) gene polymorphisms and clinical variables were assessed by uni/multivariate analyses. RESULT: The frequency of polymorphisms did not differ between ROP and non-ROP patients. The TT genotype of g.+13553 showed a higher odds ratio for non-severe ROP than CC genotype (P=0.006). Multivariate analyses indicated that low birth weight, blood transfusion and respiratory distress syndrome, but not polymorphisms, were the risk factors of advanced ROP (≥ stage 3). CONCLUSION: A genotype of the VEGF pathway weakly affects the severity of ROP compared with other clinical factors.

Dupuytren's disease following acute injury in Japanese patients: Dupuytren's disease or not?

This paper reports the development of Dupuytren's disease following acute injury in 16 hands in 14 Japanese patients. The patients included six women and eight men. Five patients developed disease following trauma, one following infection and eight following elective surgery. In the present series, the patient age and sex are irrelevant. The disease was unilateral, confined to a single digital ray, and without ectopic lesions in most cases. Disease presented predominantly in the ring or middle finger rays. There were only three patients who underwent surgery for definite flexion contracture. Diabetes mellitus was the most frequently associated risk factor. Our results suggest that Dupuytren's disease following acute injury could be considered a separate entity from typical Dupuytren's disease. At present, we believe that this condition should be considered a subtype of Dupuytren's disease.

Modification of IkappaBalpha by taurine bromamine inhibits tumor necrosis factor alpha-induced NF-kappaB activation.

OBJECTIVE AND DESIGN: Eosinophils play a prominent role in the pathogenesis of various common human allergic diseases, including asthma. Taurine chloramine (TauCl) and taurine bromamine (TauBr) are products of activated neutrophils and eosinophils. TauCl has strong anti-inflammatory properties. However, much less is known about TauBr. The aim of this study was to compare the anti-inflammatory capacity and membrane permeability of TauBr to those of TauCl. MATERIALS AND METHODS: Jurkat cells (T-lymphocytes) and YJ cells (myeloid-committed eosinophils) were used throughout this in vitro study. Tumor necrosis factor (TNFalpha) was employed for activation of the cells. Degradation of the cytosolic NF-kappaB inhibitor protein (IkappaBalpha) was studied by Western blot analysis. Assessment of NF-kappaB DNA binding activity was performed by an electrophoretic mobility shift assay (EMSA). RESULTS: TauBr inhibited degradation of IkappaBalpha and TNFalpha-induced NF-kappaB activation. TauBr exerted an anti-inflammatory effect by a similar process to that of TauCl. TauBr administered extracellularly in phosphate buffered saline (PBS) shifted the IkappaBalpha band at a relatively low concentration of 50 muM. In addition, TauBr was membrane-permeable as demonstrated by the inactivation of glyceraldehyde-3-phosphate dehydrogenase (GAPDH). CONCLUSIONS: TauBr was found to be highly membrane-permeable. TauBr might be generated both extracellularly and intracellularly by eosinophils at inflammatory sites in allergic disease and play an anti-inflammatory role.

An objective method to evaluate the risk of recurrence and extension of Dupuytren's disease.

This study was undertaken to assess the influence of the factors related to Dupuytren's diathesis on the rates of recurrence and extension of Dupuytren's disease after surgery. The records of 65 patients who underwent surgery for Dupuytren's disease were retrospectively studied and the presence of factors related to diathesis were recorded. The sensitivity and specificity of each factor for predicting recurrence and extension were calculated. Odds ratios and 95% confidence intervals were also calculated and a discriminant analysis was performed to explore correlations between recurrence and extension and the significant variables. Our results confirmed the prognostic value of diathesis. The results have been used to develop a new scoring system for evaluating the risk of recurrence and extension.

Dupuytren's disease on the radial aspect of the hand: report on 135 hands in Japanese patients.

We studied 135 hands in 77 Japanese patients to assess the frequency of radial involvement and its association with recurrence and the Dupuytren's diathesis. The radial aspect of the hand was affected in 22% of the hands. Diseased cords were observed in ten patients who underwent surgery on the radial aspect of the hand. Longitudinal cords on the radial side of thenar eminence and distal transverse interdigital cords were common. The radial aspect of the hand was the most common site of disease extension, though recurrence never occurred after excision of a radial lesion. Ectopic lesions, bilateral hand involvement, and recurrence were significantly more frequent in patients with the radial side involvement. Thus the results of this study suggest that radial side disease is associated with the Dupuytren's diathesis and is a risk factor of recurrence.

Surgery for Dupuytren's disease in Japanese patients and a new preoperative classification.

The surgical outcome of Dupuytren's disease was evaluated in 73 hands of 57 patients in a Japanese population. Subtotal fasciectomy was performed in all cases. Surgical results were evaluated using the percentage improvement of extension in each finger joint. Statistical analyses were performed on the risk factors associated with recurrence and extension. The surgical outcome depended on the degree of contracture of the proximal interphalangeal joint. Recurrence of disease occurred in eight patients (14%) and extension occurred in nine (16%). Recurrence and extension frequently occurred in those who had ectopic lesions or involvement of the radial side of the hand. The present results suggested that the Dupuytren's diathesis had an influence on recurrence and extension. We proposed a new classification of Dupuytren's disease that might help to predict the surgical outcome and facilitate surgical planning.

Lupus anticoagulant in myasthenia gravis associated with IgM gammopathy.

The plasma of a patient with myasthenia gravis had strong lupus anticoagulant activity and his IgM paraprotein displayed non-specific inhibition to coagulation factors IX, XI, XII, prekallikrein, and high molecular weight kininogen. He was placed on prednisolone, which resulted in improvement in his myasthenic symptoms, but the prolongation of APTT and macroglobulinemia remained. Double filtration plasmapheresis successfully decreased the serum IgM level from 1,190 mg/dl to 375 mg/dl and APTT improved from 58 s to 38 s. Myasthenia gravis is frequently associated with other autoimmune diseases, but the association with lupus anticoagulant and IgM gammopathy is rare.

Role of hypertension, dyslipidemia and diabetes mellitus in the development of coronary atherosclerosis in Japan.

The present study evaluated the effect of hypertension (HT), dyslipidemia and diabetes mellitus (DM) on the development of coronary atherosclerosis in the Japanese population, using a cross-sectional study of 433 patients (254 men and 179 women) aged 30 years or older who underwent coronary angiography for suspected or known coronary heart disease angina at 5 cardiology departments in the Fukuoka area between September 1996 and August 1997. Patients with a disease duration of 6 months or more were excluded. The main outcome measure was angiographically defined coronary artery stenosis and was found to a significant degree in 146 patients (33.7%). HT, DM, low levels of high-density lipoprotein cholesterol (HDL-C) and hypertriglyceridemia remained as significant coronary artery disease (CAD) risk factors even after controlling for age, sex, hospital, smoking, alcohol use, body mass index and leisure time physical activity. However, hypercholesterolemia was not a significant risk factor after adjusting for these variables. After controlling for these variables, DM, low HDL-C and hypertriglyceridemia were significant CAD risk factors for men, but only DM was a significant CAD risk factor in women. These results indicate that in Japan DM, low HDL-C and hypertriglyceridemia may be more important CAD risk factors than hypercholesterolemia.

Successful staged-Fontan operation in a patient with ectopia cordis.

Ectopia cordis is a very rare and often fatal disease. We report a successful surgery case of thoracoabdominal ectopia cordis with univentricular heart. This patient underwent a three-stage Fontan procedure, a right-modified Blalock-Taussig shunt at the age of 1 month, bidirectional Glenn shunt and pulmonary arterioplasty at 2 years 8 months, and finally a total cavopulmonary connection at 4 years. This patient was discharged from the hospital in good condition and has been doing well since. Thus, ectopia cordis is not a contraindication for a Fontan operation.

Xanthogranulomatous cholecystitis mimicking gallbladder cancer: report of a case.

A 61-year-old woman was admitted to our hospital with abnormal findings of abdominal computed tomography. Whereas she had neither fever nor abdominal pain, a cholecystitis was suspected. Ultrasonography showed a mass in the gallbladder with several stones, and an unclear border between the gallbladder and liver. Computed tomography showed a large-mass in the gallbladder with findings that seemed to indicate hepatic invasion and para-aortic lymph node metastasis. On the basis of these findings, we made a diagnosis of gallbladder cancer associated with hepatic invasion and lymph node metastasis. We treated this gallbladder tumor by hepatic arterial infusion chemotherapy via catheter with cisplatin and 5-fluorouracil. Four weeks after administration of the anti-cancer drugs, the tumorous lesion of the gallbladder could not be detected by abdominal imagings, and the gallbladder wall revealed no irregular findings. During laparotomy, the gallbladder showed signs of chronic cholecystitis, and a cholecystectomy was performed. Findings of the resected specimens showed severe inflammation, fibrosis, and bleeding in the gallbladder wall with infiltration by many foamy cells. Histopathological diagnosis was xanthogranulomatous cholecystitis. We report here a case of xanthogranulomatous cholecystitis mimicking gallbladder cancer and review the literature.

[Patching of the raw surface of the posterior right ventricular wall in Ross procedure to prevent bleeding and to confirm anastomosis of the conduit].

An 8-year-old boy underwent Ross procedure to repair aortic regurgitation and subaortic stenosis. In reconstruction of the right ventricular outflow tract, the raw surface of the right ventricular posterior wall was covered with autologous pericardial patch to prevent bleeding and to confirm the anastomosis of the pulmonary tract conduit made of expanded polytetrafluoroethylene. Bleeding from the posterior wall was absent and he led uneventful postoperative course. Same technique was used in 4 other patients, and satisfactory results were obtained. This technique, first reported from India, seems very useful in Ross procedure.